This ENT Blog will keep track of all the activity undertaken by the ENT Specialty Group, noting and reporting insights along the way, and will be a shared point of contact for anyone who wished to keep up to date on the groups progress or contribute to the ongoing work. If you have any enquires about the project or any of the blog posts, please go to the Scottish Access Collaborative contact page and email us direct.
Workshop One ENT: common symptoms
In October 2018, the Scottish Access Collaborative ENT speciality specialty group met for the first time with the Digital Health and Care Institute design research team to explore potential innovations for ENT services in Scotland. The aim for this first design workshop was for the group of expert stakeholders to map out the current state of ENT services across Scotland from multiple perspectives, and look for opportunities for innovation.
The workshop began with a general discussion led by one of our audiologist on the role and state of audiology services in current ENT provision. The consensus was that there is currently variation in the way patients are referred to audiology. All GPs should have direct access to their local audiologists, although some continue to refer through their local ENT department. Direct access to audiology also varies, in the main by age but also who can refer, in some boards you have to be over 50 to get a direct referral and in some you have to be over 16, so there is a big ‘gap’ in terms of the national picture of who can be direct referred. Variation in who can refer also exists.
What happens at vetting in secondary care is also currently variable, with some clinics sending all hearing referrals to Audiology for them to vet for patients they deem appropriate for their services and the rest sent back to ENT. They decide what they can deal with rather than whoever is responsible for triage in the ENT team.
Some clinics are piloting this alternate pathway involving audiology. In Lanarkshire for example, anyone with a referral for hearing loss goes direct to audiology for a pre-test, and there is a direct access for GP too. By their estimation, in this system around 15% of hearing loss get seen and discharged by audiology and the rest come to ENT.
Following the general discussion, the conversation moved onto talk about the most common symptoms that ENT are presented with. The aim was to map typical pathways for symptoms and then focus in on specific opportunities that the group would like to carry forwards for the next workshop.
- Symptom: Hearing Loss
Some form of hearing loss is a relatively large volume of presentations for secondary care. This can be up to 50% of all referrals for paediatrics. A very high volume symptom. Or can be up to 15% of adult referrals. Still a high volume. It was recognised there are very different pathways for adults and children and during the conversation we had leaned more toward the adult pathways.
There was agreement that there is an opportunity to develop consistent referral criteria for what goes to ENT and what goes to audiology. In some boards, currently any health professional can refer into audiology rather than through ENT, and this would be an ideal scenario.
Workplace related hearing loss was discussed next. Current practice in workplace hearing tests is variable in quality which impacts on the reliability of the test results. If a workplace tests registers a problem with a person’s hearing, they invariable are referred to ENT where that person can have an unnecessarily long wait following which they are seen, audiometry is repeated and the individual in a significant number of cases is discharged with no ENT condition other than hearing loss. The patient may also then be referred to Audiology for ongoing support and care. There is an opportunity to look at more direct pathways for this scenario, in particular to Audiology in the first instance as opposed to ENT.
“What is the pathway for good quality audiology service at the time of need?”
There was some discussion regarding how the NHS and ENT can collaborate with the private sector and the high street, both already offer a hearing test service, but without consistent standards. NHS Scotland's Audiology Services apply both professional and service quality standards to practice. While Private Sector practitioners are also required to adhere to professional standards, the education and training historically of private sector staff has been different and practice is often seen to be different. Better understanding across sectors and use of the same standards is required to resolve this.
Finally for hearing loss, the group talked about parallel pathways and how they are often implemented but that in some areas this opportunity may not be fully utilised. Use of parallel pathways is required to ensure that the patient continues (safely) on their journey(s) and that neither ENT nor Audiology issues hold this up. Extended roles for Audiologists has seen a number of improvements too with an example given of where an audiologist, after an initial audiological examination, will refer a patient directly for an MRI scan after which they are picked up by ENT for results. This ensures that the Audiology pathway continues and that any additional intervention required by ENT is also accessed but without stopping the patient journey.
- Symptom: Vague Throat Problems (no red flag)
The next symptom was throat problems. While it was recognised that throat problems can encompass lots of different manifestations, the most common are a sore throat, a feeling of something in the throat, and a cough. The general consensus was that ENT see a lot of throat problems, with around 19 out of 20 being non-malignant, but you need to catch the one.
For patients with a cough (a common symptom), a typical pathway might involve a referral from a GP to ENT after having already seen a respiratory consultant. Returning to see a GP in between seeing specialists may be an unnecessary step in the pathway. There is potential to look at addressing this issue, improving the patient journey, potentially with some form of joint pathway for ENT and respiratory and risk stratified joint referral criteria.
Discomfort in the throat or a ‘sore’ throat was next to be discussed. This is an extremely common symptom for ENT with multiple possibilities of diagnosis, yet few that cannot be managed in primary care.
“this is a bulk symptom”
The feeling of something in the throat or F.O.S.I.T for short (so common it has an acronym) is another large proportion of ENT work. Often this has to do with lifestyle (diet, smoking, drinking, stress). This is a big concern for patients (fear of cancer) but not for ENT (1 in 20 have any worrying pathology). Generally, patients who come to clinic are scoped just to reassure that nothing is wrong. It is believed that 95% of patients will have no worrying pathology and are discharged reassured. 5% will have a problem and it is dealt with.
“lots of this is about reassurance”
The question raised in the workshop was how to find other ways to reassure patients other than bringing them to clinic where they often receive a diagnostic scope.
Next the group talked in more detail about how diagnostic scopes could be performed. In Grampian, scopes are done by a speech and language therapist, showing that it can be done in primary care by someone other than a consultant. The opportunity is to look at a new service model for this test on this particular pathway.
Finally, the group talked about tonsil stones and snoring. While not specifically one of the common throat problems it was recognised as a service that varies and in need of some discussion. There is an opportunity to develop national agreement and clarity on whether removing tonsils for adults is an NHS responsibility or not, as currently it varies according to region.
“we need national clarity”
- Symptom: Facial Pain
Next, the group talked about facial pain. This is another volume symptom for ENT, the big issue being that most facial pain is referred as sinusitis when actually there is no infection.
“We see lots of sinusitis that is not sinusitis, the patient has facial pain”
This is another symptom where currently clinics will ‘scope’ to reassure the patient, even though diagnosis of facial pain is largely based on the patient history and a physical examination.
The opportunity is to look at potential strategies for primary care led or where appropriate patient self-management of this symptom. The discussion focussed on the potential for patient led “symptom diaries” or patient questionnaires being employed as part of the pathway.
Finally, the group talked about the minimum treatment advice for facial pain and sinusitis, what information available could be easily available for GPs and patients. The danger of relying solely on online resources was flagged. To avoid health inequality, we need multi modal forms of information and interaction, not just having everything online.
- Symptom: sleep apnoea in children below 16. Usually presents as snoring. Breathing problems.
As the session neared a close the group discussed sleep apnoea in children. The normal cause is mechanically obstructive to do with the tonsils, so normal procedure is to take them out. About 60 or 70% of all tonsillectomies are sleep apnoea in children related. It is a big part of ENT work, and most are done by staff grade surgeons.
The rate limiting step with the current common pathway is the waiting time for the sleep study.
“there is probably something smart we can do around sleep studies”
There are examples of consultants using short 10 second videos shot by parents as part of the consultation, and there was discussion around making this part of the common path. For the ‘barn door’ cases, not waiting for sleep study will speed up the path and reduce an unnecessary step. There is opportunity to look at ways of shortening wait times for this scenario.
- Symptom: Dizziness
Next the group talked briefly about dizziness. The most difficult question to answer with this symptom is “what do you mean by being dizzy?” The issue is that lots of things qualify as dizziness in terms of a referral. There is a discrepancy between what is referred as dizziness and what the dizziness actually is. From an ENT perspective, they are most effective at dealing with vertigo. The discussion centred on how to support GP colleagues to decide what is truly vertigo and help and advice on what can be managed in primary care or by the patient. There is an opportunity to look at tools to support patients input into diagnosing this symptom, it was suggested that a well-designed questionnaire could help with appropriate diagnosis and referral. There is also an opportunity to explore the role physiotherapists can play in helping dizzy people manage their symptom in the community.
“lots of this can be dealt with in primary care”
- Symptom: Blocked nose
Finally, the group talked about blocked noses. Lots of people have a ‘blocked nose’, it can often give a patient facial pain, but it is treated as a different symptom to facial pain.
The treatments very much depend on the cause. If the blockage is caused by physical trauma then a surgery can be performed, for example, but the majority of people are given medical treatment that they could have got in primary care. If was felt that there is another opportunity with this symptom to empower the appropriate patients to manage this problem themselves. The opportunity is to develop clear decision trees and good diagnostic tools like patient questionnaires.
Of all blocked nose referrals to ENT, a very small number have anything seriously wrong, less than one in twenty. Generally, this is a ‘mechanical’ thing to do with the shape of the nose. There is a slight risk of cancer with some nasal blockage (possible but rare). It is now on the cancer guidelines, so it has increased the GP referrals for suspected cancer, but there is an opportunity to develop other pathways that are more patient led.
- Staff Training and Recruitment
Throughout the day the group discussed the lack of appropriately trained staff for ENT services, the career pathways for new roles, the provision of training, and recruitment. It was discussed that approximately 15% of patients who come to ENT will need some form of surgical intervention. The other 85% can be dealt with by medication. Of the 15% that come through for some form of surgery, only around 15% of those will need an operation by a highly trained specialist consultant, the rest can be done by other appropriately trained staff. The point was that much of ENT work does not need a consultant as such, it needs specially trained individuals who are appropriate for the job that is required.
“we don’t need more ENT consultants; we need more ENT specialists”
There is a big issue with staffing and recruitment in ENT and this is something the group want to explore more during the next sessions.
The next step is to bring the insights from workshop one back to the group to ‘sense check’ what we have already raised, add detail to the mapping of current ENT services, flag any issues and turn those issues into challenges to collectively address in the final workshop.
The Scottish Access Collaborative was created in 2017 to work closely with multi discipline teams from a range of specialisms to collectively develop new ideas for health service improvements in Scotland. A crucial part of the ongoing work of the collaborative is to serve as a platform where expert practitioners and patients can come together to share experiences, ideas and examples of service innovation. Over the past month the ENT specialty group have been sharing their own examples of current innovative practices and proposals for new service ideas. This blog shares some of the discussions and ideas we have captured during the ENT workshops.
Examples of New Practice Ideas
During our workshops the group shared an example of a proposal for a new vestibular service that would deal more directly with patients for whom vestibular rehabilitation would be appropriate.
The proposed service would use an agreed template to vet appropriate patients directly to audiology where an audiologist would assess the patient, perform an audiogram and make the decision whether they could be referred directly to vestibular physiotherapy or whether they should be referred to an ENT clinic.
- A patient who has dizziness is referred from primary care
- The referral is vetted by a senior decision maker
- Appropriate patients are sent for examination of their eardrum and hearing assessment by audiology
- Patients with appropriate results are referred back to ENT
- Patients where the audiologist is satisfied there is no need to refer to ENT are sent directly to vestibular physiotherapist
The key to these pathways is relationship with ENT. Vestibular physiotherapists and audiologists need close links to ENT so if there are any issues they can refer to ENT and get quick access.
One Stop Throat Therapy Clinic
The ‘one stop clinic’ example for throat problems, mainly the feeling of something in throat (FOSIT) was shared by colleagues in Grampian. The clinic is led by a speech and language therapist who examine patients, provide them with a flexible laryngoscopy, and gives the patient their results in one appointment.
- A patient is referred to ENT by their GP
- ENT, led by senior consultant, vet each referral and refer appropriate patients to the one stop clinic
- The patient presents for a one stop 45-minute appointment where the patient receives a flexible laryngoscopy and the results
- The patients that have no worrying pathology are discharged with advice after their first visit
- Patients for whom the appointment uncovers an issue are referred on for further investigation or treatment
- At the end of each clinic a consultant will review the recordings of the throat scopes to confirm any diagnosis from the clinic.
Colleagues recognise that the one stop appointment is long, but initial pilots of this model illustrate the benefit of taking the time to reassure patients, explain what the potential causes for the symptom are, and to give some advice about how to manage it. It was discussed that around two thirds of people referred to a one stop clinic are discharged with advice and one third are referred on for further investigation or treatment.
Colleagues in Lanarkshire are looking into this model for occupational voice users (e.g call centre workers, teachers) who have intermittent hoarse voice. Rather than the current model they too will be vetted to a one stop clinic first to see a speech and language therapist who are trained to perform laryngoscopy and for most, will provide the necessary reassurance. There will be strong team working with ENT for any support.
Video Endoscopy Clinic
The idea of the video endoscopy clinic is to bring an endoscopy service to those people living in remote regions of Scotland.
Video clinics are offered to appropriate patients who have a local resource infrastructure to provide the video conference facility needed for the service, and appropriately trained staff on hand.
- Patients are invited to attend a local facility where there is a video conference connection with a consultant in hospital
- Appropriately trained staff perform endoscopy with the patient, and the consultant views the images in real time in their clinic
- Once the scope is complete, the consultant, the person doing the scope, and the patient have a joint video consultation to discuss the results.
Colleagues reported the success of this video consultation model with paediatrics, where children had expressed that the experience of using a digital interface was much better.
The key to this type of services is getting the properly trained people into the regions where you want to run the clinics.
There is potential to use this method for follow ups as well as diagnosis, and to think about how virtual services can be rolled out for more than just remote patients to anyone who has difficulty travelling to clinics.
Early November saw the Access Collaborative ENT specialty group come together for the second time with the Digital Health and Care Institute design research team to continue their work on service innovation for ENT. The first workshop explored the current landscape of ENT service provision in the NHS, highlighting some of the key, high level areas for focus that we could take forwards in our subsequent work. This second workshop aimed to develop our collective understating of these areas for focus, by adding the perspectives of multiple stakeholders, considering the factors that influence the current system, and developing challenges for services that the group can begin to address in the third and final workshop together.
To concentrate the group onto the high-level areas of focus, we produced five key issues from workshop one, and asked small multi-discipline working groups to think about each issue from the perspective of the various stakeholders involved in each. To prompt each group, we had provided some questions distilled from the group discussions at workshop one. The following summarises the group feedback for each issue.
- Issue one: waiting times when reassurance is needed
Form a GP perspective they see many patients who are anxious about their condition and need reassurance. Sometimes, the reassurance can only come from diagnostic tests and investigations, and the tests can only be done in secondary care and so the GP has no choice but to refer the patient. From a consultant perspective, they would like referral guides designed in such a way that they can identify more readily the urgent and the routine at vetting. They would like to use more virtual options for consultations. From the patient point of view they just want to know what is going on while they wait for appointments and where possible avoid unnecessary trips to the hospital. Nurses would like more opportunities for training and introduction of more nurse led clinics for certain aspects of ENT. Managers would like to avoid unnecessary tests and outpatient appointments and see a need for alternative models to direct the intake of outpatients.
- Issue two: sleep studies for children
From the GP perspective, they want to get a good history about the child’s health and any other relevant health issues. One issue for them is the wide range of symptoms parents describe and it would helpful if parents could, for example, video record their child while sleeping to support GPs understanding. Parents are concerned about the long-term effects of lack of sleep and just want the problem to go away. Consultants need to balance the available resource for sleep studies which is variable across the country, and the demand. For the appropriate cases they want to perform tonsillectomy and adenoidectomy for obstructive sleep apnoea, this is still good practice but not necessarily the default and only response. There is a question as to whether more investigations (sleep studies) lead to less surgery as you can effectively screen more people.
- Issue three: facial pain
From a patient perspective, the online information available about facial pain tends to be written in ‘jargon’ using language majority of people will not find useful, or the information is the ‘worst case scenario’ leading to anxious uniformed patients that self-diagnose. From a GP perspective, the patient could be referred for any number of treatments and determining this is difficult. Often misdiagnosed as “sinusitits”. Consultants are frustrated by unrealistic patient expectations but they don’t have the ‘full story’ of the patient journey before they reach clinic. They would like to see more use of digital and AI systems for history taking and patient questionnaires that could support more effective referrals. Patients are frustrated when they wait for an ENT appointment only to then discover they perhaps need to see a dentist or other specialist as the cause of the facial pain is not ENT related.
- Issue four: access to audiology
Patients with hearing problems want a ‘one stop shop’ service and they want to be seen and treated quickly with good follow up care. GPs need to know the available pathways for audiology and supports to know when and where to send patients. Audiologists are asking why they are not able to order MRI scans directly, a view shared by consultants too.
- Issue five: staff and training
The general perspective on staff and training for the future of ENT services is that there should be a shift in the balance from consultant led secondary care to more holistic care. It was recognised that there is a lack of GPs with the specialist ENT knowledge and the same applies to specialist nurse practitioners too. One model for change in practice will require perhaps more ENT specialised primary care practitioners and the relevant training to support the change. Transition to a more balanced model, with more roles for primary care, will also need well defined routes into specialist care that are easily accessed when required.
How might we….?
Once each small working group had documented and shared perspectives for each of the five focus areas, the group collectively developed some key challenges for ENT for the future. Each of these challenges were framed as a series of ‘how might we’ statements, each statement posed a challenge as a positive question that will be taken into the third ENT workshop where there will be prioritised and the most salient addressed by the group. Included in the how might we statements for ENT are:
How might we…
- Reduce the number of investigations where reassurance is all that is needed?
- Identify patients who just need reassurance and facilitate that reassurance?
- Develop robust patient completed questionnaires/AI systems covering key points to help direct treatment?
- Develop a national consistent approach to tonsillectomy?
- Develop good quality public health information for conditions such as facial pain and cough?
- Develop direct patient access to audiology, including the High Street?
- Engage across Scottish ENT services to share innovative practices?
- Develop ENT skills in a multi-professional workforce?
These how might we statements along with the rest of the challenges collectively highlighted by the ENT group will be taken forwards into a third collaborative design workshop. In this third workshop the focus will be on developing suggestions for how key challenges can and will be addressed for the future ENT service. Ultimately, it is these suggestions that will constitute the basis of the ENT Access Collaborative report and will form the roadmap for future innovations.
December 2018 saw the Scottish Access Collaborative ENT speciality group come together for the third and final time in their series of design led workshops. For this last workshop, the Digital Health and Care Institute design research team collated the insights and issues gathered from workshops one and two, and used them as a basis for a series of innovation challenges for ENT services in Scotland. The challenges were framed as a series of ‘how might we’ statements that focussed in on the groups’ collaboratively developed ‘key areas for focus’. The ENT group had formulated over 20 statements addressing opportunities such as staff and training, communication between services, and integrating new technology. With such a wide variety of themes, issues and challenges the first task was for the group to review and prioritise their ‘how might we’ statements selecting the most salient six to address during the workshop. In some cases, the ‘how might we’ statements were similar in their content or had a shared thematic, in these cases the group decided to combine certain statements and slightly re-frame the challenge to reflect the change.
Once ranked and prioritised, the whole group broke away into three smaller multi-discipline working groups, each addressing two of the six challenges. While every effort was made to gather representation from across the ENT services in Scotland, two of the working groups did not have primary care representation. To balance this, the DHI design research team will aim to engage with primary care representation and give them the opportunity to comment on the suggestions that will go into the ENT Access Collaborative report before its publication.
Once each group had developed some responses and suggestions on how we might tackle each challenge ‘we’, their ideas were presented back to the whole group for wider discussion and refinement. The following summarises the ideas from each working group and the discussions that took place with the whole group.
1. How Might We: ensure consensus and implement consistent pathways
Currently there is poor communication between ENT stakeholders, some variation in interpretation of waiting time rules, and different skill mixes in different areas. This leads to ENT services having “different waiting times for different conditions in different geographical areas at different times”. The difference in skill mix especially is a barrier to implementing consistent pathways.
Therefore, the group suggested:
- A need for better feedback to stakeholders about how they perform comparatively to one another.
- A need to develop consistent and improved use of the SCI Gateway system. To achieve this there is a need to understand the current barriers to GP colleagues using the system more effectively, if clinical guidance is provided within this system, but referrals are made by administrative staff
- Piloting patient self-referral in one area to build an evidence base for change.
- Utilising technology to enhance referrals and enable more shared decision making between patients and clinicians, such as device based questionnaires and programs that garner consistent and meaningful information and show potential pathways to patients.
- A series of centrally organised pilot studies that look at immediate effects of changes and the long-term impact. Key to this will be effective dissemination of results to increase the chances of impact across ENT service.
2. How Might We: improve the referral process to ENT
Currently there are difficulties with SCI Gateway, consultants find it difficult to give advice ‘back’ to GPs, and it is not effective at signposting or holding information. The level of ENT knowledge within primary care is an issue, representative of the lack of ENT content in GP training. Referral guidance embedded into SCI Gateway is not always visible to GPs if they do not compile the electronic referral themselves. Public health information designed to detect cancer earlier has driven up referrals.
Therefore, the group suggested:
- SIGN could produce a GP referral pathway as part of the process of creating guidelines.
- More “pre-GP” patient questionnaires or apps that capture symptom information, including the impact in the individual, and show the potential pathways to patients.
- A more realistic public health message.
3. How Might We: retain and grow the workforce
Currently there is a shortage of all grades including consultants, nursing staff, junior staff, etc. Multiple units are trying to fill all the gaps. The “skill mix” needs to be re-invented. The current national selection process of placing doctors is a barrier to recruitment in certain areas
Therefore, the group suggested:
- A re-think of the skill mix with an increase of different roles such as GP, staff grades, non-specialists.
- Target trainees early in their training with a mix of online resources, face to face contacts, and innovative competitions.
- Review the national selection process including visible career progression routes.
- Develop a “hub and spoke” model for Scotland with regionally employed consultants and new job roles linked to a new workforce strategy.
- Look at the role and contract conditions for colleagues in audiology with a view to enhancing their current capacity.
“we should accept that lots of ENT work can be done by a non-consultant in a regional hospital”
4. How Might We: develop advanced practice roles for audiologists
Currently, there is variation in terms of services provided and not all service providers provide all services. There is a recruitment issue and the current number of people in training will not meet the demand for the service. There are few if any post- graduate courses in specialist areas and advanced practice, for example, management oftinnitus. There is variation in terms of ‘who does vetting’ of referrals, e.g. it can be consultant, audiologists, nurse, etc.
Therefore. the group suggested:
- Developing safe vetting criteria for audiologists so they can actively direct audiology cases to their service.
- Develop more standardised post graduate training opportunities.
- Develop nationally agreed roles in audiology.
- Enhance the role of audiology in vetting.
- Regional or national support for training provision.
5. How Might We: identify who needs reassurance and facilitate that reassurance
Currently, the referral rate to ENT is increasing but the prevalence of disease is not. Volume of ENT presentations are putting GPs under strain and they struggle to keep up. There are lots of resources of information for patients from different sources which is very confusing.
Therefore, the group suggested:
- Developing quality, trusted, realistic ‘pre-GP’ information for patients.
- A more realistic public health message, to reduce the expectation of automatic specialist referralfor certain symptoms.
- Developing systems (apps, questionnaires) to gather patient information and generate tailored advice back to the patient.
- Easier access to advice for GPs, including better communication with secondary care and validated pools of resources GPs can direct patients to.
- Utilise more innovative new imaging technology to enhance vetting and triage and make an image part of a standard referral (much like dermatology).
- Develop community (potentially pharmacy) and primary care capacity to take ownership of imaging for referrals.
- Better identification of and psychology support for frequently anxious patients.
6. How Might We: safely manage obstructing earwax
Currently, earwax is an increasing number of ENT cases, potentially linked to a changing demographic but there is no real understanding for the change. GP practices are stretched and removing obstructing earwax is not a priority. There is an opportunity to look at enhancing a current role to handle earwax removal. More private clinics now offer wax removal. Some hospitals are not offering earwax removal services, some are, but there is variation in their criteria.
Therefore, the group suggested:
- A need for national agreement on the role of the NHS for earwax removal, led by the health boards.
- A national training plan for practice or community nurses or health care assistants to clear earwax, potentially enhanced with online resources for nurses and for patients.
- A nationally strategy for who deals with this issue and relevant role enhancement training to support a change.
- National agreement on advice to patients regarding self-irrigation.
- Develop guidance on the best forms of treatment for earwax before removal as there is no real evidence for what works best.
The DHI design research team will now take the ENT speciality suggestions and add them to the Access Collaborative ENT Report. The report will be reviewed and published through the Access Collaborative website in the new year.