E.N.T. Referrals And how to reduce them

Between 2005 and 2009: GP referrals to outpatients increased by 19% Consultant to consultant outpatient referrals increased by 40%

Patient has the symptom Patient is referred for investigations or admitted for operation or sent for tertiary opinion Patient is seen in ENT clinic --------------------------------------------------------------- Patient is seen by GP Patient has the symptom

Reasons for a referral 52% to establish a diagnosis 48% for treatment or an operation 33% for a test or investigation which the GP cannot order 32% for advice on management 17% for reassurance for the GP / 2nd opinion 7% for reassurance for the patient or family 11% other Referral rates to a particular specialty within a single area can vary by as much as 10 fold between GPs

Reasons for an increase in referrals An ageing population An unhealthier population NICE / QOF requirements Defensive practice Lack of undergraduate training in that specialty Increase / decrease in consultant to consultant referrals Early discharge from hospital Discharges from long term outpatient follow up Shorter waits – high level of supply gives high referral rate Not so much private practice Patient expectation

Factors associated with referral rates GP Factors GP beliefs or expectations about benefits of referral, gender or age or experience of GP, degree of training in specialty, GP-patient relationship, congruence between GP and patient’s attitudes, GP relationship with specialist, practice size, fund holding history, services available in practice, GP psychological characteristics Patient Factors Severity of symptoms, desire for referral, age, gender, social class, diagnosis, co-morbidities, help-seeking behaviour, perception of the problem, attitudes towards treatment Structural factors Distance to specialist services, area deprivation, availability or accessibility of specialist care, alternatives to specialist care, time available for consultation

ENT Referrals 1,150,000 new ENT referrals in 2009/10 in England Population of England = 51 million = 22 new ENT referrals per 1000 population per year Approx 75 % of new ENT outpatient referrals come from G.P.s = about 16.5 ENT referrals per 1000 population per year

ENT Referrals Average list size in UK = 1800 About 30 ENT referrals / GP / year

Main presenting complaint Ear problems 59 % Nose / sinus problems 16 % Throat / neck problems 25 % 50 % of all referrals would need audiometry

Ear problems Hearing loss 34 % Vertigo 6.3 % Tinnitus 4.4 % Otitis externa 3.6 % Wax 2.4 % Plus: otalgia, ear discharge, foreign body, lumps and bumps on pinna

Nasal / sinus problems Epistaxis 4.8 % Nasal block 3.9 % Sinusitis / facial pain 2.9 % Plus: nasal discharge, nasal polyps, rhinitis, anosmia, foreign body, nasal trauma

Throat / neck problems Voice problems 5.2 % Tonsillitis 4.3 % Throat discomfort 4.0 % Snoring / sleep apnoea 2.9 % Swallowing problems 1.7 % Plus: neck lumps, lump in throat sensation, cough, foreign body

Local Population

Relative Referral Rate % of referrals in that age group / % of local population in that age group

Hearing Loss

Hearing Loss Refer to audiology if you want just a hearing test or a hearing aid opinion

NHS Bournemouth and Poole and NHS Dorset Grommet / Ventilation Tube Policy Jan 2011 Prior approval not required in the following circumstances: CHILDREN Disabilities e.g. Turner’s or Down’s Syndrome or cleft palate where the insertion of ventilation tubes is part of an established pathway of care Clinically significant retraction pocket in pars tensa Frequent episodes (at least 6 in 12 months) of AOM or complications, documented in primary care records Bilateral glue ear when ALL of the following are met: Age between 3 and 16 years Period of watchful waiting for 3 months and the glue ear persists Child has poor listening skills, indistinct speech or delayed language development, inattention and behaviour problems Hearing level in the better ear of 25 dB or worse

NHS Bournemouth and Poole and NHS Dorset Grommet / Ventilation Tube Policy Jan 2011 Prior approval not required in the following circumstances: ADULTS As part of middle ear major surgery Clinically significant retraction pocket in pars tensa Hearing loss post radiotherapy if hearing aids not appropriate As part of postnasal space biopsy for cancer investigation Glue ear (unilateral or bilateral) when all of the following criteria are met: Watchful waiting period of 3 months and the glue ear persists Hearing level of 30 dB or worse in the better ear Hearing aid use is not appropriate

Reinsertion of Ventilation Tubes NHS Bournemouth and Poole and NHS Dorset Grommet / Ventilation Tube Policy Jan 2011 Reinsertion of Ventilation Tubes Adults Prior approval required for second or subsequent procedures Children Prior approval required for 4th and subsequent procedures

Tinnitus

Tinnitus

A lot of your patients have tinnitus Some of your patients see you Some of these we refer for investigation or for hearing therapy Some of these you refer to ENT (but only about 1 a year) Some of your patients see you because of their tinnitus A lot of your patients have tinnitus

Tinnitus referrals When to refer: Unilateral continuous tinnitus Severe tinnitus not responding to first line management and especially if causing depression Tinnitus associated with asymmetrical hearing loss or vertigo Patients requiring the reassurance of a specialist assessment Tinnitus associated with ear disease e.g. CSOM Objective tinnitus (usually pulsatile)

Vertigo

Vertigo

Vertigo ‘Red Flags’ Persistent, worsening vertigo or dysequilibrium Atypical ‘non-peripheral’ vertigo such as vertical movement ‘Bizarre’ nystagmus (not simple lateral jerk or rotatory) Vertigo associated with: severe headache, especially in the morning diplopia or other cranial nerve palsies dysarthria, ataxia or other cerebellar signs papilloedema

Urgent Vertigo Referrals Should you be referring to: ENT ? Neurology ? Cardiology ? Elderly Care ?

Vertigo Referrals to ENT BPPV – should you learn the Epley manoeuvre? Vestibular Neuronitis (Labyrinthitis) – usually better by the time they are seen Meniere’s Disease – an over-diagnosed condition Migrainous Vertigo – an under-diagnosed condition? Others (especially multisensory, psychological)

Ear Wax

Ear Wax To syringe or not?

Otitis Externa Keep dry Avoid trauma Remove debris Swab for MC+S ? Do not overtreat with topical antibiotic

Epistaxis

Epistaxis

Nasal Injury

Nasal Injury If an acute nasal injury needs to be seen in an ENT clinic, make sure it is within 7 days of the injury so that the MUA can be done within 14 days

Nasal Block

Nasal Block

Sinusitis / Facial Pain

Sinusitis / Facial Pain

Nasal Polyps

Nasal Polyps

Tonsillitis

Tonsillitis

NHS Bournemouth and Poole and NHS Dorset Tonsillectomy Policy Jan 2011 Prior approval not required in the following circumstances: 1. Adults or children for cancer or suspected cancer 2. Adults or children with spontaneous tonsillar haemorrhage 3. Adults or children for cases of quinsy 4. Adults with proven obstructive sleep apnoea where other treatments have failed or are inappropriate 5. Adults or children with tonsil crypt debris (tonsilloliths) that are visible and recurrent 6. Adults or children who are immunocompromised or have other medical conditions, e.g. diabetes, cystic fibrosis or guttate psoriasis, which would leave them at risk of severe complications as a result of tonsillitis

NHS Bournemouth and Poole and NHS Dorset Tonsillectomy Policy Jan 2011 7. In adults and children for tonsillitis if ALL of the following criteria are met: Sore throats are due to tonsillitis There are 7 or more episodes of tonsillitis in the last year, or at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years (episodes must be documented in primary care records) There have been symptoms for at least a year The episodes of sore throat are disabling and prevent normal functioning

NHS Bournemouth and Poole and NHS Dorset Tonsillectomy Policy Jan 2011 7. In adults and children for tonsillitis if ALL of the following criteria are met: Sore throats are due to tonsillitis There are 7 or more episodes of tonsillitis in the last year, or at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years (episodes must be documented in primary care records) There have been symptoms for at least a year The episodes of sore throat are disabling and prevent normal functioning

Voice Problems

Voice Problems

Swallowing Problems

High - ENT Low - Gastroenterology Swallowing Problems High - ENT Low - Gastroenterology

Lump in Throat Sensation

Lump in Throat Sensation

Sleep Apnoea / Snoring

Sleep Apnoea / Snoring ENT - Snorers Respiratory - Sleep Apnoea Surgery for snoring and laser surgery to the palate not funded by PCT

What can we list without prior approval? Pinnaplasty Children 5-18 only Rhinoplasty Post-traumatic cases or congenital abnormality Complications following previous surgery where the airway is obstructed and where treatment would alleviate the problems Removal of benign NO skin lesions / lipomata Repair of earlobe NO

Reducing referrals to ENT How to do it Active Referral Review Comparative information about GP and practice referral rates by specialty Routine audits at practice level Discussion of a sample of referrals to examine referral quality and appropriateness ‘right place, right person, right time’ Redesign of elective care pathways Referral guidelines (but only if combined with feedback from peers or specialists) +/- desktop summaries, structured referral sheets, pro-formas or standardised letters and risk factor checklists Closer integration of GPs and specialists

The End The End