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

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

3. 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

4. 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

5. 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

6. 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

7. 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 ENT referrals per 1000 population per year

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

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

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

11. 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

12. 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

13. Local Population

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

15. Hearing Loss

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

17. 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

18. 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

19. 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

20. Tinnitus

21. Tinnitus

22. 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

23. 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)

24. Vertigo

26. Vertigo

27. 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

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

29. 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)

30. Ear Wax

32. Ear Wax
To syringe or not?

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

35. Epistaxis

36. Epistaxis

37. Nasal Injury

38. 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

39. Nasal Block

40. Nasal Block

41. Sinusitis / Facial Pain

42. Sinusitis / Facial Pain

43. Nasal Polyps

44. Nasal Polyps

45. Tonsillitis

46. Tonsillitis

47. 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

48. 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

49. 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

50. Voice Problems

51. Voice Problems

52. Swallowing Problems

53. High - ENT Low - Gastroenterology
Swallowing Problems
High - ENT
Low - Gastroenterology

54. Lump in Throat Sensation

55. Lump in Throat Sensation

56. Sleep Apnoea / Snoring

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

58. 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

59. 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

60. The End
The End