Ear, nose and throat (ENT) summit: 8 December 2022

A ministerial ENT summit was held in December to discuss what the system needs to do collectively and individually in response to the slow recovery from the pandemic and the increasing numbers of patients waiting for outpatient appointments (both new and follow up) and treatment to commence.

Prior to the meeting health boards were asked to develop their plans to improve performance and recover their ENT and to set out their approach to transform their services to ensure that they become sustainable.

The summit was structured around five themes, these were:

1. Implementation of a sustainable pathway
2. Interventions not normally undertaken (INNU)
3. Cancer waiting times
4. Paediatrics
5. Audiology

Andrew Sallows, National Director for Planned Care Improvement and Recovery opened, setting out the rational for the summit. He described a service that has gone from one that was relatively close to balance prior to the pandemic to one where there are now increasingly long waits. This had been due in part to the inability to undertake airborne procedures during the COVID pandemic. Health boards have been tasked to
identify and implement new ways of working that will need to include delivering a modernised service model to clear the backlog of patients through increasing virtual activity, utilising a multidisciplinary team approach and to increase the use of community services.

The national plan for Transforming Planned Care and Recovering Waiting Times 2022 to 2025 published last April sets out a very clear aspiration for recovery. It is very clear about the actions needed to be taken now to increase activity. The approach for recovery focuses on removing the backlog of those who are waiting too long for their first outpatient appointment, follow up appointment and treatment, as well as working towards a more sustainable approach utilising transformed models of care, further engagement utilising the community sector and clinically led, best practice ways of working which will deliver more robust, efficient, safe, and timely pathways and services.

The delivery unit presented a detailed analysis of the current waiting lists and activity data. The data showed that whilst some progress had been achieved against the ministerial measures that there was considerable variation between health boards.

Outpatient referrals remain below pre COVID levels at around 88% in September 2022. Outpatient activity also remains lower than pre-pandemic at 83%, there is a real need to increase outpatient activity. Inpatient and day case activity at 71% is considerably lower than it should be and health boards need to take action to increase activity as quickly as possible. There are a concerning number of patients who are waiting over 3 years at both outpatient and treatment stages, over 1,500 in total. There are too many patients waiting for a first outpatient with over 20,000 people waiting over 52 weeks and over 8,500 waiting over 104 weeks at all stages. The paediatric waiting list has grown from just under 9,000 a year ago to almost 10,500. Paediatric patients equate to approximately 16% of the total waiting list. There are a high number of cancer patients within the ENT speciality that need to be seen and treated due to the high level of clinical urgency.

Over the six-month period between April and October 2022, there has been a reduction of over 2,000 patients in the 104-week wait category There is a huge opportunity for more of the national ENT caseload to be treated on a day case basis if the right facilities and expertise could be put in place. In a recent review, GiRFT found wide variation in day case rates across ENT services, not explained by variations in age and case mix.

The Minister for Health and Social Services in her address was clearly set out her expectations along with clear targets for recovery that she expected all the Health Boards to deliver. She acknowledged that there is no doubt that ENT services, despite how hard everyone is trying, is struggling to cope to respond to the numbers of patients needing to be seen. Her priorities are clear, we need to reduce the backlog in waits caused by the pandemic, while working smarter as a whole system to improve the flow in our hospital urgent and emergency services. We need to do this by working differently and together.

She highlighted that the approach for ENT recovery must focus on the backlog of those who are waiting too long for their treatment, but that the service needs to work towards a more sustainable approach to transformed pathways and ways of working which will deliver more robust, efficient, and timely pathways and services for future care.

The Minister expressed a desire to reduce variation and noted that one health board has 500 patients waiting over 104 weeks, whilst still too many, this is considerably better than some others who have over 2,000 patients waiting over 2 years. We need to do more to minimise variations and ensure that everyone operates at the same level.

The Minister is acutely aware of the stress and anxiety felt by these patients, including a large proportion of children who need to be treated as quickly as possible. The Planned Care Recovery Plan published in April set out a clear aspiration for recovery, with clear actions that need to take now to increase activity and reduce the backlog whilst working smarter as a whole system.

The Minister has significantly invested in planned care services. Some of this has been used to improve the workforce. This has included additional staff and a considerable investment in training places. As demand continues to increase, it is imperative that services continue to adapt. This includes the exploration of job planning and working with key services such as audiology to increase capacity. A short-term plan was being
developed to help deal with current pressures on the workforce. The National Workforce Implementation Plan will set out the multi-faceted approach to building and supporting the entire workforce.

Clinicians have been clear they want to protective services to deliver more prudently, efficiently, and effectively.

The Minister concluded by asking health boards to consider:

• Health boards to focus on reducing the longest waits and implement the national pathways.
• Accelerate the use of see on symptoms and referral pathways.
• Increase activity levels and develop a more sustainable service.
• Removing the need for ad hoc initiatives and pressure on staff to do more.
• Prioritising cancer patients and those patients who are clinically urgent and reducing the paediatric waiting times.

Alun Tomkinson, the clinical lead for ENT presented a model for sustainable delivery for ENT to the summit. This focused upon the need for effective service redesign of focusing upon:

• primary care
• pathways
• departmental redesign
• planned care
• emergency / urgent care
• OPD
• diagnostics
• theatres

This then needs to be underpinned by service transformation with a focus upon:

• advice – pathway and system
• advice – individual
• triage
• patient review
• waiting list management
• diagnostics
• patient treatment

Community health pathways, interface GPs, Consultant Connect, SoS, PIFU and job planning all support this service transformation. 

ENT clinical colleagues have previously agreed to adopt the clinically led ENT health pathways across Wales. It has however, proven difficult to roll these out to their full potential. It is acknowledged that further work needs to be done to implement these at pace. Cardiff and Vale have made many of the changes and this is noted in their data and performance. 

John Day, Clinical Director of Audiology, BCUHB, presented to the summit as to how audiology can support patients and secondary care, on behalf of Audiology leadership in Wales. He highlighted the audiology journey and the relationship with ENT over recent years, setting out the benefits this changing relationship has had. He outlined the important role of the first point of contact Advanced Practice Audiologists. He set
out the following opportunities:

• roll-out of primary care audiology
• roll out of direct access to audiology (from primary care) to include hearing, tinnitus, balance and referral for MRI (HBs)
• joint (equitable) planning with ENT at local level
• recruit locally (to HBs and Wales), Introduce more apprenticeships, train existing staff into higher level roles, retain staff
• optimise national workforce planning and commissioning
• extend roles

There was a clinically led discussion which focussed on the opportunities to embed sustainable approaches into ENT services.

The discussion included the following:

• Approaches to planned care need to be revaluated to maximise the capacity of the service. This includes utilise the services provided by primary and secondary care staff, GPs, allied health professionals and associate physicians
• Navigating patients through planned care services should encompass all facets of the pathway. Pathways should be redesigned where appropriate to allow for streamlines processes and shorter wait times. When redesigning pathways, every step should be considered. Best practice ENT services should consider not only the clinical aspect of the patient experience but also the estate. This includes primary care services, emergency and urgent care units and efficient use of OPD, diagnostic units and theatres.
• Whilst building futureproof services, health boards should integrate safe interfaces for GP’s and embed the ‘5 Goals for Planned Care’ into all pathways and services.
• Planned care redesign should incorporate the following themes.
• Provide relevant and consistent advice as early as possible.
• Redesign of services and or clinical boards.
• Incorporate the nationally planned care agreed ENT / audiology health pathways.
• Utilise Consultant Connect for consistent advice.
• Establishment and implementation of SOS / PIFU.
• Created sessions in job plans to routinely review follow up and waiting list backlogs aligned with Consultant Connect sessions.

There is a need to look for opportunities, shared learning, and suggested further development of:

• Streamlined pathways that improve waiting list positions and the outcomes for patients
• Primary care / General Practitioners Committee Wales engagement
• Pathways one of four key objectives in national recovery plan
• Utilisation of SOS/PIFU pathways where possible
• Exploration of ENT INNUs and monitor their activity
• Alternatives to main theatre – use of dedicated outpatient space
• Virtual appointments
• Strengthening relationships with audiology

The summit delegates discussed the need for audiology to become better aligned to ENT services. Suggestions to improve this were:

• Effective national professional collaboration – working with the Welsh Government and other key stakeholders
• Produce and publish a national plan for integrated care
• Audiology has a good track record of staff development for expert and agile workforce, this should be learnt from and embedded into other key areas
• Effective collaboration with HEIW
• NHS Wales Audiology is UK leader in service innovation and quality assurance:
  • advanced Practice Primary Care Audiology – joined up primary through to secondary
  • memory assessment pathways
  • nationally endorsed service quality standards
  • first point of contact Advanced Practice Audiologists in primary care
  • new national ear wax management pathway introduced
  • optimise national workforce planning and commissioning

The Minister for Health and Social Services was clear about her expectations on the service. She urged delegates to think creatively whilst planning for sustainability. She was also clear that in order to improve the patient experience we must learn from the past and implement new innovative ways of working as well as clinically led best practice into all models of care. The Minister acknowledged the hard work of everyone
working to reduce the backlog and improve services and noted that the next few years would be financially challenging. As a result, it is important that service change is expedited. She also commented “We need to make better use of sharing our successes and learning from each other.”

The following expectations and actions were set:

• Health boards to focus on reducing the longest waits and implement the national pathways.
• Accelerate the use of see on symptoms and PIFU pathways.
• Implement Health Pathways for ENT as a matter of urgency, proposals to do this are required by the end of March 2023.
• Review existing INNUS to ensure that these are up to date by the end of March 2023 and the NHS Executive to review adherence to these lists.
• Each health board to develop proposals to implement all or some of the Cardiff ENT model. These plans to be shared with the NHS Executive and implemented by the ENT speciality board by the end of March 2023 and to form part of the health board IMTP.
• Embed primary care audiology.
• Increase activity levels and develop a more sustainable service.
• Prioritising cancer patients and those patients who are clinically urgent and reduce the paediatric waiting times.
• Implement ENT GiRFT Recommendations (Nov 2019) as follows:
  • Increase the use of day case across ENT
  • Reduce the number of non-elective spells (admissions) where no procedure take place.
  • Formalise networks for out-of-hours provision.
  • Increase the day case target for paediatric tonsillectomy to 80%.
  • Reduce readmission rates following tonsillectomy.
  • Reduce day of surgery cancellations.
  • Making best use of consultant out-patient time.
  • Maximise the use of appropriate aural care services for the post-operative care of ear surgery and in chronic disease management.
  • Maximise the use of appropriate audiology services for follow-up after grommet insertion.
  • Reduce new to follow-up ratios, making optimal use of clinical out-patient resource.
  • Enable reporting of patients who are waiting for a date for their follow-up appointment so this can be considered alongside follow-up date. 
  • Procurement.
  • Improved coding.