Redbridge CCG PLEE 16 th November 2013

1. Redbridge CCGPLEE16th November 2013 Mr Samuel Jayaraj Clinical Director ENT - Barts Health NHS Trust Consultant ENT Surgeon - Whipps Cross University Hospital and Forest Medical Centre Sam Jayaraj CD ENT Barts Health / Whipps Cross

2. Barts Health NHS Trust • Largest NHS Trust in England • Barts, Newham, London Chest, RLH and Whipps Cross University Hospitals • Maintaining high quality ENT Services locally at WX • WX receive ENT referrals from across Redbridge • Especially from Wanstead/Woodford Polysystem and Fairlop Polysystem Sam Jayaraj CD ENT Barts Health / Whipps Cross

3. Local ENT Structure – Whipps Cross University Hospital • Mr. Sam Jayaraj, • Lead Clinician • Paediatrics • Rhinology • MrNitesh Patel • Lead at Newham • Otology • Paediatrics • Mr. Mike Papesch • Head and Neck • Mr. Guy Kenyon • Rhinology • Mr. Abir Bhattacharyya • Voice • Locum • Head and Neck Sam Jayaraj CD ENT Barts Health / Whipps Cross

4. ENT Patients in primary care • Not here today to teach ENT • Raise discussion points for break out groups • Ideas for CCG to reduce secondary care referrals • Treat patients within primary care setting • Work with you Sam Jayaraj CD ENT Barts Health / Whipps Cross

5. Headlines • Basic surgery denied by NHS trusts to cut costs, say surgeons • Operations refused mirror those in McKinsey cost-cutting report for Department of Health • Darling: ‘we will cut deeper than Thatcher’, 26 March • Basic surgical procedures that could improve the lives of thousands of people are being withheld by NHS Trusts desperate to save money, according to some of the country’s leading doctors. Sam Jayaraj CD ENT Barts Health / Whipps Cross

6. the presidents of associations representing six of the biggest surgical disciplines claim "patients attend their GP surgeries with conditions that can be effectively treated by surgery and are being turned away”. Sam Jayaraj CD ENT Barts Health / Whipps Cross

7. Some of the patients may not even be told that an operation could help their problem, the surgeons say. Even when the sick are referred to a hospital consultant they can be refused operations because trusts have "arbitrarily defined a number of operations that reduce pain, improve quality of life and prevent serious long-term complications as being of 'limited clinical value'". Sam Jayaraj CD ENT Barts Health / Whipps Cross

8. Surgeons claim cost-cutting lies at the heart of moves to "ration patient care". • Last week the Department of Health revealed a new age of austerity in the NHS – signalling that trusts would have to save £1.5bn by reducing "unnecessary prescriptions and hospital referrals". Sam Jayaraj CD ENT Barts Health / Whipps Cross

9. Johnson said what would in the past have been considered routine surgeries for removing ear glue in small children and taking out tonsils have been "withdrawn effectively from the health service. These procedures have been classified as of low clinical value. But a child who cannot hear has his or her development impaired. Sam Jayaraj CD ENT Barts Health / Whipps Cross

10. “procedures of limited clinical benefit” might include treatments which whilst not life threatening could be problematic to patients who would be denied treatment. • Those patients who are referred to a specialist may now find that they are refused funding for surgery by their PCTs, which have arbitrarily defined a number of operations that reduce pain, improve quality of life and prevent serious long term complications as being of “limited clinical value”. Sam Jayaraj CD ENT Barts Health / Whipps Cross

11. PoLCE Effectiveness • Or PoLCV Value Sam Jayaraj CD ENT Barts Health / Whipps Cross

12. Grommets – The PCT will fund treatment with grommets for children with otitis media with effusion (OME) where: • There has been a period of at least three months watchful waiting from the date of the first appointment with an audiologist or GP with special interest in ENT; AND • The child is placed on a waiting list for the procedure at the end of this period; AND • OME persists after three months AND the child (who must be over three years of age or over 2 if there are exceptional clinical circumstances) suffers from at least one of the following: • At least 5 recurrences of acute otitis media in a year. • Evidence of delay in speech development. • Educational or behavioural problems attributable to persistent hearing impairment, with a hearing loss of at least 25dB particularly in the lower tones (low frequency loss). • A significant second disability such as Downs syndrome. Sam Jayaraj CD ENT Barts Health / Whipps Cross

13. Adenoids and Tonsils • Unequivocal indications for tonsillectomy: • Suspected malignancy • More than one Peri-tonsillar abscess (Quinsy) • Acute upper airways obstruction • Recurrent sore throat where the following applies: • 7 or more episodes in the last year, OR 5 or more episodes in each of the last two years AND • There has been significant severe impact on quality of life indicated by documented evidence of absence from school/work; AND/OR • Failure to thrive. • Using the SIGN list as indicative of bacterial infection, an eligible episode of tonsillitis must have three points, one each for any of the following 5 criteria documented: • a. History of Fever (.38.3C) • b. Tender anterior cervical lymph nodes • c. Tonsillarexudate • d. Absence of cough • e. Age under 15 but age 45+ subtracts a point • OR • Positive culture of group A beta haemolytic streptococci Sam Jayaraj CD ENT Barts Health / Whipps Cross

14. The PCT will consider funding for tonsillectomy in sleep apnoea syndrome in children when one or more of the following apply: • A positive sleep study. • A significant impact on quality of life demonstrated. • A strong clinical history suggestive of sleep apnoea. • Note: The case is much more likely to be approved where there is supporting evidence such as sleep studies, growth charts, letters from GPs and letters from employer and school. Sam Jayaraj CD ENT Barts Health / Whipps Cross

15. Snoring • None • Other procedures which fall into this policy also include: • correction of deviated septums • surgical reduction of the tongue • removal of tonsils Sam Jayaraj CD ENT Barts Health / Whipps Cross

16. Surgical Treatment for Sleep apnoea • The PCT will consider funding surgical treatment of sleep apnoea in the following circumstances: • Patient has moderate to severe symptoms (measured for example by the Epworth Sleepiness Score: 15-18= moderate, >18 = severe); OR • Patient is sleepy in dangerous situations such as driving (regardless of Epworth Sleepiness Score); AND • Patient has significant sleep disordered breathing (as measured during a sleep study, usually by the Apnoea/Hypopnoea Index: 15-30/hr = moderate, >30/hr = severe); AND • Patient has already tried continuous positive airways pressure (CPAP) unsuccessfully for 6 months prior to being considered for surgery OR patient had major side effects to CPAP such as significant nosebleeds; AND • A specialist believes the individual patient will benefit (according to available literature the subgroups in which surgical intervention may be effective are not currently known); AND • The patient is fully informed as to the limited effectiveness of procedures, the lack of long term outcomes and likely adverse effects including pain following surgery. Sam Jayaraj CD ENT Barts Health / Whipps Cross

17. ENT Patients in primary care • Ideas for CCG to reduce secondary care referrals • Treat patients within primary care setting • Work with you • Specific examples of high volume ENT cases that could be treated in primary care setting Sam Jayaraj CD ENT Barts Health / Whipps Cross

18. Specific examples • General Practitioners • BPPV • Nasal cautery • LPR symptoms Sam Jayaraj CD ENT Barts Health / Whipps Cross

19. Specific examples • General Practitioners • BPPV • Nasal cautery • LPR symptoms Sam Jayaraj CD ENT Barts Health / Whipps Cross

20. Specific examples • General Practitioners • BPPV • Nasal cautery • Laryngopharyngeal reflux symptoms Sam Jayaraj CD ENT Barts Health / Whipps Cross

21. Specific examples • Nurse practitioners • Ear syringing • Skin Prick Allergy Testing • BPPV • Epleycanalith repositioning manouevre Sam Jayaraj CD ENT Barts Health / Whipps Cross

22. GPwSI • BPPV • Nasal cautery • ENT training and experience • Microscope • Education programme • ENT Community Specialist Service • Lower tariff Sam Jayaraj CD ENT Barts Health / Whipps Cross

23. What have we done at Whipps? • In order to optimize the appropriateness of timely care given to patients and to improve the service offered to General Practitioners, we have produced guidelines for certain conditions/symptoms so that patients can receive early treatment in the community and then if required, be referred on to the most appropriate place for further care. • These guidelines/pathways have been agreed with the Primary Care Clinical Director for the locality. Sam Jayaraj CD ENT Barts Health / Whipps Cross

24. Advice & Guidance Service • Guidance on common frequently referred conditions for which treatment could be commenced in Primary Care Sam Jayaraj CD ENT Barts Health / Whipps Cross

25. Laryngo-Pharyngeal Reflux (LPR) • Symptoms: lump in the throat, intermittent dysphonia, sore throat, a bad taste in the mouth, dry cough, tightness in the neck/throat, burning feeling. • LPR is a frequent cause of common ENT symptoms. Patients often respond to advice about lifestyle measures they can adopt to reduce acid reflux (see attached information sheet), and to medical treatment with proton pump inhibitors and/or alginates. • Patients with a feeling of a lump in the throat, intermittent dysphonia, sore throat, a bad taste in the mouth, dry cough, tightness in the neck/throat and a burning feeling rising up should all be treated for LPR. • Please note that a ‘burning feeling’ does not have to be present for the diagnosis of LPR to be made; in fact it is frequently absent. • Patients with red flag or target symptoms (e.g. persistent dysphonia more that 2 weeks, weight loss, dysphagia, earache etc as per target referral form) should be referred through the 2 week referral / Target referral pathway. • All other patients not requiring a target pathway referral should be treated empirically for LPR for 6 weeks. If after this time they are still symptomatic, then a referral will be accepted for the ENT clinic at Whipps Cross University Hospital. Sam Jayaraj CD ENT Barts Health / Whipps Cross

26. Patients with tonsillitis considering tonsillectomy • There are now PoLCE guidelines for this procedure and therefore patients should only be referred to the ENT clinic if they fulfil the criteria for tonsillectomy as laid out on the Tonsillectomy PoLCE form. • This applies to paediatric and adult patients • The Paediatric ENT service at Whipps Cross is run by Mr. Samuel Jayaraj (WX & FMC) and Mr. NiteshPatel (WX & NGH). Sam Jayaraj CD ENT Barts Health / Whipps Cross

27. Nasal Allergy • Patients with symptoms suggestive of inhalant sinus and nasal allergy (i.e. nasal congestion, sneezing, itchy nose, runny nose, itchy eyes, should all be treated empirically with topical nasal steroid sprays, anti-histamines and anti-leukotrienes (if asthmatic). • If the history suggests a particular allergen, then allergen avoidance measures should be advised and the use of barriers and nasal douching should be considered. • We have set up a community based allergy clinic for inhalant allergy skin prick tests and your patients can be referred to this service for allergy testing and the results will be given and discussed with the patient and they will be discharged back to your care. • If patients fail to respond to conservative medical treatment after complying for 6 weeks, they may then be referred to the ENT clinic (Mr. Samuel Jayaraj and Mr. Guy Kenyon) at WXUH for endoscopic evaluation for other pathology and consideration for surgical intervention. • Please do state on the referral letter that the patient has complied with conservative medical treatment for 6 weeks and has not responded and hence the need for the referral. Sam Jayaraj CD ENT Barts Health / Whipps Cross

28. Hearing loss in the over 60s • Patients with gradual hearing loss as the sole ENT symptom and normal ear examination should all be referred directly to the Audiology department at WX for assessment. • If there is ear wax present this should be removed with ear wax softening drops and syringing and if the ear drum examination is normal, then the patient should be referred to the audiology service • The majority of these patients will have presbycusis, which will be managed by the audiology department with hearing aids if indicated. • If patients are subsequently found to have a possible alternative diagnosis to presbycusis, they will then be referred on to the ENT Clinic. Sam Jayaraj CD ENT Barts Health / Whipps Cross

29. Snoring • Please note that current PCT guidance regarding PoLCE does not support ENT Surgery as an option for these patients. Therefore please do not refer patients with simply snoring as the sole complaint as these referrals will have to be returned. • Suspected Obstructive Sleep Apnoea (OSA) - Patients with daytime somnolescence and an Epworth score > 10 should be referred for consideration for sleep study tests by the Respiratory Physicians at Whips Cross. • Remember that many patients who present with snoring may have nasal or throat pathology that may be amenable to ENT treatment and have NHS funding for this. Therefore do ask your patients if they have nasal or throat symptoms as if so they may still be eligible for ENT treatment. Sam Jayaraj CD ENT Barts Health / Whipps Cross

30. Proposed Redbridge ENT Community Specialist Service Sam Jayaraj CD ENT Barts Health / Whipps Cross

31. Proposed Redbridge ENT Community Specialist Service Pilot ENT CSS aims to provide care of ENT patients closer to home through • Offering a community based consultant triage and treatment service • Improving patient access to early specialist assessment and diagnostic services • Reducing waiting times for ENT outpatient appointments, outpatient waits as well as referral to treatment and referral to test times • Improving appropriate referrals to secondary care; as a triage service ensuring patients get speedier access to the most appropriate service be it secondary care, primary care or a specialised community service • Achieving value for money, ensuring that underutilised primary care resources are optimised Sam Jayaraj CD ENT Barts Health / Whipps Cross

32. Location of West Redbridge ENT CSS • Ideally, equipped practice within West Redbridge • Equipment • Accessibility • Bus • Tube • Car parking • Forest Medical Centre Sam Jayaraj CD ENT Barts Health / Whipps Cross

33. Redbridge CSS ENT Provider Name: Whipps Cross University Hospital (Barts Health NHS Trust) Provider Team: Mr Sam Jayaraj, Mr NiteshPatel, Kathy Cooper RGN Service Manager contact Telephone: 020 8539 5522 ext 6400 Conditions eligible for treatment: • The following conditions are eligible for treatment within this service • Allergy testing • Allergic rhinitis • Tinnitus • Vertigo • Balance problems • Lesions on ears • Micro suction • Otitis externa • Mastoid cavity care Treatment exclusions: • Patients in need of surgical care • Patients with sudden hearing loss • Cases where cancer is suspected (e.g. cases with hoarseness, neck lumps or with dysphagia) • Patients with multiple/complex co-morbidities • Patients who have already had a complete work up and treatment options within the community • Paediatric patients (during pilot phase) Sam Jayaraj CD ENT Barts Health / Whipps Cross

34. CSS ENT – Pathway Patient seen in general practice Inappropriate referrals returned to GP stating Outcome and management ENT condition requiring specialist input according to ENT protocol Refer via Choose and Book to community ENT service or Paper referral Referral to secondary care for assessment and treatments requiring scope Referral triaged by community ENT service Consultant within 5 working days Appointment booked for patient within 20 working days Patient seen in community ENT clinic within 20 working days Management plan discussed with patient Discharged back to GP Referred to secondary care Follow up arranged within service Discharge letter sent to referring GP within 7 working days including diagnosis, treatment given and management plan Sam Jayaraj CD ENT Barts Health / Whipps Cross

35. ENT Consultant Delivered Triage Service and Advice & Guidance Service • GP makes ENT Referral • OR • GP asks for Advice and Guidance Sam Jayaraj CD ENT Barts Health / Whipps Cross

36. ENT Consultant Delivered Triage Service and Advice & Guidance Service • GP makes ENT Referral • ENT Consultant Triages referral • Accepts referral for ENT SCC at Forest Medical Centre • Accepts referral for ENT Clinic at WX • Offers Advice and Guidance to referring GP Sam Jayaraj CD ENT Barts Health / Whipps Cross

37. ENT Consultant Delivered Triage Service and Advice & Guidance Service • GP asks for Advice and Guidance • ENT Consultant responds within 2 working days • GP acts on advice Sam Jayaraj CD ENT Barts Health / Whipps Cross

38. ENT Consultant Delivered Triage Service and Advice & Guidance Service • GP asks for Advice and Guidance FIRST • GP acts on A&G or GP makes ENT Referral Sam Jayaraj CD ENT Barts Health / Whipps Cross

39. Key Benefits • Key Benefits: • Consultant-led clinical triage of ENT referrals • Email advice and guidance service for GPs provided by ENT Consultant • Convenient location and quick access to ENT community services • Coupled with ENT training and development sessions for GPs Sam Jayaraj CD ENT Barts Health / Whipps Cross

40. Patient Experience • Service will be piloted initially. • Clinics will be held at Forest Medical Centre • Activity will be closely monitored throughout the pilot to determine/identify the following: • Number of patients treated in the SCC • Number of patients that required onward referral to Whipps Cross • Patient satisfaction surveys (including whether their expectation met) • DNA rates • Demand for the community service will be constantly monitored and additional capacity provided where indicated Sam Jayaraj CD ENT Barts Health / Whipps Cross

41. Examples of referral letters Sam Jayaraj CD ENT Barts Health / Whipps Cross