We present a model for streamlining the paediatric grommet referral pathway and follow-up that we have been piloting at St George’s Hospital.
Most grommets are inserted for hearing loss associated with a middle ear effusion. Between 10 and 30 per cent of children suffer from OME before the age of three years.
Of course, most do not require intervention as the majority are transient, or simply do not cause developmental issues. Along with clinical and audiological criteria, NICE guidance recommends three months watchful waiting from the time that the glue ear was first documented, before considering surgery. Most commissioning criteria, although occasionally more conservative audiologically1, recommend the same time period of three months for watchful waiting.
Grommet referral pathway
Typical access in to the system involves patients presenting with suspected hearing loss to their GP. They are subsequently referred to community audiology or hospital audiology and then to ENT; or they may have been referred directly to ENT by their GP (Figure 1).
Figure 2 shows one of the possible typical “old” pathways to grommet insertion in our hospital. In this pathway, the GP refers the patient to community audiology. Naturally, there is an initial wait for that appointment. If a hearing loss is found to be associated with glue ear, the patient is referred to ENT for a period of watchful waiting, incurring a further appointment waiting time. Practice based commissioning in some regions have an additional referral step via central referral systems, and may need to be re-referred by the GP2.
If glue ear persists, the patient spends a period of time on the waiting list before surgery. Referrals between departments and the hospital and community services use up valuable time, and although the 18-week countdown may stop during watchful waiting, when it starts again at decision to treat, targets may be difficult to achieve because there is insufficient time remaining to satisfactorily coordinate surgery quickly enough.
In this system, referrals for suspected hearing loss can be made directly to ENT by the GP, or patients may self-refer to community audiology cutting out one possible referral step. Ease of access varies depending on the referral route and there is therefore inequality.
A further source of delay and inequality arises from problems of ENT follow up appointments. Unfortunately they are frequently postponed because of leave. Some patients experience this more than once, leading to significant delays, taking them well beyond the recommended three-month watchful waiting period.
The other issue is duplication of hearing assessments. Before commencing watchful waiting, most ENT surgeons request hospital audiology, in addition to the already performed community audiology, to ensure that the glue ear is still present. Distraction testing is often necessary for children under three, which is labour intensive and time consuming.
Generally, watchful waiting in the community conforms to the guidelines of three months more successfully because easier access makes patients less likely to cancel, and there is cross cover for leave.
However, if the pathway still requires a further appointment with ENT before adding their name to the waiting list, a delay in waiting for that appointment may be incurred. This is unlikely to impact on the 18-week rule as it would remain suspended under watchful waiting during any such delays, but the patient journey for some is significantly protracted.
New streamlined pathway for improvement
The model for improvement deployed at St George’s allows the ENT consultant to book patients on to the waiting list on receipt of the referral letter from designated individuals from hospital and community audiology. The system works because strict commissioning criteria are used to determine appropriate patients, and this documented criteria is sent on a PCT commissioning form with the referral letter. At the same time as writing the referral, the healthcare professional also sends written acknowledgement to the GP, the patient and the waiting list manager. Information leaflets are included.
On receipt for the request for surgery, the waiting list manager books a date for surgery and a consultant led, pre-operative clinic to confirm that surgery is still required, obtain informed consent, address any other ENT problems, and provide swim plugs.
Figure 3 shows the new streamlined pathway. There are fewer stages for potential appointment derived hold-ups, and there is more equitable access to the system regardless of the initial route of referral.
Paediatric grommet follow-up
An appointment soon after insertion of a middle ear ventilation tube is important to ensure that the grommet is in-situ and patent and that there is normal hearing. Later appointments are important to ensure resolution with no perforation.
A typical “old” regimen of follow-up at St George’s consisted of an appointment a few weeks after grommet insertion with an ENT surgeon and an appointment with an audiologist to undergo behavioural testing. Patients are then seen at intervals with further ENT and audiology input, as necessary, until extrusion and resolution.
Our new follow-up protocol of paediatric patients after grommet insertion is an appointment with audiology only, at two weeks. The next consultation is scheduled 12 months later for a more traditional ENT follow-up appointment with audiology input as required. Most parents have been pleased with the short waiting times offered by a single appointment. Freeing up follow-up slots in the ENT clinic has allowed other patients to be seen. The change in service delivery has increased efficiency and capacity.
There is the infrastructure for a wider application for this method of follow-up. Most ENT and audiology departments and community audiology clinics have the staff with the expertise and the equipment. If the same service was adopted nationally for the 34,000 grommets inserted each year,3 there is the potential to create a similar number of additional ENT clinic appointments with little additional capital or staffing costs.
Our philosophy is to create partnerships between ENT and hospital and community audiology services to improve the patient experience. Recent Department of Health documents have expressed an explicit desire, derived from what the public wants, for more community services and improved integration.4,5 Such explicit intention, and rationale for this community service integration, is nowhere better illustrated than the case for audiology services as outlined by audiology specific department of health documents6-8. Recent political rhetoric suggests that services driven by public desire are here to stay. We believe the next step for integration for us will be to encourage GP referral to community audiology, with follow-up in the community, and mechanisms for easy referral back to ENT if required.
Two relatively simple steps, made possible by teamwork, have streamlined access and follow-up. The system is more equitable and has increased efficiency and capacity.
1. Wandsworth PCT www.wandsworth.nhs.uk
2. “Benefits of a GP PBC Co-Op.” www.pulsetoday.co.uk/story.asp?storycode=4114869§ioncode=40
3. HES data 2008
4. Our health, our care, our say: a new direction for community services. NHS 2006
5. High Quality Care for All. DH 2008
6. Improving access to Audiology services in England. DH 2009
7. Transforming Services for children with hearing difficulty. DH 2009
8. Community provision of hearing aids and related audiology services. DH 2009
This model was presented to a representative from the DH Transformations Group in Audiology.
Robert Harris, Department of Otolaryngology (St George’s) Sarita Fonseca, Community Paediatrician (Wandsworth) Lila Pilling, Business manager (St George’s) Ewa Raglan, Department of Audiovestibular Medicine (St George’s) Hamid Daya, Department of Otolaryngology (St George’s)
Robert Harris, Sarita Fonseca, Lila Pilling, Ewa Raglan, Hamid Daya