Developments in ENT services in primary care and the acute setting

Dr Cristina Warren outlines the benefits of the Fellowship in ear, nose, and throat skills for the community and the new emergency department at the Royal Victoria Eye and Ear Hospital, Dublin 

In July 2021 a Fellowship for ear, nose and throat (ENT) skills for primary care, funded by HSE National Doctors Training and Planning and accredited through RCSI, was created through the Aspire Programme. 

The Fellowship was open to applications from recently qualified general practitioners who had a special interest in otolaryngology and in systems development. The Fellowship programme has been renewed for a second year and is currently accepting applications. 

I applied for the Fellowship in 2021 and was lucky enough to gain the position. Fellowships of this kind are not about upskilling a single individual, but are intended to have a wider impact on the healthcare discourse. It is hoped that by the end of the programme, the Fellow in ENT skills for the community will be able to provide education on ENT conditions to their peers in general practice.

 

With the skills acquired, they will have the capacity to become a referral resource for non-complex ENT conditions. It is envisioned that the Fellow will become an advocate for GPs with special interests and for the creation of a formalised framework of GP specialists that are locally accessible to their colleagues for appropriate referrals. 

The Fellowship this year, and hopefully in years to come, aims to support the upskilling of the general practitioners who wish to make ENT their special interest, promoting accessibility to ENT expertise through an educational domino effect. 

In the past few months we have embarked on a four-part webinar programme in conjunction with Medcafe for community healthcare workers, which provides education on ENT-related topics and look forward to providing content for an ICGP webinar. 

ENT services and primary care 

In 2020, an article appeared in this publication which outlined the challenges facing ENT services that were being exacerbated by the Covid pandemic. Among the issues highlighted were the below EU average number of ENT specialists in the Irish system and data which suggested that one-third of patients referred for specialist opinion had non-complex ENT issues, which could be safely evaluated and treated in the community by upskilled practitioners. 

The article pointed hopefully to the training of GPs and nurses through the RCSI postgraduate credentialing certificate in ENT skills for primary care practitioners, as well as the GP trainees who receive supervised procedural experience during ENT rotations. The idea that a shift towards diagnosis and treatment in the community would be beneficial to our healthcare system is at the heart of Sláintecare. The Aspire Fellowship for ENT skills in primary care was created on foot of this impetus to upskill community healthcare workers. 

To my mind, advocating for the resourcing of primary care, to ensure that conditions with the lowest level of complexity are delivered in the community safely, is the most important part of this role. Inadequate resources are frequently cited by GPs as the biggest barrier to sub-specialist service provision. The Fellowship provides space for a general practitioner to input on the feasibility of services and skills that can be reasonably provided in an average GP surgery. 

Resourcing is a barrier that must be addressed if we are to follow through on the vision set out in the Sláintecare document. A healthcare system rooted in its principles embraces practitioners with a mix of skillsets and champions healthcare roles with new competencies. “Expansion and substitution of traditional and new cadres is important to deliver quality care,” according to Sláintecare. 

New ED 

A large proportion of the clinical exposure afforded to the Fellow takes place in the emergency department (ED) of the Royal Victoria Eye and Ear Hospital (RVEEH) in Dublin. On 10 November 2021 Minister for Health Stephen Donnelly was invited to open the new ED at the hospital. The Minister was met by a group of healthcare workers who were proud of the work they were doing and keen to impress upon him the changes the department had undergone. 

Far from simply a change of aesthetic, this is a department that has negotiated major operational changes. On a physical level, the building complies with the gold standards of pandemic care: The treatment rooms have been optimised to minimise disease transmission through the installation of a negative pressure airflow systems. Ameliorating the risk of disease transmission to patients and staff is paramount in a department that deals with the airways of an often elderly and therefore vulnerable demographic. 

There has also been seismic change in ethos and style of healthcare implementation. The ENT ED now finds itself operating in a manner that decisively breaks with the past and applies the Sláintecare principles of an integrated healthcare setting to a working hospital environment. The ED utilises the skills of a range of healthcare professionals including staff nurses, clinical nurse specialists, surgical trainees, GP trainees and the GP Fellow, all under the direction of a senior ENT surgeon. 

A hub and spoke model of leadership and resource allocation has been implemented. This emerged organically in response to the necessity of halting ‘walk-in’ presentations in conjunction with the success of telehealth triage. Triaged patients are all discussed at a ‘navigation hub’ meeting, where a consultant ENT surgeon decides on the most appropriate healthcare pathway for each case. 

The range of options includes audiology, vestibular physiotherapy, a nurse specialist clinic or an appointment for definitive diagnostic evaluation or procedural management. This rationalisation of resources provides the healthcare staff with a controlled environment where time is appropriately allocated to allow for safe treatment as well as professional development and learning. This approach utilises recommendations made in the ENT model of care document, published in 2018, and acknowledges the importance of well-trained and motivated staff. 

Through the pandemic, telehealth triage has emerged as a new and valuable modality. In the context of the RVEEH ED, it highlighted to senior ENT clinicians the benefits of direct primary care access to timely specialist opinion and identified the need for a specialist e-referral form. The department is currently developing a form to enable access to urgent ENT services. The Fellowship provides an opportunity for the specialist to collaborate directly with a GP to create a user friendly proforma that optimises appropriate triaging. Templates under consideration seek to offer guidance and teaching to users in an intuitive manner, as well as clarity regarding prioritisation rationale. 

Being an outsider to the ENT service and to hospital medicine provides opportunities for reflection and observation. This is a department constantly seeking to improve its messaging to patients and referring clinicians. It is heartening to see the efforts of the ENT ED at the RVEEH uphold and further the goals of Sláintecare. Its leaders are constantly re-examining how they operate and how best to provide the right care, by the right person, in the right place, at the right time. 

The staff continue to modify care strategies in response to the new challenges the pandemic presents and this flexibility of approach is serendipitously bringing them closer to creating an equitable, accessible health system. 

Through a combination of engagement with GP trainees, the support of postgraduate certification, the creation of the fellowship and the development of an instructive e-referral tool, a cultural shift is occurring. Primary care operating in an enhanced capacity, and the gradual move away from our current hospital-centric system will be advantageous to patients. To me, it seems obvious that formalised GP specialisation is an important step along the road to a high functioning health system. Like many general practitioners I am eager to see a safe and sustainable expansion of services offered by primary care through similar engagements with secondary care. The Fellowship has been a wonderful experience and I would encourage anyone interested in upskilling in community ENT to apply. 

Dr Cristina Warren is a GP undertaking a Fellowship in ENT skills for the community in the Royal Victoria Eye and Ear Hospital, Dublin.