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Many non-complex ENT conditions can be treated in primary care, but this requires education and training
Unaddressed hearing loss has a detrimental impact on an individual’s quality-of-life. It may result in limiting educational potential, impede socioeconomic advancement, and negatively impact social engagement.
The World Health Organisation (WHO) cites lack of access to ear and hearing care as the third largest cause of global disease burden. Currently, more than 1.5 billion people experience some degree of hearing loss. This number could potentially double over the next 25 years.
In order to address these issues, the WHO is campaigning for universal access to safe, timely and affordable hearing and ear care by integration of these services within primary care.
The WHO estimates that 60 per cent of ear conditions are non-complex and could be safely evaluated and managed by primary care. It proposes achieving these goals through the introduction of targeted clinical ear, nose, and throat (ENT) education, and skills training and capacity building, at the community level.
World Hearing Day 2023 aimed to “highlight the importance of integrating ear and hearing care within primary care, as an essential component of universal health coverage”.
On 3 March 2023, the WHO launched a Primary ear and hearing care training manual aimed at community healthcare providers.
In the Republic of Ireland, ENT conditions account for a significant number of adult primary care visits (30-to-50 per cent). ENT referrals from general practice represent the third largest group of patient referrals to secondary care. However, Ireland has the lowest number of ENT consultant specialists in the EU, with one consultant per 82,000 population, compared to an EU average of one consultant per 19,500.
In the Irish setting, age-related ENT conditions occur in approximately 60 per cent of patients over 65 years. Simple conditions, such as cerumen impaction, in this cohort of patients are linked to the progression of cognitive impairment and left untreated can place a significant burden on the Irish healthcare system.
Currently, over 42,000 patients are waiting for a public ENT outpatient appointment, according to the latest National Treatment Purchase Fund data.
The ENT outpatient waiting numbers represent one of the largest group of patients waiting for a specialist opinion. This has been further compounded by the impact of the Covid-19 pandemic.
Almost 11,000 patients are now waiting more than 18 months for an ENT specialist. Waiting list validation has identified that approximately 33 per cent of these patients have non-complex ENT conditions, which are amenable to safe and effective treatment in primary care. However, there is limited ENT education and skills training in postgraduate primary care programmes. Many GPs are, therefore, not currently in a position to offer non-complex ENT care to their patients and have to refer the patient to the secondary care setting.
To address this deficit, we developed a novel ENT educational and training Fellowship programme for GPs who wish to deliver community-based ENT care in an Irish setting. The 12-month programme is delivered at the urgent care ENT department in the Royal Victoria Eye and Ear Hospital, Dublin, by the Programme Director Prof Camilla Carroll. The Fellowship is funded by the HSE National Doctors Training and Planning (NDTP) Aspire Fellowship pathway and the curriculum is accreditation by the RCSI.
The concept of integrating non-complex ENT care into a universal healthcare model is in keeping with the Otolaryngology Head and Neck Surgery: A Model of Care for Ireland launched in February 2019 and based on Sláintecare principles and WHO guidelines.
The inaugural Fellow Dr Cristina Warren, appointed in 2021, has now established a Community ENT service in Grangegorman, Dublin. This community ENT clinic is the first of its kind nationally providing a patient-to-specialist GP ENT service. The service has been very well received by patients to date.
To address capacity building for the provision of primary ear and hearing care in the community setting in Ireland, we have also developed and deliver a micro-credentialing postgraduate certificate (PG Cert) programme at the RCSI. The PG Cert in the ‘Management and care of the ENT patient’ is aimed at the multidisciplinary ENT healthcare team, working in a community primary care setting.
This unique education and skills programme consists of three modules covering ear, nose, and throat conditions commonly encountered in primary care practice. The postgraduate ENT programme will equip the course participant with the necessary knowledge, skills, and professional attributes required to work as part of the multidisciplinary ENT team, tasked with the delivery of high-quality patient care. We have successfully graduated 25 practitioners from this programme, who are now delivering ENT care in a community setting.
The WHO has emphasised the need to raise awareness of ear conditions and hearing loss as a global healthcare priority. In the Irish setting, the 2019 implementation of the ENT model of care was the first step in policy development at national level towards the integration of ear and hearing care service delivery into the primary care environment.
The provision of educational funding by the NDTP in 2021 to facilitate the delivery of a targeted primary care ENT Fellowship has enabled skilled GP ENT specialists to enter the Irish healthcare workforce.
Scaling up to provide a significant number of skilled GP ENT specialists in primary care is possible through initiatives such as the PG Cert in ENT. It is now time to introduce probably the most important aspect of the ear and hearing care programme and focus on public engagement. The education of young people and adults of all ages about the importance of ear and hearing care and knowing when to seek medical attention will have a beneficial impact on maintaining a good quality-of-life and a meaningful contribution to society now and into the future.
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