Evidence submitted by the British Association
of Otorhinolaryngologists (WP 57)
INTRODUCTION
1. ENT UK is the specialty association for
Ear Nose and Throat Surgeons in the United Kingdom. Well over
90% of ENT surgeons in the UK are members and the specialty is
the third largest surgical specialty in the College of Surgeons
of England. We have conducted detailed surveys of our workforce
and working practices, the most recent in 2005, and we have details
on working patterns, best practice, demand for the specialty,
and facilities and support services needed to provide a high quality
service for patients.
2. The scope of ENT is wide. It includes
the following:
(a) Ear conditions, in particular the assessment
of hearing loss and ear disease and the diagnosis, treatment and
rehabilitation of Hearing impairment. There are very close links
with Audiology in this field.
(b) Diagnosis and management of nasal and
sinus disease.
(c) Management of throat and voice disorders—again
we work very closely with Speech and Language therapy in this
field.
(d) The diagnosis and management of diseases
arising in the neck, salivary glands, thyroid gland, and cancers
of the throat and neck.
ENT treats the entire population from newborn
to old age. The specialty treats more children than any other
surgical specialty. About 35% of an average ENT Surgeon's surgical
cases are under 16. The scope of ENT overlaps with Oral &
Maxillofacial Surgery, Neurosurgery, Plastic Surgery and General
Surgery and we collaborate with all these surgical specialities
and many others.
3. Referrals to ENT services are very high
and rising. The Department of Health figures indicate that in
England alone, over two million patients were referred to ENT
last year, which would be predicted to generate over five million
consultations in ENT per annum, and 700,000 surgical procedures.
Approximately 20% of referrals from General practice to hospital
services are to ENT. Demand for ENT appointments has doubled since
1993.
4. The trained specialist workforce in ENT
in England is lower per head of population than elsewhere in the
UK, and in England there is less than one specialist (Consultant)
per 100,000 population. There are currently the equivalent of
487 whole time ENT surgeons in England. Our target figure is for
one per 50,000 (997 whole time equivalents) and existing demand
indicates that we need at least 1,092. The existing number also
compares very unfavourably with every European country except
Ireland. The number of specialists in mainland Europe varies between
one for 8,000 population in Greece to one for 43,000 in the Netherlands.
5. ENT UK has consistently worked with the
Workforce Review Team and its predecessors, and with the Department
of Health in such initiatives as Action on ENT to improve services.
We supported expansion of the specialty, and there has been a
17% expansion between 1999 and 2005, but it remains seriously
inadequate for the workload. We welcome the opportunity to submit
this memorandum to the Health Committee, and would be very pleased
to have the opportunity to present evidence to the committee on
how to meet the demand for ENT services.
THE FUTURE
In answer to the specific points raised in the
Terms of Reference, our responses are as follows:
1. Recent policy announcements—moving
services into the community. This raises issues relating to quality
of service. Many of the issues became apparent when GP fund holding
was in place. ENT clinics require the following equipment and
personnel in addition to medical staff.
(a) Specialist nursing staff who assist,
advise and facilitate the patient's journey in clinics and sterilise
and maintain the specialist diagnostic equipment. Specialist nurses
often provide additional services such as skin prick testing for
allergy and microscopic ear toilet for ear infections.
(b) Audiologists trained to assess and rehabilitate
the hearing impaired and Audiological testing with calibrated
equipment in sound-proofed booths or rooms.
(c) A range of specialist instrumentation,
including the expensive flexible fibreoptic and rigid Hopkins
rod endoscopes, requiring appropriate maintenance and sterilisation
by staff trained to care for this expensive equipment.
(d) The use of diagnostic microscopes, with
the associated care and maintenance.
(e) Access to imaging (mainly CT & MRI
scanning).
(f) Access to diagnostic cytology services
for the prompt and accurate diagnosis of the causes of neck masses.
This is essential to meet the current standards for Head and Neck
Cancer care.
2. Technological advances. These
are mentioned above. In particular the use of endoscopes has enhanced
our diagnostic abilities and accuracy and has improved patient
understanding and tolerance. This has allowed a dramatic reduction
in the need to do diagnostic endoscopy under General Anaesthetic
in operating theatres. ENT UK has published a document on standards
for outpatient provision. We regard the use of these instruments
as essential to provide a modern, one stop assessment and diagnostic
service for patients.
3. Ageing population. As with most
medical services, demand is increased in the ageing population.
A high proportion of the elderly need assessment and treatment
for hearing impairment. Audiologists can do much of this directly,
but access to ENT is essential for the diagnosis of atypical hearing
loss and associated disorders such as vertigo. Head and Neck Cancers
are more common in the elderly.
4. The use of Private Providers. Private
providers are able to meet the standards achieved in the NHS,
but few private ENT clinics provide the range of staff available
in the best ENT clinics—medical, nursing, audiology, speech
and language therapy—and few are equipped to the same level
to allow a one stop assessment and diagnostic service. Minimising
the number of visits to ENT clinics is one of the best ways of
improving the efficiency of the existing resources.
EFFECTS ON
THE ABILITY
TO MEET
DEMAND
1. Financial constraints. All accept
that the NHS is always subject to financial constraints, but quality
services require the level of equipment detailed above used in
dedicated facilities by specialist staff. ENT UK considers that
the best service for patients is provided by maximal use of well
equipped facilities. Thus, if a clinic can be fully equipped and
fully utilised at least five days a week, this is most cost effective
without compromising quality. Good access for patients to specialist
clinics is critical. Occasional use of expensive equipment in
multipurpose facilities where it is maintained by staff who are
unfamiliar with it may be appealing, but this is undoubtedly suboptimal.
2. European Working Time Directive.
This has little bearing on meeting the referral demand for
ENT services. 85% of ENT is non-emergency, and most patients are
dealt with on an outpatient basis within office hours. Emergency
cover is a concern, but can be dealt with best by providing beds
and operating facilities in larger institutions. Day case surgery
can be provided along with outpatient services in well used facilities
on the "hub and spoke" pattern. ENT does a range of
highly complex surgery including Neuro-otology, skull base surgery
and major sinus and head and neck surgery for cancer and benign
conditions. This work is best done in major centres where there
are dedicated facilities and multidisciplinary support.
3. International Competition. There
is no perceived threat from international competition. There are
trained surgeons looking for posts in the UK and ENT is a popular
specialty among trainees. We are able and willing to expand training,
but NHS trusts appear reluctant to advertise consultant posts
currently, possibly due to uncertainties over funding.
4. Early retirement. Again, this
is not an issue. Given that there is a shortage of posts being
advertised and there are increasing numbers of trained surgeons
available because of our support for expansion under the NHS Plan,
ENT could supply specialists to meet the needed expansion.
MEETING DEMAND
1. ENT UK feels that we can meet demand
"in house" if expansion is allowed. We have rising numbers
of trained UK specialists becoming available to permit this over
the next five years.
2. Recruitment and retention are not currently
issues for medical ENT staffing. There are shortages in some of
the allied health professional groups.
3. International recruitment is not currently
necessary or desirable for medical ENT staff.
UNDERTAKING PLANNING
1. This should be done in collaboration
with ENT UK, along with professional representatives from those
professional groups closely associated with us, specialist nurses,
audiologists and speech and language therapists. We already have
been involved with planning under Action on ENT and we are currently
establishing a forum with the Department of Health.
2. Ensuring flexibility. There is
a risk that flexibility comes at the expense of high quality.
By definition, specialism limits flexibility. ENT UK's position
is that we should look to provide the highest quality service
possible within the resources provided. This necessitates high
quality well trained staff from all the related disciplines working
in a dedicated appropriately equipped environment which is readily
accessible to patients.
3. Within this framework there are many
examples of good practice around the UK.
Representatives of ENT UK would be happy to
provide data to support the issues raised above and would welcome
the opportunity to address the Health Committee or provide further
documentation if requested. Given the major difference between
demand and supply for ENT services in England, we are very keen
to be involved in any discussions and initiatives to improve access
to the specialty for patients.
Alan Johnson
Workforce Lead and President Elect, Ear Nose and
Throat UK
March 2006
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