ENT UK OUTPATIENTS REVIEW AND RECOMMENDATIONS A Jardine, R Moorthy, G Watters Date of review: June 2022
BACKGROUND ENT UK have published guidelines with indicative numbers of s to be seen in Out Clinics (Appendix 1).Since their publication there have been a number of changes in current practice including: Increasing numbers of referrals with pressure to meet targets both cancer and 18 weeks Introduction of electronic systems including results, PACS, ordering tests and electronic notes Changes in postgraduate medical training with reduction in placements to 4 months and reducing numbers of core trainees Ensuring compliance with SAC requirements for trainee timetables The process of informed consent starts in the out clinic. Following the recent ruling in Montgomery vs Lanarkshire Health Board the consent process needs a more detailed and individualised approach exploring the s agenda and tailoring treatment according to specific wishes and needs rather than assuming that the would choose the standard treatment recommended. The premise that a surgeon would be protected by doing the same as a body of opinion held by other surgeons (Bolam test) no longer holds. Information must be provided in both a verbal and written format. A cooling off iod is needed and GMC guidelines on consent state that s should not be consented on the day of surgery unless in an emergency. As a result ENT UK is receiving an increasing number of queries regarding these issues and the impact on length of individual consultations. In 2016 ENT UK Council therefore set up a small working group (AJ, RM, GW) to review the guidelines. AIM Review the current practice and pressures on out clinics Review the additional time needed to meet the new standards of consenting Review the variation of practice around the country and identify practices which may compromise care. Identify best practice to ensure safe standards throughout the country METHOD The working group designed a survey, which was amended and approved by the ENT UK Survey Guardian, to collect information regarding current practice and views on future out delivery. Opportunity to comment on pressures and problems delivering service at present. The survey was distributed to all ENT UK Consultant Members in October 2016. An
initial draft of the new guidelines was then also distributed to ENT UK members in April 2017 and some further revisions were made in light of the feedback received. RESULTS 773 sent the survey, 175 consultants responded. Therefore response rate was 22.6%. Responses indicated a good demographic spread though the country.there were almost equal number of responses from consultants in DGHs (48%) and teaching hospitals (42%). Consultants on average did 2.3 general (range 0-6) and 1.9 (range 0-4) specialist clinics. 96% were aware of the ENT UK guidelines for out working. Only 16% of trusts complied with guidelines, 39% sometimes and 40% never. 70% of consultants saw between 6-8 new s clinic. 45% of Specialty Registrars (ST3+) saw 5 or fewer new s clinic and 41% saw 6-8 s. 56% of SAS doctors saw 6-8 new s clinic and 26% saw 5 or fewer new s clinic. 62% of consultants saw between 6-8 follow-up s clinic 52% of Specialty Registrars (ST3+) saw 6-8 follow-up s clinic and 29% saw 5 or fewer follow-up s. 64% of SAS doctors saw 6-8 follow-up s clinic. Comments raised included the variability in clinic organisation especially new: follow-up or total numbers seen The majority felt that 6-8 new and 6-8 follow up s clinic was an acceptable number for consultants. The majority felt that SPRs should see less than or equal to 5 new s and 6-8 follow-up s. The opinion was split between 5 or less, and 6-8 new s for SAS doctors. The majority felt that 6-8 follow-up s was appropriate. Specialist clinics have similar numbers of new s though there is a tendency towards less numbers, particularly for voice, balance and auditory implant. Head and neck oncology and neck lump tend to have more new s. Number of follow-up s seen and recommended is significantly lower than in general clinics, implying quite a lot of specialist clinics are one stop for diagnosis and a management plan.
Paediatric and head and neck oncology clinics warrant more follow-up appointments. 60 % of trusts do not reduce the number of s for other grades when the consultant is away. The use of electronic systems to view pathology and imaging results is almost universal. Approximately 70% of respondents use electronic systems to order pathology and radiology investigations. 50% of respondents using an electronic notes system. 40% have electronic oation notes and electronic TCI cards The majority of respondents indicated that the use of electronic systems increased the time of the consultation, especially electronic notes and ordering investigation. Comments focused on electronic records being efficient when all systems computerised providing the computers were working quickly. Some clinicians described being poleaxed by inefficient computer systems which severely reduce out efficiency. 95% of respondents discuss consent in the out clinics and 50% will complete and sign the consent form. A near universal view was that consent increased the time of the consultation. Summary Based on previous guidelines, the results of the survey and change of practice to include the Montgomery ruling, indicative number of s to be booked into a 1 PA (4 hour) clinic is presented in Table 1. All administration associated with that clinic including booking investigations, dictating letters, electronic documentation and oation listing is included. Time for other administrative duties such e-mails, reviewing results on other s, signing off letters from previous clinics etc, considered to be embedded administration in previous guidelines, has been omitted for clarity. This will need separate consideration by clinicans who have historically had this included in their clinics. Distinguishing between new and follow-up appointments is probably unnecessary for most clinics due to a number of factors including: Flexibility in the ratio of new to follow-up appointments Reduction in easy follow-up consultations through changes such as audiology follow-up after grommets and writing with result of normal investigations Patients attending for follow-up are often complex and take as long as new s
IT and electronic records may increase consultation time although this is evolving and may not always be the case. Therefore this was not considered separately in the table.
Table 1: 2017 Guideline for indicative number of s to be booked in Out Clinic. RECOMMENDED NUMBERS SEEN IN ENT CLINICS Maximum in One 4 hours Maximum in One 4 hours Maximum in One 4 hours GENERAL CLINICS Administration related to clinic only.( booking oations, investigations, dictation of letters) With consent including signing Teaching or Suvising SPR/ SAS Consultant or Associate Specialist Higher Surgical Trainee (ST3+) (Must be suvised) 12 10 Reduce by 1 for each junior doctor suvised 10 9 ENT Specialty Doctor or GPSI (Must be suvised) 10 9 If reached top of scale will be working as associate specialist equivalent see above Suvised refers to the requirement for a consultant or associate specialist (pre 2008) to be timetabled to be in every session undertaken by a junior doctor (leave excepted). Specialty Surgeons (SDs) must be fully suvised until the top of the scale has been reached. Core Trainee GP trainee ST 1 and 2 SHO Emergency /Acute referral clinic 6 Max There to be taught and can have 3-6 s booked Sub Specialist Clinics Voice Skull Base Rhinology Otology Balance Head and neck# 8 8 8
# Specialist head and neck refers to the MDT clinic where s have been diagnosed and treatment needs to be discussed, or s are reviewed after treatment. 2 week wait diagnostic clinics and neck lump clinics can have the same clinic template as for general ENT clinics. CONCLUSION 1. In general clinics, assuming a 4 hour PA, the numbers booked should be standardised and implemented across the country with a maximum of 12 s (though new:follow-up ratio may vary). This would mean a scheduled appointment time of 20 minutes for each. Reduction of out numbers for SPRs, SAS and for consultants suvising a trainee or junior SAS doctor is recommended as detailed in table 1. Medical student teaching needs to be considered locally. A reduction in out numbers is recommended for any grade of doctor teaching them. 2. Where consent is given in clinic, including the signing of the consent form, additional time will be needed, particularly in the light of the Montgomery ruling. In a 12 clinic it is likely that 2 or 3 s may need this and a total of 30 minutes is needed to achieve the history, examination, management plan and consent, including signing. This would support the reduction of number of s to 10 s PA for a consultant by allowing 30 minutes for 2 of the scheduled appointments. Where suvision of a trainee is also to be undertaken this should definitely be reduced to 10. The ratio of new and old will depend on local practice and should be left to the individual unit to organise. 3. The aim of these recommendations is to provide safety standards for out service provision nationally. However clinicians will have some sonal flexibility and in some circumstances it may be safe to see more s. In particular this may apply in head and neck practice, provided higher clinic numbers and shorter consultation times are initiated by the clinician and any additional support required is provided. More efficient, new ways of working, will be supported and may result in units being able to increase the numbers without compromising standards. 4. Guidelines will be disseminated to consultant members and medical directors to ensure awareness of guidelines. Implementation will be supported by linking this to CQC inspections which will ensure compliance.
Appendix 1. Current Guidelines RECOMMENDED SAFE NUMBERS SEEN IN ENT CLINICS Maximum in One Maximum in One Maximum in One GENERAL CLINICS Without Patent Administration (i.e. separate PA s for clinic administration) With Imbedded Administration (i.e. all admin done within clinic session time) Reduced by 25% when teaching or Suvising To see the cases and teach Consultant or Associate Specialist 20 minutes 12 10 9 or 7 Higher Surgical Trainee (ST3+) (Must be suvised) 20 minutes 12 ENT Specialty Doctor (Must be suvised) 20 minutes 12 If reached top of scale will be working as associate specialist equivalent see above Trust Doctor or equivalent (Must be suvised) 20 minutes 12 Suvised refers to the requirement for a consultant or associate specialist (pre 2008) to be timetabled to be in every session undertaken by a junior doctor (leave excepted). Specialty surgeons (SDs) must be fully suvised until the top of the scale has been reached. Core Trainee GP trainee ST 1 and 2 SHO No Patients Booked There to be taught and can have 3-6 s booked
Sub Specialist Clinics Head and Neck Skull Base Advanced Rhinology etc 30 Minutes 8 6