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At the heart of general practice since 1960

Moving simple ENT into primary care

Saving money while improving patient care does not always require large-scale service redesign. Dr Steve Brown, a GPSI in ENT in Buckinghamshire, explains how his simple community clinic is transforming the patient’s experience

At an early stage of my career, when I did six months’ ENT as part of my medical training, I could see it was an area primary care could do a lot more of.
I noted that there was a lot of return business, so the workload was there and often the procedures were simple and quickly made a difference to the patient.
In fact, in hospital, the simple procedures are often left to the SHO, which I was at the time.
It seemed to me that the only barriers to doing more ENT work in primary care were equipment and training.

Getting started

In 2008, I did a one-year ENT diploma at Rila in London. It was funded by the Buckinghamshire Primary Care Collaborative, as we were at that time. I attended ENT training at three local hospitals and passed the required assessments to get a GP diploma.
Initially, the idea had been to offer basic ENT procedures to the patients in our practice to reduce hospital referrals, but it quickly expanded to become a service offered to all 34 practices within the collaborative, through a system of collegiate working.
To start with, the practice funded basic equipment – a microscope and some disposables. At this point, I was just doing microsuction for wax, treatment of otitis externa and removal of foreign bodies.
But I have since bought a soundproof hearing test booth, a tympanometer and a nasolaryngoscope.
To publicise the service to GPs within the collaborative, we advertised through the website and in the weekly newsletter, and I did a couple of talks at the monthly collaborative study afternoons.
Numbers of referrals steadily increased, from 38 referrals in October 2010, to 70 in October 2011, and 90 in October this year. Once a practice started referring, it kept on going, because, based on their experience and patient feedback, the doctor thought it was a good service and told other doctors within the practice who then also referred.
The referral criteria have been expanded. I now treat nosebleeds with cautery, offer the Epley manoeuvre for benign positional vertigo, check vocal cords and check noses for polyps, and our nurses do hearing tests.
I have treated a few children who need wax removing, but they have to be able to lie still, so I rarely deal with the under-fives.

Cost-effective care

At the moment the contract is between me and the commissioning group and this is currently changing to a standard NHS contract.
The contract is a list of the procedures and conditions I can treat. I am paid for up to two consultations per patient but, if I see a patient three or four times, I do not get paid for those additional consultations.
I get £80 per consultation including procedure and £40 for a basic consultation. This compares with a first outpatient appointment cost of around £120, so my cost is about two thirds of the hospital bill.
The Payment by Results tariff does not apply, as my service is not the same as what is being offered in an acute setting.
The costs to me in running the clinic vary for each patient and depend on the procedure and the equipment I need to use, but my quarterly expenditure on disposables is about £3,000.
My maximum waiting time is two weeks but, if a GP calls me and says it is urgent, I will try to see the patient the same day or the next day, which is the same as the hospital.
For non-urgent appointments at the hospital outpatient clinic, a patient will be waiting a few weeks.
Our practice admin team provides support for the clinic and this is all included in the fee. We have simplified it as much as we possibly can to reduce the time they need to spend on it.
We get the referral by fax; then the GP is told that the patient has to ring for an appointment 48 hours later. My practice has been very supportive and we have built flexibility in the system to enable me to fit in the ENT appointments.
We were in a position to take on the extra work because we used to have a contract with an army base for five hours per week that was withdrawn, so there were five hours of doctor time available.
To fit that time in, I only see my own patients – we still have personal lists – and I do fewer duty shifts.
I also see ENT patients when my colleagues are running an extended-hours clinic on a Monday.

Outcomes

The clinic is becoming increasingly popular and I am now seeing an average of about 80 patients a month, most of whom need just one visit. 
Data from questionnaires for the GPs and patients show that everyone is very satisfied with the service; GPs are happy and patients are happy.
The figures show we have reduced referrals at the hospital by the same number who are coming to me. That is against a backdrop of rising referrals in neighbouring hospitals that do not have a GPSI service.
The rough estimate is that the service is saving the PCT and soon-to-be CCG around £50,000 a year – not bad for one doctor running a clinic from his practice.
In terms of access, our practice is about five miles from the hospital and we are in a fairly central position within the CCG. The parking is good and they do not have to wait a long time to see me. Therefore, while we are not necessarily closer than the hospital for many patients, they prefer to attend this non-hospital-based service.
In addition to providing a safe, quick and more cost-effective service for patients, it has delivered benefits to the practice, such as raising our profile in the community and with GPs who refer to us. It has also helped back-fill some of the squeeze on traditional practice income.

Barriers

When I originally came up with the idea of setting up this service, I had a varied response from the ENT department at the hospital. A consultant from the hospital helped me with the training and acted as my mentor, which was a requirement for passing the training and working independently.
If hospital waiting lists go down because I am taking on some of their referrals, it will make them more attractive on Choose and Book.
The collaborative and now CCG were, and remain, very supportive and were the main reason the service was so simple to get up and running. As well as funding my training, they did all the contractual discussions with the PCT.

 

The future

As part of the process of CCG authorisation, we are beefing up the contract and making sure it meets all the statutory requirements, but we do not envisage any problems with the service continuing.
It will be upgraded to be a contract between our practice and the CCG, rather than between just me and the CCG, which means that I can subcontract.
From next year, I am considering employing an ENT nurse to come in and help with some procedures as the workload is growing and I think a nurse could take on about a third of the cases.
For anyone thinking of setting up a similar clinic, the training is quite hard – it is like going back to medical school – and there are exams, so you need the support of your partners and local hospital clinic.

Dr Steve Brown is a GPSI in ENT in Buckinghamshire

The commissioner’s view

Jeremy Newton, operations director at Chiltern CCG
From a commissioner’s point of view, we are always trying to improve patient outcomes, improve patient experience and reduce costs and if you can do all three with one service then of course we should be doing it.
We were keen to support the work of Dr Brown from the start and it was part of a programme we had when we were the commissioning collaborative to utilise the skills of the GPs within our practices.
The idea was to think of ourselves like a super-surgery and make use of the skills we had within our team.
We are looking at a similar model for another speciality that we are in the process of finalising.
One disadvantage in terms of continuity is that we are heavily reliant on Dr Brown and his skills to provide the service. If for any reason he could no longer do it, the fallback would be the hospital.
If there was someone else within the CCG or a neighbouring CCG who had a similar interest we would consider how we could use that to develop the service further.
Sometimes it is the simplest services that work best and this does everything we are looking for.

Readers' comments (2)

  • Dr Brown's experience is a really good model for the cost effective delivery of what is perceived to be a 'specialist' service but where a significant proportion of presentations are in reality primary care problems easily manageable in GP practices or community settings.
    A barrier to effective delivery of certain specialist services in primary care which resulted from lack of adequate GP experience within the speciality -this can be achieved within a reasonably short time frame from 6 months to 2 years perhaps- to deal competently and effectively with sometimes the majority of complaints within that speciality has for too long existed, a situation exacerbated by a lack of equipment or time which, in the context of potential cost savings, would not be expensive.
    Many of the presentations to primary care which might have traditionally been referred, like ENT, Ophthalmology, Dermatology, Psychiatry or Gynaecology problems, are straightforward and well within the remit of most GPs with a SI if they have the set-up in place to provide the service.
    This traditional gap-fostered to a large extent by the profession's own attitudes to training -between 'specialised ' and primary care medicine-doesn't really exist for the patient with basic but problematic ear, eye or skin conditions who should have them competently dealt with as quickly as possible instead of waiting months maybe to to be seen in the hospital.
    The introduction of CCGs, with the scale to be cost effective, a desire and need to pool resources and the requirement to provide extra services, will hopefully foster a change in attitude to the provision of a range of 'specialist' services, such as the author's ENT clinics, that can be delivered by GPs or SI doctors, and will also hopefully help break down artificial barriers that existed between 'specialist' and 'primary care' medicine that suited neither GPs nor consultants, and least of all patients themselves.

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  • Thank you for publishing this. I am looking into ENT service redesign as a member of a commissioning board in West Herts, and it's very helpful to read about your experience.
    There are quite a few GPs with ENT experience around I have discovered; and so if a locum or replacement was needed on a temporary or permanent basis for Dr Brown, I suspect you would easily find one.

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