Mr Samuel Jayaraj Clinical Director ENT - Barts Health NHS Trust
Consultant ENT Surgeon - Whipps Cross University Hospital and
Forest Medical Centre Sam Jayaraj CD ENT Barts Health / Whipps
Cross Slide 2 Barts Health NHS Trust Largest NHS Trust in England
Barts, Newham, London Chest, RLH and Whipps Cross University
Hospitals Maintaining high quality ENT Services locally at WX WX
receive ENT referrals from across Redbridge Especially from
Wanstead/Woodford Polysystem and Fairlop Polysystem Sam Jayaraj CD
ENT Barts Health / Whipps Cross Slide 3 Local ENT Structure Whipps
Cross University Hospital Mr. Sam Jayaraj, Lead Clinician
Paediatrics Rhinology Mr Nitesh Patel Lead at Newham Otology
Paediatrics Mr. Mike Papesch Head and Neck Mr. Guy Kenyon Rhinology
Mr. Abir Bhattacharyya Voice Locum Head and Neck Sam Jayaraj CD ENT
Barts Health / Whipps Cross Slide 4 ENT Patients in primary care
Not here today to teach ENT Raise discussion points for break out
groups Ideas for CCG to reduce secondary care referrals Treat
patients within primary care setting Work with you Sam Jayaraj CD
ENT Barts Health / Whipps Cross Slide 5 Headlines Basic surgery
denied by NHS trusts to cut costs, say surgeons Operations refused
mirror those in McKinsey cost-cutting report for Department of
Health Darling: we will cut deeper than Thatcher, 26 March Basic
surgical procedures that could improve the lives of thousands of
people are being withheld by NHS Trusts desperate to save money,
according to some of the countrys leading doctors. Sam Jayaraj CD
ENT Barts Health / Whipps Cross Slide 6 the presidents of
associations representing six of the biggest surgical disciplines
claim "patients attend their GP surgeries with conditions that can
be effectively treated by surgery and are being turned away. Sam
Jayaraj CD ENT Barts Health / Whipps Cross Slide 7 Some of the
patients may not even be told that an operation could help their
problem, the surgeons say. Even when the sick are referred to a
hospital consultant they can be refused operations because trusts
have "arbitrarily defined a number of operations that reduce pain,
improve quality of life and prevent serious long-term complications
as being of 'limited clinical value'". Sam Jayaraj CD ENT Barts
Health / Whipps Cross Slide 8 Surgeons claim cost-cutting lies at
the heart of moves to "ration patient care". Last week the
Department of Health revealed a new age of austerity in the NHS
signalling that trusts would have to save 1.5bn by reducing
"unnecessary prescriptions and hospital referrals". Sam Jayaraj CD
ENT Barts Health / Whipps Cross Slide 9 Johnson said what would in
the past have been considered routine surgeries for removing ear
glue in small children and taking out tonsils have been "withdrawn
effectively from the health service. These procedures have been
classified as of low clinical value. But a child who cannot hear
has his or her development impaired. Sam Jayaraj CD ENT Barts
Health / Whipps Cross Slide 10 procedures of limited clinical
benefit might include treatments which whilst not life threatening
could be problematic to patients who would be denied treatment.
Those patients who are referred to a specialist may now find that
they are refused funding for surgery by their PCTs, which have
arbitrarily defined a number of operations that reduce pain,
improve quality of life and prevent serious long term complications
as being of limited clinical value. Sam Jayaraj CD ENT Barts Health
/ Whipps Cross Slide 11 PoLCE Effectiveness Or PoLCV Value Sam
Jayaraj CD ENT Barts Health / Whipps Cross Slide 12 Grommets The
PCT will fund treatment with grommets for children with otitis
media with effusion (OME) where: There has been a period of at
least three months watchful waiting from the date of the first
appointment with an audiologist or GP with special interest in ENT;
AND The child is placed on a waiting list for the procedure at the
end of this period; AND OME persists after three months AND the
child (who must be over three years of age or over 2 if there are
exceptional clinical circumstances) suffers from at least one of
the following: At least 5 recurrences of acute otitis media in a
year. Evidence of delay in speech development. Educational or
behavioural problems attributable to persistent hearing impairment,
with a hearing loss of at least 25dB particularly in the lower
tones (low frequency loss). A significant second disability such as
Downs syndrome. Sam Jayaraj CD ENT Barts Health / Whipps Cross
Slide 13 Adenoids and Tonsils Unequivocal indications for
tonsillectomy: Suspected malignancy More than one Peri-tonsillar
abscess (Quinsy) Acute upper airways obstruction Recurrent sore
throat where the following applies: 7 or more episodes in the last
year, OR 5 or more episodes in each of the last two years AND There
has been significant severe impact on quality of life indicated by
documented evidence of absence from school/work; AND/OR Failure to
thrive. Using the SIGN list as indicative of bacterial infection,
an eligible episode of tonsillitis must have three points, one each
for any of the following 5 criteria documented: a. History of Fever
(.38.3C) b. Tender anterior cervical lymph nodes c. Tonsillar
exudate d. Absence of cough e. Age under 15 but age 45+ subtracts a
point OR Positive culture of group A beta haemolytic streptococci
Sam Jayaraj CD ENT Barts Health / Whipps Cross Slide 14 The PCT
will consider funding for tonsillectomy in sleep apnoea syndrome in
children when one or more of the following apply: A positive sleep
study. A significant impact on quality of life demonstrated. A
strong clinical history suggestive of sleep apnoea. Note: The case
is much more likely to be approved where there is supporting
evidence such as sleep studies, growth charts, letters from GPs and
letters from employer and school. Sam Jayaraj CD ENT Barts Health /
Whipps Cross Slide 15 Snoring None Other procedures which fall into
this policy also include: correction of deviated septums surgical
reduction of the tongue removal of tonsils Sam Jayaraj CD ENT Barts
Health / Whipps Cross Slide 16 Surgical Treatment for Sleep apnoea
The PCT will consider funding surgical treatment of sleep apnoea in
the following circumstances: Patient has moderate to severe
symptoms (measured for example by the Epworth Sleepiness Score:
15-18= moderate, >18 = severe); OR Patient is sleepy in
dangerous situations such as driving (regardless of Epworth
Sleepiness Score); AND Patient has significant sleep disordered
breathing (as measured during a sleep study, usually by the
Apnoea/Hypopnoea Index: 15-30/hr = moderate, >30/hr = severe);
AND Patient has already tried continuous positive airways pressure
(CPAP) unsuccessfully for 6 months prior to being considered for
surgery OR patient had major side effects to CPAP such as
significant nosebleeds; AND A specialist believes the individual
patient will benefit (according to available literature the
subgroups in which surgical intervention may be effective are not
currently known); AND The patient is fully informed as to the
limited effectiveness of procedures, the lack of long term outcomes
and likely adverse effects including pain following surgery. Sam
Jayaraj CD ENT Barts Health / Whipps Cross Slide 17 ENT Patients in
primary care Ideas for CCG to reduce secondary care referrals Treat
patients within primary care setting Work with you Specific
examples of high volume ENT cases that could be treated in primary
care setting Sam Jayaraj CD ENT Barts Health / Whipps Cross Slide
18 Specific examples General Practitioners BPPV Nasal cautery LPR
symptoms Sam Jayaraj CD ENT Barts Health / Whipps Cross Slide 19
Specific examples General Practitioners BPPV Nasal cautery LPR
symptoms Sam Jayaraj CD ENT Barts Health / Whipps Cross Slide 20
Specific examples General Practitioners BPPV Nasal cautery
Laryngopharyngeal reflux symptoms Sam Jayaraj CD ENT Barts Health /
Whipps Cross Slide 21 Specific examples Nurse practitioners Ear
syringing Skin Prick Allergy Testing BPPV Epley canalith
repositioning manouevre Sam Jayaraj CD ENT Barts Health / Whipps
Cross Slide 22 GPwSI BPPV Nasal cautery ENT training and experience
Microscope Education programme ENT Community Specialist Service
Lower tariff Sam Jayaraj CD ENT Barts Health / Whipps Cross Slide
23 What have we done at Whipps? In order to optimize the
appropriateness of timely care given to patients and to improve the
service offered to General Practitioners, we have produced
guidelines for certain conditions/symptoms so that patients can
receive early treatment in the community and then if required, be
referred on to the most appropriate place for further care. These
guidelines/pathways have been agreed with the Primary Care Clinical
Director for the locality. Sam Jayaraj CD ENT Barts Health / Whipps
Cross Slide 24 Advice & Guidance Service Guidance on common
frequently referred conditions for which treatment could be
commenced in Primary Care Sam Jayaraj CD ENT Barts Health / Whipps
Cross Slide 25 Laryngo-Pharyngeal Reflux (LPR) Symptoms: lump in
the throat, intermittent dysphonia, sore throat, a bad taste in the
mouth, dry cough, tightness in the neck/throat, burning feeling.
LPR is a frequent cause of common ENT symptoms. Patients often
respond to advice about lifestyle measures they can adopt to reduce
acid reflux (see attached information sheet), and to medical
treatment with proton pump inhibitors and/or alginates. Patients
with a feeling of a lump in the throat, intermittent dysphonia,
sore throat, a bad taste in the mouth, dry cough, tightness in the
neck/throat and a burning feeling rising up should all be treated
for LPR. Please note that a burning feeling does not have to be
present for the diagnosis of LPR to be made; in fact it is
frequently absent. Patients with red flag or target symptoms (e.g.
persistent dysphonia more that 2 weeks, weight loss, dysphagia,
earache etc as per target referral form) should be referred through
the 2 week referral / Target referral pathway. All other patients
not requiring a target pathway referral should be treated
empirically for LPR for 6 weeks. If after this time they are still
symptomatic, then a referral will be accepted for the ENT clinic at
Whipps Cross University Hospital. Sam Jayaraj CD ENT Barts Health /
Whipps Cross Slide 26 Patients with tonsillitis considering
tonsillectomy There are now PoLCE guidelines for this procedure and
therefore patients should only be referred to the ENT clinic if
they fulfil the criteria for tonsillectomy as laid out on the
Tonsillectomy PoLCE form. This applies to paediatric and adult
patients The Paediatric ENT service at Whipps Cross is run by Mr.
Samuel Jayaraj (WX & FMC) and Mr. Nitesh Patel (WX & NGH).
Sam Jayaraj CD ENT Barts Health / Whipps Cross Slide 27 Nasal
Allergy Patients with symptoms suggestive of inhalant sinus and
nasal allergy (i.e. nasal congestion, sneezing, itchy nose, runny
nose, itchy eyes, should all be treated empirically with topical
nasal steroid sprays, anti-histamines and anti- leukotrienes (if
asthmatic). If the history suggests a particular allergen, then
allergen avoidance measures should be advised and the use of
barriers and nasal douching should be considered. We have set up a
community based allergy clinic for inhalant allergy skin prick
tests and your patients can be referred to this service for allergy
testing and the results will be given and discussed with the
patient and they will be discharged back to your care. If patients
fail to respond to conservative medical treatment after complying
for 6 weeks, they may then be referred to the ENT clinic (Mr.
Samuel Jayaraj and Mr. Guy Kenyon) at WXUH for endoscopic
evaluation for other pathology and consideration for surgical
intervention. Please do state on the referral letter that the
patient has complied with conservative medical treatment for 6
weeks and has not responded and hence the need for the referral.
Sam Jayaraj CD ENT Barts Health / Whipps Cross Slide 28 Hearing
loss in the over 60s Patients with gradual hearing loss as the sole
ENT symptom and normal ear examination should all be referred
directly to the Audiology department at WX for assessment. If there
is ear wax present this should be removed with ear wax softening
drops and syringing and if the ear drum examination is normal, then
the patient should be referred to the audiology service The
majority of these patients will have presbycusis, which will be
managed by the audiology department with hearing aids if indicated.
If patients are subsequently found to have a possible alternative
diagnosis to presbycusis, they will then be referred on to the ENT
Clinic. Sam Jayaraj CD ENT Barts Health / Whipps Cross Slide 29
Snoring Please note that current PCT guidance regarding PoLCE does
not support ENT Surgery as an option for these patients. Therefore
please do not refer patients with simply snoring as the sole
complaint as these referrals will have to be returned. Suspected
Obstructive Sleep Apnoea (OSA) - Patients with daytime
somnolescence and an Epworth score > 10 should be referred for
consideration for sleep study tests by the Respiratory Physicians
at Whips Cross. Remember that many patients who present with
snoring may have nasal or throat pathology that may be amenable to
ENT treatment and have NHS funding for this. Therefore do ask your
patients if they have nasal or throat symptoms as if so they may
still be eligible for ENT treatment. Sam Jayaraj CD ENT Barts
Health / Whipps Cross Slide 30 Slide 31 Proposed Redbridge ENT
Community Specialist Service Pilot ENT CSS aims to provide care of
ENT patients closer to home through Offering a community based
consultant triage and treatment service Improving patient access to
early specialist assessment and diagnostic services Reducing
waiting times for ENT outpatient appointments, outpatient waits as
well as referral to treatment and referral to test times Improving
appropriate referrals to secondary care; as a triage service
ensuring patients get speedier access to the most appropriate
service be it secondary care, primary care or a specialised
community service Achieving value for money, ensuring that
underutilised primary care resources are optimised Sam Jayaraj CD
ENT Barts Health / Whipps Cross Slide 32 Location of West Redbridge
ENT CSS Ideally, equipped practice within West Redbridge Equipment
Accessibility Bus Tube Car parking Forest Medical Centre Sam
Jayaraj CD ENT Barts Health / Whipps Cross Slide 33 Redbridge CSS
ENT Conditions eligible for treatment: - The following conditions
are eligible for treatment within this service - Allergy testing -
Allergic rhinitis - Tinnitus - Vertigo - Balance problems - Lesions
on ears - Micro suction - Otitis externa - Mastoid cavity care
ClinicsTimeLocation tbc Forest Medical Centre tbc Forest Medical
Centre Treatment exclusions: - Patients in need of surgical care -
Patients with sudden hearing loss - Cases where cancer is suspected
(e.g. cases with hoarseness, neck lumps or with dysphagia) -
Patients with multiple/complex co-morbidities - Patients who have
already had a complete work up and treatment options within the
community - Paediatric patients (during pilot phase) Provider Name:
Whipps Cross University Hospital (Barts Health NHS Trust) Provider
Team: Mr Sam Jayaraj, Mr Nitesh Patel, Kathy Cooper RGN Service
Manager contact Telephone: 020 8539 5522 ext 6400 Sam Jayaraj CD
ENT Barts Health / Whipps Cross Slide 34 Patient seen in general
practice ENT condition requiring specialist input according to ENT
protocol Refer via Choose and Book to community ENT service or
Paper referral Referral triaged by community ENT service Consultant
within 5 working days Appointment booked for patient within 20
working days Inappropriate referrals returned to GP stating Outcome
and management Referral to secondary care for assessment and
treatments requiring scope Patient seen in community ENT clinic
within 20 working days Management plan discussed with patient
Discharged back to GP Referred to secondary care Follow up arranged
within service Discharge letter sent to referring GP within 7
working days including diagnosis, treatment given and management
plan CSS ENT Pathway Sam Jayaraj CD ENT Barts Health / Whipps Cross
Slide 35 ENT Consultant Delivered Triage Service and Advice &
Guidance Service GP makes ENT Referral OR GP asks for Advice and
Guidance Sam Jayaraj CD ENT Barts Health / Whipps Cross Slide 36
ENT Consultant Delivered Triage Service and Advice & Guidance
Service GP makes ENT Referral ENT Consultant Triages referral
Accepts referral for ENT SCC at Forest Medical Centre Accepts
referral for ENT Clinic at WX Offers Advice and Guidance to
referring GP Sam Jayaraj CD ENT Barts Health / Whipps Cross Slide
37 ENT Consultant Delivered Triage Service and Advice &
Guidance Service GP asks for Advice and Guidance ENT Consultant
responds within 2 working days GP acts on advice Sam Jayaraj CD ENT
Barts Health / Whipps Cross Slide 38 ENT Consultant Delivered
Triage Service and Advice & Guidance Service GP asks for Advice
and Guidance FIRST GP acts on A&G or GP makes ENT Referral Sam
Jayaraj CD ENT Barts Health / Whipps Cross Slide 39 Key Benefits
Key Benefits: Consultant-led clinical triage of ENT referrals Email
advice and guidance service for GPs provided by ENT Consultant
Convenient location and quick access to ENT community services
Coupled with ENT training and development sessions for GPs Sam
Jayaraj CD ENT Barts Health / Whipps Cross Slide 40 Patient
Experience Service will be piloted initially. Clinics will be held
at Forest Medical Centre Activity will be closely monitored
throughout the pilot to determine/identify the following: Number of
patients treated in the SCC Number of patients that required onward
referral to Whipps Cross Patient satisfaction surveys (including
whether their expectation met) DNA rates Demand for the community
service will be constantly monitored and additional capacity
provided where indicated Sam Jayaraj CD ENT Barts Health / Whipps
Cross Slide 41 Examples of referral letters Sam Jayaraj CD ENT
Barts Health / Whipps Cross
