Remote Assessment And Practice Implementation For Disorders Of Ears, Nose And Throat - Info and Reading Options

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Background Hearing and ear problems, alongside nasal symptoms, are common in primary and secondary healthcare with ear pain, discharge, recurrent infections, chronic rhinosinusitis, and allergic rhinitis particularly common. While primary care management may suffice, many patients need specialist ENT referrals for diagnosis and management. However, lengthy waits, often exceeding twelve months, are commonplace for specialist consultations. Emerging evidence suggests ENT patients are more commonly managed with advice and medications and then discharge, compared to other specialties (such as orthopaedics or gynaecology), where further interventions are often required. Hospital Episode Statistics (HES) 2022-2023 show 2,629,146 ENT outpatient appointments in England, of which 1,178,437 were first appointments. With 45% of patients with ENT problems impacted by prolonged waiting times (>18 weeks), this equates to over half a million patients having increased time spent with disease, distress and potentially a poorer prognosis. Teleconsultations accounted for 6% of these initial consultations. There were 1,179,040 follow-up attendances with 310,755 follow-up teleconsultations, indicating an increasing adoption of telehealth services. The most recent NHS England referral-to-treatment data shows 651,027 patients waiting to complete treatment, around 8.5% of the entire national NHS backlog and the second-highest of any specialty. The environmental impact of the patient-related travel to the ENT clinics is significant. While the NHS has committed to a Net-Zero strategy, aiming to reach zero emissions by 2040, NHS travel represents 17% of total emissions. Centralised care leads to increased mileage and adds to the carbon footprint of the current service model. Attempts have been made to reduce the number of appointments required for diagnosis with “one-stop” clinics. Such services are often based in referral centres, restricting the number of patients able to access services, or leading to increased mileage for external referrals. Potential solution: the RAPID ENT pathway In response to this lack of capacity, the Remote Assessment and Practice Implementation for Disorders in Ear, Nose, and Throat (RAPID ENT) system was developed by our team of collaborators, capitalising on advances in endoscopic nasal and ear imaging and boothless hearing tests. Our earlier pilot study, comprising 53 patients, demonstrated that 83% of cases could be effectively managed remotely, with high levels of satisfaction reported by both patients and General Practitioners (GPs). A larger scale application was employed in our RAPIER study with more than 1,000 participants successfully assessed and managed using remote audiometric and endoscopic equipment. The RAPID ENT service uses trained staff to ‘collect’ the necessary patient data, thereby allowing consultants to remotely diagnose and manage patients. This pathway enables optimisation of resources through face-to-face, technician-delivered clinics in varied locations with consultants providing opinions flexibly. The service will be placed in different locations, closer to the patients, reducing travel and environmental impact. The University Hospitals Birmingham (UHB) NHS Foundation Trust has introduced this novel pathway into their outpatient referral pathway from primary to secondary care. However, there is still a need to further understand its real-world effectiveness and acceptability across different stakeholders (patients, clinicians, managers), compared to the traditional face-to-face consultation model. My research focus will evaluate the clinical and cost-effectiveness, acceptability, and environmental sustainability of the RAPID ENT model, compared to the current pathway. Research Aims The outcomes we will capture are the following: i) Clinical Efficiency: - Compare clinician time and appointment numbers from referral to definitive treatment between RAPID ENT and traditional pathways. ii) Health Economic Analysis: - Conduct a cost-consequences analysis detailing waiting times, quality of life, resource use, costs, time off work, and productivity for both study arms. - Perform cost-effectiveness and cost-utility analyses from an NHS perspective, focusing on cost per QALY gained compared to the NICE threshold of £20,000–£30,000 per QALY. - Employ decision modelling to evaluate hidden costs and patient journeys. iii) Real-World Implementation: - Examine barriers to implementation, training needs, scalability, and throughput, including any “voltage drop” from the original model to wider application. - Evaluate the rate and effectiveness of complete remote management across settings and demographics. - Determine the optimal setting for data capture (e.g. GP surgeries, diagnostic hubs, hospital outpatient facilities) and assess geographic variation. - Assess impact across different demographics, especially under-served populations. iv) Environmental Sustainability: - Calculate the direct (patient journey) and indirect (clinic output) carbon footprint of the ENT outpatient service by assessing Carbon Dioxide Equivalents (CO2Eq) for both new and existing clinic models by location.

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