Hospital services and your General Practice
Meredydd L. Harries, BSc, FRCS Rob Low, Chief Audiological Scientist J. Anthony McGilligan, FRCS ORL Michael O'Connell, BSc, MPhil, FRCS ORL John H. Topham, FRCS Robert M. D. Tranter, FRCS, FDS, RCS Simon J. Watts, FRCS ORL John S. Weighill, FRCS
Brighton and Hove City Primary Care Trust Brighton and Sussex University Hospitals NHS Trust
In our second information sheet we have focused on ENT services and how we currently use these resources within our Local Health Service. If you have any suggestions how we may improve this feedback, please let us know, Contact details: Susie Rockwell Commissioning Susie.Rockwell@gp-G81046.nhs.uk Jacqui.Nettleton@bhcpct.nhs.uk
Dear Colleagues, Earlier this year, we undertook an audit to look at the breakdown of referrals by clinical speciality. The ENT department receive between 7,500 and 8,500 referrals a year and approximately 30% of these are accounted for by hearing loss, tinnitis and tonsillectomy. In this newsletter we have provided some patient information and some patient advice leaflets on rhinitis and tonsillectomy. Further work is needed to review access to Audiology services, and a further newsletter will be sent on Audiology later in the year. Tonsillectomy still makes up a significant part of the surgical workload. Due to historic clinical practice of high rates of operative intervention for tonsillectomy there are significant patient expectations that removal of the tonsils will result in significant health improvements. The Scottish Intercollegiate Guidelines Network has produced evidence-based guidelines on when tonsillectomy is indicated. These have been incorporated into the patient information sheet on tonsillectomy so patients are fully aware of when surgery is indicated. The sheet is designed to be given to patients so that they can complete the table listing the periods of sore throat they experience. It is hoped that they will not feel the need to attend the surgery each time they have symptoms but if and when they do meet the criteria for tonsillectomy they can attend with the table. This can then form the basis of a referral. The table will provide objective evidence that the operation is in the patient’s best interests. By better selection of patients being referred for tonsillectomy, we should be better placed to ensure this happens.
1st Attendence at ENT by Practice per 1000 Population April 2002 - March 2003 40 35
30 25 20 15 10 5 0
The graph shows the numbers of outpatient first attendances per 1000 population by GP practice for ENT conditions. This information can be used as an approximation of referral patterns by practice. As it has been calculated as a rate per 1000 population, it has been adjusted for the size of each practice. It does not make any adjustments for other variables that may have an influence, e.g. deprivation or the relative age and sex breakdown of a practice. Although there is no target level for referral rates, it is hoped that the observed variation will stimulate discussion within and amongst practices. More detailed information on referrals from your practice can be obtained. Please contact Dr. Mike Warburton on (01273) 295490. We would welcome your comments and feedback.
McConnell & Partners Stewart Eadie & Partners Tate & Partners Harper & Partners Chiang Higson & Partners Williams & Partners Stuart & Partner Baker & Partner Van Ryssen & Partners Kirkland & Partner Sripuram Crichton & Partners Heal & Partner Chang & Partner Stalker & Partner Supple & Partners Rodriguez-Pineda & Pritchard Kelleher Sargeant & Partner Knott Sacks & Partners Rukmani Hermitage Condon & Partners PCT Total Phillips & Partners Sharman & Partners Parikh Gray & Partners Evans & Partners Khot & Partners Amin Henderson Parish & Partners Wright & Partners King & Partners Craigie & Partners Barker & Partner Biddulph & Partners Earl & Partner Sutcliffe & Partners Elvidge & Partners Allenby & Partner Daly & Partner Hacking & Partners Carter & Partners Sharp & Partner Shah
Rhinitis is often self-limiting but bacterial sinusitis may require treatment with antibacterials. There are few indications for nasal sprays and drops except in allergic rhinitis and perennial rhinitis. Topical nasal corticosteroids or oral antihistamines control mild cases of allergic rhinitis; systemic nasal decongestants are of doubtful value. More persistent symptoms and nasal congestion can be relieved by topical nasal corticosteroids and cromoglicate (cromoglycate); topical antihistamines (azelastine and levocabastine) are also used in allergic rhinitis. In seasonal allergic rhinitis (e.g. hay fever), treatment should begin 2 to 3 weeks before the season commences and may have to be continued for several months; treatment may be required for years in perennial rhinitis. In allergic rhinitis, topical preparations of corticosteroids and cromoglicate have a well-established role; although it may be less effective, cromoglicate is often the first choice in children. Topical antihistamines are considered less effective than topical corticosteroids but probably more effective then cromoglicate. Sometimes allergic rhinitis is accompanied by vasomotor rhinitis. In this situation, the addition of topical nasal Ipratropium Bromide can reduce watery rhinorrhoea. Very disabling symptoms occasionally justify the use of systemic corticosteroids for short periods for example in students taking important examinations. They may also be used at the beginning of a course of treatment with a corticosteroid spray to relieve severe mucosal oedema and allow the spray to penetrate the nasal cavity. The following graphs show the cost of prescribing rhinitis treatments. The cost for each practice is standardised for list size using GI Star PU values, as in your PACT data.
Price com parison for 30 days supply of topical Nasal Sprays 25 20
Cost in £
low er dose higher dose
15 10 5 0
e Bu de so ni de R hi no co D rt ex Aq aua R hi na sp ra y D uo Le vo ca ba st in cr e om og ly ca te 4% So di um
Antihistamine nasal sprays Steroid nasal sprays Sodium cromoglycate nasal sprays
et ha so ne
as on ex
Be cl om
Prescribing costs for nasal allergy £140.00 £120.00 £100.00 £80.00 £60.00 £40.00 £20.00
If you would like to get involved in developing local services, please contact Jacqui Nettleton in Acute Commissioning at Brighton and Hove City PCT on 01273 295408.
Chang YF Henderson Craigie IT Amin RG Sutcliffe VA Elvidge JB Crichton ARC Khott ASS Kirkland B Gray R Sripuram SG Stalker MJ Stuart MH Bach CD Williams RA Phillips DL Evans PC Allenby LM McConnell M Van Ryssen Sargeant C Earl DF Eadie EJ Pritchard HW Harper DR Carter HR Sharp MJA Supple DL Sharman MJ Daly PG Hacking RS Tate RT Shah AC Parish SPE Higson N LocumCondon JA Whitehawk Barker CR Sacks SL Wright CMv Stewart DB Hermitage AP Chiang VS Biddulph MJP Kelleher DIF Parikh JK Baker J Rukmani KS Knott MH
Az el as tin e
Fl ix on as
Be co na s
Sy nt ar is
as ac or t