ENT•UK BRITISH ASSOCIATION OF OTOLARYNGOLOGISTS HEAD AND NECK SURGEONS www.ENTUK.org

Vol. 20, No. 1, February 2010 THE NEWSLETTER FOR ENT PROFESSIONALS

Vote early and vote often Contents Tony Narula

Vote early and vote often aving been elected to the have dried up follow- Council of the Royal Col- ing the change in immigration Managers- lege of Surgeons in 2004 rules last year. it is time to take stock of don‟t you just love them? H what is going on in the medico- SAFETY political landscape as I seek re- Patient safety is the new buzzword Procedure Based election in early 2010. being used by everyone from Sir Assessments (PBAs) Liam Donaldson downwards EWTD (upwards?). It‟s a bit like mother-

Members of ENT-UK will have seen hood and apple pie: everyone is in Independent practice acres of comment on this issue. favour of this but being in favour survey Especially from the President of doesn‟t make it happen. All sorts the RCS John Black. I have fully of new institutions have sprung up Notes supported his stance that rules like the National Patient Safety introduced to protect truck drivers Agency to protect the public. Re- Goodbye to All That or production line workers are not validation also comes into this appropriate for professionals. On (see later). In fact Safety will be-

the other hand no-one can deny come a fig-leaf to close . English college council that in certain specialties (eg The CEO of the NHS has said quite report 2009 Emergency Medicine, Obstetrics) explicitly that he wants to transfer prolonged hours are unreason- huge swathes of activity into the ENT UK charitable able. But for most surgeons community and that hospitals will (including ENT) a maximum of have to „change‟. As Safety/ Qual- conations & „The about 60 hours on call allows TM ity are mentioned more and more Giving Machine ‟ avoidance of shifts (which are uni- we can predict some conse- versally hated) and also time to quences. For example the arrival On the other hand- BACO gain enough experience – espe- of designated „stroke‟ centres fees cially in emergencies. This figure means that not all existing hospi- chimes with experience from the tals will take unrestricted emer- OME / adenoid position USA and Germany. What has been gency referrals. This is in con- sad is the failure of other major junction with the related major paper ENT-UK 2009 Royal Colleges to publically align trauma centres. Thus if your hos- themselves with the RCS – what- pital is not in either category your Indications for ever they may have said in private. A&E is at risk and soon thereafter tonsillectomy - ENTUK Interestingly the College of Emer- your acute status in general is at position paper gency Medicine have said they risk. That will swiftly be followed cannot sustain a 24 hour A&E by downgrading to a community

without a surgical presence. Cur- with large budgetary sav- Just a short talk (RSM!) rently it appears that many hospi- ings as staff will no longer be re- tal rotas are shams with unfilled quired at previous levels. Developing links between posts in order to be EWTD compli- NoE-ENT & ENT in ant and increasing problems filling REVALIDATION Many of you will know that I am Malawi these rota gaps as locums seem to Vol 20, No, 1 Page 1

the RCS revalidation lead. Each spe- three day selection process that cialty is working hard on this to set Managers—don‟t you sounded as if it was modelled on „The appropriate standards and describe the just love them? Apprentice‟. She must have been scarily means of demonstrating adherence to clever as the ratio of applicants to those standards. In practice the DH is places was a staggering seventy to one. uncertain of the point of revalidation: Ray Clarke The training programme as she out- sometimes it is to prevent another lined, involved rotating appointments serial murderer (Dr Shipman) and at Contact with „twenty-some- in various trusts, on-the job training, other times it is to enhance safety and thing‟s‟ is hard to come by shadowing senior managers, some quality of patient care. Without a clear at my age so I am always classroom-based teaching on NHS fi- statement of aim it is hard to see how glad to see the medical students. They nances, commissioning, providing this innovation will help us or our pa- update me on the soaps, the X factor services and a good deal of exposure to tients. One can however predict the and the perverse selection process for clinical practice - hence the clinics. She risk of a massive increase in bureauc- Foundation Programme jobs. They tell will do a series of rigorous assessments racy. Sometimes I just think a 5 yearly me about their exotic gap-years, their and gain a postgraduate qualification in exam would be simpler: that‟s a meas- elective in the Seychelles, the best health service management. She was as ure of how worried I am about this nightclubs on Merseyside and where enthused and excited about the pros- topic, not because I think an exam is a the twenty-four hour shops can be pect of improving patient care as were good idea found. I get to hear of the prohibitive any medical students I have ever cost of apartments on the docks and of taught. I know it is fashionable- almost QUALITY ACCOUNTS how tough it is when you have a mod- a rite of passage- for us doctors to All NHS Trusts will have to publish est sports car and a vibrant nightlife to sneer at managers and assume they are quality accounts in the near future. I run on nothing but a measly and unfeeling, devilish, horned creatures have looked at the draft standards and grudging parental supplement and a whose „raison d‟être‟ is to save money, am afraid that this is just another box student loan. In return they get to lis- obstruct medical initiatives and en- ticking exercise with quality as a ten to a grumpy old curmudgeon going sconce themselves in plush offices smokescreen. If it means re- on about the latest crazy management where they are insulated from the coal- introduction of Performance Indicators initiative, what a disgrace our politi- face of clinical encounters. Isn‟t is us by another name it is a regressive step. cians have become, how hard we all doctors who have a monopoly on em- As always, if you make it important to worked when I was a junior, and how pathy and caring, looking after pa- measure something, that thing soon only one lad in our class- now an emi- tients, responding to their needs, advo- becomes important by virtue of meas- nent professor of surgery- had a car cating for them, driving services for- urement not because it has intrinsic and we all had to cadge lifts off him in wards, and keeping the nasty managers value. This is often known as MacNa- return for either lecture notes or pints out of our conspirational rapport with mara‟s fallacy as experienced during of Guinness. If we are on a good run in patients? Well, no, it isn‟t and we don‟t. the Vietnam War when the Body Count clinic and there is extra time I get them Medical graduates – like humanities was announced every day by the Penta- to take some of the histories, show graduates and everybody else- can be gon even as the USA was losing the them how to use an auriscope, and remote, self-absorbed, belligerent, war. In the same way we have recently dispense the odd pearl of wisdom, all stubborn, mendacious, duplicitous, had the spectre of Basildon Hospital the while peering at them over the rims manipulative and venal. Managers don‟t being criticised for being filthy even of my reading glasses. It‟s a „win win‟ have exclusive call on these qualities. though the Trust had awarded them- really. Many managers- as is the case with selves 6/7 points for cleanliness when many doctors- are exceptionally compe- filling in the forms! Nothing beats a I was hesitant recently when the clinic tent, idealistic, committed, and care site visit as any Royal College could tell manager asked me if a management deeply about improving the lot of pa- you from the days of regular (5 yearly) student could sit in my clinic. A medi- tients. It will pay dividends for us all if visits to accredit surgical training. cal consultation after all is a private we nurture, encourage, train and re- encounter; patients don‟t always want ward them. We should support and FINANCIAL ISSUES an unqualified observer listening to advocate graduate training schemes I have been Honorary Treasurer of the their medical histories- hence I always that ensure the most talented of our RCS since July 2008. Like every other ask if they are happy to have the stu- youngsters think about NHS careers organisation (and the UK Treasury) we dent doctor present. How would they rather than being seduced by large have experienced a difficult time. How- feel about a non-clinical student? Worse salaries in the city, retail, and banking. ever, we have avoided any compulsory still, one who was planning to be a Even more pertinent for us, we –and redundancies and maintained our im- manager? After some thought I agreed. our patients- can profit hugely from portant work streams throughout the I then reflected on the unspoken cama- working closely with our managerial past 18 months. Our endowment has raderie that we medics enjoy, and on colleagues, particularly in the challeng- recovered most of the losses of the how it extends to medical students, ing economic times ahead. Despite the past 2 years and now stands at around who are seen as part of the „club‟ at a disingenuous claims of politicians –and £60 million. At the same time the ENT very early stage and are privy to inti- some doctors -that you can maintain based Lionel Colledge Fund has bene- mate details relating to patients. Non- and expand „frontline‟ NHS services but fited greatly from the decision of Ce- medics, rightly or wrongly, sometimes make massive cuts in administrative cilia Colledge to leave the bulk of her see this camaraderie as insular, elitist, costs by sacking managers, any NHS $2 million estate to the fund. We have and hostile to „non-members‟ –i.e. „this accountant will tell you that the poten- renamed it the Colledge family Memo- lot all stick together‟. Health service tial for making savings in this way is rial Fund and already the sums avail- managers tell me they feel this very very marginal indeed. By comparison able for awards have increased to about acutely; it can make for an uncomfort- with senior managers in other arenas- £50,000 p.a. I regret that UK PLC is able barrier to working relationships including most parts of the public ser- unlikely to demonstrate such good with us. I needn‟t have been too con- vice- NHS managers have very modest news and I predict severe cut backs in cerned about privacy as patients univer- pay packages. No organisation can the next 5 years: whoever wins the sally agreed to have a management prosper without good managers. Like it 2010 general election. trainee sit in on their consultation- or not we need administrators, secre- many thought it a novel and long over- taries, clinic co-ordinators, theatre THE FUTURE due initiative. supremos, service directors and senior As in the past a flexible approach is executives to steer improvements for- required to political imperatives along Whisper it softly, I don‟t want the medi- ward. We need non-clinical as well as with well worked up policy decisions cal director to know I have occasional clinical leaders of the highest calibre, which allow us to set the agenda rather quiet moments in clinic but in some of and it behoves us all to work produc- than reacting to it. Reconfiguration of these quiet interludes the young lass tively and openly with them. units is a big challenge ahead as well as patiently sitting in with me explained maintaining enough expertise in your that she was on a graduate training Make friends with your manager; he or hub unit while taking services out to programme for aspiring NHS managers. she could help you through some very the new spokes. I look forward to A first-class honours economics gradu- rocky times ahead. taking part in this over the next 4 years ate, she had come through a gruelling

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has 57 and urology has 26) which make Procedure Based them a more versatile and useful tool Independent practice Assessments (PBAs) for assessment. survey 41 further PBAs relevant to ENT Andrew Robson have recently been written, and the Tony Jacob current ones updated, in order to Part of the assessment map them more appropriately to the To clarify what is current process for the Intercolle- curriculum. They cover both elective „normal practice‟ in our spe- giate Surgical Curriculum and emergency procedures in all cialty, under the auspices of Project (ISCP, iscp.ac.uk) is aspects of the speciality. It was the IPC and ENTUK, we under- the requirement to per- agreed by the SAC that, in line with took a survey of all consult- form Work Place Based ISCP requirements, surgeons should ants in the UK earlier this year. Assessments (WPBAs) to have the opportunity for piloting the demonstrate progression draft PBAs so that modifications can Just over 50% of all practicing ENT to competence in various domains of be made prior to implementation. The Consultants responded and of those the syllabus. These assessments should draft PBAs were therefore sent to all over 96% undertake some private prac- take place in a formative manner (they otolaryngologists on the NAPDENT tice. Almost 14% now practice in a are assessment for learning rather than website with the request to pilot them partnership or group model of some assessment of learning). The WPBAs with their trainees over the next few sort. A third of practitioners have a web are: Case Based Discussion (CBD), mini months. Any modifications will then be presence and therefore in one way or Clinical Evaluation Exercise (mini-CEX), discussed and incorporated into the another market their services. Direct Observation of Procedures PBA. These would then be adopted and Comment: The figure of 96% may rep- (DOPS) and Procedure Based Assess- placed on the ISCP website for use in resent a bias as those that do not un- ments (PBAs). The latter have been assessment of training. dertake any private practice may have devised to assess competence in per- chosen not to participate in the survey. forming specific surgical procedures. The idea is to use them „real time‟ so The number of partnerships in play has They test competence at all aspects of that the trainees can work to a struc- risen and there are a wide variety of a surgical procedure, including under- ture. The trainer should feed back their models out there. Anecdotally it would standing of indications, consent, preop- assessment identifying strengths and also appear that those in groups have erative preparation, surgical technique development needs with an action plan noticed a stability of income, if not an and post-operative care. if necessary. Feedback should take no actual increase in the last few years. longer than 5 minutes and can easily There are two aspects to PBAs; generic be carried out between cases in thea- A large percentage (40%) have noticed a aspects and procedure specific aspects. tre. Using the PBAs during the pilot will drop in income over the last 3 years. The generic template can be modified effectively identify improvements for 55% of those surveyed earned below to make it applicable to specific proce- adoption, so the more people who do £100k per year with about 10% earning dures. For example whilst one item this, the better! well over £300k. On average a new refers to preparing the skin appropri- patient consultation was charged be- ately for an incision, this is clearly not The draft PBAs should be available tween £125 and £175 (70% of respon- applicable for many ENT procedures, from your programme director and dents) and most (89% of respondents) for example tonsillectomy; this item other training representatives. Please charged just under £125 for a follow can be omitted from the PBA to make it use them and make comments that up visit. more applicable. may help improve their standard. Comment: As seen in the 2003 survey Please feedback any comments to your there is wide geographical variation in Currently there are 11 ENT PBAs (some programme director or direct to myself charges reflecting overheads and mar- applicable ones can be found in other at [email protected]. ket forces, so it is very difficult to de- specialities‟ syllabus). Whilst very useful termine an „average consultation fee‟ for assessment these do not cover We plan to discuss adoption at the next that is applicable across the country enough of a range of ENT procedures SAC meeting on March 1st 2010 so I and perhaps what we should accept are to ensure meaningful formal assess- would be grateful for comments to „regional averages‟. ment of the surgical aspect of the cur- come in before then. The next step will riculum to take place. Other specialities be to update and enlarge the DOPS Choose & Book services - on average have many more (eg paediatric surgery portfolio for ENT.ey showed that on the fee for a new consultation is be- tween £25 and £75 with the follow up fee considerably less! The vast majority did not receive any remuneration for outpatient procedures (eg ear micro- suction). Notes Comment: Seeing NHS patients in the private sector is underpaid. The prac- CHAMPAGNE RECEPTION AT THE ANNUAL MEETING IN WARWICK 2010 tice also polarizes views – there are those who believe it is a good use of The President is hosting a champagne reception for newly appointed Consultants and „spare capacity‟ in the private sector those recently retiring. This reception marks the two most important Rights of Pas- whereas others firmly believe that it sage in a Consultant‟s career and is an occasion not to be missed. muddies the water for very little return.

Invitations will be extended to those appointed as Consultants between September More than half of our respondents 2009 and September 2010. If you know of anyone to whom this applies, please let participated in NHS waiting list initia- Nechama know . Those who are retiring around these dates should also let the office tives, carried out in the NHS or in the know. It is said that retirement is a time when you become too busy to work, but it is private sector. A session – a 4 hour hoped that as many as possible will make the time to meet the people who will be slot, was remunerated at £600 or more following in your footsteps. for the majority of respondents. Comment: These figures should help MEDICAL TRAINING INITIATIVE inform (local) negotiations for those who are remunerated at a lower level. Registrars, soon there could be an international medical graduate on this scheme working with you. I am sure you will make them welcome and help them acclimatise In our outpatient clinics, 95% would to the wonders of the NHS. The MTI is providing Tier 5 training visas for a maximum charge separately for procedures done of 2 years specialist training in the UK. These posts are at ST3 level and above and in the clinic such as microsuction of the utilise the training being made available when the National Training Numbers reduce ears and flexible nasendoscopy and over the next few years. We will be welcoming the brightest and the best from many most do so using the BUPA rates as a countries who can return home with valuable skills and experiences, and hopefully guide. The vast majority (82%) would life long friendships. not charge additional fees when using topical local anaesthetic.

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Comment: While it seems perfectly It was also shown that approximately Comment: This is a very important appropriate and normal practice to 30-40% of our in-patient surgical in- statement that to come from this sur- charge for additional outpatient proce- voices contain multiple codes. vey. It shows the frustration we have as dures, there is a groundswell against Comment: This too is an important professionals who feel our independ- charging for the administration of topi- point to note in a time where more and ence and our patients‟ free choice is cal anaesthetic. more insurers are accusing doctors of being threatened by middle men and “unbundling” when in fact it probably insurers. The survey showed that on average 2% reflects the complexity of procedures of our overall activity is through inter- and also ambiguity in existing codes. In asking „what you expected from the mediaries such as Alliance Surgical. IPC‟ the most common response was Comment: However this is not the true The majority of respondents (76%) said that the IPC should be a common voice picture, as the vast majority did no they would be willing to revert to billing for the Independent ENT practitioner in work from intermediaries at all. There the patient directly (rather than the negotiations with insurance companies was a small number of consultants for insurance company) thereby maintain- and to be a source of advice to its whom it made up 25-50% of their pri- ing the patient-doctor relationship and members. The IPC is grateful to all who vate income and for one respondent it reinforcing the fact that the patient is responded to this survey. If anyone made up 99% of his income thereby ultimately responsible for settling in- wishes to see the full survey results, skewing the overall results. voices. email: [email protected]

Goodbye to All That asts have their place but the key is to that it is fair to patients to have inexpe- find practical ones, a much more diffi- rienced doctors learn surgery on them Adrian Drake-Lee cult task. I hope that such people now without showing to their trainers that constitute the SAC, as they are effec- their skills are up to the mark. When I SAC chairman tive in getting things done. My legacy was a trainee, I did eight temporal “Where have all the young men gone, long is involving people with a track record bones before touching a patient. We time passing?” Pete Seeger, Where have all the flowers gone? in medical education. Time will tell if need formal training on temporal this is true and I wish my successor bones, the sinuses and head and neck “How many roads must a man walk down before you call him a man?” Bob Dylan, every best for the future with this dissections as well as simulators even- Blowin‟ in the Wind. committed group. tually with agreed standards before Choices determine the future. We trainees are let loose on friends and I learnt these songs in the need to select nationally in the same family. This is a minimum standard and early sixties. At the time I did not way as we test people in exams. It is all something that I hope my successor know that the tunes were borrowed about setting standards and fairness. will continue and we will discuss it at from the folk tradition: the words rang Time again will tell if national selection the next SAC meeting. home to me. They do still. Life was will work. I understand fully the reac- The commonest non-vocational changing and I was going over the top tionary position in North London and degree that people study is History. into no man‟s land. That is what it feels why the more vociferous consultants do Many politicians studied history and like again as I say goodbye to everyone. not agree but their stand is counterpro- law subsequently. What have they I know that within three months people ductive for the development of our learnt? Precious little it seems. The will ask, „Who?‟, life moves on. specialty. We need to control the work- North West Frontier was considered I visited the RNTNE hospital a cou- force; otherwise it is divide and rule. untamable by the British in the eight- ple of years ago. I was a registrar and Particularly if some of the other issues een nineties and so we have sent our senior registrar there and my approach come up in future as I suspect that they troops to Afghanistan after the Rus- was to get all the trainees involved. I will. sians failed. Some of the severely in- ran the journal club and found projects We have more than our fair share jured come to the centre of defence for the other doctors because I have of „also rans‟ training in the specialty at medicine at our hospital and I have always been able to see opportunities. present. The SAC meeting has a sec- managed their ENT injuries. My only tangible mark was to get the tion devoted to the liaison member for So I leave with a sense of frustra- registrars a room to work in and there each region outlining the reasons for tion too where I see what was good it was still when I visited. My involve- the problem trainees. At the bottom is destroyed along with what was bad: ment was unknown to those using it. a fearful deanery with inadequate pa- much of it due to political interference. This attitude to life has permeated perwork, worrying about litigation and Yes, it is time to reflect. I have read my thinking as chairman of the SAC. a large payout rather than the safety of very few books more than once except Look for opportunities and try to get the patient. textbooks. Goodbye to All That, the people involved. As there are so many If the year starts in August for early years autobiography by Robert more people trying to follow their paths Foundation and Core trainees in fixed Graves was one that I have read three and they too have visions, it is much term training posts, future trainees will times, once at school, again at univer- more difficult. I hope that this approach only come out once a year. Next make sity and finally a couple of years ago. I has healed the rift between the SAC all the registrars start at the same time got something different out of it each and the programme directors. We have of year and the country is split between time. When I was growing up, the peo- joint days that work well and we coop- August and October. There will be a ple around me had been involved in erate better so on the surface it ap- problem in finding suitable locums for either the First or Second World War. pears to be a success. training for gaps from August to Octo- The woman who helped look after me If I were asked to say what my ber, as the best will select to go for had lost her fiancée in the First War. biggest contribution was, I would have posts starting in August. Compound One of the people who helped out in to answer that it was not while I was this with a directive allowing only six the garden spent two years getting over chairman but soon after I was ap- months extension of training and there his from a bullet in his left pointed to the SAC that it occurred. I will be problems staffing registrar rotas arm when he was wounded in 1916 at was asked to look at the feasibility of for the last six months of the training the Battle of the Somme. My parents an electronic logbook. The opportunity year, as there will not be good trainees fought in the Second World War. The was the Edinburgh FHI e-logbook and around. I would call this a, crystal balls last survivors of the Great War are gone together we created one for ENT. Like up. and my parents‟ generation is dying. I many, I consider that I have a sense of So we will be left with a bunch of have grandchildren and a son who is a realism and this creation has to work duffers doing locums, nothing changes Foundation doctor facing his career for the lowest common denominator, here does it? The next group of poor choices. the lazy trainee. The same will hold trainees will get selected into our pro- Yes, it is time to move on. I have true for recertification where it will grammes and will include these people. been learning to finger pick Christmas have to work for the consultant preoc- The simplest solution is to make the carols on the guitar recently. I won- cupied with private practice. It will period of grace at the end of training dered what I would learn after these never be all singing and dancing as an last a year. but now the answers is obvious, protest enthusiast would want. I am a ninety- I would like every trainee to be songs. Perhaps I will have another five percent man. skills tested before he or she starts career now, one never knows. Beware of the enthusiast. Enthusi- operating on humans. I do not think

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vide a College „position‟ on this issue. English college Clearly we may come to a similar posi- ENT UK charitable council report 2009 tion as the College of Emergency Medi- donations and „The cine, but we do have to be aware that TM Chris Milford all Foundation Trusts may ignore the Giving Machine ‟ College position and simply advertise a This is a brief update on post without College approval or in- Andrew Swift the College Council volvement. It certainly highlights the business over the past fact that all of us with 2.5 SPA‟s in our Several weeks ago during an executive meet- few months. I hope the contract will have to be able to argue ing I became aware of a completely new term following may be of our case in the future and justify the 10 that I had no idea about – the words were „The some interest to you as hours per week. Giving Machine‟. Alan Johnson directed a surgeons „at the coalface‟ : short discussion in which I tried not to look too bemused, and then turned to me with the MRCS (ENT) - At its meeting on 13 No- Recertification – the College has words „Andrew, can you lead on this one!‟ vember 2008 Council approved the worked closely with ENTUK to set stan- award of Membership of the College to After a few nights of feeling as if I should dards for the Specialty. All doctors on candidates in ENT Surgery who passed learn to keep up, I soon became aware that I the specialist register will need to dem- Part A or Parts 1 and 2 of the MRCS was not the only one with little understanding onstrate they meet standards that apply examination and both parts of the about this topic. However, after a little re- to their medical specialty in order to be search I rapidly started to grasp the concept Intercollegiate Diploma of Otolaryngol- and the guidelines for the website soon fol- recertified (Tony Narula is the College ogy Head and Neck Surgery (DO- lead in this area and I am sure he would lowed. HNS). As part of the process of the be happy to provide further information review and resubmission of the ISCP Quite simply, „The Giving Machine‟ provides a if you contact him). The Department of assessment system to PMETB for ap- means of raising charitable donations by Health have identified six sites where proval the nature of the equivalence internet shopping. The Giving Machine portal pilots for surgery may be conducted can easily be downloaded as a red heart onto between the examinations has been your internet toolbar. When the portal is (including teaching and non-teaching revisited by the Intercollegiate Commit- hospitals). Phase 1 College piloting will entered, you are directed to an online shop- tee for Basic Surgical Examinations ping site in which there are over 200 leading begin in June 2010 and will be com- (ICBSE). ICBSE has agreed to recom- brand names. If you purchase goods or plete by March 2011.Implementation mend that with effect from the imple- services from any of these brand names, a for piloted specialties could therefore percentage of the total money spent is mentation of the revised MRCS in May potentially commence in the second pledged to a charity of your choice. ENT UK is 2010 (subject to PMETB approval) the registered with the list of charities and can be quarter of 2011. Phase 2 pilots for basis of the equivalence should be remaining specialties would begin in set as the charity to which all funds are di- amended such that the award of Mem- rected during the simple registration process. the second quarter of 2011 (although bership of a College be granted to there has been significant „slippage‟ in candidates in ENT Surgery who passed The concept of the site is to minimize the this project already and it would not Part A or Parts 1 and 2 of the MRCS overheads incurred in collecting charitable surprise anyone if implementation did donations and to encourage small but fre- examination and the Intercollegiate DO- not start until 2012 or later!).The Eng- quent donations. The site is very easy to HNS Part 2 (OSCE). Council endorsed lish College e portfolio (designed to navigate and retailers are easy to find. There the recommendations that: holders of is in fact a wide range of retail possibilities help surgeons record the data required Part A or Part 1 and Part 2 of the MRCS that include banking, insurance, food shop- for their appraisal/recertification) has and Part 2 (OSCE) Intercollegiate DO- ping, theatre tickets, flowers and holidays. been „soft launched‟ on the website i.e. HNS examination to be admitted as The percentage that will be donated to charity from each purchase is clearly displayed by it is available but may still undergo Members of the College and such can- some changes depending on the feed- each retailer: most donations are in single didates be awarded MRCS (ENT) Di- back provided regarding its ease of figures but some are substantial and exceed ploma of Membership. The Colleges of 20%. use. Edinburgh and Glasgow have made TM e portfolio/logbook – there has been an similar recommendations. Once you register with „The Giving Machine ‟ and set your choice of charity to „ENTUK‟ the „outbreak‟ of common sense regarding As I have mentioned in my other re- donations will be sent directly to our own the ongoing „fight‟ between the English ports, as an elected member of Council charitable fund with each internet purchase. & Edinburgh Colleges over the develop- (and an ENT surgeon) I cannot pretend The process is to be started by supporting a single charity and we are appealing to mem- ment of a portfolio for surgeons to use that I (or the College!) can solve all of for appraisal/recertification . As you bers to provide suggestions as to what this your problems. However, I can know the majority of ENT surgeons use should be. -be available – email: the Edinburgh logbook, the trainees [email protected], A guidance note that further explains „The have been told they must use the ISCP Giving MachineTM ‟ site is now on the ENT UK Mobile tel 07731668297 English College logbook and both Col- -act as your link to Council/College website. Your help and support with our fund -raising project would be gratefully valued and leges are developing an e portfolio. Get things onto Council Agenda / to There is now a „will‟ to produce a joint with Christmas coming, this is the ideal time the President product that all members/fellows of of year to start. Happy spending. both Colleges will use – negotiations If you have a problem I am more than continue about how this is achieved but happy to try and help (as will ENTUK, the belief is that an agreement will be Regional Specialty Adviser etc). reached in 2010 to produce such a product. On the other hand- BACO fees SPA/PA ratios in new job descriptions – as Council lead for the Advisory Ap- Chris Pearson pointment Committees, I have been Salil Nair (ENT UK Newsletter, October 2009) invites debate concerning involved recently in dealing with several whether or not invited speakers at our conferences should pay their own new job descriptions which have not way: I fear that he may find little sympathy for his viewpoint amongst the conformed with the 2.5 SPA/7.5 PA wider membership. Invited speakers make their reputations by virtue of their presenta- ratio that was negotiated by the BMA in tions. Although this may be difficult to quantify in monetary terms (other 2003 (several jobs have been reviewed than by clinical excellence awards), it undoubtedly has value for them. Why by Regional Specialty Advisers in differ- then should speakers not pay for the privilege of speaking? Normal prac- ent specilialties with ratios of 1.5 tice requires those who present free papers or posters to register for conferences. The vast major- SPA/8.5 PA or 1 SPA/9 PA). I have dis- ity of these are trainees, on lower incomes and without the ability to offset their expenses against cussed this issue with the President and tax. Why should they be the only ones who pay in order to attract an audience? Mr Nair suggests that a number of first-choice speakers had declined their invitations to BACO. I had no reason to it was discussed at the December Coun- believe that those who did speak were second-rate. I have noticed that conferences often include cil meeting. I have been asked to liaise the same speakers year after year. This may well impose a financial burden upon them, but there with the BMA and the College of Emer- must be many other worthy colleagues who would be only too happy to present their work. Might gency Medicine (who have already re- the prospect of fresh faces, with new ideas, not attract more delegates? Famous keynote speakers fused to recognise any job description and eponymous lecturers (for example Hunterian Professors) are of course a different matter, but I without a 2.5 / 7.5 split) and then pro- humbly submit that ENT UK is fully entitled to ask us to pay our way on equal terms.

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loss, concerns about speech, language logarithmic decibel scale, even a 3dB OME / adenoid or other associated problems are those increase in sound equates to a dou- position paper ENT- potentially eligible for surgical interven- bling of intensity and hearing sensitiv- tion. In the persistent cases, of course, ity. After 12 months there is, predicta- UK 2009 surgical intervention is inevitably de- bly little residual difference, in some layed by this watchful waiting policy, series, between treated and control Peter Robb, Janet Wilson and leading to concerns that the UK surgi- groups, as the hearing in both groups cal cut backs imposed over the last is now normal. Most parents (and Alan Johnson decade might have been excessive6, teachers) do not want a child to spend driven by cost-cutting rather than clini- a year in a school classroom with sub- Role of surgery in treating glue ear cal evidence. This was the finding in normal hearing. The only effective intervention for treat- Australia, where an independent medi- ing childhood hearing loss caused by cal investigation concluded that there Many other quoted studies include no glue ear (otitis media with effusion; was now actually an under-utilisation of hearing test data, as the children re- OME) is the insertion of grommets, ear nose and throat surgery in children cruited were too young to perform the (ventilation tubes). In selected cases - i.e. children requiring surgery were test. In this context, early, active man- removal of the adenoid from the back going untreated. agement is supported by the testament of the nose, adjacent to the Eustachian of adults with glue ear7, who regularly tube opening (which allows air pressure Limitations of RCTs of surgical inter- present for treatment and well articu- equilibration) is also recommended. vention due to parental choice late the daily functional impact of a Grommet insertion and adenoidectomy The UK TARGET study was a random- middle ear effusion. Any specific ration- work by reducing low grade infective ised trial design of surgical treatments ing of children‟s glue ear treatment, 1 biofilm load in the back of the nose, for glue ear versus non-intervention, imposed by policy, would and causing a massive increase in oxy- and final results reporting is imminent. appear to represent a form of age dis- gen tension in the middle ear; this in The delay in the MRC team‟s publishing crimination favouring adults at the turn, further inhibits inflammation mucin gene activity and hence the Max potential reduction Max potential savings formation of middle ear fluid (glue)2. “Relatively ineffective” in procedures (%) (£m) Most grommet and adenoid procedures Tonsillectomy 90 45 are carried out as day cases with very little systemic morbidity or risk. Back pain injections and 90 24 Intervention criteria infusions In 2008, the National Institute for Grommets (glue ear) 90 21 Health and Clinical Excellence (NICE) published guidance following expert statistical and health economic review Table 1 the overall trial outcome is partly be- Extract from Table “Up to £700m could be of the optimum international scientific cause almost 60% of children with glue saved if PCT‟s decommissioned some proce- evidence (CG60, Surgical management ear who were randomly selected into dures”: 2009 report by McKinsey manage- of OME). NICE states that children who the „no-surgical treatment‟ limb were ment consultants commissioned by the DH, will benefit from surgical intervention switched out of the nonsurgical group as published in the Health Service Journal, 10 Sept 2009 are those with persistent bilateral glue by their parents, who decided their ear, documented for a period of 3 children should undergo surgery rather months or more, and a hearing level in than suffer continuing hearing loss for expense of children. the better ear of 25–30 decibels hear- the purposes of the research study. In Earlier this year, McKinsey submitted a ing loss or worse, averaged at 0.5, 1, 2 other studies of similar high quality, up vision of wholesale withdrawal of 90% and 4 kHz. (For reference, a 16 to 25 to 85% of parents of children allocated of NHS funded surgical treatment for dB hearing loss may be mimicked by to the „no treatment‟ group requested a hearing-impaired children (Table 1). plugging the ears with the index fin- move to the treatment group. gers). At even 16dB, a child can miss ENTUK is concerned that there is no 10% of the speech signal even when the The fact that parents tend to switch scientific basis for selection of the 10% listener is 4 feet away. Thus, in a class- children out of no treatment into sur- of English children still in future to be room environment, a 25 - 30dB loss gery for glue ear has two important judged „worthy‟ in the eyes of the man- presents an appreciable educational implications. Firstly, of course it under- agement consultants to receive defini- difficulty. lines the level of concern and the rec- tive therapy. Parents, paediatricians, ognition of the effectiveness of surgical audiologists and otolaryngologists do The rate of UK surgical intervention for intervention on the part of parents. not want children to be disadvantaged. childhood glue ear has fallen steadily Less obvious, but equally important is The surgical alternative - to provide all over the past 15 years. Adenoidectomy the fact that not all studies properly children with glue ear with NHS digital rates fell dramatically in the late 1990‟s report the results according to who hearing aids is neither cheap for pro- from over 16,000 procedures per an- switched from no surgery to have sur- viders nor acceptable to the vast major- num, and in 2008-09 there were 5529 gery. The statistical impact of this habit ity of service users. Health economic adenoidectomy operations in children is to underestimate the difference be- modelling by NICE is fanciful in its 3 <15 years . Childhood grommet inser- tween the surgery and no surgery speculative and evidence-free cost tion has also fallen from over 43,300 groups, as those gaining surgical bene- estimation of this alternative. At the operations in 1994-95 to under 25300 fit continue to be analysed as part of end of the day, most of us, given the in 2008-09 – a 42% reduction, largely the no treatment group. choice, would prefer not to have to due to the better understanding of the wear a hearing aid when a safe and natural history of glue ear and the role Implications for children of severe effective day case surgical treatment of „watchful waiting‟. rationing of surgery for glue ear fixes the problem as a day case proce- ENTUK is therefore alarmed to learn dure. Watchful waiting or „active monitor- that non-medical „consultants‟ on ing‟ Health Service resource allocation have References 4 Watchful waiting is now recognised as recently stated that the treatment of 1 Fergie N et al. Is otitis media... Clin Oto- an essential, preliminary period of children‟s hearing impairment is largely laryngol 2004; 29: 38-46. observation with monitoring of hearing „unnecessary‟. One problem for com- 2 Ubell ML et al Mucin... Laryngoscope 2009, loss, since research by ENTUK sur- epub ahead of print missioners scrutinising the results of 3 www.hesonline.nhs.uk geons, funded by the MRC (the TARGET surgery is that sound is measured by 5 4 Browning GG. Watchful waiting... Editorial. multicentre trial ) has shown that 50% the decibel scale which is logarithmic; Clin Otolaryngol 2001; 26: 263-264. of children with a bilateral hearing loss the 2005 Cochrane review showed 5 Hall AJ et al Developmental... Clin Otolaryn- of at least 20dB are likely to recover to about 9dB improvement from grom- gol 2009, 34: 12-20 normal with no treatment in the first mets in the first six months after op- 6 MRC Multi-Centre... Clin Otolaryngol 2001;26: 417-424. three months after diagnosis. The re- eration, 6dB in the next.. The raw num- maining 50% with persistent hearing 7 McCluney NA et al The assessment... Clin bers look unimpressive – but due to the Otolaryngol 2009, 34: 377-80 Vol 20, No, 1 Page 6

and prevent normal functioning use of antibiotics by GPs is well docu- Indications for mented as serving mostly to increase tonsillectomy - Those with very frequent infection (>8 reattendance rates4. per annum) or who are hospitalised ENTUK position paper with extremely severe tonsillitis or Benefits of Tonsillectomy peritonsillar abscess (quinsy) may seek Published data using generic and dis- Janet Wilson and Alan Johnson intervention within a year of symptom ease specific patient reported outcome onset. Very similar guidance has measures on both sides of the Atlantic Introduction evolved independently in the USA and confirm the marked health status bene- 5-8 This is a short paper produced by EN- Australia. fits in children . These include both TUK to define the current position of significant benefits in the general tonsillectomy as a surgical procedure in Changing practice health perceptions, parental impact and terms of the indications, predicted In the 1950s there were about 200,000 family activities reported by over 90% outcomes and benefits of surgery. This tonsillectomies performed a year. In of parents. The quality of life benefits document is based on the available the last 15 years the rate of tonsillec- in adults are likewise unequivocal (large evidence and references are available to tomy has fallen in all age groups from effect size improvements in health care support its conclusions. 77,604 in 1994-95 to 49187 in 2008- utilisation, swallowing, and breathing, 2 09 , a 37% reduction. In children, the as well as general health related quality Description of Tonsillitis Department of Health identified almost of life physical functioning). Tonsillitis is an acute infection of the 56,000 childhood tonsillectomies in palatine tonsils. Episodes last for 5 to 1994-95. By 2008 – 09 HES data show About one in five tonsillectomies in 14 days, during which the patient ex- under 27,400 tonsillectomies in those are performed for tonsillar periences some or all of the following: aged ≤ 15 years. Of these, an estimated enlargement, which is associated with fever, malaise, nausea, severe throat 25% were for enlarged, obstructive Sleep Related Breathing Disorder pain, white spots on the tonsils, tonsils, the remainder for infection. In (SRBD). SRBD (formerly classed as enlarged lymph glands in the neck (and adults there were just under 22000 obstructive sleep apnoea) is a poten- sometimes abdomen). The attacks are tonsillectomy procedures in 2008-09, tially life threatening condition and is common in children and their fre- the majority for persistent tonsillitis. the main indication for tonsillectomy in quency may reduce with age, but the The reason for the reduction in the rate approximately 25% of UK children. - loss of time at school – usually 3 to 5 of surgery is because surgeons have Adenotonsillectomy is curative in 75 to days per attack, several times per an- used the data available to refine the 80% of cases of OSA. In the USA, the num – can impact significantly on edu- indications for surgery so that the op- performance of adenotonsillectomy for cation. Tonsillitis is not as common in eration is now only offered to patients obstruction has increased markedly in adults, but attacks can be as frequent most likely to benefit. the past 30 years from 12% in the early 9 and even more severe than in children 1970‟s to 77% in 2000-2005 . It is to and may cause significant loss of work Increasing hospital admissions for be hoped that national drives to pro- due to illness. A severe complication of tonsillitis and quinsy mote healthy lifestyle in children will tonsillitis arising mainly in adults is There is now a risk that too few tonsil- prevent the UK ever experiencing such peritonsillar abscess or quinsy, and this lectomies are being carried out. An an epidemic, as Sleep Related Breathing condition often requires hospital ad- increasing number of adults and chil- Disorder has a well documented, huge mission for treatment and pain control. dren are being hospitalised annually for impact on childhood quality of life. The throat . In 2000-01, there proportion of adults undergoing tonsil- The cost of tonsillitis were 30,942 tonsil-related admissions lectomy for obstructive symptoms The economic impact of tonsillitis is for medical treatments. By 2008-09, the (2171 in England in 2007-08) is under considerable. Annually, 35 million days figure had risen to 43,641 medical 10%, possibly due to lower levels of are lost from school or work due to admissions for throat symptoms, an morbid obesity than in the USA. sore throats in the UK. GP consulta- increase of over 41% (12700 admis- tions for sore throat cost around £60 sions in England) in 8 years. The inci- Conclusion million annually. dence of admissions for quinsy is also Tonsillectomy remains a highly effec- rising - 6352 admissions in 2000-01, tive intervention in appropriate pa- Indications for surgery rising to 7683 in 2008-09, an increase tients, not only in elimination of severe Tonsillectomy, the removal of the pala- of 1331 admissions (over 20%), with a sore throats or upper airway obstruc- 2 tine tonsils, has three principal indica- total of 11865 bed days . Quinsy is an tion, but also in terms of patient and tions: extremely painful and debilitating com- parent reported quality of life. There plication of acute tonsillitis, which are no data to suggest that the proce- 1 Recurrent attacks of tonsillitis requires intraoral drainage in the fully dure is overused or abused the in the (typically Streptococcal). conscious patient, followed by admis- UK. Tonsillectomy rates are lower in 2 Enlarged tonsils causing obstruction sion for intravenous antibiotic therapy. the UK than in any other country in of the airway, which may be the cause These conditions are cured by tonsillec- Europe. In fact the trends of increasing of Obstructive Sleep Apnoea – recurrent tomy and as tonsillectomy rates fall it is hospitalisation for quinsy and severe airway obstruction at night – and this predictable that hospital admissions for forms of tonsillitis might indicate that has serious effects on health and well- severe tonsillitis and its complications rather than performing too many tonsil- being. will rise, and this is borne out by the lectomies in the UK, we are now per- 3 Possible malignant disease in the data available. Any further reduction in forming too few. tonsils – typically squamous carcinoma the rate of tonsillectomy is likely to be or lymphoma. associated with increases in hospital References admissions for tonsillitis. 1 SIGN guideline No. 34 Management... 2 www.hesonline.nhs.uk For many years the UK guidance on Alternative Treatment 3 Petersen I et al Protective effect...BMJ 2007, tonsillectomy for tonsillitis has been 335: 982-4 only to consider surgery in those with Antibiotic treatment is the standard 4 Little P et al Open randomised.. BMJ 1997, attacks of at least moderate severity treatment for acute bacterial tonsillitis, 314: 722-7 (several days‟ duration) per annum, for but the evidence is that increasing this 5 Goldstein NA et al Quality of life... Otolaryn- > 1 year – the SIGN guidance summa- treatment is likely to be neither good gol Head Neck Surg 2008, 138: S9-S16 6 Witsell DL et al Quality...Otolaryngol Head rises the current consensus1: medical practice nor cost effective. Recent UK analysis of a million cases of Neck Surg 2008 138: S1-S8 7 Kubba H et al Measuring quality... Otolaryn- Patients should meet all of the follow- sore throat treated in the 1990‟s gol Head Neck Surg 2005, 132: 647-652 ing criteria: showed a significant reduction in 8 Robb PJ et al Paediatric tonsillectomy...J quinsy by the use of antibiotics – odds Laryngol Otol. 2009, 123: 103-7 3 -sore throats are due to tonsillitis ratio 0.84 - but due to the relative 9 Erikson BK et al Changes in incidence..., 1970-2005. Otolaryngol Head Neck Surg -five or more episodes of sore throat incidence of sore throat and quinsy, the number needed to treat was 4300, and 2009, 140: 894-901 per year -symptoms for at least a year the use of antibiotics for all sore -episodes of sore throat are disabling throats remains hard to justify. For recurrent sore throat, indiscriminate

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anonymous bomb hoax might still just Just a short talk save us and cancel the meeting? The Developing (at the RSM) last minute nervous trip to the gents links later proved my downfall. between NoE Liam Flood It is funny how confidence returns,

As I write, it is getting near to Christ- once you are standing up there facing -ENT & ENT in Malawi the multitude. Or, at least, till the pe- mas and, so, to appraisal time, when nultimate slide. I was momentarily annually, the gifts of whiskey are less Chris Bem important than the attached distracted as I realised that I had given Visiting ENT Lecturer and Surgeon to cards from grateful colleagues, the whole presentation with my trouser fly below half mast. That three to four Malawi, since 2003 now sans tonsils or turbinates. I sit in Kings Cross Station, wait- seconds of hesitation, I now see on the In UK, population 61 million, there are ing to depart from my very last recording, was the uncertainty as to whether corrective measures would some 630 consultant ENT surgeons. In SAC meeting. worsen things, or should I rely on the Malawi, population 15 million, there is December 7th is always a time podium for cover? one ENT surgeon, Wakisa Mulwafu, a for reflection for me, remember- Malawian who two years ago, returned ing as I do one William J Flood Came the questions. All speakers, with- from specialty training in Cape Town to out exception, answered a totally differ- (distant relative, same name!) become the country‟s first ENT special- ent question to that posed, attendees th who commanded Wheeler Air ist. On 25 September 2009, he came Force Base, Pearl Harbor at 0756 on will recall. When questioning, I have to Bradford at the invitation of the that date, in 1941. The real threat to long learnt that “Flood, Middles- North of England ORL Association to brough!” is seen more as a good sug- his fighters was surely sabotage from give a talk on ENT in Malawi at its au- the substantial Japanese population of gestion than an introduction. Similarly, tumn meeting and to spend a week as Oahu, not air attack. So he pushed all Ed Fisher‟s talk was greeted with the guest of the Bradford ENT Department. cry “Jim Fairley, Kent!”. As I whispered the planes very close together for easy His visit was part of a project to stimu- guarding. But, just in case, let us make to Des next to me, “He‟s not that bad late links between ENT departments in sure that some are fully fuelled and you know” (The gag only works in a UK and places in our globe where ENT South African or Queen Elizabeth pre armed. Like MMC, this probably services are poorly developed or non- 1970 accent). existent. seemed like a good idea at the time. Experimenting with what was then a The reward, a decent lunch at the RSM, novelty, a US made radar set, the two tasted far better than had breakfast. We In Malawi, health care services remain operators were baffled to pick up their were a bit loud, once our raging thirsts under-resourced and patchy. Although first ever return, but a signal so big it had been quenched (my apologies to a peaceful, democratic and relatively was clearly faulty. Their shift finished at the elderly couple at the next table, no uncorrupt country, in 2008 its annual 0800 anyway. We have all done it. We not David Proops and Martin Bailey, but GDP per capita was only $300 (World set up sophisticated screening systems to the respectable couple beyond). Bank) and of this $14 per capita spent and then switch off the irritating alarm Now, my Narula joke could raise much on health. For the country as a whole, when it does finally go off laughter, but also agreement that my there are approximately 1 (anaesthetists, take note). Our patient wife had been right in advising against and 26 nurses for each 100,000 of the charts must now carry traffic light col- it. There is still the Doncaster Course population. There are limited diagnos- ours to remind the FTSTA2 locum (I mind... tic and surgical facilities (just 17 have met such a creature) that the trained surgeons for the whole coun- pulseless patient is at risk. Back in for the afternoon session, at try), and no audiology service. the December RSM. This, as always, The RSM last Friday! A fine suggestion opened with an audience of two men The Queen Elizabeth Central Hospital in from the Otology Section President way and a dog and even they were inebri- Blantyre, where Wakisa works, is a back in January was „What I Learn from ated, watching Wee George hand over 1000-bedded hospital, the tertiary the Journals‟. Then I saw my the ENT UK Clin Oto Prize for the best referral centre for the country and the topic...Chronic Otitis Externa! Never review article in the journal in 2009. He university hospital where medical stu- mind, it is not till the end of the year; bluffed well, in handing over the empty dents from the Malawi College of Medi- there is the BACO talk to think of first. envelope. ENT UK staff had spent the cine receive much of their clinical train- All too soon, though, I had made the whole of lunchtime trying to find him, ing. It has an annual budget of ap- day return trip to Liverpool (someone or to give the £2000 cheque to anyone proximately $4 million a year. had to man the Boro‟), I‟d paid my who would take it! £450 entry fee to give my 20 minute For a number of years, visiting ENT talk and then had to face this enthrall- The talk is done. Unlike my effort in 1985, when the RSM projectionist surgeons from Britain and Holland have ing subject for December. been providing some ENT presence in dropped my carousel, which had Malawi. With the appointment of I‟d promised Robin no nostalgic pic- jammed, without a lid, the presentation tures of my misspent youth and no worked. My wife says I have stopped Wakisa, an ongoing link with Bradford Tony Narula jokes. I couldn‟t resist a muttering about OE in my sleep but I Royal Infirmary and a developing link with the North of England ORL Associa- picture of a 1979 UCH ward round. A am still none the wiser about manage- full turn out (no EWTD-inspired shifts ment. As indeed are you all who lis- tion together with funding from the Beit then. We worked a 1 in 2 on call, kids tened! Talking at the RSM reminds me Trust, Christian Blinden Mission (CBM) and the UK Hearing Conservation Coun- nowadays...) all in full sleeved white of John Graham‟s suggested treatment coats. Well, the slides were mailed in for tinnitus; to cast oneself naked into cil, a programme to upgrade ENT ser- and the morning drew nigh. Five very a bush of nettles. It is an unpleasant vices in Malawi is being planned. Ex- pressions of interest in this project are experienced speakers stood outside the prospect, but, once it is all over, noth- invited. RSM, very subdued, wondering if an ing ever seems so bad again! [email protected] Newsletter Contact Information Editor:- Mr Gerard Kelly Assistant Editor:- Mr Tony Jacob Email:- [email protected] Email:- [email protected] ENT Surgeon ENT Surgeon Leeds General Infirmary University Hospital Lewisham

Administration Manager:- Address for correspondence: Nechama Lewis ENT UK, The RCoSE Tel: 020 7611 1731 35-43 Lincoln‟s Inn Fields Fax:0207 404 4200 London WC2A 3PE CharityVol No:20, 1125524No, 1 Page 8