Otolaryngology services

Transcription

1 Otolaryngology services Item Type Report Authors Comhairle na nospideal Publisher Comhairle na nospideal Download date 19/09/ :53:40 Link to Item Find this and similar works at -

2 Otolaryngology Services.qxd 26/09/ :25 Page 2 COMHAIRLE NA NOSPIDÉAL OTOLARYNGOLOGY SERVICES May 2005

3 Otolaryngology Services.qxd 26/09/ :25 Page 3 Comhairle na nospidéal OTOLARYNGOLOGY SERVICES May 2005 Comhairle na nospidéal Corrigan House, Fenian Street, Dublin 2 TEL: FAX: info@comh-n-osp.ie WEBSITE: Chairman: Dr. Cillian Twomey Vice-Chairman: Dr. Donal Ormonde Chief Officer: Mr. Tommie Martin

4 Otolaryngology Services.qxd 26/09/ :25 Page 4 CONTENTS Foreword 4 Executive Summary 5 1 INTRODUCTION Background Membership of the committee The consultation process Overlap between the three related specialties of otolaryngology, plastic surgery and oral & maxillofacial surgery 7 2 WHAT IS OTOLARYNGOLOGY? Definition and scope of Otolaryngology Sub-specialties of Otolaryngology Paediatric Otolaryngology Training in Otolaryngology Qualifications specified by HSE for posts of consultant otolaryngologist 10 3 THE OVERLAP / INTERFACE BETWEEN OTOLARYNGOLOGY AND THE RELATED SPECIALTIES OF PLASTIC SURGERY AND ORAL & MAXILLOFACIAL SURGERY Introduction Head and Neck Surgery Head and Neck Cancer 12 4 PREVIOUS COMHAIRLE NA NOSPIDÉAL REPORTS Introduction Development of Ear, Nose and Throat Services November Report of the Committee on ENT Services in the Southern Health Board Area November Development of ENT Services in Cork City and County June Otolaryngology in South East Dublin EXISTING OTOLARYNGOLOGY SERVICES National Distribution of Otolaryngology Services East Midlands Mid-West Northeast Northwest Southeast South West Special interests within otolaryngology Otolaryngologists in full-time private practice Distribution of NCHD posts in otolaryngology 20 6 MAJOR ISSUES CONSIDERED BY THE COMMITTEE International manpower in Otolaryngology Referral patterns for complex and common procedures Audiology services Head and Neck Cancer Paediatric Otolaryngology Day Procedures 25 2

5 Otolaryngology Services.qxd 26/09/ :25 Page Cytology Services Waiting Lists Teaching and Training 25 7 RECOMMENDATIONS 26 General Recommendations 26 Priority Recommendations 26 Recommendations on future consultant staffing by region 28 Other Recommendations 31 8 OVERVIEW OF FUTURE CONSULTANT STAFFING IN OTOLARYNGOLOGY 33 9 CONCLUDING REMARKS REFERENCES APPENDICES 39 Appendix A List of questions posed to all health boards and relevant public voluntary hospitals 39 Appendix B Meetings, submissions and site visits 40 Appendix C Higher Specialist Training Posts in Otolaryngology 41 Appendix D Referral patterns for some common ENT procedures 42 Appendix E Summary of ERHA Report on Audiology Services 44 Appendix F Audiology Services current configuration 45 Appendix G Newly diagnosed head / neck cancers in Appendix H Waiting List Data / National Treatment Purchase Fund Data 47 Appendix I Recommendations Facilities 51 A CUTE MEDICINE 3

6 Otolaryngology Services.qxd 26/09/ :25 Page 6 FOREWORD Arising from the Government s Health Service Reform Programme, the Health Service Executive (HSE) was established on 1st January 2005 pursuant to the Health Act The Act provided for the dissolution of the ERHA and its three area health boards, the health boards established under the Health Act 1970 and certain other bodies, one of which was Comhairle na nospidéal. Under the terms of the Act the HSE is charged with managing, delivering or arranging the delivery of health and personal social services in Ireland in the context of policy developed by the Government and the Minister for Health & Children. In line with section 57(2) of the Health Act 2004, the functions of Comhairle na nospidéal, as specified in section 41(1)(b)(i) and (ii) of the Health Act 1970, were transferred to the HSE on its establishment date of 1st January Prior to the establishment date, the members of Comhairle were requested by the then Minister M. Martin, T.D. and Mr. K. Kelly, the then Chairman, HSE, to remain until the scheduled end of their term of office in December 2005 to complete ongoing specialty reviews and to provide advice to the HSE on the regulation of consultant, specialist registrar and senior registrar appointments. This report has been prepared and adopted by Comhairle na nospidéal. It is intended that it will inform and guide the Minister for Health & Children, the Department of Health & Children and the HSE in relation to policy and consultant manpower requirements in Otolaryngology services in Ireland. 4

7 Otolaryngology Services.qxd 26/09/ :25 Page 7 EXECUTIVE SUMMARY The Comhairle na nospidéal review of otolaryngology services commenced in July 2001, following the establishment of a committee to review consultant manpower requirements for plastic surgery services. Due to the overlap between otolaryngology, plastic surgery and oral & maxillofacial surgery, it was decided that the one committee should examine the three specialties in parallel. While this report focuses specifically on otolaryngology services it may be read together with the reports on plastic surgery services and oral and maxillofacial surgery services for a comprehensive understanding of all three specialties. This report builds on the recommendations of previous Comhairle reports on otolaryngology services, most notably the 1983 review. Requests were made to each health board and relevant voluntary public hospital to make submissions to the committee. The committee met with management and consultant staff of these organisations and carried out site visits at a number of hospitals. The committee took into account the principles of the Government s Health Strategy Quality & Fairness, A Health System For You, as well as literature and the recommendations of the relevant professional bodies in Ireland, the UK, Europe and North America. There are currently 36 posts of consultant otolaryngologist in the public sector in Ireland, representing a consultant / population ratio of 1:108,000 (all consultant/population ratios in this report are based on Census 2002 figures). Expansion in consultant otolaryngology numbers has been small relative to other specialties. Total consultant numbers, across all specialties, have seen a 67% increase since This compares with only a 25% increase in the consultant establishment in otolaryngology in the same period. The main principles identified for the future development of otolaryngology services are; An equitable and patient-centred service, ensuring accessibility for all, regardless of geographic location; Regional self-sufficiency, with the exceptions of cochlear implants and major head and neck cancer surgery; A minimum of three consultant otolaryngologists at each ENT centre; All consultant appointments should have local outreach services, including appropriate inpatient consultation, outpatient and day surgery services, in line with quality and safety; All major head and neck cancer surgery should be undertaken at five designated major ENT centres Beaumont, Mater, St James s, CUH/SIVH Cork and UCH, Galway; Cochlear implant surgery should continue to be undertaken only at Beaumont Hospital Collaboration between the three related specialties of otolaryngology, oral & maxillofacial and plastic surgery in respect of relevant patients. The key recommendations are as follows; A ratio of one consultant otolaryngologist per 70,000 population, based on a minimum of three consultant otolaryngologists per ENT centre; A total of 20 new posts of consultant otolaryngologist, including 10 priority posts, to give an overall total of 56 posts in Ireland; The immediate establishment of a locally based otolaryngology service in the northeast; The development of paediatric otolaryngology services, both in terms of staffing and facilities, particularly at the centres at Cork and Galway. The development of academic posts in otolaryngology, with one post at each of Galway and Cork having a formally designated academic commitment; The development of training in otolaryngology, leading to the accreditation of a full training programme; Investment in audiology services; Investment in inpatient and outpatient resources. 5

8 Otolaryngology Services.qxd 26/09/ :25 Page 8 1 INTRODUCTION 1.1 BACKGROUND At its meeting on 24th November 2000, the 8th Comhairle considered a request from the Irish Association of Plastic Surgeons that it establish a committee to review consultant manpower requirements for plastic surgery services. As its term of office was coming to an end, the matter was deferred to the incoming Comhairle. At its meeting on 28th February 2001, the 9th Comhairle decided to establish a committee, which held its first meeting on 23rd May The issue of overlap between Plastic Surgery and the related specialties of Otolaryngology and Oral & Maxillofacial Surgery was considered by the committee and it was decided by Comhairle na nospidéal, in May 2001, that the committee should also review the specialties of Otolaryngology and Oral & Maxillofacial Surgery. The membership of the committee was extended accordingly The committee took into consideration the principles of the Government s Health Strategy 1 Quality and Fairness, A Health System for You of equity, people-centredness, quality and accountability in its deliberations and the formulation of its recommendations, which are set out in section 7 of this report. 1.2 MEMBERSHIP OF THE COMMITTEE The following members were appointed to serve on the Otolaryngology, Plastic Surgery and Oral & Maxillofacial Surgery Committee: Dr S Ryan (Chairman) CEO, Western Health Board Ms A Cody Clinical Nurse Manager II, Mater Hospital Dr E Connolly Deputy Chief Medical Officer, Department of Health and Children Prof M Leader Consultant Histopathologist, Beaumont Hospital/RCSI Mr P McLoughlin CEO, Southeastern Health Board Mr K Moran Consultant General Surgeon, Letterkenny General Hospital Prof D Moriarty Consultant Anaesthetist, Mater Hospital Mr T Nadaraja Consultant Otolaryngologist, Sligo General Hospital Mr T Martin - Chief Officer, Comhairle na nospidéal Ms C Mellett, A/Higher Executive Officer was Secretary to the Otolaryngology Committee and she undertook the research and initial drafting of this report The first meeting of the committee for all three specialties took place on 19th July It was decided that each specialty would be reviewed individually, that areas of overlap between the specialties would be examined and that a separate report would be drafted and published in respect of each specialty. This report deals with Otolaryngology. The terms of reference of the otolaryngology committee were as follows: To examine the existing arrangements for the provision of consultant level otolaryngology services nationally and following consultation with the interests concerned, to make recommendations to Comhairle na nospidéal on the future organisation and development of otolaryngology services. The review will focus on updating the 1983 Comhairle report taking into account recent advances in and increasing demand for otolaryngology services. 6

9 Otolaryngology Services.qxd 26/09/ :25 Page THE CONSULTATION PROCESS Requests were issued to each health board and relevant public voluntary hospitals to make submissions to it pertaining to the three specialties. The Committee subsequently conducted an extensive consultation process, meeting initially with representatives of the Irish Association of Plastic Surgeons, the Irish Institute of Otolaryngology, the Consultant Oral & Maxillofacial Surgeons Group and the Department of Health & Children. The Committee then met with representatives of every health board during April 2002, carrying out site visits at relevant hospitals. The committee also met with representatives of the ERHA and its three area health boards as well as with representatives of the voluntary hospitals in Corrigan House, in April The Committee wishes to extend its gratitude to all those involved in the consultation process and in the compilation of submissions. A special mention must be made of Professor Michael Walsh, Beaumont Hospital / RCSI, who provided particular advice to the committee over the course of its work. 1.4 OVERLAP BETWEEN THE THREE RELATED SPECIALTIES OF OTOLARYNGOLOGY, PLASTIC SURGERY AND ORAL & MAXILLOFACIAL SURGERY Over the course of the consultation process, all three specialties were discussed and it became apparent that the nature and extent of the overlap between the three was varied. The issue of the overlap and interface between the three specialties is dealt with in each report (see section 3 of this report) The overlap between otolaryngology and plastic surgery was clearer than that between oral & maxillofacial surgery and the other two subspecialties. However, the lack of clarity surrounding the overlap of OFM surgery with the other surgical areas may be due, in part, to the fact that there are fewer consultant OMF surgeons in Ireland. Currently, the subspecialty of the surgeon performing surgeries which fall within the broad overlap between the three specialties is often determined by the appointment / non-appointment of consultants in particular specialties, resources and the training undergone by the surgeon (e.g. the content of ENT training in Ireland or the UK might be slightly different to that in the USA so that slightly different skills may be learnt and practised by surgeons depending on where they trained) It would be expected that with the development of the three specialties as recommended by the committee, clear guidelines would be drawn up regarding clinical pathways for patients, which would identify the lead clinician and the role of the multidisciplinary team, in line with agreed protocols. Comhairle feels that the RCSI and the professional bodies involved are best placed to formulate guidelines to identify, devise and manage the overlap between the three related sub-specialties of otolaryngology, plastic surgery and oral & maxillofacial surgery. 7

10 Otolaryngology Services.qxd 26/09/ :25 Page 10 2 WHAT IS OTOLARYNGOLOGY? 2.1 DEFINITION AND SCOPE OF OTOLARYNGOLOGY Otolaryngology has traditionally been referred to as Ear, Nose and Throat (ENT) Surgery. However, though this title is descriptive, it does not acknowledge the fact that the specialty has expanded to include diseases of the thyroid gland, most head and neck surgery, which includes surgery on the salivary glands, lymph nodes and cancers in the neck, as well as the diagnosis, management and rehabilitation of communication disorders Otolaryngology is defined 3 as the combined specialties of diseases of the ear and larynx, often including the upper respiratory tract and many diseases of the head and neck, tracheobronchial tree and oesophagus. In its Policy Document 4, the Irish Institute of Otolaryngology Head and Neck Surgery (IIOHNS) recommended that the title Otolaryngology/Head and Neck Surgery was most appropriate for the specialty. The title of the specialty as recognised by the Medical Council is otolaryngology and this title has been used throughout this report. It is a diverse specialty, allowing specialists to apply both their medical and surgical skills in the management of patients, and affording the specialists the chance to work with a broad spectrum of patients, from neonates to the elderly, depending on their chosen sub-specialty ENT problems account for approximately 9% of all hospital referrals, with the bulk of these patients being referred by General Practitioners 5. The transference rate in Ireland (i.e. the percentage of elective referrals to consultant otolaryngologists admitted for surgery) stands at 14% 3. A large proportion of the work of an Otolaryngologist involves the treatment of the ear - hearing, ear infections, balance disorders, ear noise (tinnutus), nerve pain, facial and cranial nerve disorders, congenital disorders of the inner and outer ear; treatment of the nose - care of the nasal cavity and sinuses, allergies and sense of smell; treatment of the throat - diseases of the larynx (voice box) and the upper oesophagus, including voice and swallowing disorders; and treatment of the head and neck infectious diseases, both benign and malignant tumours, facial trauma and deformities 5. Diseases and disorders of the head and neck involve overlap with the specialties of general surgery, plastic surgery and oral & maxillofacial surgery (see section 3 of this report). 2.2 SUB-SPECIALTIES OF OTOLARYNGOLOGY The three bases of otolaryngology are otology, rhinology and laryngology. Sub-specialties have arisen to date in Ireland as a result of individual expertise rather than being designated in the structuring of the consultant post. The IIONHS has identified a number of sub-specialties in otolaryngology. These are Otology, Neuro Otology/Skull Base Surgery, Head and Neck Surgery (Oncology/Non Oncology), Rhinology, Paediatric Otolaryngology, Head and Neck Reconstructive Surgery and Phoniatric Surgery. 2.3 PAEDIATRIC OTOLARYNGOLOGY Paediatric Otolaryngology is considered to be a specialty within a specialty, with a large volume of the work of a paediatric otolaryngologist involving congenital abnormalities, tonsils and adenoids, causes of deafness, foreign bodies in the ear or nose, tumours of the head and neck and other diseases involving the ear, nose, throat, head and neck and associated structures and collaboration with colleagues in plastic surgery and oral & maxillofacial surgery in the management of cleft palates 6. The issue of paediatric otolaryngology is dealt with in more detail in section six of this report. 8

11 Otolaryngology Services.qxd 26/09/ :25 Page The main sub-specialty areas within paediatric otolaryngology are: - Paediatric Airways - Cochlear Implants - Head and Neck Oncology in children Children requiring treatment in the above areas should be treated by otolaryngologists with a special interest in paediatric otolaryngology. The paediatric otolaryngology team is made up of the otolaryngologist, nurses, speech and swallowing therapists and other health care professionals who provide a multi-disciplinary approach to the care of children with ear, nose and throat problems. 2.4 TRAINING IN OTOLARYNGOLOGY Training in Otolaryngology in Ireland Under the Medical Practitioners Act 1978, the Medical Council is the body charged with assuring the quality of postgraduate training of specialists in Ireland. To this end, the Council recognises 12 postgraduate training bodies responsible for the provision of a wide range of postgraduate training programmes In Ireland, the Higher Surgical Training Committee in Otolaryngology/Head & Neck Surgery (a subcommittee of the Irish Surgical Postgraduate Training Committee - ISPTC) of the Royal College of Surgeons in Ireland is responsible for the organisation of higher training in Otolaryngology. The six year programme is divided into a four year Specialist Registrar Programme and a two year Senior (Specialist) Registrar Programme. The four-year Specialist Registrar programme involves rotations through teaching hospitals in Dublin, Galway, Cork, Limerick and Waterford. The entry requirements for the programme are the completion of two years of basic surgical training and the possession of the Associate Fellowship or Membership of one of the Royal Surgical Colleges. Following completion of this four year programme, most trainees spend a year or two in a clinical fellow or research post in Ireland or abroad before applying for the two year programme of Senior Specialist Registrar, following successful completion of which, the candidates will be eligible to apply for the award of CCST in Otolaryngology 7, There are 21 posts recognised by the Specialist Advisory Committee* as suitable for SpR training in Otolaryngology/Head and Neck Surgery in eleven hospitals Beaumont, South Infirmary-Victoria Hospital/Cork University Hospital, Crumlin, Mater/Temple Street, Royal Victoria Eye and Ear, St James s Hospital, Tallaght, Limerick Regional Hospital, Waterford Regional Hospital and University College Hospital, Galway. The SAC has deemed seven of these posts as suitable for the full (six year) duration of training. Details of these can be found at Appendix C. Following requests from the ISPTC seven posts of Senior Specialist Registrar (SpR 5-6) have been approved by Comhairle na nospidéal. The committee believes that all SpR training posts in Otolaryngology should be recognised for the full duration of six years. The recommendations contained in this report, in terms of consultant manpower, will allow the development of greater complexity at more centres, which will, in turn, enable the extension of SpR training programmes to meet the needs of future consultant staffing in the specialty. * The Specialist Advisory Committee works on a Britain and Ireland basis and members are selected based, primarily, on their expert knowledge and experience of the training system in the UK and Ireland. The SAC advises the Joint Committee on Higher Specialist Training (JCHST) of the Royal Colleges of Surgeons on the suitability of units for higher surgical training posts. Inspections are carried out at five-yearly intervals for established training programmes posts. More frequent revisits to individual units may be necessary when significant changes are brought to the attention of an SAC, or where significant deficiencies in a programme have been highlighted which cannot be addressed through interim reports 9. 9

12 Otolaryngology Services.qxd 26/09/ :25 Page Training in Otolaryngology in the UK In the UK, the Postgraduate Medical Education and Training Board (formerly known as the Specialist Training Authority) is responsible for specialist training. On its behalf, the SAC in Otolaryngology of the JCHST oversees the higher specialist-training programme for Otolaryngology, which is of 6 years duration, leading to the award of the CCST on completion of satisfactory training. The SAC programme provides an intensive and structured training programme for those that have completed Basic Surgical Training so that they can enter independent practice in otorhinolaryngological surgery (ORL/HNS). The first four years of the programme cover the basic sciences and surgical procedures and the Intercollegiate Specialty Examination is taken at the end of the fourth year. The fifth and sixth years involve more advanced ORL/HNS training. The SAC specifies guidelines with regard to the keeping of log books, research, training abroad, courses etc. Following the successful completion of the training programme, the SAC makes a recommendation to the appropriate Royal College, which in turn recommends the award to the trainee of the CCST to the Specialty Training Authority of the Medical Royal Colleges 10, Training in Otolaryngology in the USA In the US, the American Board of Otolaryngology (ABOto) is responsible for the organisation of Otolaryngology training programmes. Five years of postgraduate specialty training is required, including one year of general surgery and four years of otolaryngology-head and neck surgery in an Accreditation Council for Graduate Medical Education (ACGME) approved residency programme. The final year of the four years of otolaryngology education must be at chief resident level. Successful completion of both a written and oral exam are then required to achieve certification by the ABOto 12, Training in Otolaryngology in Canada The Royal College of Physicians and Surgeons of Canada is the national body responsible for setting and maintaining the standards for postgraduate medical education, for certifying specialist physicians and surgeons in Canada and for promoting their continuing education. The College sets the criteria for the designation of a specialty; develops and defines the educational objectives and national standards for medical, laboratory and surgical specialties; accredits the specialty training programmes and conducts examinations for certificates of qualification in medical, laboratory and surgical specialties and subspecialties. In Canada, the five years of approved training in otolaryngology are divided into two sections. The first two years involve core training in surgery, in which up to 12 months must be spent in otolaryngology or related designated specialties. The following three years must be of approved resident training in otolaryngology and may include six months in clinical or basic research in a department approved by the Royal College of Physicians and Surgeons of Canada QUALIFICATIONS SPECIFIED BY THE HSE FOR POSTS OF CONSULTANT OTOLARYNGOLOGIST The following qualifications are specified by the HSE for consultant appointments in otolaryngology: Consultant Otolaryngologist (a) Full registration in the General Register of Medical Practitioners maintained by the Medical Council in Ireland or entitlement to be so registered and (b) The possession of the Fellowship in Otolaryngology of the RCSI or a qualification equivalent thereto and (c) (i) Inclusion on the division of otolaryngology of the Register of Medical Specialists maintained by the Medical Council in Ireland 10

13 Otolaryngology Services.qxd 26/09/ :25 Page 13 or (ii) Eight years satisfactory postgraduate training and experience in the medical profession including six years in otolaryngology Consultant Otolaryngologist with a special interest in paediatric otolaryngology (a) Full registration in the General Register of Medical Practitioners maintained by the Medical Council in Ireland or entitlement to be so registered and (b) The possession of the Fellowship in Otolaryngology of the RCSI or a qualification equivalent thereto and (c) (i) Inclusion on the division of otolaryngology of the Register of Medical Specialists maintained by the Medical Council in Ireland or (ii) Eight years satisfactory postgraduate training and experience in the medical profession including six years in otolaryngology and (d) including one year in paediatric otolaryngology. 11

14 Otolaryngology Services.qxd 26/09/ :25 Page 14 3 THE OVERLAP/INTERFACE BETWEEN OTOLARYNGOLOGY AND THE RELATED SPECIALTIES OF PLASTIC SURGERY AND ORAL & MAXILLOFACIAL SURGERY 3.1 INTRODUCTION Over the course of the committee s work, it became apparent that the nature and extent of the overlap between the three related specialties of otolaryngology, plastic surgery and oral & maxillofacial surgery was varied. While complementary for the most part; all share natural areas of overlap. While there is more overlap between otolaryngology and oral & maxillofacial surgery, 14 the areas of overlap are less clear than those between otolaryngology and plastic surgery. As regards the interface between otolaryngologists and oral & maxillofacial (OMF) surgeons, otolaryngologists mainly operate on the ears, nose, throat, salivary glands, lymph nodes, upper respiratory tract and cancers of the head and neck while OMF surgeons deal mainly with fractures of the jawbone, mandible and orbit as well as carrying out dental work (realignment etc.). Plastic surgeons are involved in the restoration of form and function of congenital, traumatic and acquired conditions. An example of the crossover between the specialties occurs in the case of rhinoplasty (nose realignment). This procedure is typically classed as cosmetic surgery, leading to the perception that such work is done by plastic surgeons only whereas such surgery may also be undertaken by otolaryngologists (e.g. in relation to the septum) and OMF surgeons. In some cases, training and manpower resources etc. will determine which surgeon (i.e. from which of the three specialties) does which surgery. Comhairle suggests that there should be clear clinical guidelines and a consensus regarding protocols in this regard. Areas where significant overlap between OMFS and plastic surgery occurs, and where otolaryngology input may also be required, include cleft lip and palate surgery and craniofacial surgery. In these cases, multidisciplinary teamwork, including OMF and plastic surgeons is vital. These particular issues are dealt with in greater detail in the committee s reports on Plastic Surgery and OMF Surgery. 3.2 HEAD AND NECK SURGERY In Ireland, the majority of head and neck surgery is performed by otolaryngologists. This is also the case in North America. However, in the UK, head and neck surgery is also carried out by oral & maxillofacial surgeons. OMF surgeons play a complementary role in head and neck cancers e.g. neck dissections for oral cancers. The primary centres for head and neck surgery are Dublin (St James s, Beaumont and Mater Hospitals), Cork and Galway. 3.3 HEAD AND NECK CANCER In Ireland, the vast majority of head and neck squamous cancers are treated by otolaryngologists, who also treat salivary gland cancers. Thyroid gland cancers are treated by both general surgeons and otolaryngologists while lip and skin cancers are treated by plastic surgeons and less commonly by otolarygologists 15. The committee is aware that the treatment of head and neck cancer in Ireland is similar to that in North America and differs from that in the UK vis-à-vis which specialists treat head and neck cancer patients. In the UK, head and neck cancer surgery is primarily undertaken by plastic surgeons as distinct from otolaryngologists, whereas in Ireland, as in North America, otolaryngologists are usually more involved in the treatment of head and neck cancer. This may be due, in part, to the fact that many of the consultant otolaryngologists in Ireland have trained in North America. The committee feels that the question of a common training base is a matter for the training bodies. The issue of head and neck cancer surgery is further addressed in section 6.4 of this report. 12

15 Otolaryngology Services.qxd 26/09/ :25 Page 15 4 PREVIOUS COMHAIRLE NA NOSPIDÉAL REPORTS 4.1 REPORTS Comhairle na nospidéal has published a number of reports on otolaryngology services. Its report on the Development of Ear, Nose and Throat Services was published in November Subsequent reports, in 1990 and 2000, dealt with ENT Services in the Southern Health Board area and Cork City & County, respectively. A report in 2000 dealt with ENT Services in South East Dublin. 4.2 COMHAIRLE NA NOSPIDÉAL REPORT DEVELOPMENT OF EAR, NOSE AND THROAT SERVICES NOVEMBER The 1983 Comhairle na nospidéal report, entitled Development of Ear, Nose and Throat Services recommended a ratio of 2 ENT consultants per 200,000 population It proposed the establishment of three designated ENT units in which specialised services, over and above those available in standard units, would be developed. Two of these designated units would be based in Dublin, at St James s Hospital on the southside, and Beaumont Hospital on the northside, with the third unit being based in Cork. The report recommended that each health board area should have its own locallybased ENT unit. The position in 1983, the recommendations of the report in terms of consultant manpower and the current situation are outlined in the following table: REGION & CONSULTANT RECOMM- CURRENT IMPLEMENTATION CURRENT CONS. / CURRENT POSTS ENDATIONS CONSULTANT (current consultant POPULATION POPULATION A (MAY 1983) OF 1983 ESTABLISHMENT establishment as % RATIO (base region) REPORT of recommendations of report) East %+ 1/77,000 1,401,441 (incl. 4 paediatric) Midlands %+ 1/75, ,363 Mid-west % 1/113, ,591 North East n/a n/a 344,965 North West % 1/111, ,574 South East % 1/141, ,616 South % 1/145, ,356 West % 1/127, ,297 TOTAL %+ b 1/112,000 3,917,203 Notes: a 2002 Census figures 16 b The total number of consultant posts recommended has been reached. Extra posts have since been approved by Comhairle in the Midland Health Board and the ERHA region. However, all of the specific posts recommended have not yet been put in place. 13

16 Otolaryngology Services.qxd 26/09/ :25 Page With the exception of the southern region and the north eastern region, these recommendations, in terms of consultant staffing, have been implemented. The details of the recommendations are as follows: Eastern region: Government policy at the time envisaged that services in Dublin would be organised on a North Dublin/ South Dublin basis, with three major hospitals on each side of the Liffey i.e. Beaumont, the Mater and James Connolly Memorial Hospitals on the north side and St James s, St Vincent s and Tallaght Hospitals on the south side. In July 1980, the Minister for Health announced a new strategy for the future provision of specialty services that would not be based at every hospital. ENT was one such specialty. The level of activity of specialty units was graded as regional, hospital or service. The regional unit would represent the highest level of service provision. The hospital unit would consist of consultants, beds and out patient clinics. The service unit would comprise out patient facilities and beds as appropriate, for minor procedures, with regular consultation from staff from the nearest regional unit. In July 1980 the Minister decided that in North Dublin, a regional unit should be provided at Beaumont Hospital with service units at the Mater and James Connolly Memorial Hospitals. In South Dublin, he decided that there should be a regional unit at St Vincent s Hospital and at St James s Hospital and that a service unit would be appropriate to the (then) proposed Tallaght Hospital. In its 1983 report Comhairle recommended that the Royal Victoria Eye and Ear Hospital should be incorporated into St James s Hospital, with corresponding joint consultant appointments. It further recommended that the St James s unit function in close association with the paediatric ENT beds at Our Lady s Hospital for Sick Children, Crumlin. Comhairle further recommended that St Vincent s Hospital should continue as a hospital unit and its consultant ENT surgeons should provide out patient clinics at St Columcille s Hospital, Loughlinstown. It was recommended that Tallaght Hospital incorporate a hospital unit and that the small inpatient units at St Michael s Hospital, Dun Laoghaire and Monkstown Hospital should be phased out and replaced by service units Midland region: It was recommended that a regional centre at Tullamore Hospital, staffed by two consultant Otolaryngologists, serve the population of the midland region Mid Western region: At the time of publication of the 1983 report, tentative plans were underway to provide a new voluntary general hospital in Limerick and on this basis, a recommendation on the location of the ENT unit for the region was deferred pending a final decision on the provision of hospital services in Limerick. However, Comhairle recommended the appointment of an additional consultant to the region, to be based at Limerick Regional Hospital, where a regional centre had already been developed North Eastern region: Comhairle recommended that a minimum-scale ENT unit, staffed by two consultant otolaryngologists, should be located at the new Cavan Hospital and that regular out-patient ENT clinics should be provided at all of the general hospitals in the North Eastern region North Western Health Board: It was recommended that Sligo General Hospital, with two consultant otolaryngology posts, should continue as the centre for the region as a whole, except for limited paediatric services at Letterkenny (which were provided by a Consultant from Altnagelvin Hospital, Derry). Out-patient clinics would be provided at Letterkenny Hospital. 14

17 Otolaryngology Services.qxd 26/09/ :25 Page South Eastern region: Comhairle recommended the continuation of the services at Waterford Regional Hospital, provided by three consultant otolaryngologists Southern region: At the time of the publication of the 1983 report, it was intended that the future provision of general hospital services would be at two hospitals - the Cork Regional Hospital and a second, large general hospital, to replace the five existing voluntary hospitals. Comhairle recommended, as an interim arrangement, pending the provision of the proposed second hospital, that the major ENT unit should be developed under the Cork Voluntary Hospitals Board at the Cork Eye, Ear and Throat Hospital with a small number of beds being provided at Cork Regional Hospital and with joint arrangements for services at consultant level. It was further recommended that the small ENT units in the Mercy and the North and South Infirmaries should be phased out and that the in-patient ENT services at Mallow Hospital should be phased out. The plans for a new, second general hospital did not proceed and ENT services were assigned to the South Infirmary-Victoria Hospital in 1987 in the context of the Government s hospital rationalisation programme. The 1983 Comhairle report recommended that, given the distances involved, the consultants based in Cork city should conduct regular outpatient clinics at the general hospitals at Tralee, Bantry and Mallow Western region: Comhairle recommended the continued development of the unit already established at Galway Regional Hospital, to serve the needs of the Western region as a whole in close association with the medical school at University College, Galway. 4.3 COMHAIRLE NA NOSPIDÉAL REPORT REPORT OF THE COMMITTEE ON ENT SERVICES IN THE SOUTHERN HEALTH BOARD AREA NOVEMBER 1990 The report recommended, inter alia, a complement of four consultant ENT surgeons at the designated regional unit, Cork Regional (University) Hospital; that the ideal consultant/population ratio was 1 consultant per 100,000 population; and that a formal Joint Department of Otolaryngology should be set up. As an interim arrangement, the committee recommended the existing resources and facilities in the South Infirmary-Victoria Hospital, the Cork Regional Hospital and the Mercy Hospital be pooled in order to facilitate the provision of an increased and more comprehensive service than currently exists. Specifically, the committee recommended (i) that complex ENT procedures and emergency ENT work should be carried out in Cork Regional Hospital; (ii) elective ENT surgery on adults should take place in the South Infirmary-Victoria Hospital; and (iii) elective ENT surgery on children should take place in the Mercy Hospital. It was further recommended that in-patient otolaryngology at Mallow Hospital be phased out. 4.4 COMHAIRLE NA NOSPIDÉAL REPORT DEVELOPMENT OF ENT SERVICES IN CORK CITY AND COUNTY JUNE 2000 The report recommended an increase in consultant manpower from three consultants to four consultants and that, as an interim arrangement, the South Infirmary-Victoria Hospital should be developed as the regional ENTHNS unit, pending the relocation of the unit to Cork University Hospital or to a new hospital. There were then two consultant otolaryngologists serving the population of Cork city and county and a third was approved by Comhairle na nospidéal in November The report reiterated the recommendations of previous Comhairle reports that inpatient otolaryngology services should be phased out at Mallow General Hospital but that sessions should be provided there for day surgery, ward consultation and outpatient clinics. 15

18 Otolaryngology Services.qxd 26/09/ :25 Page COMHAIRLE NA NOSPIDÉAL REPORT OTOLARYNGOLOGY IN SOUTH EAST DUBLIN 2000 Arising from a joint application from Crumlin and St Vincent s Hospitals for a replacement post of Consultant ENT Surgeon, a meeting was held in January 2000 with service providers to discuss the application and ENT services in South East Dublin generally. In order to bring about a rational development of services, it was agreed that there should be three posts including one with an academic component. In April 2000, the replacement post was approved with a designated special interest in paediatric otolaryngology, the first special interest to be formally designated in the specialty. In October 2000, a joint application from the Royal Eye and Ear Hospital, St Vincent s University Hospital and University College Dublin for a post of consultant/professor was approved. 16

19 Otolaryngology Services.qxd 26/09/ :25 Page 19 5 EXISTING OTOLARYNGOLOGY SERVICES 5.1 NATIONAL DISTRIBUTION OF OTOLARYNGOLOGY SERVICES Otolaryngology is one of the oldest of the surgical specialties. Otolaryngology services are provided in every health board region in Ireland, with Comhairle approved consultant posts being based in each region except for the northeast. There are currently 36 Comhairle approved permanent posts of consultant otolaryngologist in publicly funded hospitals in Ireland, including four posts of consultant otolaryngologist with a designated special interest in paediatric otolaryngology. Eight posts (five replacement and three new) of consultant otolaryngologist and two posts of consultant otolaryngologist with a special interest in paediatric otolaryngology (one new and one replacement) have been approved during the lifetime of this committee. The committee stressed during the consultation process that its work would not inhibit the processing of permanent applications by Comhairle na nospidéal for consultant posts in Otolaryngology There has been little improvement in the number of consultant posts in otolaryngology since the publication of the previous national review of services by Comhairle in 1983, relative to other specialties in the same period. There has been a 25% increase in consultant numbers in otolaryngology since 1983, compared with 67% across all specialties. Despite the long waiting lists and waiting times associated with otolaryngology, the appointment of additional consultants in this specialty has not always been a priority in many hospitals vis à vis other specialties. The consensus view is that the specialty needs significant development in the context of long waiting times and equity for all patients, as highlighted in the Government Health Strategy Figure 1 compares the distribution of the state population with that of public consultant otolaryngology posts in Ireland. The population of the eastern region represents 35.7% of the total population of Ireland and has 18 (50%) of the consultant otolaryngologists. It should be noted that a significant amount of complex otolaryngology procedures are carried out at the Dublin hospitals and these hospitals have become referral centres for the rest of the country as a result of the particular expertise of individual consultants. This number includes one post dedicated to cochlear implants and four otolaryngologists with a designated special interest in paediatric otolaryngology who treat children from all over the country. The northeast region comprises 9% of the state population but has no approved post of consultant otolaryngologist. 17

20 Otolaryngology Services.qxd 26/09/ :25 Page EAST Population: 1,401,441 The eastern region comprises counties Dublin, Kildare and Wicklow. Otolaryngology services, both in-patient and out-patient, in the Eastern Region are provided by eight acute general hospitals, including two separate childrens hospitals, in addition to the specialised Royal Victoria Eye and Ear Hospital (RVEEH). Out patient facilities are also available at three further hospitals Connolly Hospital, Blanchardstown; St Columcille s Hospital, Loughlinstown; and St Michael s Hospital, Dun Laoghaire. There are eighteen consultant otolaryngologist posts in the region. Six of these have sessions to the paediatric hospitals. The posts and their sessional commitments are set out hereunder; CURRENT POSTS BEAUMONT CONNOLLY MATER TEMPLE ST ST VINCENT S RVEE ST JAMES TALLAGHT CRUMLIN OTHER (RCSI) (RCSI) * (11) (St Luke s) (paed) (paed) (paed) (UCD) ** (St Luke s) (paed) 4 7 Total (sessions/wk) Beaumont CH Blanch Mater Temple St. St Vincent s RVEE St James s Tallaght Crumlin Other * Post 4, with 11 sessions at Beaumont Hospital, is devoted to providing a national cochlear implantation service and for that reason has been omitted from the calculations above. ** Post 15 is designated as a Clinical Professor with a link- though no formal sessions to Trinity College Dublin. 5.3 MIDLANDS Population: 225,363 There are three posts of consultant otolaryngologist in the midlands, all based at Tullamore. The catchment area is served by out-patient clinics, which are held at Portlaoise, Mullingar, Longford and Athlone. 5.4 MID-WEST Population: 339,930 There are three consultants in the mid-west, all based at Limerick Regional Hospital. Each consultant is responsible for the provision of outpatient clinics at one of the other general hospitals in the region Ennis, Nenagh and St John s. 18

21 Otolaryngology Services.qxd 26/09/ :25 Page NORTHEAST Population: 344,965 There is no Comhairle approved post of consultant otolaryngologist based in the northeast. An otolaryngology service is provided at Drogheda by an otolaryngologist in a non-comhairle approved post. In addition, weekly outpatient services are provided in Cavan/ Monaghan Hospital by a Northern Ireland based consultant who is registered with the Irish Medical Council for these services. Some patients from these hospitals are referred to Tyrone County Hospital, Omagh (50 miles from Cavan) for in-patient and day-case surgery. Approval for these arrangements has not been sought from Comhairle na nospidéal or the HSE. 5.6 NORTHWEST Population: 221,574 There are two consultant posts in the northwest, both of which are based at Sligo General Hospital. Weekly day case surgery (non-general anaesthetic) and out-patient clinics are provided at Letterkenny Hospital. 5.7 SOUTHEAST Population: 423,616 There are three consultant posts in the southeast, all of which are based at Waterford Regional Hospital. Weekly out patient clinics are provided at Wexford, Kilkenny, Carlow and Clonmel. 5.8 SOUTH Population: 580,356 There are four consultant posts in the south, one based at Tralee General Hospital and the other three based at the South Infirmary-Victoria Hospital, Cork, reflecting the interim arrangement outlined in the 2000 Comhairle report. The posts are structured as follows (sessions per week), Sessions per week South Infirmary-Victoria CUH Tralee Post Post Post Post 4 11 Total Surgery (inpatient and day case) and out patient clinics (4 sessions per week) are provided at Mallow General Hospital by a temporary ENT consultant in a post that is not approved by Comhairle na nospidéal or the HSE. 5.9 WEST Population: 380,297 There are three consultant posts in the west, all of which are based at University College Hospital, Galway. Out patient services are provided in Roscommon County Hospital (1/week), Mayo General Hospital, Castlebar (2 weekly and 2 monthly), and Portiuncula Hospital, Ballinasloe (2/month). 19

22 Otolaryngology Services.qxd 26/09/ :25 Page SPECIAL INTERESTS WITHIN OTOLARYNGOLOGY The consultant otolaryngologists working in the public hospitals in Ireland have a wide range of specialised expertise in different areas of otolaryngology including, otology, head and neck oncology, paediatric otolaryngology, rhinology, neuro-otology and cochlear implantation. Some of these subspecialty interests have been formally designated to specific posts by Comhairle na nospidéal while others have developed on the basis of the expertise of the appointee to individual general posts OTOLARYNGOLOGISTS IN FULL-TIME PRIVATE PRACTICE There are six ENT specialists in private practice two in Dublin, two in Cork, one in Kilkenny and one in Tralee DISTRIBUTION OF NCHD POSTS IN OTOLARYNGOLOGY There is a total of 66.5 non-consultant hospital doctor posts in otolaryngology in Ireland. There are 21 training places recognised by the SAC as suitable for SpR training in Otolaryngology but only 7 are accredited for the total duration of training (i.e. years 1-6). According to the PGMDB figures below there were, in fact, 23 SpRs in post as at 1st October The NCHD posts are distributed by hospital and grade as follows, HOSPITAL SHO REGISTRAR SPR TOTAL CONSULTANT CONSULTANT NCHDS POSTS (WTE) POSTS: NCHDS Beaumont :1 Crumlin :2 Limerick Regional :2 Mater :1 RV Eye & Ear :3.4 Sligo General :3.5 St Vincent s :1.5 South Infirmary-Victoria :3 Tallaght / St James s :1.7 Temple Street :1.3 Tralee :3 Tullamore :2 UCHG :1.33 Waterford Regional :2 Total * 1:2 Source: Postgraduate Medical & Dental Board NCHD Staffing and Comhairle na nospidéal Consultant Staffing * Excludes university and notional sessions 20