This is the second episode of our mini-series looking at the UK’s earwax crises.

Across 4 episodes you’ll hear from specialists who have come up with innovative ways of treating patients. 

In this episode, Julia who is the Head of Audiology for Signia, speaks to Mark Newman, Head of Audiology at the Barking, Havering and Redbridge University Trust. Mark has managed to form an agreement with his CCG to fund their wax management through reimbursement, allowing his trust to have a full Audiology-lead wax care pathway. 

Got a question for Mark? Email him mark.newman7@NHS.net

Got a topic you think we should be talking about? Get in touch here: marketing.uk@signia-hearing.com

For more information about Signia UK and Ireland, visit: https://www.signia-pro.com/en-gb

Sounding it Out by Signia, is produced by Annie Day from Fresh Air Production.

FULL EPISODE TRANSCRIPT

[00:00:00] Julia: Hello and welcome back to Sounding it Out, a podcast dedicated to audiology, brought to you by Signia UK and Ireland. I'm Julia van Huyssteen, your host and Head of Audiology at Signia. This is the second episode of the miniseries about the wax management crisis we are facing here in the UK. As we discussed in the last episode, the situation started to deteriorate in 2019 when the British Medical Association decided it would no longer be considered part of the core services GPs were obliged to provide. It's created a postcode lottery for patients suffering from ear wax, the RNID, or Royal National Institute for Deaf People are concerned that the situation is risking people's hearing health with hearing loss, earache, tinnitus, and dizziness as some of the symptoms. In the last episode, I spoke to Frankie Oliver, audiology advisor at RNID about their worries.

[00:01:06] Franki: I don't think we can really overstate the risks that people compose when, they are forced to try and remove wax themselves. People are being forced to do this because private removal is either inaccessible or too expensive or they're just not able to access any care on the NHS . So people are using dangerous methods to try and remove wax, and then this is posing your risk to the really delicate anatomy of the middle ear and therefore posing a risk to someone's hearing.

[00:01:34] Julia: If you missed the conversation, you can go back and listen for free. In this mini-series we're speaking to people in the profession who have come up with some innovative solutions. I'm going to be joined by people who have found new and inventive ways of tackling the problem in their trusts and we will draw on that expertise.
My first guest is Mark Newman, who is the Head of Audiology at the Barking, Havering and Redbridge University Trust. Hello, Mark. 

[00:02:06] Mark: Hello, Julia, and thank you for asking me along, 

[00:02:09] Julia: Mark, you've taken a really fresh approach to tackling earwax management in your trust, can you explain what you've done and why it was needed please?

[00:02:18] Mark: As with a lot of audiology departments, we were very frustrated at seeing our patients come through the door for our GP direct access appointments, and also seeing our existing patients where they'd have problems with their hearing aids and we would find wax in the ears and also a lot of our direct access patients are being triaged over the phone by the GPs having a telephone appointment, them being sent through to us with, not even looking in the year. It's always been frustrating thing for us as caring clinicians trying to provide good care for our patients, having to just stop the appointment and send them back to the GP knowing full well, but the services weren't really there to help them.
We found that between about 12 and 14% of our patients, although this could vary, were coming in with wax at one point or other. The problem is, as change takes a long time within the NHS , but I was very determined to see this one through seeing these patients in my clinics, I could share with their frustration as to how long this whole process took, and it just wasn't very satisfactory for me as a clinician trying to provide care as well.
So what I managed to do was actually negotiate a audiology led wax removal clinic, with a full blessing of the ICBs as they are now, or the CCGs as they were then which was, meant we had a fully funded audiology led wax removal clinic. 

[00:03:40] Julia: Wow. So my next question then is, of course, going to be how you managed to get this agreement with your CCG, how did you go about conversations and what arguments that you used to justify the cost?

[00:03:51] Mark: I was quite lucky because I've only been in this department about four years, but we're doing an awful lot of change and we're trying to make, and just trying to shuffle things around really and make things a bit better for the patient.

So during that time I've already managed to get a good line of communication with the CCGs or ICBs as they are now, of course and I was already attending a couple of the meetings, which is quite important to get a foot in the door. It's actually very difficult as this line of management to actually get access to the people who can make the decisions.

So sometimes you need to do a little bit of manoeuvring and ensure you're in the right meetings with the right people in order to make effective change. During that, I was able to add the wax removal process to the to the agenda. I'd already done my research. I had all my stats. I had all the kind of quality data to show the need.
And of course, on these meetings were representatives from the GPs, so I was able to draw on the GPs frustrations with the management of wax, and they were a very good voice in terms of supporting my cause. And also I asked a few patients just to put a few notes to me so I could quote them as saying look, these are from real life patients.

These are their frustrations and their issues. It would alleviate an awful lot of pressure on the primary care. So just through, basically through these meetings, I was able to demonstrate there is a dire need for the wax removal. I was able to demonstrate what we had capacity and I was able to demonstrate, but we would be able to do a good and professional job by taking the wax out.

It also helps to clean up the process, as well, so instead of all this boomeranging about, I believe, referred to earlier, it would be like a bit of a one stop shop. Sometimes we were able to take the wax out on the day, but obviously we're all running very busy clinics. So what we'd normally do is ask them to use drops for between week and a half, and then book them into the following week. What we were able to do at that time, keeping things very flexible the timetable helps, I was able to do a hearing test and a, like a DR continuation appointment immediately after taking the wax out, there was a consideration about temporary threshold shifts, but on the flip side, it was like, in terms of patient access and in, in terms of trying to provide that one stop shop model, it was deemed more appropriate, both clinically and for patient convenience to actually do the wax removal and then do the, the appointment soon or soon after.

We'd normally have about half an hour gap to allow the patient to go and get a cup of tea, and just reboot for the next part of the appointment. 

[00:06:25] Julia: So what I'm hearing there is that you were able to, through these conversations and being involved in the meetings that mattered to have a voice, you were able to talk about the benefits for the GPs, the benefits for the patients, the benefits for ENT for your department. So really having a multi-angle approach to demonstrate the benefit of this wax setup that you have. 

[00:06:47] Mark: That was very important, Julia. So essentially you're trying to demonstrate how obviously the CCGs and the ICBs, they're mostly concerned with money. So when you think about how much money it would cost for the GP to see this patient for the second time, for them to send them on to say an ENT consultant, we don't need ENT consultants taking wax out of people's ears.
It's quite ridiculous to be charging that as a consultant outpatient appointment and the cost and time to the patient as well and the , inconvenience of attending multiple clinics multiple times because we feel like, there's an assumption that a lot of our patients are retired with nothing to do on their hands.

But of course we see patients from all walks of life and people are very busy nowadays. So it was about actually making clear the savings, but people could find, and that's in cost of saving in time for the GPs in primary care, in the ENT consultations, and of course with us, at least, if they're referred to our servic , then at least we can actually take care of them. The other thing is, the feedback I was getting from the GPs is that they just want to say, this patient has an ear problem, can you please deal with it? We don't really want them coming back and forth. You don't really need to ask for our permission to do this or that or the other.

This isn't patient with an ear problem regardless of the cause. It'd be really good if you could just sort it all out, and I think that was a very attractive proposition which I, managed to paint the picture to the ICBs, which allowed them to, , pass this through. And the savings, in terms of the costings, I was putting it roughly against the cost of staff and administration and rooms and so on and so forth.
But throughout the NHS we use HRG codes and I was able to adapt that as a template. and the CCGs were quite happy with the cost I came up to, which I couldn't actually reveal obviously, cause that'd be... but yes, it was quite amenable all round. 

[00:08:46] Julia: Thank you for that, Mark and I'm sure that our listeners will take lots and lots of really good information and advice away from that because there's many steps to, the answer that you've just talked me through.
I'm interested though, how long has the service been going, the audiology led wax service, and you talk about all the steps that you had to go through, when did you start the process with your CCGs? How long did the whole thing take? 
[00:09:10] Mark: So the whole thing probably took about a year and a half. Maybe a little bit longer. It wasn't easy it was just a huge amount of persistence. There were several points where you felt you were just banging your head against the wall. There were several times where me and my deputy thought, we are really trying this and not getting anywhere. We could just open up a private wax removal business ourself and then retire in our fifties,

I think given the amount of people coming through our doors with wax, however, it did take about year and a half really. It has to be signed off by contracts. It has to be signed off by finance, by the senior management here, the senior management over in the CCGs and ICBs. And there was a few other bits and pieces.
So our actual wax removal service has been going on for nearly two years now. I think we kicked it off in, January of 2020. We had a few mock test clinics, going back to say, October the year before. We were also quite keen to make sure we gave a quality service and to give assurance to, other audiologists in the department, but also the ENT and our senior management.

So as such, we did a few test ears under the, under the care of the ENT. A lot of audiologists had already incidentally been taking wax out for nine or 10 years or longer. But we thought just to go through a kind of a reassurance and kind of a clinical assurance program with ENT we demonstrated before and after pictures talk through any complications on how we'd manage them, and they were quite happy to sign off on that.

[00:10:48] Julia: Great success so far with your audiology led wax clinic. You mentioned earlier that there were times where you were banging your head against the wall. Can you share some additional examples too, with our listeners, of the main barriers that you faced during this lengthy process, you mentioned a year and a half, and maybe give them some advice, some practical advice on how to overcome these, because no doubt if somebody's listening to this podcast, episode and they are thinking about following in your footsteps or your example, so to speak, they would want to have some shortcuts because you've already been through the process.

[00:11:24] Mark: Oh yeah, sometimes it's a little bit difficult to create any obvious shortcuts, but for certain you need to highlight and illustrate the problem, which is, known, but also you've gotta provide the right solution. So getting that strong voice, both from your patients, from yourselves, from the GPs, all helps.
You really have to demonstrate your vision, though. Sell that idea. You need to demonstrate to your management that you've got the capacity. You need to demonstrate how money will be saved. Again, managers listen when you tell them that they're going to save money, if you say, Okay, we do a quick audit of your ENT clinics, how many of these referrals have been just for wax removal? Your ENT consultants could be doing something much more worthwhile with their time. We can take on that work with the caveat of course, but we are doing the more straightforward work and leaving the more complex stuff to the ENT.

[00:12:20] Julia: Just out of interest, was there any surprises along the way in terms of barriers, any strange protocols or procedures or questions that you were not expecting? I'll give you an example, of a particular trust that was interested in trialling the Earways Pro tool, which we'll talk about a little bit later, and they, health and safety picked up on the fact that within their booths they have carpet on the floor, and of course we know that audiologically, when we perform a hearing test, we don't want many reflective surfaces. So that was a little bit of a surprise to them. Have you had anything strange, like that pop up in your experience?

[00:12:54] Mark: As a, as audiologists, I think we're used to all these like little random things, that do pop up from time to time. Certainly the carpeted rooms would be an issue, thankfully, we've got a mixture of both carpeted rooms with the booths and more kind of straightforward clinic rooms with Lino. We'd already got or procured a kind of a dentist chair type thing. Really, you just have to make sure that your communications are good. You would be surprised that the number of people who come out the woodwork when these things, go into production, as it were, one of the things we had to make sure, for example, but all the data was being collected efficiently from our clinics.

That meant talking with the guys who pull the information off the back of Auditbase, for example, and ensuring that they match that against the HRG codes. So you're trying to get finance guys to talk to the data guys and come up with solution, but works for everyone. And then there's always little sort bits and pieces. Make sure you've got your infection control guidelines done and dusted. Make sure you've got your SOPs in place. Make sure you communicate widely with ENT and the team. To ensure that you are getting the right sort of patients. So we spent a lot of time just refining our, referral criteria.

[00:14:16] Julia: So Mark, you mentioned earlier about the DMO one. In real life. , how did you manage expectations in terms of delivering , the hearing test within six weeks? 

[00:14:27] Mark: So this is actually quite a big thing. As we know, we are held to account on both our DMO one, which is our diagnostic pathway. Which means we have to see patients within six weeks and our RTT referral to treat, which is the 18 week pathway.

One problem we had with try and obviously deliver the service within six weeks to include the wax removal was that we might see them at week three, which is not too shabby, but by the time we actually got them in, , and spent a week and a half actually doing the oil and the drops or whatever we'd recommend, , we were really pushing the six week margin.

As such, I was able to negotiate an exemption from the DMO one for these patients, which meant that in a similar manner to a surgeon having to see, , a patient and saying look, yes, you are very much suitable for, say, knee surgery, for example, I want to get your heart rate sorted out first, or we'd like you to lose two or three stone to make it more beneficial to you in the long run and to save the, any kind of clinical complications  when we're operating, I was able to use a similar mechanism to say, we're gonna we can't pause the DMO 1 , but they're actually exempt from the DMO one now because we have demonstrated that we are unable to complete the hearing test due to the wax being present.

This in fact meant that we were able to see them, let's say week three, identified the wax and we're able then to take the wax out and then continue the testing and continue the direct referral appointment, but without having to worry about actually get them getting them in within the six weeks.

We did try, for the most part, most of our patients get seen within that six weeks, but obviously with annual leave and sickness and so forth, it was just nice to have that little bit of, head room so that if we did go over the six weeks, we wouldn't actually suffer any consequences for that.

This meant that the actual service was actually viable, because obviously if we had to do everything within six weeks, that would make it very challenging to deliver that. So this was actually quite a critical point. Getting those patients exempt meant we was able to deliver the service, without any dire consequences of running over the six weeks.

[00:16:35] Julia: So kudos to you for making it all happen, and I am sure that there's many listeners that will take inspiration from your advice. Just out of interest how big is your department and how many audiologists are delivering this audiology led wax service? And did you have a certain selection criterion that you use to select these audiologists? Do they have the, have a certain band or training? 

[00:16:59] Mark: So we are not the biggest department in the world, but we also would just , have a kind of high volume of patients through. We had about three or four audiologists delivering the service, and obviously people come and go. So we had the plan in place to do a continual training.

A lot of audiologists had been taken wax out previously in different trusts. And coincidentally, I had met my deputy Jonathan about a year and a half before I joined the department at a wax removal training session. So we made sure all of our audiologists had some relevant wax removal training.

Made sure that was all up to date, made sure they were confident, made sure we had ENT review our work, review our techniques and are happy with that we could provide a safe service and were confident in using the equipment. In terms of banding, we'd be band six or above and it just make sure they had some relevant training.

We'd obviously have a little bit of a couple of sessions sitting in with them. We'd do a little portfolio again just to run past me and the deputy and also ENT to ensure that everybody's happy and that the audiologists are comfort and they feel safe doing the doing the clinics. 

[00:18:11] Julia: And whilst we're on the topic of audiologists, I wonder how they've responded to this audiology led wax removal service. Was there any objections before? Was there anything in particular that they liked or disliked about this new service? Did you have to do lots of convincing for the audiologist within the department in terms of the value to the department all? 

[00:18:33] Mark: So the audiologists found this an absolutely fantastic idea and they were so happy when it is actually implemented. We all had massive frustrations with trying to see these patients and we really want to help them and sometimes, we'd allowed extra time in our appointments, because we found that a lot of patients had a lot to say. We forget that at the time this was being launched was all coming out of like post covid and all this sort of thing, and our patients have had a horrible time and then a massive wait to see the GP and then to actually look in their ears and see wax it's so frustrating. So it was really nice to be able to provide this service for them. We sat down with the whole department, we went through the criteria we took on board any suggestions or ideas, that they had as a group, which was fabulous. because it just, , posed a few questions maybe we hadn't thought about and that just goes to show the importance of kind of involving the team as a, as a wider decision making process. 

[00:19:30] Julia: So yeah, it's important to get the buy-in from the team too, and that we can see that because you've had that. They are happy with how the service runs at the moment. I'm just interested also to see or hear whether you've had to create any extra capacity for your wax removal clinic.

So I'm thinking did you have to recruit any extra staff? Did you have to think about your, mentioned earlier that you had some rooms that was already suitable for it, but did you have to find some additional clinics in the diary. So how did that all work in terms of capacity? 

[00:20:03] Mark: Capacity is often an issue across the audiology world as we're often forgotten about until too late and then we are shoved in some basement or random part of the hospital, which is certainly the same for us. However, we are quite lucky in as much as, a lot of the audiologists we had working, myself included, were very keen to do the wax removal clinics. We managed to find a bit of space in a suitable room. Capacity is an issue. We ultimately want to get to a direct access wax removal clinic, so the GPs can refer directly electronically from seeing the patient in front of them straight into our wax removal clinic against a certain criteria. But that is pending. 

[00:20:47] Julia: And also alongside whilst we are talking about patients, what is the feedback from the patients on this service? 

[00:20:54] Mark: So the service is available to all of our patients, primarily coming through the GP direct access route. Cause obviously they're the guys who really need the help most urgently, it might be worth picking up on the whole DMO one thing in a minute, but certainly we try and see as many of the patients as we can and also our existing patients who might come in for a retube or say that actually my hearing aid's not working. We check the hearing aid, everything's working with hearing aid. We're look in their ears and obviously it's block full of wax. We get those guys in as well.

The criteria is probably quite universal, but it's, we are only gonna do the bread and butter things, so any patients with any complex issues. We'd still go and see ENT. We gotta keep everything safe for the patient and ourselves as Audiologists. So I, we go through a brief history, make sure there's no ear pain, discharge, perforations, any operations, any kind of unilateral losses, history of epilepsy.
Just straightforward stuff like making sure they can keep their head still, and if they're able to get in and out of a chair. Because we might need to make the dentist chair, we have just rise up and down to ensure we can get a good view of the ears in terms of the patient feedback.

Patients have been genuinely really grateful, but we're able to do it. Unfortunately, we are here too often, but we have some quite bad experiences. Our patients have had from either the nurses or GPs try and take the wax out or unfortunately third party providers as well. They haven't always had the the best experience and they really did seem quite comfortable coming back to see us. 

Obviously we spent that time with doing all the history in the DR and it's nice to have that sense of continuation and we might not see them for the DR but we do the DAC, but we try and book them back with the same person they initially saw, if at all possible, just for that continuity.

So they're finding it really useful and not only the patients, but also the the relatives of the patients the husbands and wives and the, sons and daughters who are finding it very useful as we can start the audiological process of helping them with their hearing problems. 

[00:23:14] Julia: So all in all, really positive. I think you've got some stats for us about the number of patients that you were able to prevent being discharged back to their GPs because of your audiology led wax clinic. Can you share some of those with our audience? 

[00:23:28] Mark: Certainly, so we do run this about every two months or so. I haven't quite had the time recently to do the October and November ones and I didn't want to just make it up, but we did actually see 98 patients between August and September of this year in 2022, which was brilliant because it stopped nearly a hundred patients from having to go back to their GP and just all that extra time, if you think a hundred appointments in primary care say half of them going to ENT and all the wait time and you start doing the maths and you'll see it's actually been a really valuable service, which I'm very happy and proud to provide. 

[00:24:06] Julia: That's a staggering numbers really, if you think about it. Just as a out of interest, which wax removal tools do you and your department have in the toolbox and when would you select a certain tool over another.

[00:24:19] Mark: So we use a kind of a range of different tools within our arsenal for wax removal. Most of our audiologists, myself included, grew up I suppose with micro suction which is our first port of call. We also have various pulsing machines. I'm not too sure we can mention brands on here, but several are available and some are a little bit better than others which are handy for certain types of wax.

We do obviously say to our patients, do use oil. But sometimes they're either they either forget or occasionally they go, oh yeah, put it in this morning for you and didn't quite get the assignment on doing it for the week or so. So rather depends on the situation that presents in clinic, micro suction is our first port of call.
We also use the micro pulsing water, if that's indicated, but we've also started using the Earway Pro, which is a kind of a helical wax removal tool, which we've used with varying degrees of success. It does lend itself to getting us out of a little bit of trouble. I've used it a few times myself for certain patients and yeah, had some good results with it.

Last time I used it, I think I managed to get a partial removal, which was gonna be very difficult with micro suction, but that revealed a little bit of softer wax behind it, which I was unable to take out , much, much easier. Yeah, certainly a very good tool in our wax removal arsenal and we're certainly looking at expanding the use of this to our home visit service as which shows potential there.

This is pending a little bit of a clinical review. Because obviously the patients we see in their own homes tend to be those with slightly more difficulties or additional clinical issues, which may prevent them from being, having their wax taken out in the first place, but certainly something we're looking to explore.

[00:26:11] Julia: Thank you very much. And just for our listeners sake, in our last episode in this series, we will have a little bit more from a guest that has been using the Earways Pro tool for quite some time. So we'll have some more information on that for you too. Mark, and this is my final question for you, you mentioned earlier that when you want to make a big change like this, you need to show that there will be some money savings and that there will also be some capacity improvements. Are you able to share with our listeners some of the cost and time savings that you've had before you've changed over and compare it to how the current service works.

[00:26:49] Mark: It's a little bit of a tricky one. So obviously all this went into my kind of initial presentations to the CCG as it was then. I obviously didn't have the figures for how much does a, an appointment cost in a GP surgery because that can vary, although I did give it a bit of a Google of course, and of course we know, that the outpatient appointment for ENTs between about 120 to 180 pounds or something thereabouts, depending on the situation and the scenario. And just the, it was the cost of time really to the primary care and to ENT. And I think it was just a commonly held frustration, but we wasn't doing the right thing for the patient.
I think the CCG understood, but since they made those changes, it put massive pressure on primary care and of course massive frustration for the patients. They just want their wax out. They'll go to their GP in good faith thinking they can take it out. And they get told no, and then they get to refer to ENT and ENT say no, and then they just go round and round in circles. So I think presenting a good solid case, good solid idea, backed by actual figures and facts, that you can do this job and do it well. I think, they weren't so worried about me demonstrating the actual costs to them within the primary care service, but certainly I could just say, look, we could do this for a modest modest fee. And they were more than happy to do that with the all the other considerations taken on board. 

[00:28:18] Julia: Many thanks to you, Mark, for sharing your experiences and expertise. I've thoroughly enjoyed our conversation and I've learned a lot. I conclude that it takes fresh ideas, guts, determination, perseverance, and resilience to get a CCG funded audiology, wax removal clinic, and clearly you have all of those. Well done and long may you, your department and your patients benefit. 

[00:28:42] Mark: Oh, thank you, Julia. 

[00:28:43] Julia: If you are interested in any further information from Mark, you can contact him on mark.newman7@NHS.net. In the next episode, I'll be speaking to Nicola Phillips, the Principal Clinical Scientist and Head of Primary Care Audiology at Swansea Bay University Health Board. She'll be talking about a trial that the Health Board have been doing since 2016. 

[00:29:07] Nicola: All our patients access primary care audiology through their GP surgeries. In some practices, patients get triaged by the receptionist and book directly into audiology slots or the wax removal slots. In other practices, GPs will triage over the phone and then book them directly into clinics using a shared booking system.

Julia I'll end by reminding our listeners of the RNID campaign's priorities, and that is firstly for ear wax removal services to be brought back into primary care or community settings. Secondly, for the Department of Health and Social Care, NHS England and local health bodies to explore new models for delivering ear wax removal services to make sure people can access timely and appropriate treatment.

And thirdly, for the NHS to publish clear information on how people can manage ear wax build-up themselves at home. If you found any of what you've heard in these episodes helpful, please tell your colleagues so as many people as possible can share the knowledge. And if there's a topic you think we should be covering, drop us an email to the address on the show page and remember to follow wherever you get your podcast so you don't miss an episode.

This is a Fresh Air production for Signia UK and Ireland. Until next time, goodbye.