Welcome to part 3 of our 4 part mini-series about the UK’s earwax crisis.

We’re speaking to industry experts who have come up with innovative ways in their clinics for addressing the earwax problem.

In this episode, Julia speaks to Nicola Phillips, who is the Principal Clinical Scientist and Head of Primary Care Audiology at Swansea Bay University Health Board. 

Nicola and the team have come up with a system that enables patients with hearing, tinnitus or wax problems to be triaged directly to the Audiology Department – which then acts as the first point of contact, freeing up other general practitioners to see patients with more complex health conditions. 

Nicola would love to share her experiences so email her: nicola.phillips@wales.nhs.uk 

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

For more information about Signia UK and Ireland, visit their website

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 am Julia van Huyssteen, your host and Head of Audiology at Signia. This is the third episode of a miniseries about the wax management crisis we are facing here in the UK. In 2019, the British Medical Association decided it would no longer be considered part of the core services they were obliged to provide.

This has created a postcode lottery for patients suffering from ear wax. We've already spoken to the RNID or the Royal National Institute for Deaf People about their concerns. If you missed that conversation, you can go back and listen for free wherever you get your podcasts. We are also speaking to people in the profession who have come up with some innovative solutions.

Last time I spoke to Mark Newman, Head of Audiology at the Barking, Havering and Redbridge University Trust. He has managed to form an agreement with the CCG to fund their earwax management through reimbursement, which allows Mark's trust to have a full audiology lead wax care pathway.

[00:01:15] Mark: 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.

[00:01:23] Julia: If you missed the conversation, you can go back and listen for free.

My guest today is Nicola Phillips, who is the Principal Clinical Scientist and Head of Primary Care Audiology at Swansea Bay University Health Board. Nicola, hello.

[00:01:41] Nicola: Hello. Thank you for having me, Julia.

[00:01:44] Julia: So my first question to you really is about a paper that you co-authored very recently, and that has been published in the BMJ or as it used to be called the British Medical Journal. That's so exciting and congratulations. I'm really pleased for you and this paper details a trial that you've been running at the University Health Board. Can you please give our audience an overview of this paper?

[00:02:07] Nicola: Yeah. Thank you Julia. We are delighted to get the first ever primary care audiology publication and myself and the team are very delighted about that. The title of the article is Approved on Healthcare and Practice, an Integration of Audiology Services into Primary Care. So back in 2016, delivering audiology in a primary care setting was set up as a pilot project within the health board. The main aim of the service being enabling patients with hearing, tinnitus or wax problems to be triaged directly to audiology, acting as the first point of contact.

And it greatly benefits the patients as they're seeing specialists in hearing care within a matter of weeks, whilst also freeing up important time for GP and practice nurses. And we do see the amount of referrals being sent to ENT in secondary care, which as we know is very costly.

[00:02:55] Julia: Thank you very much for that, Nicola. So I was actually lucky enough to come and observe this primary care approach in person a month ago or so, and although the service runs like a well-oiled machine, for the most part, it has taken, as you say, a long time to get to this point. I think you mentioned the start date of being 2016. In your opinion, why do you think it has taken this long?

[00:03:18] Nicola: I think, delivering an audiology service within primary care had never been done before. So we needed firstly research, primary care activity, and then start collecting as much data as we possibly could because at that time, there's no data around for us to work with.

So we began the project in two of the eight GP clusters. This enabled us to audit the service to access its true potential before expanded further clusters. Once we had the information we needed, we be began to expand to the remaining clusters. The main challenges I feel were, highlighting the service and an audiologist being the best person for patients to see at the first point of contact we needed to educate patients into accessing new healthcare pathways.

Patients had always seen a doctor and initially they didn't like the thought of seeing anyone else. So I think getting that message out to patients and educating them in these new patient pathways was really important, I think still is important. We've worked really hard with our comms teams in the health board.

We've done some publications in local newspapers, websites, Facebook pages, things like that. Just educate the patients in the new way to access services. I think recruiting new

 staff as well and training staff was another challenge. It takes a lot to forward thinking, of planning and departments really need to start training staff to take on these roles used in advance.

And that that's what we did. We started thinking about this progression then - back in 2016, you have to train the staff over the period of time and it is very timely. The biggest challenge though, I think was acquiring permanent funding. This was a very challenging process indeed.

There are lots of board meetings to get these kinds of things passed through the health board, again, forward thinking is a must. Collaborative working using primary care and secondary care funding is how our permanent funding was achieved in June of this year. So I think it's just having that little… you know, thinking out of the box approach where you know, where you're a service in secondary care and primary care, utilize that knowledge of both parts of the health board and really think about how you can achieve the funding from different pots so you don't have to achieve the funding from one pot.

It can come from different parts and then all together, you can achieve the funding. So that's something that's worked really well in our health board. I'm not saying that would work for everybody, but it is something that's worked really well for us.

[00:05:32] Julia: Wow. That's a very comprehensive answer. Thank you so much Nicola, and so many angles that you would have to consider if you wanted to align with the approach that you and your trust have followed. Certainly some angles I didn't think about was the patient's response and how you had to re-educate them about accessing services not directly from their GPs . That wasn't something I thought about before and a really interesting point.

My next question is around the pilot project that you actually have just mentioned in your previous answer. How important do you think a pilot project is in terms of being successful? So do you think this is a vital first step for other trusts to consider if they wanted to have a primary care approach, or do you think they could simply build on the pilot that yourselves did? And maybe just putting together a strong business case purely based on numbers is good enough evidence?

[00:06:21] Nicola: Yeah, I think for us it was important cause as I said, it was the first time it had ever happened. There was no previous data available. We were the first audiology department to deliver an actual wax removal service, and a first point of contact service, we had no numbers or data to go on.

So we had to collect as much information as a we could. I can remember auditing spreadsheets upon spreadsheets and just looking at it for hours, collecting data in the beginning. It has been done now .We are one of the departments which are leading the way in primary care audiology with our colleagues up in North Wales as well.

And we are happy to give any help and advice and support to our colleagues nationally and setting up the services. I think that's something that we are really proud to be an example of. I think it's good to know every area will be different. Geographically some areas are much bigger and more spread apart, which may offer more challenges in setting up audiology services in primary care. But certainly we are happy to give any help or advice and provide any help with data collection wherever we can for our national colleagues.

[00:07:21] Julia: Wow, what a fantastic offer. And I hope that our listeners will indeed take you up on that because you've gone through this experience with some really rich information and help that you can share with anybody that's thinking about approaching wax removal or wax management in a primary care fashion like you have.

You make me smile when you were talking about the spreadsheets because it's something that I certainly don't have much interest in, but it's absolutely necessary when you do a pilot project like this. Well done you for persevering. You mentioned earlier that you ended, I think the previous question with that, the greatest barrier really was acquiring permanent funding.

And I understand - having an NHS background myself, how big a barrier this can be when you start up something new. So for our listeners' sake, which parties are important to involve in this process of getting funding? Who are the key stakeholders that you can approach right from the start and that you should think about and what's the right approach? Is email okay? Is a phone call okay? Is attending a GP meeting Okay? What are the different types of things that we need to consider when we are looking for acquiring permanent funding?

[00:08:28] Nicola: Yeah, I know. I think this will differ in different health boards but speaking from our experience, our funding is based on funding from both secondary care and primary care. The clusters, the GP cluster support the service as well as the health board. And this has worked well for us, so how they will be individual in health boards would be the most appropriate way of funding? I think, we set up from the beginning we went with a various that we wanted to gain a very good rapport with our , with our cluster leads, with our practice managers.

I think that's paramount in any primary care service. Cause without them on board, you're gonna really struggle in booking in patients and getting the service up and running etc, etc. There's so much that they need to help us with. So it's very collaborative working. And once you've got them on board we do work together.

And once you're doing a pilot project, they see the benefits, they see how that’s benefiting their GP time and they see how it's benefiting the patients and therefore they're much more likely to look at funding. So we ask our clusters, every GP cluster, for some funding. And then our health board, the secondary care section met some funding as well.

So yeah, we had to come in from a few different pots, but I think it, it worked really well and I think it is a good example of acquiring the funding, so yes that's our experience. I think meetings and any GP cluster meetings. I think any emails, it's always good to send emails cause there's an email trail.

But yeah, attending meetings face-to-face and speaking with cluster leads face-to-face or whether it be teams meetings. Now that's always good as well because I think now that's where the rapport really builds up with your colleagues.

[00:10:04] Julia: Wow. Just from that answer there, you mentioned earlier forward thinking and the angles that you considered in order to get this funding in working with the GPs and, securing some funding from secondary care as well.

Just make me think, almost the cliche saying of don't take no for an answer, if there's a will, there's a way. So again, and your trust. So my next question is, I'm just trying to form a picture here of the setup that you've got within your trust in terms of the audiology department. So obviously you run the primary care side of things, the secondary side of secondary care side of things. How is all of it spread in terms of audiologists what is the setup and the locations that the department functions within?

[00:10:46] Nicola: Yeah, so all in all we have approximately 40 staff that's including admin staff as well. We have two main hospital locations and three for the outreach clinics for secondary care activity. And then the primary care service runs over seven further primary care locations. 15 of the 40 staff make up the primary care audiology team. It is, it is a nice working mix.

All the primary care audiology team also do a day or two maybe in secondary care as well. So I think from a, from the career aspect, it is a nice way of working. People tend to enjoy it. But yeah, so there's a lot of sites though. So a lot of sites means a lot of clinics. A lot of clinics means a lot of equipment. It is hard keep on top of equipment calibration what's where, what do we need, what stock? So it has those challenges. But we do tend to try and keep on top of it as much as we can.

[00:11:33] Julia: Okay, quite a big department with a widespread working very well together. You also mentioned, , in your answer about recruiting staff, because this was a completely new setup, did you have to create completely new positions for the primary care settings? And then also alongside with that, how did the staff respond to this primary care setup? And then also going along with that, whilst we're talking about staff, I guess you mentioned, needing certain qualifications. So does it mean that in order to be able to perform wax management, for example, in primary care, you need to be a certain band? So I guess this question is about recruiting staff. What are the qualifications for being in those positions, and how did the staff respond to this set up.

[00:12:16] Nicola: Yeah we did have to create some new positions and these were all included in our business case. The staff were all very positive and it does create new positions and has enabled some members staff to be promoted.

So it was excellent to see, these staff progressed and it's lovely that they've been with us many years and progressed through the bands. Our associates carry out the waxing removal. These are generally band fours. However, we do have a couple of band fives carrying out waxing removal, and then all the complex wax removal is carried out by the advanced practitioners who are band seven or eight. So our service is run with what we call a power working model, where you've got a sorted practitioner band four or five working alongside an advanced practitioner, a band seven or eight. They really complement each other. That's quite cost effective as well obviously running the wax removal service because band four can't work alone. So if you will run standalone wax clinics you'd have to employ band fives to do that. But the way our model is set up is quite cost effective as a band four can work alongside one of the advanced practitioners. It works really well as the parallel working model.

[00:13:19] Julia: No, it sounds, as you say, it sounds like a really good way of giving people the opportunity to come into new positions, giving people the opportunities to be able to progress. And also, as you say having a cost effective setup, which is also bringing it back to the funding that we talked about earlier, the more cost effective the model that you run, the more, , likely it is that you will acquire funding for this type of approach. The next one then is about the patients, really. How do patients access this audiology, whether primary care or secondary care in your trust. So if you maybe can talk us through a typical audiology patient pathway. So maybe when somebody sees their GP or maybe not even seeing the GP, what the likely outcomes are and how they would end up in either primary care or secondary care in the first instance

[00:14:03] Nicola: Yes, 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 we do triage over the phone and then book them directly to clinics using a shared booking system.

So I think that's something that's really to note as well is the booking system of these patients, which can be quite tricky. You do have to have a shared booking system with your GP practices. There are a few different ways of doing that. We generally work from the Vision 360, which is what our GP practices work on and we got a shared booking system then where they can access the booking and we can access the booking and the patient files and write up a little journal on the patient as well. So I think it is quite a big thing to bear in mind when you're setting up these clinics as well. So you do need to have a booking system for the patient that everyone can access. Patients will attend their audiology appointment, then after they're being booked in, they'll be assessed for their reported issues, whether that be for routine wax removal, which will be carried out in a wax removal clinic, or asymmetrical pathology, which should may be dealt with an advanced practice clinic, where all diagnostic testing is available.

Once the patient's testing has been completed, the patient will be appropriately managed by the advanced practitioner. So if the patient hasn't been discharged, any onward referrals to ENT or radiology, for MRI scans, will be managed by the advanced practitioner, along with any hearing aid for tinnitus referrals then to secondary care audiology.

And so the pathway reduced waiting lists and wait times of patients from many months really, because before we were there, these patients would really be seen in ENT before any asymmetrical pathologies and for any MRI scans. Sitting on an ENT waiting list for many months has dramatically reduced that wait time round for the patient because we are referring them for MRI scans.

And then by the time we get to see them... and they only see the ENT consultant if they need to then, if anything has come up on the scan. And when they get to see the ENT consultant, they're seeing them there with full diagnostic testing and audiograms to view, any waxes being removed and obviously their MRI results as well. So it's a much better pathway for the patient and for our ENT colleagues as well.

[00:16:13] Julia: Nicola, we've talked a lot about the way that you went about getting the service set up. We've talked about the audiologist's response and the GPs response too, what was the patient's response to this new service delivery model?

[00:16:25] Nicola: Initially patients were unsure as they were expecting to see your doctor, but they quickly realised audiologists are the right people to see for their ear and hearing problems. Patients always gave very high scores in any PROMS or PREMs, outcome measures and experience measures that we collect. We carry all those out now on a regular basis. We also audit the service regularly to see, to ensure the patient's needs and the aims of the service continue to be met. I think any opportunity in educating patients, like I mentioned earlier, in the new way of working in the NHS is really useful. Seeing healthcare practitioners in primary care rather than GP is becoming far more common, and I think it's really important to get that message across to patients as well for their expectations.

[00:17:07] Julia: So really positive from the patient perspective too. Which wax removal tools do you and your department have in your toolbox, and when would you select a certain tool over another one?

[00:17:20] Nicola: Yeah, so obviously our main go to in our wax removal clinics are microsuction. Because obviously with microsuction it doesn't matter the depth of the wax. It is very successful so that is our main go-to. But obviously we have got some manual tools such as Crocs hooks, and now we are using Earways Pro as well.

That's in our toolbox. But depending on the type of wax and the depth of the wax, we will decide on what's best to use.

[00:17:45] Julia: So a very comprehensive toolbox. You mentioned Earways Pro very briefly then, and this will be my last question actually for you. I know that your team have been collecting some data around the tool, around how long it takes, around the type of wax, around how successful it has been.

I think there's some data on safety. Can you please highlight some of the takeaway messages from the data that you and your team have been collecting regarding Earways Pro?

[00:18:10] Nicola: Yeah, I think the main take-home message that myself and the team would agree on is it can be a very useful tool. It works better with harder wax, which is in the outer part of the canal, is very quick, very effective, taking only seconds. Patients didn't report any discomfort in the evaluation. It, unfortunately, it's not so useful on soft wax or wax which is deep in the ear canal. So that's why obviously like microsuction, it is better for the those patients.

But it is nice to have the Earways Pro there for the type of wax that it is, it does work well on and it does save a lot of time. So yeah we are really happy to have it in our tool box.

[00:18:47] Julia: And like you say, thankfully the team that performed the earwax removal, they are fully trained and qualified and experienced, and then identifying the right type of wax for the right tool is of course something that they excel in.

So thank you so much. My thanks to you Nicola, for sharing your experiences and your expertise. I have learned a lot and so has our audience too. There's lots of food for thought and of course inspiration and ideas. You said earlier that you are happy to talk to people about your approach and to give some advice.

So if you wanted to reach out to Nicola, you can get in touch by email on Nicola.Phillips@wales.nhs.uk. Nicola, once again, thank you to you so much.

[00:19:34] Nicola: Thank you Julia. Thank you for inviting me and myself and the team are more than happy sharing experiences and we really are thankful for the opportunity that you've given us today to showcase our service. So thank you.

[00:19:55] Julia: In the next episode, I'll be speaking to Nora McDonald, who is the Acting Adult Lead Audiologist at Southeastern Health and Social Care Trust. She'll be talking about using the Earways Pro tool a little bit more.

[00:20:07] Nicola: It's very empowering to be able to say, oh we actually have this tool that we could try and when it's successful, oh, it really is fantastic. I usually get excited when I see a thick, smooth, completely occluding plug of darker brown wax that almost hits you in the face when you do otoscopy .

[00:20:25] Julia: I'll end by reminding our listeners of the RNID campaign 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 earwax 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 earwax build-up themselves at home.

If you found any of what you've heard today 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 subscribe wherever you get your podcasts so you don't miss an episode.

This is a fresh air production for Signia UK and Ireland. Until next time goodbye.

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