Tinnitus referral pathways within the National Health Service in England: a survey of their perceived effectiveness among audiology staff

Abstract

Background: In the UK, audiology services deliver the majority of tinnitus patient care, but not all patients experience the same level of service. In 2009, the Department of Health released a Good Practice Guide to inform commissioners about key aspects of a quality tinnitus service in order to promote equity of tinnitus patient care in UK primary care, audiology, and in specialist multi-disciplinary centres. The purpose of the present research was to evaluate utilisation and opinions on pathways for the referral of tinnitus patients to and from English Audiology Departments.

Methods: We surveyed all audiology staff engaged in providing tinnitus services across England. A 36-item questionnaire was mailed to 351 clinicians in all 163 National Health Service (NHS) Trusts identified as having a tinnitus service. 138 clinicians responded. The results presented here describe experiences and opinions of the current patient pathways to and from the audiology tinnitus service.

Results: The most common referral pathway was from general practice to a hospital-based Ear, Nose & Throat department and from there to a hospital-based audiology department (64%). Respondents considered the NHS tinnitus referral process to be generally effective (67%), but expressed needs for improving GP referral and patients' access to services. 'Open access' to the audiology clinic was rarely an option for patients (9%), nor was the opportunity to access specialist counselling provided by clinical psychology (35%). To decrease the number of inappropriate referrals, 40% of respondents called for greater awareness by referrers about the audiology tinnitus service.

Conclusions: Respondents in the present survey were generally satisfied with the tinnitus referral system. However, they highlighted some potential targets for service improvement including 1] faster and more appropriate referral from GPs, to be achieved through education on tinnitus referral criteria, 2] improved access to psychological services through audiologist training, and 3] ongoing support from tinnitus support groups, national charities, or open access to the tinnitus clinic for existing patients.

Figure 1

Standard referral pathways for tinnitus patients. The most commonly reported standard referral routes for tinnitus patients are shown. Note, not all pathways are shown. The directional arrows show the percentage of respondents who reported that their patients follow each stage of referral. Referrals to clinical psychology were reported to originate from any of the other clinical settings, and was included as part of the standard referral pathway in 18% of responses. The double-sided arrow indicates that in some cases the pathway continued on from clinical psychology to other medical services.

Figure 2

Opinion on GP management of tinnitus. Opinions on GP management of tinnitus patients are displayed according to the job role of respondents (the 95% confidence intervals are calculated for the responses pooled across all three job roles).

Figure 3

Challenges to the efficiency of the referral process. Results displayed are the percentage of respondents who identified each issue (± 95% confidence intervals). Referrer education included education of GPs and ENT specialists. A need to educate audiology staff on referral was not identified. Support from Trust included Trust managers and commissioners. Support from other clinicians included the other stages of the referral pathway and clinical psychology. Specialist training referred to specific training for audiologists on tinnitus management.

Figure 4

Long-term support networks. Responses are shown for the long-term support networks locally available for people with tinnitus. Responses are given as the percentage of respondents who indicated a type of support (± 95% confidence intervals).

Figure 5

Impact of 18-week pathway. Opinions on the impact of the 18-week commissioning pathway are shown as proportion of responses in each thematic analysis category (± 95% confidence intervals). Themes are grouped according to whether the impact was positive, negative, or neutral. Also displayed are the responses for tick boxes indicating the inability to comment due to a lack of understanding of the pathway, or 'No impact'. A neutral impact on efficiency was noted by a small number of respondents.