Introduction
In Ireland, ear, nose and throat (ENT) services have one of the longest waiting lists for access to out-patient services. National Treatment Purchase Fund (NTPF) data indicated that waiting times often exceed three years for a first consultant appointment.1
The population of Ireland continues to grow, with the most recent census reporting a population increase of 8.1 per cent between 2017 and 2022. Central Statistics Office (CSO) data indicated that this trend is likely to place further demand on healthcare services.2 It has long been contended that there are insufficient ENT consultants appointed within the Irish public health system, with approximately one consultant per 82 000 population compared with the European average of one consultant per 19 500 population.Reference Carroll and Warren3 Consequently, ENT services in Ireland have struggled to keep pace with demand. In relation to specialist ENT care, it has been recognised that, with appropriate training and support, a proportion of this workload could be delivered efficiently within primary care and by other members of the multidisciplinary team. The Royal College of Surgeons in Ireland (RCSI) highlighted this as a key component of future service delivery models.4
One proposed solution to improvement of access to specialist ENT care in Ireland is the introduction of Advanced Nurse Practitioners (ANPs) within consultant-governed services.4 Indeed, it has been recognised that ANPs have a role in ameliorating some of the challenges within the healthcare system, including improving patients’ access to services, reducing waiting lists, facilitating early discharge from hospital and avoiding unnecessary hospital attendance through innovative patient-centred models of care.Reference Elliott, Daly, Bryant-Lukosius, Fleming, Varley and Cotter5 Doody et al. also provide an integrative review of the contribution of Irish ANPs, highlighting their role in enhancing healthcare outcomes through improved coordination, patient-centred care and system efficiencies.Reference Doody, Graham, Hegarty, Marie Sloane, Walsh and Synnott6
Advanced nursing practice in Ireland is defined as ‘a career pathway for registered nurses, committed to continuing professional development and clinical supervision, to practise at a higher level of capability as independent, autonomous and expert practitioners’.7
The title of ANP is protected in Ireland and only those nurses successfully registered on the Advanced Practice Division of the Nurses Register are legally permitted to use this designation.7
Recurrent sore throats, particularly in the context of possible tonsillectomy, are among the most common reasons for referral to ENT out-patient services in Ireland.Reference Hasan, O’Riordan, Kinsella and McShane8 An analysis of 1000 patients on long-term waiting lists for ENT care nationally revealed that 18 per cent were awaiting assessment for these conditions.4 In response to this issue, one regional ENT centre included this cohort of patients among the caseload of a newly introduced ANP. Using the Health Technology Assessment of Scheduled Surgical Procedures: Tonsillectomy, developed by the Health Information and Quality Authority 2013 (HIQA),9 the ANP accepted referrals for assessment of chronic tonsillitis and recurrent sore throat as part of the ANP caseload.
Given the continued demand for ENT services and the expansion of advanced nursing practice in Ireland, it is timely to evaluate the impact of introducing an ANP-led service on access to care and service delivery within a regional ENT department. While the effectiveness of nurse-led care has been demonstrated in relation to scope of practice, patient outcomes and patient satisfaction, there has been little published on its impact on access to services.Reference Connolly and Cotter10 It was therefore important to focus on this aspect of service provision during the evaluation.
Materials and Methods
Study design
A retrospective service evaluation of routinely collected patient data was conducted focusing on patients referred to one consultant at a regional tertiary ENT centre in the Republic of Ireland for assessment for elective tonsillectomy because of recurrent tonsillitis or sore throat.
Data collection
Data were collected from the records of patients attending one consultant’s out-patient clinic between 1 January 2018 and 31 December 2018, prior to the introduction of the ANP-led tonsillectomy assessment pathway. Data were subsequently collected for patients referred to the same consultant service during the four-year period following introduction of the ANP-led pathway (2019–2022).
Variables collected are outlined in Table 1 and include demographic information, referral and assessment dates, clinic type, consultation format, eligibility for tonsillectomy, requirement for further review, discharge status and surgical outcomes. Waiting times for out-patient assessment and surgical procedure were calculated when applicable.
Variables collected during retrospective service evaluation
Table 1 Long description
This table lists the variables collected during the retrospective service evaluation and provides a short description for each variable. The variables were: unique patient identifier, recorded as hospital record number; outpatient clinic date, recorded as the date of first ENT assessment; date added to outpatient waiting list, recorded as the date the referral was added to the ENT waiting list; waiting time to assessment, recorded as time from referral to first ENT assessment; consultant service, recorded as the named consultant pathway; patient age, recorded as age at assessment; appointment type, recorded as new or return appointment; clinic type, recorded as consultant-led, NTPF or ANP-led clinic; consultation format, recorded as face-to-face or virtual consultation; whether the patient met criteria for elective tonsillectomy, recorded as yes or no; whether a second appointment was required, recorded as yes or no; date of surgery, recorded as date tonsillectomy was performed if applicable; whether the patient was discharged from the service, recorded as yes or no; waiting time from assessment to surgery, recorded as time from outpatient assessment to surgery; total referral-to-surgery waiting time, recorded as time from referral to surgery; and whether the patient declined surgery, recorded as yes or no.
As this was a retrospective service evaluation, no formal sample size calculation was undertaken. Both paediatric and adult patients referred for tonsillectomy assessment were included, reflecting the typical case-mix of a regional ENT service.
Data were extracted from the Integrated Patient Management System (IPMS) and clinic outcome letters and entered into a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA, USA). Clinic outcome letters from one consultant out-patient service for 2018 were reviewed to identify patients referred for tonsillectomy assessment with recurrent tonsillitis or sore throat. These data were used as a baseline for comparison with subsequent years following the introduction of the ANP-led pathway (2019–2022).
Data analysis
The hospital patient information system (HealthIRL) was utilised to identify patients attending ENT clinics between 2018 and 2022 when the referral reason was documented as tonsillectomy assessment. Data were extracted and entered into a Microsoft Excel spreadsheet for descriptive and comparative analyses.
Variables of interest were identified and agreed by the investigators in advance of data collection. Data extraction and verification were undertaken collaboratively by both investigators, with regular review of data points to promote consistency and accuracy throughout the analysis process.
Ethics
As this was a retrospective service evaluation of routinely collected data undertaken for audit and service-improvement purposes, it did not fall within the remit of the Health Research Regulations (2018). No patient-identifiable data were extracted.
Organisational approval was obtained in advance and all aspects of data collection and storage were conducted in accordance with the principles of the General Data Protection Regulation (GDPR) and Health Service Executive guidance.11, Reference Executive12
All extracted data were stored in a Microsoft Excel spreadsheet on a password-protected encrypted network drive within the hospital information technology system in accordance with the Data Protection Act 2018.
Results and Analysis
Patient age
Age was the only demographic variable collected. Patient age ranged from 2 to 53 years, with a mean age of 17 years.
Number of patients assessed following the introduction of the ANP service
In total, 620 patients were assessed for elective tonsillectomy between 2018 and 2022 within one consultant service pathway (Table 2).
Patients assessed for tonsillectomy before and after the introduction of the ANP-led pathway
Table 2 Long description
This table shows the total number of patients assessed for tonsillectomy and the proportion assessed through consultant-led, additional clinic and ANP-led pathways for each year from 2018 to 2022. In 2018, 93 patients were assessed: 61 per cent consultant-led, 39 per cent additional clinic and none ANP-led. In 2019, 167 patients were assessed: 5 per cent consultant-led, none additional clinic and 95 per cent ANP-led. In 2020, 170 patients were assessed: 0 per cent consultant-led, none additional clinic and 100 per cent ANP-led. In 2021, 93 patients were assessed, all through the ANP-led pathway. In 2022, 97 patients were assessed, all through the ANP-led pathway. The table demonstrates a shift from consultant-led and additional clinic assessment in 2018 to a predominantly ANP-led pathway in 2019 and fully ANP-led assessment from 2020 onwards.
Prior to introduction of the ANP-led pathway, tonsillectomy assessments were conducted through consultant-led out-patient clinics and additional waiting-list initiative clinics. Following implementation of the ANP-led pathway in 2019, most assessments were undertaken by the ANP, increasing to all assessments from 2020 onwards.
Compared with baseline activity in 2018, the number of patients assessed for tonsillectomy almost doubled during the first year of the ANP initiative and remained consistently high throughout the evaluation period.
Waiting times for initial ENT assessment
Waiting times from referral to first ENT assessment reduced substantially over the study period (Table 3).
Waiting times from referral to first ENT assessment
Table 3 Long description
This table shows mean waiting time from referral to first ENT assessment, the percentage of patients assessed within 18 months and the primary assessment pathway for each year from 2018 to 2022. In 2018, the mean waiting time was 24 months, 34 per cent were assessed within 18 months and the pathway was consultant or additional clinics. In 2019, the mean waiting time was 26 months, 9 per cent were assessed within 18 months and the pathway was predominantly ANP-led. In 2020, the mean waiting time was 21 months, 26 per cent were assessed within 18 months and the pathway was fully ANP-led. In 2021, the mean waiting time was 19.5 months, 69 per cent were assessed within 18 months and the pathway was fully ANP-led. In 2022, the mean waiting time was 9.1 months, 100 per cent were assessed within 18 months and the pathway was fully ANP-led. The table shows progressive improvement in waiting times after the initial implementation period.
During the initial implementation phase in 2019, patients waiting the longest were prioritised, resulting in a temporary increase in average waiting times. From 2020 onwards, progressive reductions in waiting times were observed.
By 2022, all patients referred for tonsillectomy assessment were assessed within 18 months of referral, and the majority were assessed within 12 months.
Patients meeting criteria for elective tonsillectomy
The proportion of patients meeting criteria for elective tonsillectomy decreased over the study period (Table 4).
Patients meeting criteria for elective tonsillectomy at first ENT assessment
Table 4 Long description
This table shows the number and percentage of patients who met criteria for surgery, declined surgery after meeting criteria, or did not meet criteria at first ENT assessment from 2018 to 2022. In 2018, 65 patients met criteria, representing 70 per cent; 5 declined surgery after meeting criteria, representing 8 per cent; and 27 did not meet criteria, representing 30 per cent. In 2019, 112 met criteria, 67 per cent; 14 declined, 12 per cent; and 55 did not meet criteria, 33 per cent. In 2020, 107 met criteria, 63 per cent; 15 declined, 14 per cent; and 63 did not meet criteria, 37 per cent. In 2021, 38 met criteria, 41 per cent; 4 declined, 11 per cent; and 55 did not meet criteria, 59 per cent. In 2022, 39 met criteria, 40 per cent; 3 declined, 7 per cent; and 58 did not meet criteria, 60 per cent. The table shows that the proportion meeting criteria for surgery decreased over time, while the proportion not meeting criteria increased.
Prior to implementation of the ANP-led pathway, 70 per cent of the patients assessed met criteria for surgical procedure. This reduced progressively during the evaluation period, with approximately 40 per cent meeting criteria by 2022. Rates of patients declining surgical procedure after meeting operative criteria remained low throughout the study period.
Waiting times from assessment to surgical procedure
Waiting times from assessment to surgical procedure increased during the initial implementation phase and throughout the Covid-19 pandemic period before subsequently stabilising (Table 5).
Waiting times from assessment to surgical procedure following the introduction of the ANP-led pathway
Table 5 Long description
This table shows mean waiting time from assessment to surgery and service context for each year from 2018 to 2022. In 2018, the mean waiting time was 2.7 months and this was the pre-ANP baseline service. In 2019, the mean waiting time was 4.5 months during initial ANP service implementation. In 2020, the mean waiting time was 11.5 months during the COVID-19 pandemic and service expansion period. In 2021, the mean waiting time was 7.0 months during the recovery phase following service disruption. In 2022, the mean waiting time was 8.5 months in the stabilised ANP-led pathway. The table shows an increase during implementation and pandemic disruption, followed by stabilisation within the ANP-led pathway.
Although waiting times from assessment to surgical procedure increased during the initial implementation and Covid-19 pandemic period, overall referral-to-surgical procedure waiting times reduced over the evaluation period.
Patients discharged following first ENT assessment
The proportion of patients discharged following first ENT assessment increased during the study period (Table 6).
Patients discharged following first ENT assessment
Table 6 Long description
This table shows the number and percentage of patients discharged following first ENT assessment for each year from 2018 to 2022. In 2018, 32 patients were discharged, representing 35 per cent. In 2019, 49 patients were discharged, representing 30 per cent. In 2020, 69 patients were discharged, representing 40 per cent. In 2021, 44 patients were discharged, representing 47 per cent. In 2022, 55 patients were discharged, representing 57 per cent. The table shows an overall increase in patients discharged following first assessment, rising to more than half of assessed patients by 2022.
By 2022, 57 per cent of patients assessed were discharged following their first appointment without requiring onward consultant review.
Discussion
Over the four-year ANP evaluation period (2019–2022), 518 patients referred for tonsillectomy assessment were reviewed within the ANP-led pathway from one consultant waiting list.
The findings demonstrate improved access to tonsillectomy assessment following implementation of the ANP-led pathway. The initiative was associated with increased out-patient capacity, substantial reductions in waiting times for first assessment and improved patient flow within the ENT service. Overall referral-to-surgical procedure waiting times decreased across the evaluation period, despite fluctuations in waiting times from assessment to surgical procedure.
This reduction in overall referral-to-surgical procedure waiting time appears to reflect an earlier assessment within the pathway, despite temporary increases in post-assessment surgical waiting times during the implementation and the Covid-19 pandemic period. These findings suggest that earlier specialist assessment may be an important mechanism through which ANP-led services improve access to care and patient flow.
Recurrent sore throat for possible tonsillectomy remains one of the most common clinical indications for referral to ENT out-patient services in Ireland.4 Prior to the introduction of the ANP initiative in ENT, all patients presenting with sore throat or tonsillitis were reviewed in consultant-led clinics.
Following the establishment of the ANP service, there was a marked shift in care delivery. In 2019, 95 per cent of patients referred for tonsillectomy assessment were seen within the ANP service, rising to 100 per cent in subsequent years as all referrals were directed to ANP-led care.
The ANP role within this pathway extended beyond redirecting referrals. Assessment required autonomous clinical decision-making within an agreed consultant-governed framework, including history-taking, application of national tonsillectomy criteria, identification of patients who did not meet criteria for surgical procedure, patient education, shared decision-making and escalation for consultant review when clinically indicated. In this way, the ANP-led pathway functioned as a structured specialist assessment model rather than an administrative triage process, supporting both patient access and consultant clinic capacity.
Initially, the service operated under a single consultant’s pathway with a narrow scope of practice: tonsillectomy assessment eligibility. Despite this, significant numbers of patients were managed through the ANP-led model. Over the four-year review period, 518 new referrals for sore throat or tonsillitis were managed within the ANP-led clinic. This reallocation probably created additional capacity within consultant clinics to review more complex ENT presentations. The number of redirected cases equated to the annual new-patient allocation for one consultant service, demonstrating the considerable workload previously managed through traditional consultant-led care.
Tonsillitis remains a highly prevalent presentation in ENT practice, and tonsillectomy continues to be the second most frequently performed otolaryngology procedure in Ireland.4
As the ANP service matured, overall out-patient throughput increased and the average waiting period from referral to assessment decreased substantially. While this initially resulted in a temporary rise in surgical waiting times, these times stabilised by 2021, with an average wait of 8.5 months for surgical procedure by 2022, representing a measurable improvement in patient flow and service efficiency.
Comparable service-improvement findings have been reported in both Irish and UK contexts. A Quality Improvement Project by Larragy in another Irish teaching hospital identified inappropriate referrals, complications and patient dissatisfaction as factors contributing to prolonged tonsillectomy waiting times, with proposed solutions including virtual triage and structured patient questionnaires.Reference Larragy13 Although implementation was halted due to Covid-19 restrictions, the present ANP initiative aligns closely with these proposals through enhanced accessibility, structured assessment and continuity of care. Similarly, Wu, Walker and Owen reported reduced waiting times within a nurse-led one-stop tonsillectomy clinic in the United Kingdom.Reference Wu, Walker and Owen14
Delays in access to specialist care are known to result in postponed diagnosis, deterioration in health status and impaired daily functioning.Reference Fluck, Jackson, Llamas-Montoya, Chana, Kelly and Jones15, Reference Faugno, Galbraith, Walsh, Maglione, Farmer and Ong16 Prolonged waiting periods contribute to increased anxiety and psychological distress for both patients and families,Reference Zhang, Tian, Shi, Qian, Gao and Zhai17, Reference Seif, Shah, Chandani and Ali18 while extended waits correlate with reduced satisfaction and diminished confidence in service quality.Reference Mosleh, Alsereidi, Aldhanhani, Alnaqbi, Alhouti and Alshehhi19
Although demand on the ENT service remains high and waiting lists have not been fully eliminated, the ANP-led model improved timeliness, capacity and patient flow.
During the Covid-19 pandemic period, some assessments were conducted virtually to support continuity of service delivery. Although virtual consultations facilitated access during this period, the service subsequently transitioned back to predominantly face-to-face assessment in later years to allow a more comprehensive pre-operative evaluation of patients with potential co-morbidities and airway-related risk factors.
Further improvement could be achieved through pre-appointment patient education. Providing an information leaflet or booklet in advance of the first consultation may help to alleviate anxiety and clarify the risks and benefits of tonsillectomy. This approach was shown to be effective in reducing pre-consultation anxiety and improving patient understanding during a Quality Improvement Project undertaken by the Greater Glasgow and Clyde Health Board.Reference Philp, Maqsood, Joshyulla-Prasanna, van der Meer, Douglas and Wood20
Recent reviews continue to emphasise the importance of the consistent application of evidence-based referral criteria for tonsillectomy. The HIQA Health Technology Assessment of Scheduled Surgical Procedures – Tonsillectomy (2013) remains the cornerstone of Irish referral guidance, outlining explicit thresholds for sore throat frequency and severity. Despite this, both Irish and European data revealed ongoing variation in adherence, with many patients on ENT waiting lists not fully meeting established criteria.4, Reference Tighe and Keane21 Improving awareness and compliance with these national guidelines in primary and emergency care could substantially reduce inappropriate referrals and waiting-list pressures, ensuring timely assessment and intervention for patients most likely to benefit.22
This study has several limitations. As a retrospective service evaluation conducted within a single consultant pathway at one regional tertiary ENT centre, the findings may not be generalisable to other services. In addition, the evaluation relied on routinely collected clinical data and was therefore dependent on the completeness and accuracy of clinical documentation. To minimise potential bias, variables of interest were agreed by the investigators in advance of data collection and data extraction was reviewed collaboratively at regular intervals to promote consistency and accuracy. Despite these limitations, the study provides valuable real-world evidence regarding the impact of an ANP-led tonsillectomy assessment pathway on service delivery and access to care.
Summary What is already known on this subject
• Waiting times for out-patient ear, nose and throat assessment and tonsillectomy remain a significant challenge within publicly funded healthcare systems.
• Advanced Nurse Practitioner-led services can improve access, efficiency and patient flow within consultant-governed models of care.
What this paper adds to our understanding
• A consultant-governed Advanced Nurse Practitioner-led tonsillectomy assessment pathway substantially reduced referral-to-assessment waiting times in a regional tertiary ear, nose and throat service.
• By 2022, all patients were assessed within 18 months, most were assessed within 12 months and many were managed without onward consultant review.
Conclusion
This retrospective service evaluation demonstrates that the introduction of a consultant-governed ANP-led tonsillectomy assessment pathway was associated with improved access to specialist ENT assessment, increased out-patient capacity and a more efficient patient flow within a regional tertiary ENT service.
Prior to the implementation of the ANP-led pathway, waiting times for initial ENT assessment frequently exceeded three years. Over the course of the evaluation period, substantial reductions in waiting times for first assessment were observed, alongside increased out-patient throughput and a reduction in the proportion of patients requiring onward consultant review.
The findings also highlighted the ongoing challenge of referral quality and adherence to national tonsillectomy criteria. A substantial proportion of referrals did not meet established criteria for surgical intervention, emphasising the importance of guideline-based referral pathways and structured triage processes within ENT services.
Although this evaluation was limited to one consultant pathway within a single tertiary centre, the findings support the role of consultant-governed ANP-led assessment pathways as a potential strategy to improve access and service delivery within high-demand ENT services.
Acknowledgements
None.
Funding
No funding was received for this work.
Competing interests
The authors declare no competing interests.
Open access
