How an iPhone attachment is helping streamline cancer referrals

9th January 2025

Dr Chris Coulson, ENT consultant at Queen Elizabeth Hospital Birmingham, UK, and CEO of Endoscope-i, talks to Beth Gault about how a new iPhone-compatible device being piloted in the West Midlands aims to streamline throat cancer referrals.

Beth Gault (BG): What is Endoscope-I and how did you first come up with the idea?

Chris Coulson (CC): Me and another ENT surgeon selfishly tried to solve our problems. We spend a lot of time looking in people’s ears, noses and throats and we generally use an endoscope for that, which you put to your eye to look through and see the area of concern.

About 12 years ago, we recognised we had a decent camera in our pocket, on our phone, and thought why don’t we connect it with the endoscope. So, we did. We created an adapter to align the endoscope with the phone to allow you to take an image or video of the ear, nose or throat, which is what the device is.

We progressed to thinking we could train someone to take a video, which then comes through to me and if the clinician has filled out a history and done a hearing test, then I could just sit down and look at them remotely. So, we put that system together.

ENT is an interesting field in that only 10% of people who see me in clinic need an operation, 90% of people – with appropriate information – can be managed remotely. That’s classically done through a face-to-face consultation, but we wondered how much of that information can I get through other means?

BG: How does the tool work?

CC: You just attach the aligner, which is a bit like a phone case, with the endoscope and the iPhone and then take a video or image and upload it to our cloud system via our referral app. It’s currently only on iPhone, not Android, but the iPhones are included with the service.

BG: The tool is now being used to try and detect and rule out throat cancer – what role can it play in cancer referrals?

CC: The symptoms that are concerning with head and neck cancer are also symptoms that sound like a cold, like a hoarse voice or a sore throat. They are general, non-specific symptoms. Most people with a two-week wait referral for cancer do not have cancer.

The number of people picked up from an urgent cancer referral clinic is tiny – about 3%.  So, the trouble that us head and neck surgeons have is how do we sift through these huge numbers of referrals to get to people who actually have cancer?

Capacity is a huge problem, so the number of referrals go up and up and up and actually the numbers of cancers are not. But you still have to deal with these referrals because you never know who is going to have the cancer.

We set up this referral pathway in Stoke where anyone with low risk for cancer went to a nurse-led clinic. The nurse used the endoscope with our camera system, took a video of their throat and then sent it to the head and neck surgeons. They were able to have a look and say who did not have cancer, and then who needed a further appointment in the clinic.

It’s really quick for us to look and know whether they do not have cancer, because it’s what we do every day. Within seconds you can look at a video and tell, but in a consultation, it takes 20 minutes.

We found through this that we can safely run a service where the nurse sees the vast majority of patients, but the consultant reports on it so it’s a consultant-level answer. 

BG: What funding have you received for this?

CC: We designed and delivered it ourselves without funding. But we then got funding from the Small Business Research Initiative to run an assessment of its delivery. We did this in Dorset County Hospital and Stoke University Hospital for head and neck cancer.

BG: What were the results of the test?

CC: We don’t have impressive numbers that say we’ve caught all these cancers, because our aim is not to find cancer, it’s to deal with the people who don’t have cancer. If you deal with them, you can have more capacity to deal with the cancer patients.

We put 1,800 people through the service and found around six cancers. All of these were low risk, so they’d likely go on to have a late diagnosis if they hadn’t used the service.

BG: If a system was interested, would integrated care boards (ICBs) or Trusts be the one to fund this?

CC: Up to now it’s been Trust funded, because it’s a way of increasing their capacity and saving money. But we do have a couple of ICBs around the country who are looking at it for delivery in their patch. My guess is in a few years we will have a combination of ICBs and hospitals. However, the one thing we won’t have is GPs funding this. The location of delivery could be in primary care, which I think is advantageous to the population, but I don’t think it will be primary care-led funding.

BG: What does it cost?

CC: Around £100,000 upfront for the kit, training and integration and then there’s a monthly license fee for security updates and ongoing support.

BG: How do you see the tool being used in the future in the NHS?

CC: I don’t see GPs using it, it’s one of the core things we’re trying to do is to make things easier for GPs, not delivering something else for them to do. It would work best with someone doing it in high volumes, rather than intermittent users, so it might be that trained staff will go out to practices or any healthcare facility to do it. It would work well in a diagnostic treatment centre as well.

We are also looking at artificial intelligence and if at some stage we can automate some diagnoses or letters, this would further increase efficiency.

BG: How do you think digital tools like this can make a difference to the NHS?

CC: There’s clearly a huge opportunity for digital tech to improve healthcare. But one of the challenges is how can you make sure that your digital tech doesn’t make things worse. We’ve got to be cautious that we don’t make things more complex.

But it’s also got to be clinically led. As soon as there’s tech designed by tech people with tech people in mind, most of us struggle to get on with it. It needs to solve a clinical problem.

This article was originally published by our sister publication Healthcare Leader.

Onward referral among primary-secondary care interface improvements from UK Government

9th May 2023

Patients requiring an onward referral from one consultant to another will no longer be sent back to their GP, the Government has announced.

In its recovery plan for general practice, published today (9 May 2023), the Government said that where a patient has been referred into secondary care and they need another referral ‘for an immediate or a related need’, the secondary care provider should make this referral, rather than sending them back to general practice.

It said that this was the ‘most common request’ from GPs about bureaucracy and would improve patient care and save time.

This is a step further than in 2016, when the GP Forward View said that onward referral within secondary care for a non-urgent condition relating to the original referral was ‘permitted’.

The pledge was one of several measures aimed at reducing the time practice teams spend on ‘lower-value’ administrative work and work generated by issues at the primary-secondary care interface, which ‘practices estimate they spend 10-20%’ of their time on, the plan said.

Working together

Together with onward referral, other measures detailed in the plan include:

• Fit notes should be issued by secondary care
• NHS trusts must establish their own ‘call and recall’ systems for patient follow-up
• ICBs should ensure providers establish single routes for GPs and consultant-led teams to communicate rapidly.

The recovery plan was published alongside a report from the Academy of Medical Royal Colleges (AoMRC) on general practice and secondary care working together.

The AoMRC report includes a series of case examples of improvements that have already been made across the country and offers a series of ‘quick-win’ suggestions to improve collaboration.

This included areas establishing regular ‘interface groups’, which it said should bring together local GPs and secondary care consultants to discuss interface issues.

New requirements

The Government’s plan said NHS England is asking ICB chief medical officers to ‘establish the local mechanism’, which will allow both general practice and consultant-led teams to raise local issues, jointly prioritise working with LMCs, and tackle the high-priority issues including those in the AoMRC report.

In addition to this, ICBs must address onward referral, and three other key areas: complete care (fit notes and discharge letters), call and recall, and clear points of contact.

NHS England said it will expect ICBs to provide a progress update on these four areas to their public board in October or November 2023.

A version of this story was originally published by our sister publication Pulse.