Updated: 15 minutes ago
Why was the pathway for audiology MRIs changed?
The LMC investigated the previous arrangements because they presented a serious patient safety issue. Previously, GPs were held responsible for the results of scans that they did not order themselves (these were requested by others without the GP's knowledge). The LMC highlighted that these investigations must not be requested or recorded under someone else’s name due to the associated medicolegal risks. Addressing this issue has allowed us to resolve a critical gap in patient safety as it became apparent during discussions that, from inception of the previous pathway, GP's felt that audiology were actioning abnormal results, audiology thought that radiology were sending them directly to ENT.
Following further discussions and a review of the available documentation, it become apparent that the original pathway agreement made by the three leads from Audiology, ENT and Radiology at the time, none of whom continue to work for the health board, was not well documented in all departments. Whilst Audiology relied on the wording of the scope of practice, this did not become the working understanding in radiology and radiology have found no evidence that the direct notification of significant findings to ENT was ever implemented.
What has been done to address this patient safety concern?
Audiology undertook an urgent audit of all MRI referrals sent from Primary Care Audiology between July 2025 and February 2026. Any missed referrals for further investigation and management will be dealt with immediately and reported via DATIX with all subsequent necessary processes.
The Primary Care Audiology lead is designing and expediting implementation of an audit that is able to capture assurance from each of the surgeries whose patients Audiology have referred onwards over a number of years. The LMC will be updated as to the results of the audit and any further steps required.
Audiology will attach an addendum to all scope of practice documents held within radiology for audiologists on the Non-Medical Referrer register altering the reference to significant findings going directly to ENT.
All cases of unilateral hearing loss follow a clear standard Operating Procedure (SOP)
Audiology will continue to consider the circumstances leading to this situation to develop further learnings and actions. Audiology will share these with radiology so that similar consideration may be undertaken as appropriate.
What is the new Standard Operating Procedure (SOP)?
Following a lengthy process working alongside ENT and audiology, a new pathway has been established. The purpose of the SOP is;
to provide a pathway which significantly reduces the demand on GPs for hearing related conditions and significantly expedite the pathway for appropriate imaging for patients
to provide a pathway that met the All Wales General Practice and Health Board Clinical Interface Standards
to provide practices with a clear pathway, which sufficiently outlined roles and responsibilities in order that they could make individual practice-based decisions about whether to opt-in to the proposed pathway
Who makes the decision to refer a patient for an MRI of the IAMs within the SOP?
The Advanced Audiology Practitioner is responsible for determining whether a patient meets the NICE referral criteria for an MRI scan of the Internal Auditory Meatus (IAM). This decision is based on a comprehensive assessment, including the patient's symptoms, clinical history, consultation findings, and audiological test results, such as the audiogram. Where the referral criteria are met, the Advanced Audiology Practitioner will arrange the MRI scan in accordance with local and national guidelines.
In whose name is the MRI requested?
The Advanced Audiology Practitioner is listed on the referral form as the referring practitioner, as they are responsible for requesting the investigation. A covering note accompanies the referral, clearly identifying the patient's GP and requesting that the MRI report is sent directly to them for review and management. This ensures that the MRI findings are reviewed and managed by an appropriately qualified medical professional, with any necessary follow-up, referrals, or treatment arranged through the patient's GP.
Does this comply with the All Wales General Practice and Health Board Clinical Interface Standards?
The Clinical Interface standards recommend that if there is agreement for investigation request responsibilities to be delegated, there must be "standard operating procedures (SOPs) to mitigate against clinical governance risks and transfer of clinical responsibility when requesting investigations and actioning the results". The new SOP ensures that any clinical governance risks are addressed and so complies with the standards.
Why does Audiology not manage the MRI results?
Audiology practitioners are not medically trained clinicians; their expertise is primarily
focused on the diagnostic assessment and audiological management of hearing and
balance disorders. MRI reports should be reviewed and managed by an appropriately
trained medical professional who can interpret the findings within the context of the patient's overall health and medical history.
What happens if an Acoustic Neuroma or CP angle lesion is reported?
If an acoustic neuroma or other cerebellopontine (CP) angle lesion is reported on the MRI scan, it is expected that the GP will review the findings and make an urgent referral to ENT for further assessment and management. The GP practice will also communicating the MRI results to the patient and advising them of the next steps in their care pathway.
What happens if any other incidental findings are reported?
If any incidental findings are identified on an MRI scan, the GP will review and manage
these findings. This includes interpreting the results in the context of the patient's overall health, symptoms, and medical history and making appropriate onward referral for further investigation or advice. This approach ensures that MRI findings are reviewed and managed by a primary care clinician with responsibility for the patient's overall medical care and coordination of any subsequent treatment pathways.
Doesn’t this pathway place more demands on the time of GPs?
The primary care audiology service saves GPs practices around 15000 patient contacts per year for hearing, tinnitus and ear/wax related enquires. The number of MRIs reported back to GPs represents small proportion of activity when compared the numbers of patients seen. Therefore, whilst there is an expectation of an increase in workload specifically related to reviewing and managing MRI results compared to the traditional secondary care pathway, the benefits of primary care audiology in controlling demand on practices related to ear and hearing conditions outweigh the time demands relating to the management of the MRI reports.
Are practices mandated to use this new pathway?
No. Practices can choose to opt in to this pathway or opt out if they prefer in their management of unilateral tinnitus using this link or by emailing sbu.audiology.primarycare@wales.nhs.uk.
What will opt-in mean for the practice?
Practices who opt-in will receive notification by letter each time that the Primary Care
Audiology service makes an MRI referral for one of their patients. Once the scan is
completed, Radiology will send the completed report to the GP for actioning and
communication to the patient.
What will opt-out mean for the practice
When a patient who is booked in to the primary care audiology clinic by a practice meets the criteria for MRI referral the audiologist will inform the GP so that the patient can be reviewed and the appropriate investigation requested. ENT would not expect to receive referrals only to request an MRI referral in the absence of any other ENT related assessment or management required. Therefore, the MRI referral must be created by the GP. If a practice opts-out of the MRI pathway, patients will continue to be able to access the primary care audiology service, on the basis described in the paragraph above, and all other activity and onward referrals managed by the primary care audiologists will continue.
What is the benefit to your patients of your practice opting in to pathway.
Patients are able to access the Primary Care Audiology service quickly, which means that any required imaging can be requested within a couple of weeks of them raising a concern regarding their ear or hearing. This is a significant benefit compared to the traditional secondary care pathways where patients would spend time on waiting lists and attend multiple health contacts along the pathway. The one-stop primary care audiology opt-in pathway can reduce patient waiting time for an MRI referral by up to twelve months.
What is the benefit of the pathway to the GP practice
Utilising the full primary care audiology service, including the MRI pathway means that the practice does not need to see the majority of patients with wax, hearing or tinnitus concerns, equating to a saving of up to 330 contacts per average sized practice per year. With regards to unilateral or asymmetric symptoms or results, practices can be assured that any necessary onward referrals are being made in line with NICE guidance for their patients and only those with an MRI finding requiring review, approximately 8 per average sized practice per year, need contact with their GP.
Why are the MRI results not sent to ENT for review
This pathway relates to patients seen in the Primary Care Audiology service. This is a first
contact service within primary care and booked via GP surgeries in lieu of a patient needing
to see their GP practitioner regarding their hearing or tinnitus. These patients are not known
to ENT at this point and for the majority of patients, their investigation can be requested and managed within primary care without requiring secondary care input. ENT will accept
referrals for patients for whom there is an ENT related finding following review of the results by the patient's GP.
What is the suggested wording for future ENT referrals?
For future patient referrals, the LMC suggests taking the following approach when referring to ENT:
"Dear ENT Team,
This patient has unilateral hearing loss. This is a specialist area outside the expertise of a GP. I am not the most appropriate professional to assess this further. Please investigate and treat as you feel indicated. I enclose a copy of the audiology assessment and MRI report."