The recently leaked McKinsey report suggested that some £700 million could be saved by the NHS by no longer commissioning procedures unable to demonstrate ‘tangible benefits’. The report includes comments on glue ear treatments and has concluded them to be ‘relatively ineffective’. However the NHS’ own watchdog, the National Institute of Health and Clinical Excellence (NICE), undertook a broad appraisal of the best evidence in 2008 and concluded that, whilst restrictive criteria had to be met, there was definite place for grommet operations.
Glue ear is the popular name for Otitis Media with Effusion (OME), a consequence of earlier acute infection of the middle ear. The middle ear becomes full of fluid, making it hard for sound to pass through. The condition is very common in children and often improves on its own, but in some cases (around 5-10% of children) it is long-lasting, with an associated hearing loss. This can be worrying and stressful for the child and for parents – if the condition goes unnoticed, children can display behavioural and educational problems, which can easily be resolved if they get access to treatment.
If children have repeated bouts of glue ear, grommet surgery is a quick and painless solution. Under anaesthetic, a tiny slit is made in the ear drum to drain out the fluid and then and the grommet is inserted – this is a small plastic ventilation tube which allows the middle ear to breathe and stops more fluid forming in the ear. After a few months, the grommets fall out naturally and good hearing is usually restored. In some cases re-infection does occur and it is then necessary to repeat the procedure.
Controversy over this operation re-surfaces every few years, especially when the NHS needs to save money. The most recent example was a Personal View column in the British Medical Journal (Friday, November 19) by a general practitioner from Glasgow, Des Spence, who made a rather emotive attack on ENT surgeons who look after children. This has provoked many ENT surgeons to respond to the BMJ, suggesting that Dr Spence has misrepresented and ignored evidence, including the fact that many fewer operations are actually done today compared to when the procedure was first evaluated in the 1980s. Many ENT surgeons have said that they do operate selectively and when appropriate, as recommended by NICE.
“Some of these arguments surrounding grommets are historical rather than factual,” said Vivienne Michael, Chief Executive of Deafness Research UK. “Otitis Media is not a trivial condition and in serious cases, grommets are essential. Unnecessary procedures were undoubtedly performed in the past when the condition was not well understood. But this should not be used as a justification for cutting funding for an often valuable procedure. With pressures on funding, we are concerned there may be delays in treatment for those children in whom the condition does not resolve itself. In the long-term, this won’t save money and, for the children seriously affected, there could be significant impact on their development which grommets could have easily alleviated.”
“As a charity in these times, we understand well that tough decisions are needed amid financial constraints,” added Vivienne. “We are doing everything we can to support research to help understand the condition better, develop new treatments and define the types of children most needing grommets. Current controversies are putting thousands of children – and their families – at the risk of suffering unnecessarily.”
Deafness Research UK’s Ear infections and glue ear leaflet offers information and advice for parents who are worried about their children’s hearing. To obtain a copy, email firstname.lastname@example.org or call our freephone helpline 0808 808 2222
For information on deafness and deafness-related conditions, visit Deafness Research UK’s website at http://www.deafnessresearch.org.uk/
Notes to editors
Background on grommet operations
Given that grommets are relatively quick, complication-free and inexpensive cost borne by Primary Care Trusts (estimated at just £754 per operation) why has it become such a target for both critics and cuts?
The modern era of grommet operations was introduced in 1954 but when screening of hearing expanded in schools and child health clinics from the 1960s and many more children received a glue ear diagnosis. At the time, doctors (incorrectly) thought the condition usually justified an operation, so a high percentage of children with glue ear received the treatment. Later research showed the condition can clear up on its own and most medical authorities consequently now recommend a period (usually three months in UK) of watchful waiting to see if the condition resolves itself naturally. Hearing is usually then checked by a hearing or ear function test at a community health clinic or at the hospital ENT department and only then, if the condition has not cleared up, will a grommet operation be suggested. Over 43,300 grommet operations per year were performed in England 1994-1995, compared to 25,300 in 2008-2009, as the condition has become better understood and surgery only performed when appropriate.
There is strong anecdotal evidence that the immediate restoration of hearing after grommet operations leads to a wider improved quality of life for children and the family in the medium term. More research needs to be done to evaluate these wider benefits and the detailed justification for operating in suitably selected cases. An Oxford University project, led by ENT surgeon, Dr Mahmood Bhutta is attempting to probe underlying forms and causes of the condition. A £15,000 grant from Deafness Research has recently been made by Deafness Research UK to help his team solve some of the debates surrounding Otitis Media.
The McKinsey Report
The McKinsey report was commissioned in February 2009 by the Department of Health. See: http://www.dh.gov.uk/en/FreedomOfInformation/Freedomofinformationpublicationschemefeedback/FOIreleases/DH_116520 Slide 51 comments on Glue Ear and other procedures the report concludes as “ineffective”, including back pain and spinal cord procedures and jaw replacement.
The McKinsey report started from the proposition that if numbers of grommet operations were reduced by 90%, it would save the NHS £21 million a year.
About Deafness Research UK
- Deafness Research UK is the country’s only charity dedicated to finding new cures, treatments and technologies for deaf, hard of hearing and other hearing impaired people.
- The charity supports high quality medical research into the prevention, diagnosis and treatment of all forms of hearing impairment including tinnitus.
- The Deafness Research UK Advisory Service provides free information and advice based on the latest scientific evidence and informed by leading experts. The Advisory Service can be contacted on Freephone 0808 808 2222
- For more information on research into deafness, tinnitus and other hearing conditions, log on to the website at http://www.deafnessresearch.org.uk/ to access a wide range of information. Alternatively e-mail Deafness Research UK at email@example.com
- One in seven people in the UK – almost nine million people – suffer hearing loss.
- Deafness Research UK was founded in 1985 by Lord (Jack) and Lady Ashley of Stoke.
- In January 2008, Action for Tinnitus Research (ATR) was linked with Deafness Research UK under a uniting direction order under section 96(6) of the Charities Act 1993.
Ref: DRUK0321 – Glue Ear and Grommets Debate 2010