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GPs buried under trusts' workload dump

Removing earwax is down to GP practices, says new NICE guideline

GP practices should provide earwax removal services rather than referring patients to specialists, according to the latest NICE recommendations.

The adult hearing loss guidelines, released today, said that if earwax is contributing to hearing loss or needs to be removed for an ear examination, practices or community clinics should provide the service rather than referring them to an ears, nose and throat specialist for the same procedure.

But the BMA's GP Committee said this guidance 'places no obligations on GPs to provide this service unless contracted to do so', and suggested CCGs needed to commission the service separately.

The new NICE hearing loss guidance also recommends that GPs:

  • Advise adults not to remove earwax or clean their ears by inserting small objects, such as cotton buds, into the ear canal, as this could cause damage or push the wax further into the ear;
  • Refer adults with sudden onset or rapid worsening of hearing loss in one or both ears, which is not explained by external or middle ear causes;
  • Immediately refer adults with acquired unilateral hearing loss and altered sensation or facial droop on the same side to an ear, nose and throat service or, if stroke is suspected, follow a local stroke referral pathway;
  • Immediately refer adults with hearing loss who are immunocompromised and have otalgia (ear ache) with otorrhoea (discharge from the ear) that has not responded to treatment within 72 hours to an ear, nose and throat service;
  • Consider making an urgent referral to an ear, nose and throat service for adults of Chinese or south-east Asian family origin who have hearing loss and a middle ear effusion not associated with an upper respiratory tract infection;
  • Consider referring adults with hearing loss that is not explained by acute external or middle ear causes to an ear, nose and throat, audiovestibular medicine or specialist audiology service for diagnostic investigation, using a local pathway.

NICE has estimated that 2.3 million people in the UK each year have problems with earwax sufficient to need intervention.

A spokesperson said: ‘The NICE guideline aims to help improve care for people with hearing loss through better management of earwax, prompt and accurate referral of people with symptoms to the right service at the right time, and robust assessment and correct treatment.

‘It recommends that GP surgeries or community clinics should offer to remove earwax if a build-up is contributing to someone’s hearing loss. This means patients do not need to be referred to a specialist ear, nose and throat (ENT) service for the same procedure.’

They added that if a patient experiences sudden hearing loss without an obvious cause, they should be referred immediately to a specialist service or an emergency department.

However GPC clinical and prescribing policy lead Dr Andrew Green responded: 'NICE is responsible for clinical guidance but have nothing to do with commissioning services which are the responsibility of CCGs.

'The fact that NICE recommends something as suitable for primary care places no obligations on GPs to provide this service unless contracted to do so.'

Readers' comments (28)

  • Vinci Ho

    Ha ha ha ha ha
    This will be one area of increasing so called ‘productivity’ in general practice.
    When all GPs are salaried , one job they must do is removing wax; sadly , electronic/video consultation or GP smartphone app cannot provide this service !
    Wonderful, salute to NICE

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  • Wonder how Babylon remove ear wax, put the phone on vibrate and put it to your ear, it may dislodge it!!!!Wonder how they will diagnose piles or an anal fissure, selfie anyone!The mind boggles Ive woken up in a perverse alternative universe.

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  • one more example of GP practices going beyond their contractual obligations. GP should really be forcing CCG to commission these services instead of doing charity by offering these free.

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  • Perhaps I am wrong but I seem to remember my indemnifying organization suggesting that ear wax removal was a medical legal hazard best avoided in primary care.....

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  • Vinci Ho

    You see
    Most of the recommendations in this NICE guidance was ‘telling me my mother was a woman’(sorry to sound like a bit arrogant).
    But the important one which I would like to emphasise was the part on Chinese and South East Asians because of higher prevalence of nasopharyngeal carcinoma.

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  • WHO CARES WHAT NICE THINKS.

    THE MONSTROUS SALARIES OF THOSE ON NICE SHOULD BE DONATED TO PATIENTS AND THE "EXPERTS" ASKED TO PACK THEIR BACKS AND EXIT THE BUILDING....STOP THE GRAVY TRAIN

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  • How about the long hair that interferes with sight, rubbing on ears and shoulders. Should GPs cut these too? What about finger and toe nails or after the toilet. All part of the nanny state care. We can always invent a name for the conditions so people can claim benefits.

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  • I maybe wrong, but I thought that nowadays the safest method of wax removal is microsuction or manual removal. Ear syringing should ideally be avoided. So are all GP practices trained and equipped with microsuction?

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  • send them to spec savers innit. £30 job done

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  • Good to get definitive guidance from the R Souls group. I hear that the Belly-Button Fluff Removal panel are meeting in July. This will certainly be another GP task. It just remains to be seen whether they order us to remove it with our teeth or not.

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  • I'm not sure I understand the gnashing of teeth here. NICE are recommending GPs do it, this puts the onus on CCGs to commission the service. When they do (and at a level of remuneration that makes it financially viable) I'll happily provide the service. Until they do I won't.

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  • This changes nothing. There is lots of stuff that should happen in primary care (from ambulatory bp monitoring to post op wound care to checking elderly folks fire alarms) but which we are not core contracted to provide. Contract it at the right money (ie no worse than break even) and if there is time in the day - my team will do it.

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  • Not. In. The. Contract.
    No further discussion required.

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  • Ben Bromilow. We have all been bitten that is why. 1)Choose and book. Payment initially then now you are obliged to do it to refer and one must provide the data manually if you do not use it.2)Once you buy the equipment and hired the nurse they would stop it and transfer the money elsewhere for new initiatives, just like QoF. Suddenly a disease area is no longer important and the money transferred but it is good medical practice to continue doing it and CQC will see to that. 3)Miscellaneous service provision. If you have been doing it for a long time (ear syringing) then it is then deemed part of your contract provided in the mysterious global sum. I hope this helps.

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  • As with 10:51, pay us appropriately and we might consider it.

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  • I have always done ear syringing in practice. we still do it. I did not know it is not a part of gms.

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  • we have adopted policy that routine ear syringing is no longer encouraged as damaging the ears natural cleaning mechanisms-so no patients new to syringing will be offeref it -and those who already rely on it , prolonged use of drops should be tried first before our nurse will syringe .This so bemused one 'regular'patient , her letter of utter bewilderment to the local- (admittedly unexciting small town weekly) - newspaper was published prominently!

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  • We should,like other contractors providing a service insist
    on charging for ALL non core work delighted to us.
    Our problem is we do not have a united credible or effective trade union in place to support us.

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  • What procedure is the lady in the picture carrying out? She has a pen torch and a face mask. Is she a SpEWn (specialist earwax nurse) or a PEWc (proactive earwax consultant)?

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  • AlanAlmond

    Copernicus 7:37pm
    The lady in the picture is an ECCo (ear canal cleaning operative). You can tell because she’s wearing red, the other ear accredited health care professionals you mention wear green (SpEWn) and blue (PEWc). Hope that clears that one up. Thanks. .

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