Commissioning a service for the surgical management of otitis media with effusion in children

The directly standardised rate of insertion of ventilation tubes (grommets) for all primary care trusts (PCTs) in England in 2006/07 was 400 per 100,000 children under the age of 12 years. While it is not expected that implementation of NICE clinical guideline CG60 on surgical management of otitis media with effusion (OME) should not require a major change in what is already current practice in many areas, there is an eightfold difference in the rates of this type of surgery across England, suggesting that there is a need to standardise practice. Some commissioners may therefore need to review their adherence to care pathways for this procedure based on the NICE clinical guideline and/or to consider disinvestment where appropriate. Implementation of NICE clinical guideline CG60 on surgical management of OME should enable commissioners to make cost-effective and unbiased arrangements for the management of this condition, thereby giving maximum benefit to children while minimising the risks of intervention.

OME is a common condition of early childhood in which an accumulation of fluid within the middle ear space causes hearing impairment. The hearing loss is usually transient and self-limiting over several weeks, but may be more persistent and lead to educational, language and behavioural problems. It is most common in young children, with a bimodal peak at 2 and 5 years of age; 80% of children will have had at least one episode of OME by the age of 10 years. In most instances of uncomplicated OME, no intervention is required because the fluid clears spontaneously.

Care pathways for children with features suggestive of OME should ensure initial assessment, and referral for formal assessment if considered necessary. Formal assessment includes hearing testing appropriate for the child's developmental stage and tympanometry. The persistence of bilateral OME and hearing loss should be confirmed over a period of 3 months before intervention is considered. This generally requires accurate audiometry at the beginning and end of this time, which may lead to an increase in referrals to paediatric audiology and may require better and more timely access to services than is currently available in some areas. The NHS in England: operating framework for 2007/08 identified the risks to delivery of the 18-week objective associated with audiology. Transforming services for children with hearing difficulty and their families: a good practice guide notes that, for many children, the maximum waiting period of 18 weeks will need to be much shorter in order to minimise the impact on their education and development. Currently there are significant variations in quality, models of audiology service, activity levels, workforce skill mix, productivity and costs^[1]. Most audiology services are located in NHS acute hospitals although some, in particular those for children, are provided on an outreach basis in the community^[1].

Commissioners may need to ensure that there is timely access to surgical treatment and that the provision of hearing aids is available where surgery is contraindicated or not acceptable. Adjuvant adenoidectomy is not recommended in the absence of persistent and/or frequent upper respiratory tract symptoms.

Benefits

The potential benefits of robustly commissioning an effective service for the surgical management of OME in children include:

• reducing the risk of inappropriate surgical or medical management, including antibiotic prescribing which may be high in some areas given the low clinical benefits^[2]
• providing timely and efficient clinical management of OME in children by ensuring appropriate audiological assessment and surgical intervention when required
• improving clinical outcomes such as improved hearing, reduced ear pain, reduced infection and improved reported speech and language development
• reducing the demand for ear, nose and throat (ENT) services by improving GP access to paediatric audiology and agreeing and consistently applying referral criteria
• ensuring consistent and effective care for children and their parents or carers
• reducing inequalities by decreasing regional variations in the threshold for surgery and improving access to services for the surgical management of OME
• increasing patient choice, improving partnership working and the experience and engagement of children and their parents or carers
• ensuring value for money, by increasing the consistency of service provision across providers - this may include opportunities for clinicians to undertake local service redesign to meet local requirements in novel ways.

Key clinical issues

Key clinical issues in providing an effective service for the surgical management of OME in children are:

• ensuring appropriate referral pathways are in place to support the implementation of NICE clinical guideline CG60 on surgical management of OME
• ensuring there is access to, and sufficient capacity for, hearing testing appropriate for the developmental stage of children presenting with OME, and tympanometry
• identifying all children with OME who may benefit from surgery
• providing effective and efficient clinical care in line with NICE clinical guideline CG60 on surgical management of OME
• ensuring the service is integrated with other health and social services for children with OME to support holistic care
• providing a quality assured service.

National priorities

National priorities and initiatives relevant to commissioning a service for the surgical management of OME in children include:

• High quality care for all: NHS next stage review final report identifies the need for locally-led, patient-centred and clinically driven change, including the work stream on children's health.
• World class commissioning.
• The NHS in England: The operating framework for 2009/10.
• National service framework for children, young people and maternity services and in particular the standard relating to hospital services for children Getting the right start: National service framework for children, young people and maternity services: standard for hospital services.
• The Care Quality Commission report on Improving services for children in hospital emphasises the standards required, including the hospital environment, training, surgery and anaesthesia.
• Joint planning and commissioning framework for children, young people and maternity services advocates effective joint planning as part of the Local Area Agreement, and commissioning as being at the heart of improving outcomes for children and young people.
• Commissioning framework for health and well-being.
• Delivering the 18 week patient treatment pathway.
• The Care closer to home initiative outlined in chapter 6 of the white paper ‘Our health, our care, our say'.
• Considering the impact of patient choice.
• A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services.
• Implementation of NICE clinical and public health guidelines. These are currently core standards, and performance against these standards will be assessed by the Care Quality Commission in line with ‘Standards for better health'.

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.

References

1. Department of Health (2007) Improving access to audiology services in England. London: Department of Health.

2. Williamson I, Benge S, Mullee M et al. (2006) Consultations for middle ear disease, antibiotic prescribing and risk factors for re-attendance: a case linked cohort study. British Journal of General Practice 56: 170-5.