3. Mr L complains a GP Practice in Lincolnshire (the Practice) did not refer him for removal of his ear wax in December 2024.
4. Mr L says he could not hear properly for weeks and was in pain. He also feels unsupported by the Practice and had to pay privately to have the wax removed.
5. Mr L would like the Practice to acknowledge what it has got wrong, to make service improvements and to reimburse him for the private fee he paid to have his ear wax removed.
6. Mr L has a history of ear wax problems dating back to 2011. He has previously had his ears syringed multiple times to remove the wax.
7. In 2023 when Mr L visited his GP with a blocked ear, the Practice advised it no longer does ear syringing. After conservative management did not work, it said this would need to be done privately which Mr L arranged and paid for.
8. Mr L attended a number of times after this about his ear wax difficulties. The appointment we are considering is his attendance on 13 December 2024. Mr L feels he met the criteria for microsuction, or referral to an ear, nose and throat specialist due to the repeat and ongoing issues. The Practice did not do this. Mr L therefore paid privately to have his ears cleared again.
13. NICE guidance on ear wax says removal should be offered if it is contributing to hearing loss or other symptoms or where the tympanic membrane is obscured by wax but needs to be viewed.
14. The local ICB emailed the Practice guidance on its referral criteria for its NHS microsuction service at the time and it asked GPs to complete referrals on the electronic system. A local health centre ran the service. The ICB’s inclusion criteria included otalgia (ear pain) or otorrhoea (discharge from the ear), a requirement to review the tympanic membrane (eardrum), or impacted wax which had not cleared with conservative management (a structured, non-invasive approach). One of its exclusion criteria was removal of simple ear wax. It said should a referral outside of the inclusion criteria be received, the referral would be rejected and the service would notify the Practice of that.
15. The BMJ best practice on ear wax says impaction is when a build up of ear wax results in symptoms, such as hearing loss, or when it prevents adequate assessment of the ear canal or tympanic membrane.
16. Mr L’s 13 December 2024 consultation record shows the GP noted he had hearing loss on the left side and the wax was impacting their view of his eardrum. From this information, Mr L had impacted ear wax from the BMJ description. We therefore do not think Mr L met the exclusion criteria of ‘simple ear wax’, as the Practice says. It was impacted and causing him symptoms. Whilst it is not documented in the consultation, Mr L says he had also had ear pain. Based on the record we cannot know whether the GP had knowledge of that at the time, but we can see Mr L told the Practice on 27 December that it had not included this symptom in his record.
17. To meet the criteria for microsuction, the guidance first requires the patient to have tried conservative management, such as using olive oil drops or a treatment from a pharmacy. The Practice says on this occasion there was no record Mr L had tried conservative management.
18. Mr L says he had tried conservative management, including support from a pharmacist, as he is familiar with this due to the recurrence of his ear wax problems. He says it was because this did not work that he booked in with his GP. He told the Practice this in his email on 27 December. There is no record of the GP checking whether Mr L had tried conservative management first during his appointment. We know from the notes of other GP appointments that Mr L was very aware of conservative methods and had tried these on a number of occasions.
19. If the GP had checked whether Mr L had tried conservative management, it is more likely than not he would have confirmed he had done this.
20. The Practice also says it offered Mr L a hearing test, due to his hearing problems which he believed was caused by the wax. Our GP adviser explained this would not have been suitable. Audiology services usually request that the ears are clear of wax before a hearing test so the audiologist can look at the patient’s eardrum. This would also have been a reason to refer Mr L to the local microsuction service, in line with NICE guidance.
21. We understand the Practice also says it offered Mr L a second opinion as he had asked for one, but noted there was some confusion around this. Mr L emailed the Practice after having private microsuction to say he was told his ear had redness with a possible suspected infection. The Practice response said it was happy to arrange a further appointment or second opinion but also that it would not change its stance. It was appropriate to offer a second opinion. But we understand why Mr L did not then accept that based on the Practice’s response. This does not change our view that the evidence shows the Practice should have referred Mr L to the local microsuction service when it saw him on 13 December.
22. We think based on Mr L’s presentation, the evidence indicates he met the criteria at the time for the Practice to refer him to the local microsuction service. It would then have been up to that service to make a decision about accepting or rejecting the referral.
Impact
23. Mr L says he could not hear properly for weeks and was in pain. He also says he feels unsupported by the Practice and had to pay privately to have the wax removed, which cost him £60.
24. We can only say Mr L met the criteria at the time for the Practice to refer him to the local microsuction service. We cannot say the service would definitely have accepted his referral. If it had, we do not know how long the wait would have been for this. General information online about waiting times for microsuction indicates this is between four and 12 weeks across the NHS. We understand the ear wax was causing Mr L pain and hearing difficulties, and he paid for microsuction privately four days after the GP appointment. On the basis of the available evidence, we cannot say he would have made a different decision if the Practice had referred him to the local service.
25. If Mr L’s pain and hearing difficulties continued after microsuction, we cannot say the Practice could have prevented this. The treatment he paid for four days after the GP appointment was the same he would have had if the local microsuction service had accepted a referral. And in fact he is likely to have waited longer for treatment on the NHS. But we understand that the Practice left him feeling unsupported and worried about his recurring ear wax problems.
What the Practice has done to put things right
26. The Practice did not accept it got something wrong in its decision to not refer Mr L to the local microsuction service. It apologised Mr L felt he was not offered the appropriate service.
27. There is more the Practice should do to acknowledge what it got wrong and the impact it has had on Mr L, in line with what we have found.
1. We partly uphold Mr L’s complaint. We have found he met the referral criteria for microsuction at the time and the Practice should have referred him to that service. We cannot speculate about what would have happened following the referral. We do not know if it would have been accepted, and if so, when Mr L would have been offered microsuction. We are therefore not asking the Practice to reimburse the private costs.
2. We have, however, found this has led to Mr L feeling unsupported for this medical problem and we understand this is particularly worrying for him as he has recurring issues with his ears. We ask the Practice to write to Mr L to acknowledge what it got wrong and the impact this has had on him.
28. In considering our recommendation, we have referred to the ‘NHS Complaint Standards’. These state that NHS organisations should be open and honest when things have gone wrong, recognise when this has had an impact on people, and identify suitable ways to put things right.
29. Mr L felt a financial remedy was warranted to recognise the impact the Practice’s mistake had on him, as he felt he had no option but to pay for the microsuction privately. As we cannot say what would have happened after the Practice should have referred him to the microsuction service, we will not be asking the Practice to reimburse that private cost.
30. Within one month of this report, the Practice should write to Mr L to acknowledge and apologise that what it got wrong has led to him feeling unsupported by the Practice with this health concern, which is worrying for him given his repeat ear wax problems. It should also explain to Mr L what it knows about the recent changes to the local NHS service provision, so he is informed about his options if he feels he needs microsuction in future.