Intended for healthcare professionals

Views And Reviews Primary Colour

Helen Salisbury: The hollowing-out of services

BMJ 2020; 370 doi: (Published 15 September 2020) Cite this as: BMJ 2020;370:m3531

Read our latest coverage of the coronavirus outbreak

  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

Like many GPs, I’ve spent too long recently discussing the deeply unglamorous topic of earwax—specifically, whether we can or should continue to remove it. Not many years ago, practice nurses spent a lot of time squirting warm water into people’s ears to unblock them: not a particularly pleasant job, but someone has to do it. The question is, who?

Then we were advised by NICE that earwax should be removed by irrigation, using a pump with controlled pressure rather than manual syringing, as this was less likely to damage the eardrum.1 The alternative is microsuction, where wax is hoovered out under direct vision, which requires expensive kit and training.

No specific funding is provided for this work, and surgeries are increasingly crossing it off their list of services. General practices will be blamed for this, but they can rightly claim that it’s not a commissioned activity and they don’t currently have enough nursing hours to provide all of the other care patients need.

As no one takes responsibility for providing or commissioning this service, it’s become increasingly unavailable. Our local ENT department will do microsuction for a select few patients with complicated ear pathology, but it lacks the capacity to treat every blocked ear in the county. High street opticians offer it, but many patients can’t afford the £50 price tag. I’m concerned that ever more patients who have tried wax softening drops with minimal success are now just suffering in silence (quite literally).

Not all medicine is dramatic and life saving: doctors spend time treating fungal infections and indigestion as well as heart attacks and major trauma. But our NHS was set up not just to save lives but also to reduce suffering and make lives better, regardless of patients’ ability to pay. The contract with the British people—the promise of cradle-to-grave care—is looking increasingly threadbare.

This reduction in what the NHS can provide is happening both in hospitals and in the community. Surgical procedures that were once routine, such as hernia repairs and treatment of varicose veins, are now “low value” and are difficult to access in many areas unless serious complications are likely.2 Services are slowly disappearing from primary care too: travel vaccinations and cryotherapy for minor skin lesions are two further areas that many practices have withdrawn from.

Earwax and varicose veins may seem trivial and hardly worth bothering about until you have them yourself or a distressed patient is sitting in front of you. When there’s competition for inadequate funds, non-life-threatening health issues lack the urgency of cancer care or the political clout of children’s services. This is how the NHS is shrinking—not with a radical introduction of upfront payments or insurance but with a gradual whittling away of services to which all patients are entitled. Not with a bang but a whimper.



View Abstract