Postcode lottery? Do clinical commissioning groups differ in their funding of prominent ear correction surgery.

In 2013 Clinical Commissioning Groups (CCGs) were created and became responsible for the planning and commissioning of health care services in their area. The Royal College of Surgeons and the British Association of Plastic, Reconstructive and Aesthetic Surgeons created guideline for the CCGs in 2013 for the surgical treatment of prominent ears. By looking at each of the CCGs' websites, we aim to review their equity and how well they adhere to standards to determine whether there is a regional variation for funding of this procedure. We found that 47% of the CCGs will fund this procedure only on an exceptionality basis, compared to 26% who had set criteria and would allow funding if these criteria were met. There was significant variation in the age at which funding would be considered with some CCGs allowing funding from 5 years of age and others not providing it until as old as 11 years. Only 11 policies made any reference to cartilage moulding and only 3 mentioned funding to allow correct fitting of hearing aids. Unfortunately, despite recommendations from the Royal College of Surgeons and the British Association of Plastic and Reconstructive Surgery, there is still variation in funding criteria between CCGs for correction of prominent ear surgery. This may result in patients being treated differently depending on their postcode. We would urge commissioners to apply more consistent and uniform guidelines for the funding of surgical correction of prominent ears.

Introduction

In 2012 Clinical Commissioning Groups (CCGs) replaced primary care trusts. Each CCG is responsible for the planning and commissioning of healthcare services in their local area. CCGs are currently responsible for approximately two thirds of the NHS England budget. Following a series of CCG amalgamations before April 2018 there are now 195 active CCGs in England.

Prominent ear deformity is a congenital abnormality that affects approximately 5% of the Caucasian population. Correction of this has been reported as early as 1845, and techniques have evolved with time. Correction has been reported to improve the child's psychological quality of life in addition to altering aesthetic appearance. Low levels of self esteem and high levels of name-calling / bullying from peers have been implicated as contributors to this effect.

In 2009 the NHS chief executive stated that £20 billion of savings must be made in the NHS by 2014, and the following year new guidelines on criteria for funding of procedures of limited clinical value emerged. Many specialties quickly saw that some procedures were requiring much more strict criteria to obtain funding than the recommended NICE guidelines. In 2013 NHS England produced guidelines on Otoplasty/Pinnaplasty as a procedure of limited clinical value

Our aim is to compare guidelines on prominent ear correction surgery published by each CCG in England, and to review equity and adherence to standards. This can help determine whether there is a ‘postcode lottery’ in obtaining this treatment.

Methods

We searched each of the 195 CCG websites for their published policy / commissioning statements on funding criteria for prominent ear correction surgery.

We were unable to locate or obtain the policies for 10 of the CCGs. Where a published policy was available we looked at how funding would be approved e.g. criteria based, individual funding request (IFR) or not funded at all. We also compared any criteria that were set such as age and degree of ear prominence.

Results

Twenty-six per cent of CCGs allowed funding if certain criteria were met without the need for an individual funding request. A further 27% published the set guidance criteria but still required an IFR approval to be completed. Forty-seven per cent % of CCGs state that this procedure would be funded only in exceptional circumstances and did not set any specific criteria/guidance. (Figure 1)

Figure 1

Chart to demonstrate how pinnaplasty is funded throughout England.

Where specific criteria were published we found significant variation in the age that funding may be approved. The lower age limit ranged from 0 to 11 years old and the upper age limit ranged from 16 to 19 years of age. (Figure 2)

Figure 2

Chart to demonstrate the different age groups between CCGs where funding would be approved.

Only 11 CCG policies made any reference to cartilage moulding despite evidence describing the success of this technique in the neonatal period.,,,

The degree of prominence was also variable and poorly defined. Forty-six CCGs stated ‘significant asymmetry or deformity’ whereas 24 CCGs specified an exact figure of 30 mm of ear prominence.

Twenty-eight per cent% of the CCGs agreed that the concern about the deformity must come from the child and not the parent/guardian. This has been used to justify a minimum of 5 years of age at which surgery would be performed, as evidence has shown that it is rare for a child to express these sorts of concerns before the age of 5.,

Reference to other potential indications for surgery such as associated hearing loss or to facilitate correct fitting of hearing aids was mentioned in only 12 and 3 of the policies respectively (Figure 3).

Figure 3

Chart to summarise the number of CCGs requiring each of the different criteria mentioned before funding was approved.

Discussion

Ear moulding techniques were described in the 1980s by Kurozumi et al. who successfully splinted a constricted ear deformity in newborn babies with foam., Other techniques have been developed since to reduce the length of time of splinting from 6–8 weeks to 2 weeks when a more rigid splint is used. Early recognition in the neonatal period is key for this to occur and can obviate the need for future surgery and minimise any risk of psychological distress., As this is not mentioned in many CCG guidelines it may be that awareness of this therapeutic modality or access to this option varies in different areas.

Some published guidelines require exact measurement of protrusion for pinnaplasty to be funded. Consensus measurement techniques or guidance was not available and interobserver variability in ear measurement and variation in ear anatomy are known to be high., Subjective commissioning statements such as ‘significant deformity’ can result in highly variable assessor-dependent access to treatment.

The wide age range that pinnaplasty is funded can again result in children having their surgery delayed depending on where they live. Despite RCS and NHS England guidance suggesting surgical treatment may be appropriate between 5 and 18 years, some CCGs will not fund this procedure until the child is 11 years of age., Although in the literature there is no set guidance on the age for pinnaplasty it is widely accepted that a child may start to experience bullying from the age of 4–5 from their peers as the concepts of self and ‘differences from self’ develop (4, 5, 7, 11). It has been suggested that a better factor to determine timing of surgery is when the child rather than the parent expresses the wish to have the surgery. Unfortunately this was mentioned only in 27% of the policies.

Finally, the funding of pinnaplasty to facilitate function and correct fitting of a hearing aid was mentioned only in 3 out of the 185 policies found. Given the importance of hearing in the development of speech, it seems inappropriate that children outside of these 3 areas would incur substantial delays because of the need to apply for an individual funding request to obtain this procedure.

Conclusion

It is clear that despite recommendations by BAPRAS and the RCS on appropriate funding criteria for pinnaplasty CCGs are continuing to create their own guidelines which in turn creates a ‘postcode lottery’ for this procedure. Given the evidence to show that this procedure can have great impact on a child from not only a cosmetic point of view but also a psychological aspect we would urge that commissioners apply more consistent and uniform guidance for funding.

Declaration of Competing Interest

None.