Ear irrigation is not stipulated within the GMS contract. The GP registered nurse/health care professional has a duty under contract to assess the patient, undertake the appropriate examination and decide whether ear irrigation is the best course of action. Never refuse appointments for those patients where ear wax may be contributing to hearing loss or other symptoms or where the wax needs to be removed to facilitate examination of the ear (NICE 2019, last updated May 2023). Ear irrigation is not always essential, if the patient has been clinically assessed as per the Rotherham care pathway.
Diagnoses, Delegation and Training
Practices are advised to take into consideration their resources, competency of staff, their training needs, patient safety and possible risk of litigation. In some circumstances the patient may need to be referred to an alternative service or make arrangements for an audiological assessment or an additional diagnostic assessment if needed.
The recommendation from the NMC, NHS Digital and the GMC is that the GP and or registered nurse/health care professional remains responsible for any task such as ear irrigation delegated to another including an unregistered practitioner e.g. HCA. The NMC requires that when a registered nurse delegates a task to another person then they are adequately supervised, have ongoing support and access to a clinician.
The role of an unregistered practitioner e.g., HCA, is not to diagnose but to work within guidelines and protocols, it is therefore not appropriate for an HCA to make the initial assessment. Medical Protection Society would support ‘reasonable delegation’ within the field of the HCA’s expertise ensuring that they are fully trained, competent and follow a robust protocol. “The degree of risk must have been assessed because ultimately the patient has a right to the same standard of care, whoever delivers it “(CQC Mythbusters Health Care Assistants in General Practice. Oct 2015).
It is essential to ensure that the person undertaking the procedure can provide evidence that they have received training are competent and capable.
This procedure is only to be carried out by an experienced healthcare worker who has received recognised training in ear care and the use of ear care equipment. This training is available UK-wide from Primary Ear Care Centre trainers. The healthcare worker should also access a two yearly update Ear irrigation guidelines 2022.pdf (earcarecentre.com).
The person undertaking the procedure may consider (if trained and competent) using a Jobson–Horne probe to remove the wax under direct vision. (Rotherham NHS Trust – Aural instrumentation guidelines.) Fundamentally it is important that if anything untoward happened in your practice, the Partners could stand in front of a Coroner or Judge and justify that the training they had provided for their staff was sufficient to ensure they were competent, and confident to undertake the task given to them.
Patient Education and Advice
Before accessing an initial appointment with a registered nurse/health care professional patients should be encouraged to oil their ears for an agreed period prior to having them re-assessed for ear irrigation. The NICE (last revised May 2023) guidelines on the management of earwax published in June 2018 suggest that the use of drops for 3-5 days prior to irrigation can work well for a significant number of patients. The research available suggests that there are some advantages of using softening agents prior to ear irrigation but there is no evidence that one type is superior to another (Cochrane study 2018).
It is essential to ensure there are no contraindications prior to undertaking the procedure and this is documented in the patient’s notes. (CKS/NICE March 2021). Many practices in attempting to reduce demand for appointments have produced a leaflet encouraging self-care (Rotherham Ear Care Centre – patient leaflets).