Clinical judgment is important for individual patients

Editor—Williams et al comment on the provision of private operations and make several sweeping statements.¹ They question the efficacy of myringotomy and grommet insertion, and allege that some health authorities are refusing to fund them. The British Association of Otolaryngologists- Head and Neck Surgeons is not aware of any such purchasing decisions currently in place with regard to grommet insertion. The effectiveness of grommet insertion and the long term effects of surgery compared with no surgery are the subject of a multicentre trial by the Medical Research Council, which is nearing completion. The main decision does not concern effectiveness of treatment but rather which children have persistent problems. To paraphrase Professor Mark Haggard, the MRC's trial coordinator: “Deciding when to intervene is difficult because you only know when it's too late that you should have intervened.”²

The article by Williams et al helps to show that making decisions about populations of people is one thing but to apply those decisions rationally to individual patients is quite another. This is where clinical judgment comes in.

Their further comment that the Commission for Health Improvement has to ensure that treatments are evidence based but that its remit doesn't apply to the private sector may be irrelevant. Patients often come to the private sector because they do not want to be treated according to a set of fixed rules (as in drug prescribing) that assume one size fits all. The NHS has always had to make harsh choices, but these include criteria based on funding and access, which do not necessarily apply in the commercial world of health care.