ENT problems occur frequently in the community, and most are managed without consulting medical services. Whilst reasonable for many problems, there are likely to be important groups in the community with ENT problems that might benefit from modern interventions.

Objective-To see whether there is a relation between grommet insertion operation and tonsillectomy rates, otolaryngology services, and deprivation scores in Scotland.Design-Analysis of routine 1990 NHS data on grommet insertions and tonsillectomies in Scottish children aged 0-15 years compared with data on general practitioner and otolaryngology services and Carstairs deprivation scores.Setting-All 15 Scottish health boards. Subjects-All children aged 0-15 (1021933).Results-Tonsillectomy was more common than grommet insertion operations in Scotland (6182:4850). Health boards with high grommet insertion rates were more likely to have low tonsillectomy rates (Spearman's rank correlation -0 59; 95% confidence interval -0*87 to -0.03). Grommet insertion rates varied fourfold (from 2-4/1000 to 9.2/1000) and tonsillectomy rates twofold (from 3'6/1000 to 8.0/1000) across Scottish health boards.Variation between health boards had changed over the 15 years 1975-90. Variation in grommet insertion rates did not reflect variation in the supply of otolaryngology consultants (Spearman's rank correlation -0.25). There was a non-significant tendency for high general practitioner referral rates to be associated with high grommet insertion rates, low tonsillectomy rates, and less deprived areas (Spearman's rank correlation coefficients 0.50, -0 53, and -0A43). Deprivation (measured by Carstairs scoring for each health board) was associated with higher tonsillectomy rates (Spearman's rank correlation 0-41; 95% confidence interval -0-22 to 0'80) and significantly lower grommet insertion rates (-0 73; -0-92 to -0.28).Conclusion-Social factors as well as differences in disease prevalence and medical practice need to be considered when studying variation in childhood grommet insertion and tonsillectomy rates.

Objective-To examine changes in immunisation performance in Grampian region after the introduction of the 1990 contract for general practitioners.Design-Retrospective descriptive study using data held on the Grampian immunisation record system's computer.Setting-All 95 general practices in Grampian region (313 general practitioners).Patients

General practitioners have a central role to play in relation to planning and delivery of primary and community care services. This paper reports the experience of one health board in using a postal survey to ascertain the views of local GPs concerning services for people suffering from dementia. The survey was sent out once only and had a 41% response rate. Non-responding GPs were surveyed to ascertain reasons for failure to respond initially to the survey. The commonest reason given was that GPs felt they were being swamped with questionnaires. The paper discusses the problems of accessig GP opinion when time and resources are limited, the alternative strategies that could have been employed and the way forward in the light of the experience.

This paper examines recent trends in glue ear surgery in Scottish children between 1990 and 1994, using routine National Health Service (NHS) data from all 15 Scottish Health Boards (total population 5,132,400 in 1994, with 1,038,296 aged 0-15). Absolute numbers, rates of glue ear operations, and variation in rates declined between 1990 and 1994 across all Health Boards. The proportion of glue ear operations which included grommet insertion increased. Grommet rates in children declined in those Boards with the highest rates, but increased in Boards with the lowest rates, thereby decreasing the variation in grommet rates across Scottish Health Boards from 3.8- in 1990 to 2.6-fold in 1994. Other operations for glue ear, particularly 'myringotomy and adenoidectomy', varied 20-fold between Health Boards. The proportion of operations performed as day cases increased, but day cases and repeat grommet insertions still showed two-fold variation across Scotland in 1994. Many aspects of surgical management still show variation, and merit further examination by ENT surgeons and Public Health physicians.