The availability of CIs comes down to money. If CIs were comparable in price to hearing aids there would be little question that bilateral CIs would be routinely available for all deaf people who need them. However, CIs are a high cost medical procedure.

The NHS national tariff for a paediatric unilateral CI operation in 2007/8, for example, was £33,246. So how much would bilateral CIs for all severely and profoundly deaf patients cost the NHS and how would this compare with other NHS expenditure?The availability of cochlear implants (CIs) comes down to money. If CIs were comparable in price to hearing aids there would be little question that bilateral CIs would be routinely available. However, CIs are a high cost medical procedure.

The background analysis commissioned by NICE estimates the additional cost of a child’s bilateral simultaneous CI operation is £5,220 (1). Current device costs are around £15,000 but at least one of the two main device manufacturers discounts a second device for bilateral implantation by 50%, bringing the extra device cost for bilateral CIs to around £7,500. The 2007/8 payment by results tariff of the Nottingham CI Implant Programme (2) states the extra cost of follow up tuning and rehabilitation for a bilateral CI is an extra £5,760 for three years intensive rehabilitation (over and above a single CI). This brings the total ‘basic’ additional cost of paediatric simultaneous bilateral CIs to £18,480. The figure for adults from the same sources is slightly less - £12,531.

We haven’t been able to source any published figures for this procedure. However, based on actual prices paid by self-pay patients and, as in step one, assuming CI manufacturers apply a 50% second device discount (some currently do, some don’t), the first three year paediatric costs come to around £33,200. This is likely to be a top-line cost because we have assumed intensive rehabilitation in years 2 and 3 which may not be needed. In practice, a patient already used to their first implant may not require such intensive rehabilitation with the second.

Using the figures in the NICE report, 390 children in England and Wales are are born with permanent severe to profound deafness each year (3). The 2006 paediatric CI caseload across the whole of the UK was 375, according to estimates published in evidence to NICE by the National Cochlear Implant Users Association (NCIUA) (4). The NICE report does not give a figure for the number of adults who present with severe to profound deafness each year. However, the NCIUA evidence reports an adult caseload of 292 across the UK in 2006 (4).

We divide this calculation into three parts:

1. Extra cost of simultaneous CIs (over unilateral CI) for a current assumed caseload of 375 children – 375 x £18,480 = £6.9 million.
2. A three year programme to provide sequential bilateral CIs to half of all children who have received unilateral CIs in the last eight years* – (0.5 x (325 x 8) x £33,200)/3 = £14.4 million. * This roughly covers half of all unilateral CI users who are currently of primary school age or below. We assume half on the basis that take-up would be affected by some families deciding against a second round of surgery. A lower historic annual caseload is assumed at 325, reflecting lower levels of cochlear implantation prior to universal neo-natal screening.
3. Extra cost of simultaneous CIs (over unilateral CI) for a current assumed caseload of 292 adults – 292 x £12,531 = £3.7 million.

Long-term patient expenditure does need to factor in the cost of ongoing maintenance, repairs, failures and upgrades. Ongoing maintenance, such as batteries and any device checking, is assumed to cost £1364 per year for children and £599 per year for adults by the authors of the background study commissioned by NICE (1). Manufacturer’s warranties cover part of the risk of failures and repairs - for ten years in the case of the internal device. Failure rates for modern devices are very low. Not enough data is available to accurately estimate long-term repair costs. However, the possibility of repairs is reduced by regular speech processor upgrades and, hence, renewals of manufacturer’s guarantees. The cost of a new speech processor is £4,500. On the assumption that a new speech processor is purchased every eight years and, if we add the same annual maintenance costs as used by NICE, the additional costs (for each of the three patient groups listed under step four) are (1) £0.7 million reducing to £0.4 million as the children get older; (2) £2.5 million reducing to £1.5 million as the children get older; (3) £0.33 million.

Our estimate of the total cost of a bilateral CIs for all (simultaneous for all new patients on current caseload figures and sequential for existing unilateral CI users of primary school age or below) is £25 million. £14.4 million of this is a one-off cost of providing a three year sequential bilateral CI programme for some existing children using unilateral CIs.

£25 million, or the recurrent cost of £10.6 million, are significant sums but they are small in health service terms. Indeed, they are less even than the contract cancellation fees that the Department of Health is spending simply because of changes to central contracts with private sector health providers. According to Financial Times the costs incurred in such fees alone are likely to be at least £28 million (5). The recurrent investment needed to provide bilateral CIs for the current caseload of both adults and children represents 0.012% of the NHS's total resource budget in 2007/8 (projected to be £87.6 billion in HM Treasury's 2007 Budget Report). Put another way, this is just 1/8200th of the total NHS resource budget.

The costs of bilateral CIs are dwarfed by the sums that the Chief Medical Officer, Sir Liam Donaldson, says could be saved by the NHS on ineffective or wasteful treatments. Presenting his Annual Report in July 2006, the Chief Medical Officer said: “With finite resources available for the provision of healthcare, it is important that effective therapies to relieve significant conditions are adopted and that ineffective interventions are abandoned” (6). His report highlighted four examples of ineffective treatments which alone cost the NHS tens of millions and, certainly, more than £23.4 million cost of investing in full bilateral CI services (6). Reporting on his findings, the Financial Times said: “more standardised procedures and protocols for treatment would also contribute to patient safety, failures of which were costing the NHS at least £3bn a year” (7).

Even extending bilateral CIs to include sequential procedures to cover all children and families that wanted them and extending the current adult and child CI caseload would cost just the tiniest, tiniest fraction of the potential £3 billion that could be freed up if the NHS followed the Chief Medical Officer’s advice.