House of Commons - Health - Fifth Special Report

Select Committee on Health Fifth Special Report

2 History

9. In this chapter we look at recent developments in audiology. We examine hearing problems, the provision of audiology services, the measures taken to improve them and the extent of waiting times and reasons for them.

Hearing problems

10. Over 7 million people in England have hearing loss of some sort. Causes include deafness from birth, trauma, infection and degenerative hearing loss. Aural disorders account for 24% of all adult disabilities in the UK.[2] 55% of people over 60 are deaf or hard of hearing, and the figure increases to 80% by 80 years.[3] As the population as a whole ages, the numbers of individuals affected by total or partial hearing loss will grow.

11. Poor hearing affects people's quality of life. The World Health Organization described deafness as a non-communicable disease that is "a cause of enormous human suffering and a threat to the economics of many countries…[that] constitutes a major contributor to the burden of avoidable risk and disease".[4] The charity Help the Aged pointed out that loss of hearing may mean that people lose their social networks. The charity Sense stated that, "deaf, deafened and hard of hearing people are vulnerable to isolation and depression".[5]

12. Only a fraction of those affected by hearing loss (about 750,000) seek help from their GP each year.[6] Many choose to ignore their hearing problems: only approximately 2 million use a hearing aid but over 4 million more could benefit from one.[7] We were also told that it was common for patients not to use analogue hearing aids once they were fitted.[8]

13. Digital aids are far superior to the older models. They give a higher quality of sound and are more comfortable to wear. They exist in many different forms; they may be worn behind or inside the ear, and can be fitted to one or both ears. They can also be used by people who are unable to use analogue aids. One recipient of a hearing aid, Margaret Howard, told us that a digital aid gave her:

…not perfect hearing, but much, much better than I had ever experienced with analogue aids. Every person with a hearing loss should be able to be supplied with a digital hearing aid.[9]

Because of their effectiveness, digital hearing aids are more popular with patients and demand has increased.

Audiology services

Provision of services

14. Audiology services are mainly provided by the NHS but the private sector also carries out assessment of patients with hearing loss and supplies digital hearing aids.

15. There are 158 audiology departments in England that assess and fit patients with hearing aids. Most audiology departments are based on acute hospital sites, although a few services operate within primary care. Within audiology departments there is a mixture of staff, including fully qualified audiologists and assistant audiologists, who often assess patients. Most adult audiology departments are run by a service manager rather than a consultant.

16. Other, consultant-led, services also provide specialist audiological care. For example, maternity units often screen newborn babies for hearing problems; Ear Nose and Throat (ENT) departments concern themselves with more complex cases of hearing loss and patients who need medical treatment or surgical intervention.

17. Most people with hearing problems attend an audiology department to have degenerative hearing loss restored through the fitting of a hearing aid. Most patients are referred directly to the local service by their GP, although some come via an ENT department. Following fitting of the hearing aid, patients receive follow-up care, which may take place in person or by telephone. Hearing aids must also be maintained, which requires the supply of batteries, repair and replacement. NHS audiology departments offer all these services. Around 500,000 adult 'patient pathways' (from GP referral to receipt of a hearing aid) are completed by the NHS in England each year.[10]

18. Approximately 25% of those who need a hearing aid use a private provider.[11] There are around 1,400 high-street practitioners which provide and fit hearing aids including several big companies, such as Boots, Scrivens, Specsavers and Healthcall. The price patients are charged for initial assessment, supplying and fitting a digital hearing aid and follow-up care varies from around £500 to £2,000 (average £1,200).[12] Following our evidence session, the Minister informed us that the cost of providing such a service to the NHS would be far less.[13]

19. There is no national tariff associated with audiology services and audiology is therefore not included in the Practice-Based Commissioning or Payment by Results initiatives.[14]

Staff

20. Fully-qualified audiologists entering the NHS for the first time train for four years, having undertaken a BSc in Audiology at one of nine universities in the UK.[15] The first set of graduates completed their training in 2006. From 2007, about 190 students will complete the course each year.[16] Audiologists can complete further specialist training, or undertake an MSc, after this point.

21. Below this level are Assistant Audiologists. Training for these individuals varies according to the trust or Primary Care Trust (PCT) in which they work. There is no formal qualification required, and most training will be in-house. A further level of Associate Audiologist, above that of assistant, is envisaged. Staff at this grade will have trained for two years, to complete a Foundation Degree (see below). Standards for NHS audiology staff are determined by professional bodies and local trusts.[17]

22. Staff working for private companies are not trained to the same level as fully qualified NHS audiologists. Most complete a six-month intensive course and then take examinations before starting work within a private dispensary, where they are closely supervised for the first six months.[18] Once the examinations, which consist of a theoretical and a practical element, have been passed and the post-examination training period completed, they become a Registered Hearing Aid Dispenser.

23. Recently, a Foundation Degree has been developed by the independent sector regulator (the Hearing Aid Council) alongside the British Academy of Audiology (BAA), British Society of Hearing Aid Audiologists and the Association of Independent Hearing Health Professionals. It is intended to be the threshold entry qualification for all hearing aid audiologists in the future, including Associate Audiologists working within the NHS and those in the independent sector.[19] The first intake of undergraduates will take place in 2007.

Modernising Hearing Aid Services

24. Before 2000, NHS patients had no choice but to receive an analogue-type aid. In 2000, the Modernising Hearing Aid Services (MHAS) programme was introduced to improve audiology services, in particular by supplying patients with newer, more effective types of hearing aid. Other changes to NHS audiology services aimed to increase capacity: audiologists were permitted to work overtime to offer 'out of hours' services and so see more patients.[20]

25. The programme was run by the RNID on behalf of the Department of Health and involved a Public Private Partnership (PPP). It started at 20 pilot sites[21] and was extended to cover the whole country in 2003 at a total cost of £125 million, which was largely spent by 2005. Funding was ring-fenced for the duration of the programme. The MHAS programme was considered a success by many; however, some failings were also pointed out. Both are discussed below.

Successes

26. NHS audiology services improved significantly following the MHAS programme. By spring 2005, all NHS trusts were equipped to fit digital hearing aids. According to the RNID, over 1 million people have received digital hearing aids from the NHS since 2000.[22] A study by the Medical Research Council in 2005, designed to examine the effectiveness of the new hearing aids and the service offered to patients, was summarised thus:

People fitted with high quality digital hearing aids in the modernised service reported 41% greater overall benefit compared to those with analogue aids. They were using their aids more of the time, finding them more helpful, and were more satisfied with the result.[23]

27. Many witnesses praised the MHAS programme. Adam Beckman, Audiology Services Manager at Plymouth Hospitals Trust, made a point echoed by several other submissions:

The huge investment that has been made to improve the quality of hearing aid services for patients is wholeheartedly welcomed. The improvements in outcomes and quality of life are extraordinary.[24]

Ruth Thomsen, audiology services manager from Charing Cross Hospital, also stressed the positive effects of the programme:

We have been completely modernised. The investment coming via the RNID from the Government has been phenomenal. We have been well educated, well trained and at last we have been able to take the ball and run with it.[25]

Failings

28. Witnesses also informed us of two main problems with the MHAS programme. The first related to aspects of the PPP, the second to the initial assessment of demand for digital hearing aids.

The Public Private Partnership

29. As part of the MHAS programme, the NHS Purchasing and Supply Agency and the RNID negotiated a contract to procure digital hearing aids from two private provider companies, David Ormerod and Ultravox. These organisations not only provided the hearing aids, but worked with the NHS to carry out assessment and fitting of the devices.

30. The PPP was an integral part of the MHAS programme; it is unlikely that MHAS would have been as effective overall without the involvement of the private providers. However, some witnesses called into question aspects of the PPP. The Hearing Aid Council (HAC) claimed that the treatment of NHS patients under the PPP was not adequately regulated.[26] Others argued that the PPP had unforeseen financial implications for NHS audiology departments. For instance, at Charing Cross Hospital, the private company engaged used NHS facilities, including the use of a room for testing patients and a receptionist to meet patients and handle telephone bookings and any problems that arose. The hospital was not recompensed for these services. Appearing before the Committee, Ultravox and Departmental officials argued that patients treated under the PPP should not have been seen in an NHS hospital.[27]

31. Other witnesses argued that the cost of treating patients in the private sector as part of the PPP was higher than in the NHS. The BAA stated that PPP activity was twice as expensive as the equivalent NHS treatment. The Academy conceded that the scheme had been successful in part, but added:

…there have been examples of the private sector partners not fulfilling their obligations, being paid for work not done and up to 50% of these patients requiring access to the NHS Audiology Service for further rehabilitation.[28]

32. The private providers disputed these claims, stating that the PPP delivered a good service, on time and in fact saved the NHS money.[29] In this short inquiry, we have had no opportunity to assess relative costs so cannot comment on this matter in detail. Other aspects of the use of private providers are discussed below.

Assessment of demand?

33. Witnesses also claimed that levels of demand for digital hearing aids were not adequately assessed before the start of the MHAS programme.[30] We were told that, in addition to new patients, there was unexpected demand from patients with long-standing hearing problems. Several submissions pointed out that current NHS services in their areas could have coped with new referrals, but the number of patients who wished to 'upgrade' their hearing aids had overwhelmed services. Claire Carwardine, an audiologist from Worcestershire, stated:

If we look at new referrals alone, the current NHS service could cope adequately, but it is the patients that have been seen previously that all need changing over from analogue to digital, that have created these waits.[31]

Moreover, patients who had not previously come forward for a hearing aid started to do so as they became aware of the benefits of the new hearing aids.[32]

34. Not only has there been a large increase in the number of patients, but the technology itself involves more work for audiology departments. Fitting a digital aid is a lengthier process than fitting an old-fashioned aid. According to Amplifon UK, an audiologist must spend three times as long fitting a digital hearing aid than an analogue type.[33]

35. The Minister agreed that the number of patients seeking NHS audiology services had been larger than expected. He told us:

When we committed ourselves to the introduction of digital hearing aids and did the modernisation project in partnership with the RNID, in my view, there was no serious analysis or assessment of the consequences of that for demand….there was simply no anticipation of the strain that that would put on the system and the expectations that that would give to people.[34]

36. All these factors meant that NHS audiology services, some of which already had significant waiting lists, received more referrals than they could cope with. Waiting times grew as a result.

Waiting times

Data collection

37. While it is clear that there are long waiting times, there is a distinct lack of reliable published data on the wait between GP referral to an audiology service and receipt of a digital hearing aid. Many witnesses claimed that information is not collected consistently across the country.[35] Some audiology departments hold detailed data on the patients they treat; others do not. Data may also be available in different forms. This means it is difficult to assess changes over time and compare services in different areas. Moreover, the data is not collected centrally. Dr Low from the RNID told us:

We think there are probably half a million people waiting for a hearing aid in the NHS right now. The reason we do not know, of course, is that neither the Department of Health nor the NHS collects waiting-time figures. There has been an initiative recently to collect the time between GP referral and having a hearing test but of course the longer wait is from the hearing test to having the hearing aid fitted.[36]

38. From January 2006, there is information available on the wait between GP referral and receipt of a diagnostic test but not a hearing aid. More detailed 'referral to treatment' information on those audiology patients referred to ENT services may also be collected from 2007. The Minister admitted, however, that robust data on waiting times from referral through to fitting of the hearing aid for all audiology patients were lacking. He added:

I personally think, although I am not committing to it, that what we should aim to be doing is having comprehensive data for all people. Because of the state we are at with audiology, which we are aware of…which is that we are not in as good a shape as we need to be in all parts of the country, I think there is a strong case for collecting data on all of the people who access audiology...[37]

Scale

39. According to the Department, in November 2006 there were 166,740 patients waiting for an audiology diagnostic assessment. Of these, 108,628 had been waiting over 13 weeks and 80,941 over 26 weeks. Taken by Strategic Health Authority (SHA), the longest average wait is in the South East Coast area (45 weeks) and the shortest is in the East of England (10 weeks, see Table 1 below).

Expected average wait (weeks) Patients waiting over 13 weeks Total waiting Percentage waiting over 13 weeks

North East 32 9,256 13,201 70%

North West 13 13,157 21,277 62%

Yorkshire and the Humber 15 11,892 15,461 77%

East Midlands 22 9,361 13,889 67%

West Midlands 20 18,234 28,026 65%

East of England 10 4,846 8,620 56%

London 20 9,465 13,829 68%

South East Coast 45 12,742 16,101 79%

South Central 12 5,594 11,110 50%

South West 16 18,927 28,518 66%