House of Commons - Health - Fifth Special Report

Select Committee on Health Fifth Special Report

3 Government plans

43. To address the long waiting times for audiology services, in 2006 Lord Warner announced that the Department planned to purchase private sector activity. Following our decision to hold an inquiry, the Government published a new framework for audiology. In this chapter we examine these plans to improve the situation.

Private sector involvement

44. In July 2006, Lord Warner announced the procurement of 300,000 audiology "service pathways" by the Department from the independent sector each year, for the next five years.[39] Contracts have yet to be negotiated but the Department aims for the first patients to be treated under this programme from the second half of 2007.[40]

45. In addition, more audiology treatments will be provided by the private sector as part of phase 2 of the Independent Sector Treatment Centre (ISTC) programme. The Department has procured 42,000 "patient pathways" per annum for the assessment and fitting of hearing aids from the private sector on behalf of seven SHAs: South West, South Central, West Midlands, North East, Yorkshire and the Humber, North West and South East Coast. This was due to start in April 2007,[41] but no patients have been assessed under the programme to date.

46. The Department stated that use of the private sector will provide additional short- and medium-term capacity and represents value for money for the NHS:

the involvement of the independent sector will drive a more commercial approach to the provision of audiology services. This could potentially increase efficiency and levels of innovation.[42]

NHS audiology departments will not be able to bid for the work available.

The new framework

47. The Minister admitted to us that "audiology has not been given the priority it deserves" in the past.[43] He argued that this situation was now changing, however, with plans to address the problems of long waiting times and limited NHS capacity not only through increasing use of the private sector, but through encouraging best practice in NHS departments and ensuring that existing targets were met. These plans were recently brought together in a new framework, entitled Improving Access to Audiology Services in England, published on March 6^th 2007. The framework contained some new information and measures, but much of it was already in the public domain.

48. The following new announcements were made:

the Department was "committed to considering the introduction of national audiology tariffs" in 2007.
new "model care pathways" for NHS audiology would be published this year. This would include the adult hearing loss pathway, which is likely to encourage one-stop assessment and fitting of hearing aids[44], telephone follow-up and prioritisation of patients needing to upgrade their analogue aids.[45] This was due to appear in March 2007, although it has not yet been published.
the Department would start to publish referral to treatment (RTT; ie. GP referral to receipt of a hearing aid) data on audiology patients treated through ENT but not those who attend an audiology clinic directly. It added that:

It would make sense to record RTT times for all audiology patients. We will consider whether a national data collection of all audiology RTT is necessary.[46]

49. Otherwise, the framework reiterated existing policy, including:

the use of the private sector to provide 300,000 pathways per year.
assessment of patients through the ISTC programme.
the six-week maximum waiting times for diagnostic tests, including audiology, that will apply from March 2008.
exclusion of audiology from the 18-week waiting time target (see below).

50. Much of the report centred on the need for improvements to NHS services through better use of initiatives that cut across all specialties, such as the Choose and Book system. The report stated that audiology services would be transformed through:

Local health systems applying to the design and delivery of their audiology services the health reform mechanisms of better commissioning and pathway redesign, choice and competition, information and incentives.[47]

Criticism of the framework

51. Many witnesses thought that the new audiology framework added very little and mainly served to bring together strategies already made public over the last couple of years. Dr Low from the RNID called it a "sop".[48] Ruth Thomsen commented on the quality of the report:

I have to say the first three words really made by heart sink. This new condition that has been invented, "hardness of hearing", did reflect "Oh, gosh, an audiologist has not read this" because it is not a condition. There is not a huge amount of new stuff in there, in terms of what we are doing at Charing Cross.[49]

The framework was also late. The RNID was expecting it in May 2006.[50] It was eventually published almost one year later, coincidentally two days before the Committee took evidence on the subject.

52. There were concerns that the framework was over-optimistic.[51] However, the Minister assured us that the framework would lead to a drastic reduction in waiting times over the next year:

The bottom line will be…have we made massive progress on waiting lists and waiting times?...I think we have given you, to be fair to us, some very clear benchmarks to judge the NHS's performance by, certainly by the end of 2008…

What I commit to doing is, at a national level, with the RNID and other stakeholders, monitoring progress…I will be reporting back to you on the outcome and hopefully that outcome will be considerably less waiting times both for assessment but frankly, more importantly actually, ultimately for fitting.[52]

Exclusion from the 18-week target

53. The framework confirmed that most adult audiology cases will remain outside the 18-week target.[53] Patients under the care of a consultant are included in the target, but audiology departments are not consultant-led, and therefore the target does not apply unless the patient has come via a department that is consultant-led, such as ENT (ENT referrals amount to about 20% of adult hearing loss cases. The Minister told us that 50% of cases were referrals from consultant-led departments but that would include other cases such as paediatric referrals[54]). However, audiology is subject to the same target as other diagnostic tests, such as x-rays and endoscopies, which requires patients to be seen within 13 weeks by March 2007 and within six weeks by December 2008.

54. The framework pointed out that no organisation would be "credible in claiming success at 18 weeks" if audiology waits remained high. We were told of several negative consequences of the exclusion of audiology from the 18-week target. For instance, we heard that GPs often tried to avoid subjecting their patients to lengthy waits for a hearing aid by referring them inappropriately to ENT services.[55] The National Deaf Children's Association stated:

Indications are that many children are now on multiple waiting lists (for example ENT as well as audiology) as GPs attempt to get access to the service for their patients in the quickest possible way.[56]

Such an approach, while understandable, is counter-productive overall. As Ruth Thomsen told us, such patients would "clog up" ENT outpatient services and the consultant would do nothing more than refer the patient on to the audiology department.[57]

55. Other witnesses told us that exclusion of audiology from the 18-week target meant that audiology would be less of a priority for trusts, funding would remain low and waiting lists long as a result.[58] Meeting the six-week diagnostic milestone by March 2008 will therefore be difficult. John Day, Head of Audiology at the North East Wales NHS Trust, claimed:

In the absence of relevant waiting times targets for hearing aid fitting…it could be anticipated that it will prove challenging for Audiology services to secure resources in competition against those services that do have associated waiting time targets.[59]

A group of London audiologists told us:

Including the fitting of hearing ads in the 18 week targets would give Audiology a higher profile within the Hospital Trusts and PCTs. This would ensure that appropriate funding reached the departments and wasn't diverted elsewhere.[60]

56. We asked the Minister why the 18-week target had not been adopted for audiology. He responded that, regardless of the reason for the decision, it was now too late to include audiology within the 18-week target:

it would be much simpler to be able to say every single person is simply covered by the 18-week maximum but, because 50% of those who need audiology were excluded from the 18-week target initially, the Department's position, understandably, is if we start adding extra things into the 18-week target on a regular basis, it makes a mockery of the target. It creates instability and it sends out messages to managers and others who are expected to implement these changes which are inconsistent.[61]

Conclusions and recommendations

57. Some PCTs have failed to give audiology services the priority they deserve. The Minister admitted that audiology services had not been seen as a priority, but this still seems to be the case. The publication of the new audiology framework was delayed for almost one year. Its publication eventually coincided almost exactly with the Committee's inquiry. The framework adds little that is new. Already some of the targets in the framework, such as publication of the adult hearing loss model care pathway by March 2007, have not been met.

58. We note the Minister's determination to meet the existing target of providing diagnostic tests for audiology within six weeks by March 2008. This will be difficult. The first stage of this target—for all patients to receive diagnostic tests within 13 weeks by March 2007—has already been missed. The Minister told us that "quite a number of people could have their hearing aid fitted literally on the same day as the assessment", presumably through the use of 'open-fit' technology. Whether this can be adopted widely is being investigated and must be confirmed.

59. The exclusion of audiology services from the 18-week target means that patients with hearing problems are waiting for over two years to receive treatment in some areas. This is particularly unacceptable since the hearing aids are so effective. The exclusion has led GPs to have their patients seen quicker by referring them to ENT departments. It is ridiculous that this loophole exists since it can be so easily exploited and increases costs and waiting times for ENT outpatient appointments. Waiting times for all audiology patients will remain long if audiology remains outside the 18-week target. It would be difficult to do it immediately, but we recommend that the Department of Health include audiology services within the 18-week target at an early date. Meeting the 18-week target should be possible once the six-week target for diagnostic tests for audiology has been achieved.

39 Ev 38, 83 Back

40 Ev 83; Qq 172-174 Back

41 Department of Health, Improving Access to Audiology Services in England, March 2007 Back

42 Ev 1 Back

43 Q 117 Back

44 This would be achieved using 'open fit' technology, which avoids the lengthy process of having an individual ear mould made. Back

45 Department of Health, Improving Access to Audiology Services in England, March 2007 Back

46 Ibid Back