House of Commons - Health - Fifth Special Report

Select Committee on Health Fifth Special Report

4 Addressing the challenges

60. As we have seen, the Government's response to the difficulties facing audiology to date, following the MHAS programme, has been unsatisfactory so far. In this chapter we examine how the issues of long waiting times and capacity should be addressed. First we consider the need to establish the extent of demand for digital hearing aids and whether it will continue to grow. Secondly, we look at what the NHS should do to increase capacity and maintain the high quality of care that patients receive once they are eventually treated. Lastly, we examine how and when the private sector should contribute and the factors that should govern its involvement.

Establishing demand

61. It is not clear whether the increase in demand for digital hearing aids is a short-term problem that may be overcome using temporary measures, or a long-term trend that needs a different approach. We received evidence in support of both points of view.

62. The BAA referred to the growth in demand as a "bulge" arising both from existing patients who wished to upgrade their old analogue device and from patients who might not have come forward for a hearing aid before but have realised the benefits of digital aids.[62] Others agreed. Mark Brindle, audiology service manager from Queen Elizabeth Hospital in Kings Lynn stated:

If all analogue hearing aids could be changed over to digital ones then the reassessment waiting times would shrink significantly.[63]

63. Some audiologists claimed that the initial demand was already falling. A group of London audiologists told us:

A typical Audiology Department such as at Chase Farm Hospital had approximately 22,000 patients registered with it on the paper system at the time of [the MHAS programme]. There is therefore a very high demand for the first few years. This initial rush is now calming down. Each month there is now a manageable amount of referrals for upgrading to digital hearing aids.[64]

64. In contrast, others claimed that the increases in demand seen over the past few years were the beginning of a long-term trend which required a long-term approach. The length of the waiting lists may currently discourage patients in need of a hearing aid from presenting to their GP[65] but Dr Low from the RNID claimed that demand would continue to grow as waiting times decreased:

…this is not just a bulge; we do not have a one-off problem that needs to be fixed. Demographics are changing so we know that the number of people presenting is increasing but also there is this huge unmet need and, as the waiting times come down, we know more people will present…this is an ongoing problem.[66]

65. There was some support for this view from within the NHS. One audiology manager stated that it might not be possible to maintain the service currently provided by the NHS in the future:

Consideration will be required to be given to the sustainability of providing an open-ended service to all people once they have been issued with an NHS hearing aid. With an ever-increasing elderly population it is almost certainly unaffordable to continue to provide the present level of hearing aid service.[67]

66. As we have seen, the demand for digital hearing aids was not accurately predicted in the past. Poor forecasting is doubtless partly due to a lack of reliable information regarding the numbers of patients waiting for treatment in different parts of the country. Reliable data are needed in order to forecast future demand. Local commissioners need to know the underlying trends if they are to procure the right levels of services for their areas. Once robust information is available regarding the current demand for digital hearing aids, it will be possible to evaluate likely future trends. However, to forecast effectively, more information than simple numbers of patients waiting is needed. The interactions between factors such as the age of the local population, patterns of presentation, and the backlog of patients waiting to 'upgrade' to digital aids should be examined, alongside the relationship of these factors to existing and predicted local capacity.

New strategies to increase capacity

67. While the precise nature of future demand is uncertain, it seems clear that in the short to medium term demand will exceed existing capacity. Additional capacity can be provided both from the NHS and from the private sector.

NHS Capacity

Spreading best practice

68. Witnesses argued that there were significant opportunities for increasing capacity in NHS audiology departments. We were told of a number of measures taken by individual departments to reduce waiting times. For instance, Charing Cross audiology department uses the Choose and Book system, operates flexible working hours to maximise the use of clinical equipment and assessment rooms and has one-stop clinics using 'open fit' technology.[68] Several other groups, such as the Pennine Acute hospital trust, told us that, in the absence of long waiting lists of their own, they had helped neighbouring trusts reduce their waiting lists.[69] The head of an audiology department within the Pennine trust stated:

The NHS has the capacity to treat high numbers of audiology waits providing that commissioners look further than their local PCT boundaries, and by talking directly to the Audiology experts locally. By employing and utilising surplus capacity/good will in adjacent areas the NHS could manage the majority of these waits…[70]

69. Other witnesses informed us of additional practices used by some departments that could increase capacity in the NHS overall, including:

Sending out appointment reminders to reduce the risk of patients not attending;
Increasing links with GPs and health centres to deliver services in the community;
Operating walk-in clinics for repairs and batteries.

The spread of good practices could make a considerable contribution to increasing capacity.

70. It should also be possible to reduce costs by the bulk purchase of hearing aids.

Increasing efficiency

71. There is also concern about waste in some NHS audiology departments. The new audiology framework referred to the "significant variations in models of service, activity levels, productivity and costs" in different areas.[71] The disparity in waiting times across the country in part attests to this. Witnesses mentioned the problem of poor skill mix in particular.[72] Some observed that highly trained staff commonly carried out tasks that could easily be taken on by assistant audiologists.[73]

Newly qualified staff

72. The NHS was criticised for not making greater use of staff who have completed the new BSc in Audiology. Only approximately 60% of graduates who graduated in June 2006 have found employment in the NHS, despite being trained at NHS expense.[74] We were told that if these newly qualified audiologists did not find jobs in the NHS, they might have to take jobs in the private sector where career prospects are limited and few of their skills will be used. The British Society of Audiology commented:

The indications are that these graduates are of incredibly high quality and could play a huge part in taking audiology forward in terms of leadership, scholarship and clinical practice. Clearly, it would be a big mistake not to train sufficient graduates of this calibre and deploy them.[75]

73. The reasons that new graduates have not found jobs in the NHS are well known, as we highlighted in our inquiry into NHS Deficits.[76] Claire Carwardine told us:

It does come down to a lack of funding and a lack of staff, due to frozen, or cut, posts.[77]

74. There was concern that SHAs were willing to pay to involve the private sector while qualified audiologists in their areas remain unemployed. Lesley Roberts, who graduated last year from Manchester University, told us of her efforts to find a job.[78] North West SHA is one of those that has requested that the Department negotiate for independent sector contracts.

PRIVATE PROVIDERS

75. Additional capacity can also be provided by the private sector. The Department has already entered into contracts to commission services from the private sector. There is a great deal of interest from many companies in providing these services to the NHS. Submissions stressed the potential benefits of private sector involvement to the patient. The British Society of Hearing Aid Audiologists, which represents high street dispensers of hearing aids, stated that competition from private companies would improve choice and quality and bring down costs.[79] Others contended that a 'one size fits all', hospital-based approach to audiology services "did not suit the majority of patients at all" and is:

failing to deliver the choice or speed of delivery to which the patient is both entitled and increasingly demanding.[80]

76. Some witnesses were concerned about both the existing commitments and about whether and how the private sector should be involved in the future. They raised a number of issues which echoed many of the points covered in our ISTC inquiry, including:

The basis on which the numbers of pathways needed was decided;
Value for money assessment;
Standards of care;
New entrants;
Cost to patients;
Additionality; and
Length of contracts.

Uncertainty about numbers of pathways needed

77. As we have seen, there are different opinions about the number of extra patients who need to be treated each year in order to reduce waiting times, and therefore the extra numbers of pathways that must be provided either by the NHS or by the private sector. The RNID told us that over 300,000 extra "pathways" were needed. Others claimed that the figure was smaller.[81]

78. The Department is also not sure how many pathways need to be procured from independent providers and, to date, no NHS patients have been assessed or provided with hearing aids by the private companies. The Minister told us that the Department was ready to negotiate but:

…the SHAs and the PCTs are saying to us, "Hold on a moment until we are absolutely certain about our in-house capacity and if we did things better and differently within our areas we may not need you to procure 300,000 pathways".[82]

He added, however, that the discussions were drawing to a close and that he expected to know how many pathways were required by each SHA within, "a couple of weeks—not months".[83] We have not yet heard the results of this dialogue.

79. We were told that the SHAs where the private sector would operate had not been selected by the Department on the basis of large waiting lists or any other factor; rather they "selected themselves".[84] Examination of the waiting times by SHA indicates that some SHAs who want to use private sector providers have similar numbers of patients waiting to those which have opted out. For instance, South Central SHA has a lower percentage of patients waiting over 13 weeks for assessment (50%) than all three SHAs that do not wish to have private sector audiology services in their areas (East of England 56%, East Midlands 67%, London 68%, see Table 1).

Value for money assessment

80. Witnesses raised a series of issues relating to value-for-money. In particular, they were concerned that:

assessments would not be carried out prior to commissioning activity from the private sector. Amicus also argued that, even if this assessment were done, auditors would have limited access to financial information:

The procurement of both private sector audiology initiatives will fall under commercial confidentiality restrictions…this limits democratic accountability, preventing a value for money comparison with NHS services to take place.[85]

the absence of a national tariff for audiology services meant that value for money assessment is difficult for both the NHS and for private companies that wish to bid for the contracts. The UK Federation of Professionals in Hearing and Balance told us that NHS departments would be better able to run their services if there was a tariff in place:

There seems to be a lack of detailed information at a local level to enable intelligent service delivery and commissioning. One way of addressing these issues is by audiology coming into tariff and being unbundled from ENT so that departments get paid for the services they provide.[86]

The private provider Hidden Hearing pointed out how the lack of a national tariff is problematic for independent companies too. It suggested:

The development of a national tariff would provide an incentive for Primary Care Trusts and Practice-based Commissioners to commission audiology services from the Independent Sector to help tackle lengthy waiting times and meet the 13 week target.[87]

NHS organisations would not be able to bid for any of the available contracts. The Government has stated in the past that it wants the NHS to become more competitive. Witnesses contended that allowing NHS departments to compete for business, when they have the capacity, would help achieve this aim. Dr Andrew Philips, Head of Audiology from the Royal Berkshire Hospital, argued:

Value for money can only be achieved if both NHS and private sector organisations can bid for commissions on an equal basis.[88]

Standards

81. The HAC regulates the assessment and fitting of hearing aids by the private sector. This responsibility will soon pass from the HAC to the Health Professions Council. The HAC told us that the current regulatory framework for hearing aid audiologists was "simply not fit for purpose"; that dispensers of hearing aids operating under the PPP were usually not regulated by any single body; and that premises were not covered by the Healthcare Commission's Standards for Independent Healthcare Providers. This left the provision of hearing aids through PPPs "completely unregulated".[89]

82. Others, however, argued that although there was "potential for a regulatory gap" during the PPP, the regulation of privately-provided services was strong:

The HAC's point regarding the limits of their jurisdiction is valid. However, under PPP each PCT established a precise professional service specification together with a formal process to ensure full patient protection. Hence, in practice, there was no void in regulation or 'consumer' protection. Further, patients, PCTs and RNID expressed satisfaction with the standards delivered by the private sector and certainly no suggestion of consumer risk or harm.[90]

The Minister also assured us:

We are certainly not, in my view, leaving the system so unregulated that we are putting patients at risk of a poor service.[91]

New entrants

83. Several companies that currently provide optical services are particularly keen to become involved in the supply of audiology services to the NHS. The Association of British Dispensing Opticians (ABDO), the Association of Optometrists (AOP) and the Federation of Ophthalmic and Dispensing Opticians (FODO) stated:

As in optics, the sector has shown itself very ready to respond in innovative ways to opportunities to improve services for patients.[92]

84. The claim that opticians were well-placed to take on the role of supplying and fitting hearing aids was challenged, however. Mr Murphy from Ultravox stated:

Optical companies probably think it is close to spectacle provision. I do not think it is, but that is probably why they are making the submissions.[93]

Ruth Thomsen told us that, "hearing aids are not like receiving glasses".[94] The RNID agreed. It argued that measures should be taken to ensure that patients are not pressured into spending more than necessary:

Any expansion in the use of the private sector by the NHS must include comprehensive safeguards for service users, many of whom are vulnerable people. It is vital that patients are not persuaded to buy products they do not need. Unlike with spectacles for correcting common visual defects, it can be difficult for people with hearing loss to identify if they are gaining optimal benefit with hearing aids. Choices are not purely aesthetic and pricing of features is not transparent or standardised.[95]

85. Ms Thomsen added that the location of opticians outlets might cause problems:

A very noisy shopping centre or high street can definitely compromise the quality of the testing and hearing aid verification which is at the heart of the process. Adequate sound proofing is costly and awkward to install correctly and would require massive capital investment.[96]

The view that adequate testing could not be performed in a high street setting was, however, strongly disputed by private providers.[97]

86. There is also concern about the cost of hearing aids which might be supplied by new entrants. We are mindful that in our inquiry into NHS Charges we found that opticians often stock limited numbers of spectacles within the price range of those using NHS vouchers and customers are encouraged to purchase more expensive frames and lenses. This could happen with hearing aids. Specsavers told us:

Most independent sector companies would need to subsidise what is, in reality, the necessary low-cost provision required by the NHS through offering private sales to those customers who wanted to 'trade up' to a higher specification of product or who chose to pay for a cosmetically more attractive option.[98]

Additionality

87. Witnesses were concerned that the increase in private sector involvement would effectively 'out-source' NHS services, leading to a diminution of expertise within the NHS and undermining NHS audiology services. Terry Allen, an audiologist at North Manchester Hospital, stated:

I am also extremely suspicious of attempts to somehow downgrade and cheapen audiology as a profession and/or as a service. Some of the modernisation thinking we hear about is shockingly regressive. Instead of promoting quality of care it seems to suggest the priority for change should be based on reducing costs…[99]

However, Departmental officials assured us:

There will be a substantial increase in the output of both NHS and the independent sector. It is not a switch from NHS to independent sector; it is adding capacity in both sectors.[100]

Length of contracts

88. Clare Carwardine told us that current waits were "an acute problem requiring an acute response".[101] The BAA also observed that the problem could be dealt with through short-term measures. It told us:

There is a possible role for the private sector to subcontract NHS work to meet short-term needs, as demonstrated by the PPP scheme…as a planned part of the NHS Commissioning Framework.[102]

89. On the other hand, the opticians' groups ABDO, AOP and FODO told us that short-term involvement of the private sector would not solve the problems:

It is vital that future partnership should be seen as a long term commitment to greater variety of supply and choice rather than a one off exercise for reducing waiting times. However, if taken forward only in this latter short term context, the problem will simply recur after a year or two…[103]

90. Witnesses also pointed out that the length of contracts offered must be attractive to private companies, or they will not invest in services adequately. Mr Murphy from Ultravox told us:

Short-term large movements of the waiting list are financially sustainable if the contract is at the right price and it is at the right length of time where you could scale up and get a return on investment.[104]

Conclusions and recommendations

Need for better forecasting

91. Both current and future demand for digital hearing aids is uncertain: many have described the current waiting lists as a short term 'bulge'; others have stated that the increased levels of demand are here to stay due to the ageing population and awareness of the benefits offered by digital aids. If local commissioners are to procure services effectively, they must have accurate information on demand both for the short- and long-term. We recommend that the Department undertake a thorough examination of the medium- and long-term demand for digital hearing aids.

Additional capacity

92. Whether the increase in demand is a bulge or more sustained, in the short to medium term there is a need for more capacity.

Improvement in NHS services

93. There is much good practice in NHS audiology services, yet we were appalled by the variability of the service. This is partly due to the lack of priority given to audiology by PCTs. There is also inefficiency; in particular, there needs to be more effective skill mix. We were told that more junior staff members could carry out many of the tests required, freeing up more experienced staff to concentrate on complex cases.[105] We recommend that audiology departments review the way in which they provide services to patients, identifying the skill mix and the levels of training or experience necessary. Their reviews should also examine the possibility of operating flexible opening hours, telephone follow-up, home visits, the use of Choose and Book and cross-boundary working to increase the numbers of patients seen. The cost of hearing aids could be reduced by bulk purchasing.

94. We received evidence about the extent of graduate unemployment. We recommend that the Department examine the situation of recent audiology graduates.

The use of the private sector

95. Several points covered in this inquiry about the use of the private sector were also raised in our inquiry into ISTCs. Again, there were concerns about value for money assessments and other evidence that has been or will be taken before contracts with the private sector are negotiated. Lessons should be learned from the ISTC programme. A tariff would allow better value for money assessment, would improve local commissioning and encourage trusts with limited waits to help neighbouring departments reduce their lists. Value for money assessment must be carried out. This will be difficult without a tariff. We note that the Department will consider this in 2007. We recommend that the Department produce a national tariff for audiology at an early date.

96. During this inquiry we heard claims that the quality of care provided by the private sector during the PPP was unsatisfactory, and that regulation was limited. We also note that these claims were strongly disputed. In a brief inquiry we are unable to assess these conflicting claims. Nevertheless, we believe that private companies must be capable of providing a standard of care equal to that of the NHS. The contracts negotiated with the private sector must ensure that patients receive adequate care and follow-up. Services must be monitored and the quality of care must be assessed on the same basis as the quality of care is assessed in the NHS.

97. We were not presented with any evidence which convinced us that that new entrants such as opticians should be excluded from providing audiology services. However, our inquiry into NHS Charges noted that finding spectacles with a value within that of vouchers supplied by the NHS could be difficult, and that customers were sometimes encouraged to buy expensive frames and lenses. We would not want a similar situation to arise with hearing aids. We are concerned that older and sometimes vulnerable people might be encouraged to buy more expensive hearing devices than necessary. The Department must ensure that encouragement to patients to 'trade up' to a more expensive hearing aid is limited.

98. A considerable number of witnesses were concerned that involvement of the private sector would mean that NHS services would be depleted and expertise would be lost. The Department must ensure that the involvement of the private sector does not undermine the NHS's capacity to provide expert audiology services. It must assess the effects of private sector activity on NHS capacity and levels of expertise within audiology departments. We were encouraged that the Department appears to be listening to local commissioners about whether private sector involvement is needed.

99. The effect of the involvement of the private sector on NHS audiology services is unknown; the Department should therefore proceed with caution with the negotiation of contracts. At the same time the private sector must be encouraged to invest in facilities and to maintain high standards. We recommend that private sector contracts be relatively short-term in the first instance but extendable subject to companies achieving and maintaining high standards of treatment and care. Future contracts should depend upon demand remaining high, as the private sector maintains will be the case.

100. This has been a short inquiry and we have not been able to assess fully the claims and counter claims relating to the involvement of the private sector. We are reassured that the Department is prepared to be flexible on the numbers of "pathways" procured from the private sector, depending on evidence received from local NHS organisations. However, this suggests that the evidence underlying the original commitment to the combined 342,000 pathways was inadequate, and that this figure was essentially plucked out of the air. Likewise, the lack of analysis of the areas most in need of private sector involvement indicates a disappointing lack of evidence-based decision-making by the Department. Decisions on the amount of activity required from the private sector have not been based on evidence, but appear to have been 'plucked out of the air'. The Department should specify criteria for private sector involvement, for example failure to meet the 18-week target once it is in place. The Department should make evidence-based decisions and ensure value for money.

62 Ev 74 Back

63 Ev 53 Back

64 Ev 74 Back

65 Ev 123 Back

66 Q 105 Back