Evidence submitted by John Beadle (AUDIO
6)
My PPI Forum Working with Darent Valley Hospital
has been researching the situation with regard to Audiology Services
for three years. Initially this was related to those provided
at our own Hospital but this was expanded as we found common problems
throughout Kent and then elsewhere in the UK.
We have produced a comprehensive Report on our
findings, which I can provide if required. However, I have also
prepared a Resume document which provides a summary of our findings.
I am enclosing a copy of this, together with a background paper
on Audiology Services, generally, and a summary of the possible
causes of the current situation.
I hope you and your Committee will find these
useful in their deliberations.
BACKGROUND
1. It is estimated that one in seven of
the UK population suffer from hearing loss of some sort. Hearing
loss can be caused by numerous factors. These include:
— Side Effects of certain Drugs.
— Exposure to Loud Noise both short
and long term.
— Sudden Changes in Pressure.
2. In the vast majority of cases a hearing
aid, which amplifies the sound passing through the ear, can be
used to "restore" hearing to a greater or lesser degree.
For small hearing losses such aids can be worn in the ear canal,
but for more severe losses a behind the ear aid has to be used,
or in very severe cases a body worn aid.
3. In a small number of cases, regular infection
or allergic reaction to ear moulds, may make it necessary to use
a hearing aid which functions by transmission of sound by vibration
through the skull to the nerve cells in the cochlea. When neither
air transmission aids nor bone transmission aids can be used due
to cochlea impairment, the final resort is to have a cochlea implant.
This involves major surgery.
4. Originally, simple air transmission hearing
aids were of the analogue type. These give a relatively crude
sound, open to distortion from background noise. Modern aids use
sophisticated digital technology providing a much clearer sound,
which in some instances can eliminate much of this background
noise.
PATIENT OPTIONS
Private
5. All forms of aid for the correction of
hearing loss are available privately from hearing aid dispensers.
These dispensers are subject to control by The Hearing Aid Council.
These dispensers operate from High Street premises; Private hospitals
or visit patients in their own home. No referral by a GP is necessary.
6. From initial contact to supply of an
air transmission aid, usually of the digital type, the time frame
is in weeks. Costs can vary from about £500 to several thousand
pounds depending on complexity of the aid chosen. Digital hearing
aids have been available from the private sector for many years.
7. Regular follow-up is given to ensure
that the Aid is being used correctly and re-testing is offered
at regular intervals to check for any progressive hearing loss.
NHS
8. The majority of patients rely on the
NHS to provide their hearing aids from Audiology Departments in
selected Hospitals. Aids are provided on loan, free of charge.
This procedure requires referral from the patient's GP.
9. Until 1998 only analogue hearing aids
were available from the NHS but at that time a small number of
pilot hospitals were selected to introduce digital hearing aids
on a trial basis. This has gradually been broadened to other Audiology
Departments and by 2005 it is expected that all will convert to
supplying digital Aids—for new patients. Digital aids were
not introduced into Kent hospitals until late 2003.
10. It is stated Government policy that,
in the long term, all patients with existing analogue hearing
aids will have their aids changed to digital. However, this process
will take up to five years.
11. It should be noted that the fitting,
and adjustment, of a digital hearing aid requires more time and
sophisticated technology than that needed for an analogue hearing
aid. Thus, given the same staffing levels and outlets as currently
exist, the number of patients able to be provided with a hearing
aid will reduce, thus increasing waiting times. Current waiting
times vary from weeks to several months, or even years, depending
on the location of the service.
ASSOCIATED PROBLEMS,
NHS
Battery Supply
12. All Hearing aids use batteries which
require replacing at regular intervals. These can vary from weekly
to monthly depending on the frequency of use and the power of
the aid. Supply of new batteries is usually via personal attendance
at an Audiology Department or by post. Batteries are occasionally
available from GP's surgeries or medical centres but this is rare.
Repairs/Replacements
13. A few audiology departments provide
"walk-in" clinics at certain times when aids can be
taken for repair or replacement. This also gives the patient the
opportunity to have their ears checked at the same time for signs
of infection or excessive wax build-up. Other audiology departments
only carry out repairs by post or by appointment.
Clinical Problems
14. The act of wearing a hearing aid that
requires ear mould causes the production of excessive ear wax
in some patients and occasionally frequent infections. When this
occurs sound is either distorted or even no longer transmitted.
This can be extremely difficult for those patients with a severe
hearing loss.
15. Excess wax may require physical removal
by syringing or by using a suction technique. Syringing is usually
carried out in local medical centres but in difficult cases or
for those patients with severe hearing loss referral to a Hospital
ENT Department where the suction technique is applied, may be
necessary. In cases of infection the patient's GP may prescribe
antibiotics to be applied in the form of drops in the ear, or
as capsules to be taken orally. It should be noted that a hearing
aid cannot be used if ear drops are being used. In severe cases
the patient may be referred to the nearest hospital ENT unit for
treatment.
16. It should be noted that for patients
with a severe hearing loss, any excessive wax build up or infection
can cause total deafness. Thus rapid treatment is essential.
17. In a small number of patients, severe
allergic reaction or frequent infections, may prevent the use
of a conventional hearing aid. In these cases, a bone conduction
aid may be offered, providing the cochlea is still functioning.
The preferred aid is the Bone Anchored Hearing Aid (BAHA). However,
funding for this aid, which requires minor surgery, is not universally
available within the NHS, despite the fact that this type of Aid
is the only one able to restore some hearing for the patient.
COMMENTARY
18. It is strange that the correction of
defective eyesight and defective hearing should receive such extremely
different treatment within the NHS. For minor changes in vision
it is normal for patients to visit an optician. These are widely
available and the patient has considerable choice. They can usually
be found relatively close to the patient's home, no referral from
a GP is necessary, and the optician will carry out tests for glaucoma,
cataract and other conditions in addition to checking for vision.
If spectacles are prescribed the patient has the option of selecting
basic NHS standard or paying extra for better quality. If the
optician identifies other problems the patient is referred back
to their GP who will refer them to the nearest NHS hospital for
treatment. Regular one or two year re-checks are offered, by reminders
from the optician. Patients who are blind or partially sighted,
to a specific degree, are recorded on a national register. Thus
the number of such persons is available for forward planning purposes.
19. For hearing loss the only treatment
available is via a private audiologist or via an audiology department
at an NHS Hospital. Treatment by a private audiologist must be
paid in full by the patient. Not all NHS hospitals have an audiology
department. Thus the patient may have to travel a considerable
distance to get treatment. Patients can only attend audiology
departments for treatment and supply of a hearing aid following
referral by their own GP. Compared with private practice NHS audiology
departments can offer only a limited range of NHS hearing aids
and there is no possibility of up-grading to a better quality
aid even by paying an extra fee.
20. There is normally no arrangement for
regular reviews of the patient's condition and this will depend
totally on the patient initiating a re-examination via their own
GP. This same arrangement applies to those patients who wish to
upgrade from analogue to digital technology as there is usually
no system in place to automatically offer an upgrade.
21. No national register is maintained of
the number of patients who are deaf or have a profound hearing
loss. Indeed there are no national statistics recording the number
of hearing aids issued by the NHS. Thus it is not possible, currently,
to predict the needs of patients for the future.
James Beadle
PPI Forum member, Working with Darent Valley Hospital
10 January 2007
Annex 1
NHS AUDIOLOGY SERVICES
TIMELINE
2000—NICE Guideline No 8 Issued
Recommended universal use of digital hearing
aids but also recommends an audit of facilities to ensure that
they are adequate to accept this new technology. Few NHS Trusts
appear to have acted on this latter recommendation. Manchester
Supra District is a notable exception with an excellent published
Audit Report.
2001—"Audiology in Crisis" Published
This Report from the RNID identifies many weaknesses
in NHS audiology services. Also recommends the separation of audiology
from ENT to provide greater accountability and efficiency. Few
Trusts appear to have taken notice. Report mysteriously withdrawn
from circulation.
2002—"Best Practice Standards for Adult
Audiology" Issued
This booklet produced after several years of
work by various organisations associated with the deaf and hard
of hearing issued jointly by the DoH and the RNID. The booklet
has a foreword by the then Health Minister, Jacqui Smith, which
states "These standards describe a service which all audiology
departments will want to work towards. These efforts, together
with Department of Health investment into Modernisation of Hearing
Aid Services will produce the best possible outcomes for deaf
and hard of hearing service users."
These standards are comprehensive and cover
all aspects of service and not merely the issue of hearing aids.
Few Trusts have implemented these standards or even attempted
to do so. The current DoH view is that these standards are not
standards but "aspirations".
MODERNISED HEARING
AID SERVICE
(MHAS) PROGRAMME
The Modernised Hearing Aid Service (MHAS) programme
was first piloted in a small number of selected hospital Trusts
and then introduced into all Trusts in 2005. Despite the title
the system serves solely to introduce digital hearing aids and
focuses on new patients. It appears to assume that the "Best
Practice Standards" are in place.
The MHAS programme was said to be "fully
funded". However this is not strictly true. The funding covers
only the major extra cost of providing digital hearing aids plus
associated computer testing equipment, with some funding of additional
staff to administer the system, it does not cover accommodation
or refurbishment to house the necessary staff and equipment.
The basis for the funding of the programme is
not transparent and appears to be related to the number of conventional
analogue hearing aids previously issued by the Departments concerned.
Thus fully modernised facilities, complying with "Best Practice
Standards" are given more funding than the sub-standard ones
leading to an increase in the "post-code lottery" variation
in service. Shortage of qualified audiologists, many of whom have
defected to the private sector, has exacerbated the problems.
THE PPP SCHEME
In 2005 the DoH authorised two private companies,
Ultravox and David Ormerod, to dispense NHS digital hearing aids.
This arrangement is purely to help reduce the embarrassingly long
waiting lists and times in NHS Trust hospitals, and relates mainly
to new patients. Money spent on the PPP scheme is then not available
to modernise NHS facilities.
These private companies are happy to receive
NHS Patients who can be "persuaded" to purchase "better"
private aids, and it is significant that one of the companies
has recently stepped up national advertising for these "better"
aids. In some cases these companies are provided with space in
NHS Trust Hospitals to operate, and this situation is also featured
in their advertising.
Money spent on the PPP Scheme is not additional
money. Money used for this purpose may prevent improvements to
NHS audiology departments. Cost per patient is probably higher
via the PPP Scheme than via NHS Trusts.
Annex 2
BASIC CAUSES
OF CURRENT
PROBLEMS IN
SOME AREAS
— Issue of Best Practice Standards
for Adult Audiology in 2002, by the Department of Health,
but failure to ensure that they were instituted or even read.
— Failure to identify the numbers of
patients expected to require digital hearing aids or even set
up a data collection system for that purpose.
— Failure to adequately fund the MHAS
programme funding not related to catchment area size.
— Failure to monitor performance of
audiology departments by the healthcare commission either in star
rating programme or in current annual healthcheck.
— Failure to review management of audiology
departments and relationship with ENT, as identified in "Audiology
in Crisis" published by the RNID in 2001.
— Total indifference to "post-code
lottery" situation by a succession of Health Ministers.
— Too great a concentration on digital
hearing aids for new patients by RNID and the Department of Health.
— Introduction of a telephone hearing
test by the RNID, without discussion with NHS audiologists, which
greatly exacerbates existing capacity problems.
Annex 3
DEFINITION OF
TERMS
Standard—A definitive level of excellence
or adequacy required, aimed at, or possible
In 2002 the Department of Health in conjunction
with the RNID issued Best Practice Standards for Adult Audiology.
This followed publication of the document Audiology in Crisis
published in 2001. These Standards were drawn up by an eminent
Group of people associated with the Deaf and Hard of Hearing together
with the NHS and Medical Practitioners.
The foreword to Best Practice Standards for
Adult Audiology clearly states the Government view at that
time. No attempt was made to ensure that these Standards were
put in place. Currently the Department of Health state that these
Standards are not Standards but "aspirations" and they
are not applicable to the NHS.
Services
The Scope of Audiology Services is clearly defined
in the Best Practice Standards for Adult Audiology published
in 2002 (Section 3 pages 23 to 28).
The RNID issued a Summary Booklet A Good
Audiology Service—What You Can Expect, following production
of the "Best Practice Standards" in 2002, for use by
patients.
The Modernised Hearing Aid Service (MHAS) introduced
by the DoH during 2005 relates solely to hearing aids and is concerned
solely with the introduction of digital hearing aids.It does not
cover the total service as defined in "Best Practice Standards"
but seems to assume that the Standards are already in place.
It should be remembered that not all patients
can benefit from a digital hearing aid.
Concentration of effort to provide digital hearing
aids to new patients has resulted in a marked diminishing of the
total service for long term hard of hearing patients.
Annex 4
DARENT VALLEY
HOSPITAL
Audiology Services prescribed by Best Practice
Standards for Adult Audiology
| Catchment area | 200,000
|
| Hearing test rooms | Four |
| Rehabilitation rooms | Five
|
| Size of Rooms | |
| Hearing test | 11m2 |
| Rehabilitation | 13m2 |
| Staffing | |
| 10 audiologists | |
Access to reception and waiting areas, treatment and testing
rooms should be suitably adapted for all users. Planning should
take into account the fact that the majority of users will be
deaf or hard of hearing. The audiology department should be well
signposted. Even with the latest renovations (April 2006) Darent
Valley Hospital fails to provide the above.
For comparison the following hospitals with a similar catchment
area to Darent Valley have been identified.
| Fairfield Hospital, Bury |
|
| Catchment Area | 185,000 |
| Staffing | 10 audiologists plus 2 clerical
|
| Equipment | 26 audiometers |
| Waiting Time (Referral to Fitting) | 9 weeks
|
| Ormskirk Hospital, Ormskirk |
|
| Catchment Area | 200,000 |
| Staffing | 8 audiologists plus 2 clerical
|
| Equipment | 4 audiometers |
| Waiting Time (Referral to Fitting) | 18 weeks
|
| Manchester Royal, Manchester |
|
| Catchment Area | 189,000 |
| Staffing | 8 audiologists |
| Equipment | 14 audiometers |
| Waiting Time (Referral to Fitting) | 21 weeks
|
| Birch Hill Hospital, Rochdale |
|
| Catchment Area | 207,000 |
| Waiting Time (Referral to Fitting) | 16 weeks
|
| Barnsley General Hospital, Barnsley |
|
| Catchment Area | 250,000 |
| Staffing | 8 audiologists |
| Waiting Time (Referral to Fitting) | 11 weeks
|
All the above audiology departments comply with best practice
standards with regard to facilities.
| 
