Select Committee on Health Written Evidence

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.


  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:

    —  Deafness from Birth.

    —  Severe Infection.

    —  Side Effects of certain Drugs.

    —  Exposure to Loud Noise both short and long term.

    —  Otosclerosis.

    —  Sudden Changes in Pressure.

    —  Ageing.

  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.



  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.


  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.


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.


  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.


  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


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".


  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.


  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


    —  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


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.


  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


Audiology Services prescribed by Best Practice Standards for Adult Audiology
Catchment area200,000
Hearing test roomsFour
Rehabilitation roomsFive
Size of Rooms
Hearing test11m2
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 Area185,000
Staffing10 audiologists plus 2 clerical
Equipment26 audiometers
Waiting Time (Referral to Fitting)9 weeks
Ormskirk Hospital, Ormskirk
Catchment Area200,000
Staffing8 audiologists plus 2 clerical
Equipment4 audiometers
Waiting Time (Referral to Fitting)18 weeks
Manchester Royal, Manchester
Catchment Area189,000
Staffing8 audiologists
Equipment14 audiometers
Waiting Time (Referral to Fitting)21 weeks
Birch Hill Hospital, Rochdale
Catchment Area207,000
Waiting Time (Referral to Fitting)16 weeks
Barnsley General Hospital, Barnsley
Catchment Area250,000
Staffing8 audiologists
Waiting Time (Referral to Fitting)11 weeks

  All the above audiology departments comply with best practice standards with regard to facilities.

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