Select Committee on Health Written Evidence

Evidence submitted by the British Academy of Audiology (AUDIO 16)


  The British Academy of Audiology (BAA) is the largest professional body representing Audiologists, mainly in the NHS with a percentage of the membership working within the independent sector.

  The Academy is concerned about the limited amount of consultation regarding the changes to a major part of NHS Audiology Service Provision. In particular the second wave ISTC contracts being awarded to the private sector, the potential threat to the future of NHS Audiology Services and the lack of clinical governance arrangements of these contracts.


  1.  Audiologists are the professional group with primary responsibility for treatment of people with hearing difficulties. The BAA is the professional body representing Audiologists, mainly in the NHS with a percentage of the membership working within the independent sector. The Academy has over 2,000 members in the UK and its members have been at the forefront of new developments in the provision of services to hearing-impaired people. We have a major stake in the successful delivery of effective and innovative services for our clients and therefore wish to be fully involved in the planning and provision of services for hearing people. The Health Select Committee offers us an opportunity to become more involved.

  2.  There is substantial unmet need for services for hearing-impaired people, partly through reluctance of people to come forward for treatment and partly through perceptions of long waiting times and unsatisfactory performance of hearing aids. Audiologists and the voluntary sector have pressed for many years for improvements in the quality of NHS hearing aids, culminating in 2000 with the DH programme of Modernisation of NHS Hearing Aid Services. This programme introduced modern (digital) hearing aids as standard NHS provision instead of outdated instruments manufactured specifically for the NHS. This step entailed very extensive re-training and development of information technology skills in the workforce and the learning of new techniques and approaches for management of people with hearing difficulties. The Modernisation programme was specifically funded by the DH and completed in 2005.

  3.  Alongside Modernisation, we have introduced a programme of graduate training as the basic entry qualification for professional audiologists, bringing the UK closer to the practices of other developed countries where graduate, postgraduate and doctoral qualifications are required. These degree programmes have been launched very successfully, selected and funded by the DH, and their output has just stared to feed into the profession. During the development of these programmes, the alternative non-graduate routes into the profession have fallen away.

  4.  A consequence of Modernisation has been an increased demand for Audiology services, especially treatment of adults. The availability of better services has probably released some pent-up demand from unmet need, while there has been a "bulge" from patients wishing to upgrade from old NHS hearing aids earlier that they would have done otherwise. These consequences have increased waiting times to an unsatisfactory amount because there was not the increased capacity available immediately.

  5.  In order to increase capacity temporarily, the DH launched a Public Private Partnership (PPP) in 2003. Two private companies worked in partnership with the local Audiology Departments, who monitored the quality of the service and data was transferred between both parties.

  6.  The results of the PPP have not been published but our impression is that the scheme met with some success, although 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 the NHS Audiology Service for further rehabilitation. The costs of PPP activity exceeded the marginal costs of treating the patients in the NHS by at least a factor of two, and hence the programme should be considered as a temporary stopgap. Following the removal of DH ring fenced funding of these services the PPP programme closed. Furthermore, increased financial constraints on PCTs and NHS Trusts have led to even more freezing of vacant posts for audiologists. As a consequence, many Audiology Services now have long waiting lists and access times for their services. Worryingly, the extent of frozen posts threatens the career prospects of new graduate audiologists who have been trained at NHS expense exactly to meet the circumstances that we are facing.

  7.  Hearing Aid Services have been included in the second wave ISTC contract and independent providers are being contracted to assess and fit patients with hearing aids. The detailed outcome of negotiations for ISTC services and the consequences for take-up by PCTs of NHS provision are not yet clear. However, given that hearing aid provision has been specifically excluded from the 18-week waiting time target, [8]there is great concern that there will be reduced funding for NHS Audiology Services that will squeeze Trust budgets and exacerbate capacity constraints in the NHS—exactly the opposite of what has been planned for over the past decade.

  8.  In addition to the second wave ISTC contracts; Lord Warner in July 2006 announced further independent sector capacity of 300,000 pathways per year for five years for Hearing Aid Services. Strategic Health Authorities had to give firm figures to the DH as to their requirements prior to Christmas 2006. This was prior to any output from the National Audiology Action Plan. The difficulty this causes is that the PCTs do not know the number of pathways they will have to achieve and by when. These pathways committed by the Strategic Health Authorities may be in fact too high, which will undermine core Audiology Services.


  9.  The BAA has major concerns regarding these contracts and their consequences for people with hearing impairments: in particular:

    —    The cost effectiveness of ISTC provision.

    —    Quality assurance/clinical governance arrangements of these contracts.

    —    Destabilising effects on NHS Audiology services and workforce development.

    —    Determination of the numbers contracted.

    —    Treatment of patients with complex needs or pathologies requiring referral.

    —    Access to a full service including counselling, repairs and maintenance, hearing therapy and assistive listening devices.

    —    Data transfer of hearing aid specifications to the NHS Audiology Services.

    —    Quality of the hearing aids provided.


  10.  In conjunction with this work the DH have commissioned a National Audiology Action Plan. Progress on the Action Plan has not been revealed but the BAA has been invited to the Stakeholder meeting where we hope to address these issues. The BAA has not been involved in the planning and decisions affecting the provision of services to the extent that might be expected.

  11.  What is desperately needed is a long-term strategic plan for Audiology that builds on the successes that have been achieve through Modernisation and educational reforms. This should differentiate between the short-term adverse impact on waiting times from the success of modernisation, the adverse impact on waiting times of reduced funding and frozen posts, and the progress that will be made when the new graduate workforce starts to fill posts that currently are empty or frozen in the near future. The plan must recognise the potential for ISTC contracts to threaten this future progress, leading to a vicious circle of reducing NHS provision and increasing expenditure at greater unit cost outside the NHS.

  12.  The BAA recommends:

    —    re-directing the ISTC funding back to NHS Audiology Services where better value for money is available (provided the funding is not creamed off for other activities); and

    —    a robust analysis of these issues needs to be undertaken to provide a proper commissioning framework for the PCTs and future GP-led commissioning.

Whether accurate data on waiting times for audiology services are available

  13.  Currently the DH is collecting information on waiting times for certain types of audiology services. There are concerns within the profession over the accuracy of the data seen so far, as some Trusts are reporting monthly figures, other Trust tri-annual figures through the census. The exact information that has been required from Audiology Services was not explicit, labelling waiting lists as "Pure Tone Audiometry", which is not meaningful in the current context. Audiologists are unsure of the specific data that are actually required about their services. We are concerned that planning is being based on inappropriate data.

Why audiology services appear to lag behind other specialities in respect of waiting times and access and how this can be addressed

  14.  As described above, Audiology Services appear to lag behind other specialities due to increase demand for digital hearing aid technology both from new and existing hearing aid patients, introduced as part of the Modernisation of NHS Hearing Aid Services. Increased funding associated with Modernisation has been appropriated by Trusts to feed into their general funds rather than directing this funding to Audiology. This can be addressed by introducing tariffs into Audiology whereby funding follows the patient and services will be funded appropriately. As there is a backlog of patients waiting, there is a requirement for additional short-term investment in NHS Services.

Whether the NHS has the capacity to treat the numbers waiting

  15.  The planned workforce developments will ensure that the NHS has sufficient capacity to treat the numbers waiting in the medium term. It will take some time for currently frozen and unfilled posts to be filled. Ensuring that funding goes to Audiology Services rather than being spent elsewhere will assist this. The increase in capacity required to shift the backlog of waiting patients is not great and once the backlog has been shifted the planned workforce developments should cope with increased demand associated with unmet need and demographic changes.

  16.  NHS capacity may be undermined if ISTC contracts lead to audiologists trained by the NHS leaving, or not starting work in the NHS.

  17.  There are issues of quality that cannot be separated from capacity. The NHS service is in the best position to following the guidelines, protocols, and complete care pathways in a quality assured service, as it has worked hard to establish these standards. Treating patients is more than assessment of hearing impairment and "click and fit" of the hearing aid; it must take into account the specific needs of the individual patient and the counselling /rehabilitation they require.

Whether enough new audiologists are being trained

  18.  As part of the DH Modernisation of Education and Training, Audiologists are now being trained in nine Universities in the UK, seven of which are in England. The BSc Audiology programmes at the Universities of Manchester and De Montford in Leicester have now been running for five years, with their first cohorts graduating in 2006. Some of these Universities also offer MSc and Postgraduate courses in Audiology. In total over 220 students are expected to complete both graduate and post-graduate courses each year. However, due to financial constraints in the NHS, there is a lack of money to enable Trusts to open posts to accept all these graduates and the cutting back on commissions for BSc courses by the NHS will restrict NHS capacity.

How great a role the private sector should play in providing audiology services

  19.  There is a role for the private sector to play in providing audiology services. Private provision of hearing aids has always been available to those who prefer to pay directly and this activity plays an important role alongside NHS provision. There is a possible role for the private sector to subcontract NHS work to meet short-term needs, as demonstrated by the PPP scheme. However, it should not take place at the expense of destabilising existing Audiology Services but as a planned part of the NHS Commissioning Framework. This needs to be discussed with local services and the PCTs in the context of the requirements of their own health economy. It needs to be fully regulated, with proper quality assurance, working in partnership with the local departments.

  20.  This partnership should ensure that patients are presented with a seamless service rather than fragmented services that do not exchange information nor coordinate provision. It is only by developing services in an atmosphere of cooperation and consultation that patients will receive the sort of service they are entitled to expect. Unfortunately, current developments have not been planned with this philosophy.

Pauline Beesley

President, British Academy of Audiology

On behalf of the BAA Board and Membership

February 2007

8   NHS Audiology Services are now faced with referral for hearing aids from GPs being excluded from the DH Delivering the 18 week Patient Pathway Updated 18 week Clock Rules of 11 December 2006. Back

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