Evidence submitted by the British Academy
of Audiology (AUDIO 16)
EXECUTIVE SUMMARY
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.
INTRODUCTION
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aids as standard NHS provision instead of outdated instruments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.
BAA CONCERNS ABOUT
ISTC CONTRACTING PROCESS
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.
THE AUDIOLOGY
ACTION PLAN
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
| 
