Evidence submitted by Charing Cross Hospital
(AUDIO 21)
This submission is from Audiology Services and
Training Centre, Charing Cross Hospital, Hammersmith Hospitals
NHS Trust, London. Our expertise includes all areas of Audiology/Training
and we have on average 22 years of experience.
INTRODUCTION
Charing Cross Hospital is nationally and internationally
recognised as a high quality flagship service for diagnostics
and rehabilitation. Many thousands of satisfied patients have
passed through our hands. The population we support includes:
— Westminster; and parts of
Total adult population for the above areas:
1,013,000 and growing.
The comprehensive Audiology services we commit
to in our Service Level Agreement include:
— Direct Access Hearing Assessments.
— Diagnostic Testing (both Vestibular
and Electrophysiological).
— Paediatric Audiology Services.
— Paediatric Habilitation.
We are a leading Training Centre and Mentor
site for Audiologists from across the country.
Since May 2004 well over 4,000 of our patients
are today benefiting from their new digital hearing aids. This
number will continue to rise as the elderly population increases,
people become more aware of their hearing-loss and patients already
fitted require their hearing aid prescription to be updated. We
are very keen to maintain and expand this important service and
have made sure the necessary foundations are firmly in place.
Our work also encompasses the newly implemented
Neonatal Hearing Screening programme. This essential service identified
children under the age of three months from the serious impact
that unrecognised hearing problems can have on their all-important
early speech and understanding.
In 2006 we were proud to host a meeting for
the All Parliamentary Group on Deafness on behalf of the RNID.
NHS Audiology services have never been so good,
we now have:
— Fantastically improved modernised
service.
— Highly skilled, educated and
trained Audiologists.
— Commitment to deliver the highest
quality of care and service.
We implore the government and the PCT commissioners
to maintain and further invest in our recently modernised services
rather than redirect funding elsewhere as a quick fix for waiting
times.
Our answers to the five questions raised are
included, in summary plus supporting detail based on real experience.
Are accurate data on waiting times for audiology
services available?
1. No comparable data at all is available
on Audiology services in the private sector. There is ample accurate
data available on all aspects of treating patients at Charing
Cross Hospital. We continue to assist in improving the quality
of the data at national level.
2. Accurate data for local NHS Audiology
services have always been available. The national collection of
data has been on going via the RNID since the implementation of
MHAS (Modernising Hearing Aid Services). Nationally the Department
of Health diagnostic waiting time's data collection is in its
infancy with regards to definitions and collection of transparent
data. Data requirements have already been amended twice and are
still very open to interpretation. Further improvements to the
current data have been suggested as national data collection guidelines
are still ambiguous.
3. Patients do not want a trade-off between
poor quality outcomes (eg a hearing aid that's poorly prescribed
and fitted) as the price for shorter waiting times. On balance
many prefer to "get it right" rather than just "get
it fast". It is important that data is not just collected
on waiting times but also that outcome measures and quality issues
are monitored to ensure a high quality delivery of services is
achieved for all patients in both sectors.
4. At present the data collection is staff
hours intensive as it can require double entry of data. Therefore
an improvement would be development and investment in a two way
link between the specifically designed Audiology Patient Management
System (PMS) (AuditBase/Practice Navigator) and the hospital PMS.
5. A way forward is to:
— Streamline this inefficient
data duplication.
— Inform and train PCTs to recognise
the valuable existing Audiology reporting system.
— Add real value for patients
by making available a sophisticated bespoke range of reports across
the entire end-to-end patient journey.
6. It is essential that any data collected
from the independent sector is of a high quality and comparable
with NHS information so that true outcomes can be monitored for
the protection of patients, some of whom are very vulnerable.
7. In our experience of the Public Private
Patients (PPP) Scheme, serious anomalies have arisen—in
fact, even the transfer of basic, valuable and important existing
patient information has been given low priority or in fact simply
ignored as irrelevant.
Why do audiology services appear to lag behind
other specialities in respect of waiting times and access and
how this can be addressed?
8. The appearance of lagging is because
the comparison is not like with like. An extra three significant
stages are included for audiology which are not included for other
disciplines.
9. The 15 diagnostic tests (in other disciplines)
that Audiology has been grouped with are purely diagnostic tests.
Audiology patient journeys cannot be compared with these figures
as the wait times need to include not simply diagnostic testing
but also assessment of patient's suitability for a hearing aid,
pre assessment counselling, hearing aid selection, impression
taking, fitting and verification of a hearing aid and a fine tune
follow up or referral to ENT.
10. The whole patient journey for Audiology
combines diagnostic and rehabilitation processes. The various
sequential phases in the journey to a successful outcome for the
patient are:
— Assessment of patient success,
pre assessment counselling, impression taking.
— Fitting an aid, Real Ear Measurement
(REM).
— Fine tuning follow-up after
patient early learning-curve.
— Verification of successful outcome.
11. A decision has to be considered (at
the assessment phase) to refer to ENT in certain cases due the
history and results of some diagnostic tests. The overall process
has five major phases in it compared with other disciplines which
are measured for one phase only.
12. Audiologists in the NHS have undergone
a massive change implementing the modernisation process. The waiting
lists are a result of many factors but mainly an increased number
of patients wanting to access our services. As a workforce NHS
audiologists have embraced these immense changes (eg MHAS) and
in tackling the recent waiting lists are implementing many innovative
solutions.
Does the NHS have the capacity to treat the numbers
of patients waiting?
13. The short answer is yes. In most cases,
both ability and volume requirements can already be satisfied.
With Modernisation, State Registration, and a BSc in Audiology
there is no doubt the ability is at an all-time high. The vast
majority of hearing impaired patients in the UK are NHS patients.
The expertise and experience gained in dealing with this volume
cannot be matched although of course there is still a strong commitment
to improvement.
14. The capacity of Audiology Services tends
to vary nationally therefore capacity should be looked at a local
level. The staffing levels of the Audiology department of Hammersmith
Hospitals NHS Trust (HHNT) were reduced due to cost improvement
savings, introduced by the Trust due to rectify financial deficit.
This situation is now resolving, new posts are being filled and
waiting times reduced enabling us to expand our service to fully
utilise out capacity.
15. The capacity can further increase by
changes in working practice such as:
— Flexible working/opening hours—maximising
the use of clinical equipment and rooms.
— One stop clinics utilising the
open fit technologies now available.
— Appointment reminders (red DNA's).
— Increase in clinical expertise
BSc State Registration.
— Building on links with GPs and
health centres delivering in community.
— Home visits/reducing timely
transport issues.
— Walk in clinics for repairs
and batteries.
16. The maximum capacity can be achieved
by utilising all possible sites for service delivery thus bringing
our services to patient's doorstep in the community. This could
include utilising space in Health Care Centres and as in current
practice, Care Homes, Day Centres, and in the patient's home.
17. Capacity can also be increased by ensuring
a proper skill mix across Audiology services including the use
of Assistants and Associate Audiologists and ensuring efficient
utilisation of highly skilled staff.
18. As the elderly population increases
the demand on Audiology Services will follow. Insightful forward
planning in conjunction with the GP's will enable more accurate
strategic planning for efficient delivery of services.
Are enough new audiologists being trained?
19. Again the answer is yes. Four fallow
years are about to end with the first cohort of BSc Audiologists
joining the workforce from nine universities this summer.
20. The four year BSc Audiology degree is
about to deliver its first cohort of graduates. The last four
years concurrently with MHAS implementation has impacted heavily
in the levels of qualified staff available for employment by the
NHS. This situation will improve now that the first cohort of
students are graduating. As the BSc course is funded by the NHS,
there should be a commitment from graduates to serve a length
of time for the NHS.
21. The development of Access courses and
Foundation degree (starting 2007) will enable part time routes
to the BSc. This will open up routes into audiology as a profession,
enabling retention and recruitment. Attention given to development
of recruitment strategies given changing nature of entry into
the NHS.
How great a role should the private sector play
in providing audiology services?
22. Their role should be strictly limited,
based only on a proven track record, and only if managed by clinically
competent staff. Experience from PPP has highlighted grave concerns
with regard to all aspects of the service delivery. Including
hidden expenses such as:
— rent-free use of NHS treatment
rooms (contractual issue);
— inadequately trained staff;
— quality control issues (referrals
into NHS as PPP performance unsatisfactory); and
23. A contractual approach that endorses
cherry-picking of very simple cases turns out in practice to be
both wasteful and damaging to patients. Any private sector role
should continue to be as a supplier to the local NHS to meet local
needs. A proven track record and well-established quality and
patient service must be the primary criteria for short term contractual
agreements with the private sector, eg a short sharp sock to reduce
this "Bump" in demand.
24. Vulnerable patients should not be at
the mercy of management decisions giving priority to maximising
profit to the detriment of patient outcomes. It is essential that
thorough consultation with highly skilled and experienced audiologists
should take place prior to contracts being awarded.
25. Hearing aid dispensing is only one aspect
of Audiology, and it is argued that this cannot be fully achieved
without a sound clinical understanding of the individual patient
diagnosis and physiological ramifications of the diagnosis.
26. As the hearing aid council (HAC) is
disbanding, an area of great concern is the lack of checks and
balances in place with the private sector. A roll-out of revised
codes of practice are to commence April 2007 until 2008 (see HAC
website www.thehearingaidcoucil.org.uk). Starting the implementation
of ISTC (audiology) is untimely, with patient safety, quality
of service, and accountability all areas of concern during this
transition process.
27. Whilst these codes of practices are
being implemented, NHS Audiologists should be given the chance
to prove how they can handle and implement change, with effective
skill mixing of staff the majority of departments can significantly
reduce waiting times.
28. BSc (NHS funded) student audiologists
on clinical placements are able to gain a breadth and depth of
training consolidated into one audiology department in the NHS.
The future workforce is dependent on this quality driven service.
Private sector training is not uniform and required qualifications
to work as a dispenser are far inferior to the essential BSc Audiology
required to practise in the NHS.
29. During the PPP contracts the companies
delivering Patient Journey services experienced recruitment and
retention issues. The work was very repetitive because only very
simple straightforward direct referral patients were offered this
route. Company staff turnover was very high because of low job
interest. This led to poor continuity of care for the patients
(and incidentally, the NHS organisations working in partnership).
30. Private sector coverage is patchy. In
one example a PPP supplier was unable to obtain premises from
which to work because retail outlets in the area were too expensive.
31. In an attempt to protect vulnerable
patients, PPP staff were provided with rent-free space and services
within NHS audiology facilities. Because of contract restrictions,
PPP staff were not allowed to contribute towards waiting time
improvements when any particular PPP patient DNA. In a similar
situation, an NHS staff member would have been re-allocated dynamically
to contribute in other ways. An extra NHS audiologist in-house
would have been a much more efficient use of space and money.
32. Historically smaller digital in the
ear hearing aids were solely offered by the private sector. Due
to local negotiations these hearing aids are now available to
suitable NHS patients.
— We can offer this product and
service to patients within budget.
— Compared with private sector
charges where costs to the patient would be in excess of £2,000
per hearing aid.
This proves we can be efficient, meet local
demand and most importantly provide a caring patient focused expert
service.
Julie Wilkins
Head of Audiology Services
Ruth Thomsen
Audiology Services Manager
Deirdre Moir
Audiology Services Manager
Charing Cross Hospital
8 February 2007
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