Select Committee on Health Written Evidence

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.


  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:

    —    Hammersmith & Fulham;

    —    Kensington & Chelsea;

    —    Westminster; and parts of

    —    Ealing & Hounslow.

  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.

    —    Hearing Therapy.

    —    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:

    —    Diagnosis.

    —    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.

    —    Telephone follow ups.

    —    Appointment reminders (red DNA's).

    —    Increase in clinical expertise BSc State Registration.

    —    Fine tuned skill mix.

    —    Building on links with GPs and health centres delivering in community.

    —    Home visits/reducing timely transport issues.

    —    Walk in clinics for repairs and batteries.

    —    Do once and Share.

    —    Choose and Book.

  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);

    —    NHS support services;

    —    inadequately trained staff;

    —    quality control issues (referrals into NHS as PPP performance unsatisfactory); and

    —     NHS utilities.

  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 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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