House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

Evidence submitted by Hidden Hearing Ltd (AUDIO 25)

BACKGROUND

1. Hidden Hearing is a leading independent sector provider of digital hearing aid services with 60 hearing centres throughout Britain. We also assist over 60 GP practices in carrying out initial hearing assessments of patients in order to reduce pressure on GPs and audiology departments.

2. We welcome this inquiry and share the Committee's concern over long waiting times for audiology services and are grateful for the opportunity to make this submission.

3. An ageing population, increased quality of life aspirations and improved technology are generating unprecedented and rising demand for hearing healthcare. 55% of people over 60 are deaf or hard of hearing[20] but the problem is not confined to the elderly. In total, over four million people in the UK have a hearing difficulty that could be assisted through the use of properly prescribed hearing aids. Only around two million have such instruments. [21]

4. People with a hearing difficulty would see their quality of life improve significantly if they could be fitted with digital hearing aids quickly and easily. In January 2006, A Sure Start to Later Life[22] was published with the aim of tackling inequalities faced by older people. The report noted that in many cases "quality of life for older people can be significantly improved by the use of aids and adaptations such as hearing aids." [23]The longer people have to wait, the greater the likelihood that their hearing will deteriorate as will their chances of successful rehabilitation with their new aids, when they are eventually fitted. Left untreated, hearing loss can lead to further health problems stemming from psychological withdrawal in social situations. This can result in feelings of isolation, lack of self-confidence and depression.

5. The Modernisation of Hearing Aid Services (MHAS) project, launched in January 2000, equipped all NHS audiology departments to deliver digital hearing aids. However it did not enhance NHS internal capacity. The launch of MHAS and greater public awareness of the benefits of digital hearing aids released latent demand which it has proved impossible to meet within existing NHS capacity.

6. MHAS did include a very limited Independent Sector involvement. Since October 2003, approximately 68,600 patients have been fitted with a hearing aid through a Public Private Partnership (PPP) involving only two companies. [24]There has been unanimous approval of the Independent Sector companies' standard and ability to complement the work of the NHS in providing fitting and follow up service. Furthermore, this service can be provided to patients in a community setting.

7. Initially finance for the PPP was ring-fenced, but this ceased in April 2005. Subsequently there has been a severe reduction in PPP activity. The removal of ring-fenced funding not only reduced commissioning through the PPP but also saw anecdotal increases in monaural aid fitting by NHS departments when binaural (two aids) had been the aspirational "norm".

8. For the last three years, the British Society of Hearing Aid Audiologists (BSHAA) has carried out a survey of local audiology waiting times. This included establishing the wait from GP referral to a first appointment for a hearing test as well as the wait between receiving a hearing test and having a hearing aid fitted. The latest survey in October last year showed average total waiting time in England had risen for the third year in succession, to between 45 and 48 weeks (compared with 43-47 weeks in 2005). [25]

9. For the first time, BSHAA also surveyed waiting times for existing NHS analogue aid users to upgrade to digital. At the moment, priority is given to patients without any hearing aid. Only when their needs are met are those with an analogue aid, from which they may be receiving little benefit, considered for a digital aid. Results showed that in England such patients have to wait on average between 68 and 72 weeks for a digital instrument; this average hides some dramatic black spots.

Whether accurate data on waiting times for audiology services are available?

10. The short answer is "no", for the following reasons.

11. Originally the Department of Health did not collect audiology waiting time data centrally. This led to BSHAA carrying out its first survey of audiology waiting times in 2004.

12. In January 2006, the Department of Health started collecting data measuring NHS audiology waiting times from referral to first assessment only. The results were published for the first time on 12 July 2006. The total number of people waiting in January 2006 was 119,285. Of these, 77,412 were waiting for more than 13 weeks and 53,941 were waiting for over 26 weeks. [26]Subsequent monthly reports have shown a continuing increase in the number of people waiting for assessment.

13. Asked at Health Questions on 18 July 2006 why the full wait from referral to treatment was not tracked, the Minister replied that "The Department does not collect waiting times for hearing aid fittings. We aim to deliver audiology diagnostic tests within 13 weeks by March 2007, and within six weeks by December 2008." [27]Subsequently work started on measuring waiting times from referral to treatment but no indication was given on how the new targets would be met.

14. In October the definition of audiology tests was expanded to include a wider number of assessments. [28]The total number of people waiting in October for assessment that month stood at 169,385. [29]This compared to 127,280 in September. [30]

15. The lack of published departmental data on the waiting time between the first assessment to the fitting of a hearing aid means that the Department of Health does not have a full picture of the extent of the waiting time problem. A full set of data would enable the Department to identify where bottlenecks exist.

16. For the purpose of assessing overall audiology waiting times, the patient journey should be measured from the initial GP consultation and referral and include the hearing assessment at the hospital audiology department (or in 20% of cases with a hospital consultant), and the diagnosis and fitting of appropriate hearing aid(s).

17. We have identified two major roadblocks: the length of wait between the GP referral and the hospital appointment; and the waiting time between the appointment and the fitting of the device. Current Department of Health statistics only reveal the extent of the former.

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

18. Audiology suffers from the simple fact that hearing loss is an invisible condition, is not life threatening and affects the elderly in the majority of cases. A direct consequence of these facts is that commissioners having to make financial decisions between competing disciplines will always relegate hearing care and audiology to the bottom of their list of priorities. Given the reluctance of the Department of Health to ring fence funding, this situation is likely to continue.

19. Since the Modernisation of Hearing Aid Services (MHAS) was launched in January 2000, the Government has consistently under-estimated the demand for digital hearing aids. Furthermore, it has provided only limited ring fenced funding (now discontinued) and made too little use of the only source of extra capacity currently available—the independent sector.

20. As more people realise the improvement that a digital hearing aid can make on their daily lives, demand for the new technology is growing. The Government has acknowledged admitted that "Waiting times in audiology, including those for digital hearing aids, are likely to have increased in some areas because of the modernising hearing aid services (MHAS) project." [31]

21. Demand on existing NHS audiology services far outstrips capacity and is still increasing. A report in Society Guardian stated that "In addition to existing hearing aid wearers, a further 250,000 people each year visit their doctor for the first time with a hearing problem, with 95% needing a hearing aid." [32]

22. Demand will continue to increase due to our ageing population. By 2015 nearly a quarter of the population will be over 60. In April 2006, the Department of Health published the priorities for the second phase of the government's 10-year National Service Framework (NSF) for Older People. One of the key aims of the framework is: "To overcome barriers to active life for older people through giving attention to equipment, foot-care, oral health, continence care, low-vision and hearing services." [33]

23. MHAS provided the equipment for the NHS to supply and fit digital hearing aids but not the extra staff resources to meet demand. There is an urgent need for trained hearing aid dispensers who can carry out hearing assessments and fit hearing aids. The Government has responded to the lack of capacity by introducing an audiology honours degree course. However, precise numbers of students are unclear. The first students have only just graduated and indicative numbers suggest these courses do not begin to fill the gap between supply and demand. Furthermore, more qualified NHS audiologists alone are not the solution to the staff capacity issue.

24. Patients require assistance to fine-tune the new digital hearing aids and then continuous aftercare to help maintain them and ensure they continue to meet their needs. This is particularly the case with the over 60s who tend to need more help over a longer period of time. But pressure on NHS audiology departments to provide the new aids is reducing the time available for rehabilitation and aftercare. In an attempt to process more people, the NHS has introduced a new telephone follow up service, which reduces the patient journey time. However, if digital hearing aids are to be used to their full potential, ongoing personal face-to-face consultations are needed. For example, many patients also do not realise that digital hearing aids available on the NHS are fitted behind the ear and not in the ear as is routinely available from independent suppliers. This leads to disappointment and the increasing possibility of hearing aids not being used.

25. On 10 May 2006 the Department of Health published its "implementation framework" for achieving the 18 week referral to treatment target, the so-called patient pathway. Audiology was excluded audiology from this target, ostensibly because "most audiology services are accessed directly from primary care" not by referral to hospital consultants. [34]In fact 20% of referrals for audiology do go via hospital consultants and the figure is rising, as GPs and patients seek a short cut to reduce waiting times by qualifying under the 18 week target.

26. Instead, audiology was highlighted as an area needing special attention due to long waiting times and a high volume of patients. It was recognised that in addition to existing waiting lists there is "a significant reservoir of unmet need that currently does not present for treatment".[35] It was revealed that the Department of Health intended to develop a separate action plan for audiology to deliver a "sustainable low wait solution". A working party has been formed to formulate this and met for the first time in November. A report is awaited but could be Spring 2007.

27. Meantime on 25 July, Lord Warner announced an additional 300,000 patient journeys[36] per annum for the next five years, to be sourced from the Independent Sector. Early indications were that this would commence early 2007. It is now clear that it will start much later, thus calling into question the targets referred to above.

28. There are also doubts about the volume of patient journeys that will be delivered. Contrary to initial indications, it is now clear that funding for the additional 300,000 patient journeys will not be ring-fenced. Instead individual SHAs and PCTs will decide what priority should be given to the provision of digital hearing aids and how much funding to allocate.

29. This is not the first time that a lack of ring fenced funding has called into question the priority accorded to audiology services by local health economies. Prior to the announcement of the additional 300,000 patient journeys, the Government had also extended the existing PPP to enable 48,000 extra patient journeys to be procured using Independent Sector Treatment Centres. However, the delivery of these journeys has been delayed and in some cases cancelled due to a lack of ring-fenced funding to guarantee their delivery. The same thing is likely to happen with the 300,000 patient journeys.

30. An additional problem is that the Government stopped collecting reference costs for digital hearing aids. This has made it difficult to set an equitable tariff for additional patient pathways to be delivered by the independent sector. The lack of a National Tariff also means that audiology is excluded from initiatives such as Practice Based Commissioning and Payment by Results—thereby inhibiting the wider use of the sector by PCTs.

31. There is a question mark over whether future provision of some audiology services will be in a secondary or a primary care setting. Audiology services should be made more readily accessible to patients. A number of sites exist which are trialling new ways of accessing audiology services. These include eight physiological measurement sites, five "Care Closer to Home" Project demonstration sites, [37]as well as independent initiatives in GP surgeries. There is scope for increased delivery of audiology services in a community setting.

32. In summary, action on reducing waiting times seems to be in limbo. The 300,000 new patient pathways are unlikely to begin coming on stream before the latter part of this year and without ring-fencing the volumes provided are not predictable. Furthermore, work on the new audiology plan has only just started and a report is not expected before the spring.

Whether the NHS has the capacity to treat the number of patients waiting and whether enough new audiologists are being trained?

33. The Secretary of State for Health, Rt Hon Patricia Hewitt MP, has acknowledged that the only way the 18 week target would be met is with "a massive increase in capacity in both the NHS and the independent sector, all of it free at the point of need." [38]

34. The NHS has acknowledged that it needs help to meet demand for digital hearing aids. The fundamental problem in the current supply process is human resources. There is a national shortage of audiologists. The Department of Health through its Modernising Audiology Workforce Education and Training (MAWFET) group continues to investigate this issue. The recently introduced Audiology degree courses at Higher Education Institutes will make a contribution but only in the long-term and on such a scale that will not solve the problem. Indeed, none of the staff models produced have forecast anything other than future shortage.

35. However, additional NHS audiologists are not the only solution to boosting capacity. The provision of hearing care is not limited to the fitting of hearing aids and requires skills beyond the strictly technical. There is a need for a massive influx of trained dispensers so audiologists can focus on acute cases.

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

36. There are approximately 1,400 Registered Hearing Aid Dispensers (RHADs) who are qualified and registered under the Hearing Aid Council (HAC) 1968. They are bound by the HAC Code of Practice, which requires that they maintain a high standard of ethical conduct in the operation of their practice. They deliver a quality assured service to hundreds of thousands of hearing impaired clients each year. This resource offers potential for contributing to the solution of the capacity problem.

37. There has been a reluctance to accept Independent Sector help in reducing audiology waiting lists. The PPP was a small step in this direction, but it only offered limited scope for Independent Sector involvement; only two companies were involved in service provision.

38. It is now accepted that additional independent sector capacity will be needed in the foreseeable future (It is estimated that the delivery of the 300,000 new patient pathways alone will require about a third of the annual capacity of the sector). However, lack of ring-fencing is fuelling fears among NHS audiology staff of "creeping privatisation" through erosion of their funding, at a time when public and private sectors need to work even more closely together if waiting times are to be reduced. The Department of Health will need to decide how this sensitive balance between the two sectors can be achieved.

39. The Independent Sector could assist with the current situation in two ways. Firstly, it can help reduce the number of onward referrals to NHS audiology departments by providing a hearing assessment filtering service in a primary care or community setting. Secondly, it can prescribe and fit hearing aids to the same high standard as NHS audiologists and provide an ongoing aftercare service. Such models are already successfully employed in other EU countries.

40. Hidden Hearing provides a free on-site hearing assessment service in over 60 GP surgeries across England. The service has been shown to reduce referrals to local NHS audiology departments by around 40%.[39]

41. GP practices participating in the scheme receive a regular monthly visit from a RHAD who carries out a hearing assessment of patients who have been referred to the service by their GP. Following the assessment, patients are referred back to the GP who recommends appropriate action.

42. In some cases patients do not require a hearing aid and will benefit from simpler treatment by the GP. The remainder are referred on to the NHS audiology department for a hearing aid or more complex treatment. Some of these may, in the interim, decide to purchase an aid from the independent sector at their own expense.

43. The service benefits all patients by reducing their waiting time for a hearing test and ensuring that they receive the correct treatment as soon as possible. The patient is treated promptly in the community, the service is free at the point of need, and the care is overseen by the GP.

44. The NHS also benefits. Pressure is taken off the GP and the resources of audiology departments are used more efficiently as patients are pre-assessed rather than being referred automatically. Two case studies are attached as appendices to illustrate the success of this service. [40]

45. The Independent Sector can also assist in reducing the delays between the referral from a GP, assessment by an audiologist and final fitting of the hearing aid. It can provide initial assessments, prescribing and fitting and aftercare services in a range of settings including high street branches, GP surgeries or people's homes as well as in ENT or audiology units.

46. Independent companies can help make audiology services more accessible to patients since they are community based. Patients can have greater choice as to where they can access digital aids. The advantages could be significant. Patients requesting a hearing aid assessment in the high street are seen immediately. Patients referred to an independent sector clinic by a GP on average are seen within two weeks of requesting a hearing test. This compares to waiting times for an NHS ENT department assessment of up to 26 months. [41]Furthermore, the commitment of the independent sector to aftercare is open-ended whereas the patient journey in the NHS is limited.

47. The re-introduction of reference costs for digital hearing aids and the development of a national tariff would provide an incentive for Primary Care Trusts and Practice based Commissioners to commission audiology services from the Independent Sector to help tackle lengthy waiting times and meet the 13 week target.

48. The longer term solution needs to be a coming together of state and Independent Sector provision to provide the skills and capacity necessary to provide a first class audiology service. This in turn requires a fusion of professional standards and training.

49. The independent sector also has ongoing difficulty in filling vacancies. Common factors affecting both sectors are lack of awareness and recognition of the audiology profession.

50. What is needed is an audiology profession of sufficient size to satisfy future demand for hearing services. Encouragement needs to be given for large numbers to enter the profession, which in turn will give education providers the confidence to create the requisite facilities. Once this is achieved, a virtuous circle will be created.

51. The optical profession is a model worth examining. State support of those requiring assistance with their sight has fostered a large-scale profession. Government policy may change but in essence its support for the individual encourages them to seek eye-care from a suitably qualified provider of their choice. This in turn encourages people to enter the profession and stimulates constant demand for training places.

52. It would be worth examining how the optical model could be adapted to hearing care to benefit the patient and provide for a long-term sustainable service.

53. The Department of Health published its review of General Ophthalmic Services on 17 January 2007. [42]The Department concluded that the system of optical vouchers works well in terms of providing "far greater choice for patients, encouraging competition between providers and promoting high standards of quality and efficiency."

54. We believe this blueprint is wholly compatible with the Government's aim for improved delivery of audiology services. Furthermore it adheres to the principle that "patients should have the right to choose from any health care provider which meets the Healthcare Commission's standards and can provide the care within the price the NHS will pay." We should be happy to elaborate our thoughts on how this principle could be applied to audiology so as to secure the future of state funded hearing care in the UK.

CONCLUSION

55. It is becoming increasingly self-evident that because of raised expectations, demand on existing NHS audiology services for the new digital hearing aids far outstrips capacity, resulting in longer waiting lists and increased waiting times.

56. A hearing care service that is inherently inaccessible is unacceptable. New and innovative solutions are needed to ensure that the funds already invested in modernisation deliver a service of acceptable `quality' in every sense.

57. As developments have shown, it is now accepted by Government that the independent sector has to be part of the solution to the problem of providing sufficient capacity to reduce waiting times for digital hearing aids. So far, however, little effective action has been taken to ensure that the financial resources are available to make this happen. Creating extra patient pathways without ring-fenced funding will have little effect on PCTs whose budgets are already strained to the limit.

58. There needs to be much closer cooperation between NHS and independent sector providers if the capacity shortages in audiology are to be permanently addressed. To date Department of Health terminology has always indicated that the use of the independent sector for audiology is a short term expedient only. The Department needs to acknowledge the fundamental difference between costing the use of available existing capacity and the provision of additional capacity and fully engage with the independent sector in meeting the demand placed upon it for high quality and accessible hearing health care. Only a long-term relationship will create the climate of re-investment required to encourage the ongoing training and resource allocation needed to achieve a lasting solution. This will require attitudinal as well as operational change and the Government will need to take the lead in breaking down the barriers between the two sectors.

59. An ageing population, greater awareness of the benefits of new technology digital hearing aids, coupled with chronic under-funding and under capacity in the audiology service mean that this is not an issue that can be solved with short-term "surges". The whole of the resources available—both the NHS and independent—must be employed in harness if we are to raise the audiology service from its current "Cinderella" status.

60. Hidden Hearing has been following the issue very closely and contributing to the policy debate. We should be delighted to help the Committee further in its inquiry by providing further information and giving evidence as the Committee sees fit.

61. Hidden Hearing provides a free on-site hearing assessment service in over 60 GP surgeries across England. The service has successfully reduced onward referrals to local audiology departments by up to 40%, reducing pressure on waiting lists and putting patients' minds at rest.

62. The Twyford Surgery, which is the focus of the case study attached as Appendix 1, [43]has been running the service for almost four years. Hidden Hearing is also working with the Whitstable Medical Centre. The practice has used the audiology hearing test service to make financial savings through Practice based Commissioning. The Improvement Foundation cites the case study within its publication High Impact Changes for Practice Teams, as an example of how to provide services closer to patients. This is attached as Appendix 2. [44]

Alan Rudge

Director, Hidden Hearing

7 February 2007

20 RNID Fact sheet: Facts and Figures on Deafness and Tinnitus: Accessed 1 February 2007. Back

21 RNID Fact sheet: Facts and Figures on Deafness and Tinnitus: Accessed 1 February 2007. Back

22 A Sure Start to Later Life, Social Exclusion Unit report, 26 January 2006. Back

23 Ibid, page 51. Back

24 Written Statement, Health Minister Ivan Lewes MP, 18 July 2006. Back

25 British Society of Hearing Aid Audiologists Survey, October 2006. Back

26 Commissioner based monthly Diagnostics-Diagnostic Return, Department of Health, 12 July 2006. Back

27 Ivan Lewis MP, Health Minister, Hansard Column 136, 18 July 2006. Back

28 Diagnostic Waiting Times, Department of Health Statistical Press Notice, 13 December 2006. Back