Examination of Witnesses (Questions 1-19)
DR JOHN
LOW, MRS
RUTH THOMSEN
AND MR
JEFFREY MURPHY
8 MARCH 2007
Q1 Chairman: Good morning. May I welcome
you to this inquiry into audiology services in England. Could
I ask you to introduce yourselves for the record, please.
Mrs Thomsen: I am Ruth Thomsen.
I am an audiologist at Charing Cross Hospital in London.
Dr Low: I am John Low. I am the
Chief Executive of RNID, the national charity representing deaf
and hard of hearing people.
Mr Murphy: I am Jeff Murphy, I
am the Chief Executive of Ultravox Holdings Ltd.
Q2 Chairman: Welcome and thank you
very much for coming along. Sheer coincidence gave us the publication
earlier this week of the Improving Access to Audiology Services
in England by the Department. I wonder if I could ask you
all as a general question (a) if you would like to comment on
it and (b) if you have learned anything new since its publication.
Mrs Thomsen: It obviously was
very timely and did not give us a lot of time to glean information
from the report. I have to say the first three words really made
by heart sink. This new condition that has been invented, "hardness
of hearing", did reflect "Oh, gosh, an audiologist has
not read this" because it is not a condition. There is not
a huge amount of new stuff in there, in terms of what we are doing
at Charing Cross. We share information with other audiology departments
and we have worked hard to implement ways in which we can reduce
our waiting lists. If we look at the back of the document, where
the key outputs are, I went through them and tried to decide which
ones we are already doing, even though the timeline for these
is further on in 2007 and 2008. At Charing Cross we are using
Choose and Book already; we triage our patients; we monitor our
patients using tools implemented by the Modernised Hearing Aid
Service and we follow very carefully defined protocols, both those
sent down from the Institute of Hearing Research and those we
have designed for Choose and Book, which have to be very stringent
and passed down to educate our GPs; we implement open fits; and
we use flexible working. There are a few areas that we could welcome,
I think, in terms of more information for patients, like they
suggest on the Healthy Choices website, and a more cohesive
information gathering system that looks at how long it takes to
get a hearing aid and not just the diagnostic area of audiology.
Dr Low: I think that strategically
this action plan is a sop, following the exclusion of audiology
services from the 18-week target last May, when that framework
was published. Audiology should have been inside the 18-week target
and it was deliberately excluded. At the time they promised an
action plan and it has taken some months but finally it has arrived.
I believe the estimates of the waits inside the NHS are probably
at the bottom end of the range. The need for an additional 300,000
patient journeys would be the minimum figure we could calculate:
we think there are probably half a million people waiting for
a hearing aid in the NHS right now. The reason we do not know,
of course, is that neither the Department of Health nor the NHS
collects waiting-time figures. There has been an initiative recently
to collect the time between GP referral and having a hearing test
but of course the longer wait is from the hearing test to having
the hearing aid fitted. We are having to use proxies: a mystery
shopping exercise by the private sector trade body. One of the
MPs, the Member for Welwyn Hatfield, did a freedom of information
survey and he came up with other figures. We reckon that approximately
40 to 45 weeks is the average waiting time for someone getting
a hearing aid for the first time and 65 weeks is typical for someone
being reassessed across the NHS. Charing Cross is a fabulous hospital.
It is among the elite. The only way this action plan will deliver
is if everything in it is made to happen. The largest single effect
in the proposals within the plan is the procurement of additional
capacity from the private sector. If we are to reduce the waiting
times by December 2008, as proposed in this plan, we will require
hundreds of thousands of additional patient journeys from somewhere.
They are saying 300,000 in the plan; I would suggest the figure
is perhaps bigger than that. Without a substantial procurement
from the independent sector, I cannot see how the NHS can deliver.
There are efficiency gains, there are some technology improvements,
certainly, but we know that, even if you take all the changes
that can be squeezed, they will deliver only a small proportion
of what is required. The key message is that we must do what Lord
Warner announced in the House of Lords in July last year, which
is to purchase 300,000 patient journeys per year ongoing for the
independent sector.
Q3 Chairman: Jeffrey, do you have
any views on this week's publication?
Mr Murphy: Yes. We welcome the
report. I do not think you could disagree with the aspirations
of the report. It will bring a more flexible and better service
for the NHS. I think the report does identify some problems and
I suggest it probably needs another layer to bottom out and explore
some of the practicalities and ways of solving them. Modernisation
is necessary. In our opinion technology does not usually solve
logistic problems, so I think there will always be a capacity
issue. We welcome the report's willingness to work with the private
sector and we believe that we have the capacity to respond to
the Government's requirements.
Chairman: We are going to move on to
a few questions about waiting times.
Q4 Mr Amess: First of all, the three
of you should sit back and enjoy this session. It is those who
will be coming before us in the second session who want to be
a little bit more anxious, but this is your opportunity to get
it all off your chest and give you some therapy. As the Chairman
has said, I am going to ask you some questions about waiting times,
but, on a serious note, it is not very clever, is it, or very
subtle that the Department bursts into life because we are having
an inquiry this week? This is not a new subject and it is not
very funny if you cannot hear properly and something can be done
about it. I would imagine from your points of view that it is
great that we are now having the inquiry and it is great that
something is being done but it is taking the mickey really. It
was announced on Tuesday and we are here Thursday, so that cannot
really inspire you with enormous confidence, can it?
Dr Low: My response to that is
that in May last year, when the 18-week framework was published
for the whole of the NHS, there was a promised action plan in
that document. We would have wished that it had been earlier than
this and I am grateful for this Committee being an incentive to
getting it published. If that is what it takes, I am grateful
for small mercies.
Q5 Mr Amess: I congratulate one of
my colleagues. It also is not very clever, is it, that my colleague
Grant Shapps had to use the Freedom of Information Act to reveal
that, for instance, in Bromley the process takes 112 weeks, in
Plymouth 108 weeks, in mid-Staffordshire, 104 weeks, and for Western
Area Hospital and East Hospitals it was 100 weeks. That is not
very good, is it?
Dr Low: It is not good at all.
If you cannot hear well, you are isolated from you family, you
are not able to function well at work, we know your physical health
deteriorates. Two years is unnecessary for a low-cost intervention.
If the resources are made available within the system, these can
be fitted within days. They do not have to take several years.
People are struggling with either no hearing aid at all or an
inappropriate hearing aid for far too long.
Q6 Mr Amess: The three of you understand
and the framework confirms that audiology will remain outside
the 18-week target period. Do you think the target should apply?
Can you tell the Committee why?
Dr Low: Yes, is the simple answer,
because it is an important intervention. Not only is it important
for the quality of life for huge numbers of people at very low
cost to the NHS, but also the failure to do so has the effect
of upward substitution of costs in the form of poor health, inability
to live independently and ultimately pushing bigger costs onto
the public purse rather than just dealing with this intervention
at the right point in time.
Q7 Mr Amess: And your two colleagues
agree.
Mrs Thomsen: Yes. There is a small
loophole, I think, in the document, where it says that if you
are referred to ENT then you come within the 18-week process for
treatment by December 2008. If a GP refers a patient who needs
a hearing aid and that is all they need, a hearing test and a
hearing aid fitting, they will have the speedier service if they
go through the middleman, the ENT surgeon, who can perform nothing
but then refer them on to us for a hearing aid fitting, clogging
up unnecessarily clinical time in ENT outpatients. A clever GP,
I am sure, would be able to work out that he is going to get his
patients through the system much more quickly if they refer to
an ENT surgeon, leaving in the middleman, so to speak, and then
they will come under the conditions of getting within the 18-week
period. If you refer directly to an audiologist, where we are
able to perform the hearing test and assessments, move the patients
into ENT if they need to see them, and then fit a hearing aid,
it is not a statutory condition that they are seen within the
18 weeks. They have written a loophole in here, which, if it gets
abused, will see huge waits and bottlenecks elsewhere along the
system.
Mr Murphy: My opinion is that
the 18-week waiting list target is a must. We see 30,000 patients
a year of an average age of 68 to 70, and for people of that age,
with a life expectancy of whatever it is, to wait two years is
not on, not acceptable and we should do something about it immediately.
Q8 Mr Amess: It is a standing joke
that as Members of Parliament it would be often a relief if we
could not hear what each other was saying, but for the rest of
the public it is pretty distressing. Why do the three of you think
audiology is such a low priority?
Mrs Thomsen: I think we were not
a low priority when the RNID were rolling out MHAS. We were a
Cinderella service and very low priority for a long time when
we were fitting analogue aids. I have been working in the NHS
since 1984 and I was changing people over from body-worn hearing
aids to behind-the-ear hearing aids and working that backlog out
many years ago, so I have seen it come a few times. It was absolutely
amazingly fantastic to have the recognition that was brought down
from the RNID and the investment in our services. Five years ago
we had one PC in our department. When the IT guys came up when
we started to revolutionise, they really could not believe that
these sorts of computers were still around. We have been completely
modernised. The investment coming via the RNID from the Government
has been phenomenal. We have been well educated, well trained
and at last we have been able to take the ball and run with it.
So we have not been neglected for a long time; it was when the
ring-fenced money was removed and the backlog still had not been
addressed that the waits started to grow. The money went elsewhere.
The majority of the time, it is not life-threatening. The majority
of patients I see are elderly. It is a patient group which often
have other health problems which will take priority. If they were
included in the 18-week wait, we certainly would have had better
funding. All departments in the UK saw a drop in interest the
minute the ring-fenced money went.
Q9 Mr Amess: You have been in it
since 1984. You are very, very pleased with what is happening,
but you now think the problem is down to what is happening generally
in the National Health Service and money.
Mrs Thomsen: Prioritising.
Q10 Mr Amess: Do you both agree?
Dr Low: We used the Freedom of
Information Act last year to find out what the budgets were. We
asked commissioners: How much are you spending? The vast majority
of them could not tell us how much they were spending on audiology
because it was just lumped inside a big pot of other funding,
that was going, if you were lucky, into ENT, but it might be going
into a bigger pot still. There was no priority. The waiting times
are still not collected between having a hearing test and getting
a hearing aid, so it is not a priority. It is a very low level
activity as far as the trust management is concerned and the commissioners.
It is simply neglected. Through the modernisation process, the
NHS is fitting high-quality hearing aids and fitting them to a
very high standard. Patients are getting a good result, they are
just waiting a very long time for them. The reason is that this
is not given any priority or attention within the management of
the NHS.
Q11 Dr Naysmith: Why was the ring-fencing
removed?
Dr Low: We campaigned in 1999
and 2000 for modernisation. Through that process we were able
to secure a lump of money. It was £125 million in total.
That was spent between 2000 and 2005 to modernise the service.
It was not an initiative to tackle the inherent backlog. When
the modernisation was finished, then the funding was put back
for general allocations.
Q12 Dr Naysmith: That is where the
upgrading of your equipment and so on came from.
Mrs Thomsen: Absolutely.
Q13 Dr Naysmith: But it was not meant
for putting more patients through.
Dr Low: That is correct.
Q14 Chairman: Ruth, you mentioned
that the majority of your patients are elderly but what about
school-age patients. What is the position at your place? Do you
have a national view of what is happening?
Mrs Thomsen: I cannot comment
on the national view. I know you have had evidence from the NDCS.
In Charing Cross we are lucky, we do adults and paediatrics. Children
take priority everywhere, because they are in education, they
need to learn. With the introduction of the neonatal screening
programme, we are fitting hearing instruments on very tiny little
babies. Their care is very intensive: you need to see them every
few weeks, because they are growing and their ears are changing,
to fit the shape of their ears. They always come first. As far
as we are concerned at Charing Cross, no child should wait. They
are fitted with top range hearing aids as well. We really achieve
to give the child every opportunity. Certainly at Charing Cross
it is not an issue with waiting with children.
Q15 Chairman: We hear these stories
of waiting times up and down the country, some of them quite horrific.
Are children likely to be caught into this situation where they
are waiting months if not years?
Mrs Thomsen: I cannot comment
on up and down the country but I certainly think there are dedicated
paediatric audiology services up and down the country where the
teams work incredibly hard. I have not heard of children having
to wait for hearing aids. It would be a very sad day if that happened.
Dr Low: It is not perfect but
it is very, very much better than the adult services. It does
get priority. They have been modernised. They have the highest
quality equipment and hearing aids and generally children are
seen as a priority very quickly.
Q16 Sandra Gidley: I would like to
disagree with you because I was lobbied last night by an MP whose
child had had to wait three years for a hearing aid—and
I can see nodding behind you—because there was simply no
prioritisation in the trust where he lived.
Dr Low: I did say it was not prefect.
That, mercifully, is the exception rather than the rule. There
are areas where there are major concerns.
Q17 Sandra Gidley: How big an exception
is it? Or do you not feel qualified to answer that?
Dr Low: I do not have figures
in front of me but I would suggest that it is a small minority
of places that have that kind of problem.
Q18 Chairman: It is not measured
and we do not know, basically. I think that is what we would have
to say.
Dr Low: Correct.
Q19 Dr Stoate: I am a GP and I know
exactly how to abuse the system to get the best out of it, so
it is not news to me that you refer straight to ENT consultants
to short-circuit some of the excessive waits. Listening to you
about how things are at Charing Cross Hospital, it all sounds
pretty wonderful. You have had lots of new investment, new equipment,
new computers, everything is modernised, you are doing one-stop
shop in some cases, you are doing Choose and Book. Are you exceptional
or is this happening elsewhere?
Mrs Thomsen: The Choose and Book
came upon us. It was not something we implemented; we were told
to implement it. I think we play an active role in linking in
with other audiology departments up and down the country, looking
at best practice, the sharing of information and with Internet
and email, with the British Academy of Audiology working groups
and regional groups. We share information. We are constantly looking
and actively seeking how to bring down our waiting lists and treat
the patients in the best way we can.
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