Examination of Witnesses (Questions 40-59)
DR JOHN
LOW, MRS
RUTH THOMSEN
AND MR
JEFFREY MURPHY
8 MARCH 2007
Q40 Sandra Gidley: Are you saying
that every time somebody has a hearing aid fitted privately they
are getting £800 worth of service?
Mr Murphy: It depends. There are
prices from £500 up to £1,500. The average price is
£1,000.
Q41 Sandra Gidley: I think I know
what I will do if I lose my seat at the next election!
Mr Murphy: The real comparison
is the retail price with the wholesale price, so it is not £70
to £1,000; it is £70 to £280. The commercial price
that retail companies are paying is well in excess of the NHS's
price.
Dr Low: The NHS is the biggest
single purchaser of hearing aids in the world and is therefore
able to command extremely competitive prices.
Q42 Dr Taylor: Do these marvellous
devices mean that people actually wear them? With the old ones,
you had people continually fiddling to get rid of the noises and
then they threw them out. Do they wear them?
Mrs Thomsen: The patients obviously
used to fiddle a lot. The digital hearing aids have very clever
technology. It is like a whole computer inside a small hearing
aid. The majority of the digital aids available on the NHS have
no volume control: they automatically adjust according to the
environment. Some patients do need a volume control because their
hearing fluctuates but the majority of the hearing aids have various
programmes for certain listening environments and they adjust
automatically. No matter what hearing aid you fit to a patient,
you will not give them back the hearing they were born with. You
have to look at the whole needs of the patient. You cannot just
put something in an ear and say, "Okay, off you go."
You need to look at their communication needs and support it with
rehabilitation, explaining expectations, talking about adaptation
time for getting used to the hearing aid. You also need to follow
them up, to make sure it has been fine tuned appropriately. There
is an infinite number of settings on these digital hearing aids
and you need to have a good working knowledge of the software
you use to programme them in order to utilise the best to match
each patient's needs. One hearing loss can look identical to another,
but the patient's perceptions and needs can be very different
and you need to tailor make for that. You need to look at supporting
them in their environment as well, connecting with social services
for things like doorbells, television aids and things like this,
and also looking at the social aspects. Obviously a lot of people
come because they have become very isolated and you need to try
to encourage these patients back into the world, to get them back
out there hearing and listening and having the confidence to start
living their lives again.
Q43 Dr Taylor: So they do wear them
all the time because they are so very good.
Mrs Thomsen: No. I sometimes say
they are a bit like shoes: it is quite nice to take them off when
you get home. If you have something in your ears all the time,
it is quite nice sometimes just to take them out and give yourself
a little rest. If a patient is sitting reading and they do not
need to be listening for doorbells or telephones, then they have
the advantage and they can have that lovely, quiet, peaceful time
to read. Some people still feel the stigma. They are still embarrassed.
There is still that area of "I don't want people to know."
I have to say, however, that over the last five to seven years
that is really, really reducing. That is not now, like it used
to be, a huge hurdle to get over, with the help of the companies
developing different colours, making them look more like mobile
phones, and the fact that the word "digital" is in there
seems to help a lot as well. When they see the knowledge and skills
needed to fit it with the software, they realise and take it on
board and do try. MHAS, when they rolled out the digital service,
talked about this as well. It was not just about the product and
what you were fitting; it was looking at the whole patient and
making sure you met their communication needs.
Dr Low: Some of the modern hearing
aids that the NHS are fitting have data loggers built in, so you
can tell how much the person is using it and at what kind of setting.
Q44 Mr Penning: Big Brother.
Mrs Thomsen: It is, yes.
Q45 Dr Naysmith: I would like to
ask Mr Murphy a few questions about the public/private partnership.
I know his company is involved with it. Do you think it has been
a success?
Mr Murphy: We think so. The positive
from the whole thing is that it was a good motivation for our
staff. I think we broke down some of the barriers between the
independent sector and the public service. Our skill levels increased.
We learned a lot from procedures that we had to perform. We processed
through our branches nearly 40,000 patients, who got a flexible
high street service. The report from the MRC, Professor Davies,
was very positive. We were measured as having better outcomes
than the NHS were supplying at that time and, also, we had a better
service to the client on the high street, in convenient areas.
We learned a number of lessons that we have now put into commercial
practice, so it was worthwhile from that point of view. We measure
outcomes better and we had an experience with some geographical
locations. There were some lessons to be learned. We made a major
investment in software. The hospitals have two operational systems
to deal with patients. That was a challenge for us. One of the
software systems did not have an import/export system to remove
patients' names and we had to invest a large amount of capital
in that. We invested in branches and staff and, because of the
size of the contract and the length of the contract, we probably
never got that investment back. From our point of view, in all,
60,000 patients went through the service, we dispensed on time
the correct instrument and had a very good outcome from it. I
think it was a major success.
Q46 Dr Naysmith: Why is it that quite
a lot of the evidence we got in was quite critical of the public/private
partnership? Perhaps I could put to you some of the things that
were said. "It cost more than National Health Services."
"Half the patients treated by private providers ended up
seeking further rehabilitation from the National Health Service."
"Some people were paid for work that was not done."
What do you say about these criticisms?
Mr Murphy: The only evidence I
have seen is the report done by the MRC. There are anecdotal comments—and
I have seen some of the evidence—that we did not experience.
We had a very tough contract. There were compliance levels that
were higher than some of the hospital levels and we complied with
those compliance levels. We complied with the service times, we
delivered our contract on time.
Q47 Dr Naysmith: Are you suggesting
that it was some other company? Because it was not just one firm
that was involved.
Mr Murphy: No, the other company
that took part had a similar experience. There were some peripheral
contracts around the PPP in which we did not participate, so it
may be they are referring to that. Officially, from reports and
feedback from the RNID who managed the project, from APASA who
awarded the contract, from the MRC who did the research I have
not had those comments in the PPP. As I say, there were other
contracts that were done independently by hospitals and they may
come from that.
Q48 Dr Naysmith: That will be published
when our written evidence is published but it is already available
now, I should think.
Mr Murphy: I have seen some of
it.
Q49 Dr Naysmith: The Academy of Audiology
was one of the bodies.
Mr Murphy: I have not seen their
evidence. Charing Cross talked about PPPs being done in hospitals.
In the contract, we could not go into the hospital. On the PPP
the specific contract was outside of the hospital in the high
street, we did not work in the hospital, we did not work with
hospital staff, so some of the evidence that I have seen does
not refer to the PPP. I think it refers to the contracts that
were outside—and there were a number of them—where
hospitals contracted separately with independent audiologists.
That might be the reports from there. Certainly the evidence in
the PPP does not show that. I can only comment on the PPP because
we did not participate outside.
Q50 Dr Naysmith: The costs of the
PPP activity exceeded the marginal costs of treating the patients
in the NHS by at least a factor of two. You can draw the conclusion
that the programme should be considered as a temporary stop-gap
and then return to the NHS. Is that an unfair statement?
Mr Murphy: I think it is unfair.
The evidence does not show that. John may make a comment.
Q51 Dr Naysmith: I am going to ask
Dr Low in a minute.
Mr Murphy: I cannot comment. All
I have seen is that there was a document that showed the estimated
cost of providing the service in ENT. It had three procedures
and hearing aids which came to a sum that was greater than the
cost of the PPP. I do not believe the PPP was at any other cost
than a cost-saving to the hospital.
Q52 Dr Naysmith: Dr Low, would you
like to comment on these matters?
Dr Low: Yes. There has long been
animosity between audiologists in the NHS and people who fit hearing
aids privately.
Q53 Dr Naysmith: I will ask the NHS
audiologist in a minute!
Dr Low: Yes, I am sure. As you
will have seen from the evidence from the Hearing Aid Council,
the current regulation of the profession of audiologists is "not
fit for purpose". That is their expression and I am not sure
I would go quite so far. It is an entirely different training
route for the two. When this contract with the independent sector
was put in place, the regulator of the independent sector would
not regulate their activities while providing NHS services. Therefore,
the clinical governance, the responsibility, had to be taken by
the head of audiology in each hospital. Some of them did it very
well; some of them did it less well. It is very difficult for
an NHS head of audiology to manage a private sector contract.
It is very important that these large-scale contracts have the
appropriate clinical governance and have the appropriate quality
systems. But there is no doubt that the MRC's measurements showed
that the private sector was capable of fitting routine cases—not
the specialist difficult cases but routine cases—to a standard
which at least matched that of the NHS. The cost of those contracts
is very similar to the proposed tariffs inside the NHS for a similar
activity and the volumes were relatively low. I believe that if
the volumes were higher, an even better commercial arrangement
would be entered into. I do not think there is a huge difference
between the private sector and the NHS delivering in an acute
care setting.
Q54 Dr Naysmith: Ruth, do you have
any experience of managing a private contract?
Mrs Thomsen: Yes. We had PPP come
into Charing Cross. Like John said, we are very good at looking
for money, finding it and implementing it, and they offered us
some services through PPP. We had reservations but we had a waiting
list and we had patients who wanted a hearing aid fitting as soon
as possible. We chose a company where we felt confident because
the trainer within that company was NHS trained. It was a stick-to-your-own
feeling. Our PPP was fine. We had issues about data collection.
We still have issues about data collection. We have not had the
facts and figures through from the company yet.
Q55 Dr Naysmith: Do you mean there
were not proper records kept.
Mrs Thomsen: No. They kept them
but to make it compatible with our service, we just have not had
them yet. They have been sent; they were incompatible. It is a
logistical issue. Historically, I think there has been a problem
of them and us between the dispensers and the NHS audiologists.
I have worked on both sides of the fence—not in dispensing
instruments but in manufacturing, so I have produced instruments
for the private market as well. I think the private market has
a role to play. We welcomed PPP when it came because it really
filled a stop-gap of doing those waiting lists. My main concern
with the Hearing Aid Council and the fact that that is changing
over—and I welcome that and I welcome that they are looking
at proper state registration for hearing aid dispensers. It is
the maverick side of it I have real concerns with. That in terms
of, probably every week, maybe every fortnight, because I see
patients every day, I listen to another sob story of some kind.
Q56 Dr Naysmith: What can we do about
it?
Mrs Thomsen: The Hearing Aid Council
and dispensers are getting their shop in order. They are looking
at a foundation degree, they are looking at a uniform qualification,
where people can then become state registered and the boundaries
will break down between the NHS and the dispenser. There will
be a proper qualification in place that will be recognised, and
we can work with that and go forward, but that will not be in
place until later. They are looking for bids for foundation degrees
now, so the foundation degrees will not start until September
2007. The foundation degree is a two-year degree, an "earn
and learn degree" as they call it, where they are part-time,
so they will be working under someone else but they will not be
qualified for two years. It says here that in 2008 they will be
coming. It will be 2009 when they are fully qualified. They will
be in the workplace, working under supervision. One of the main
concerns I have is that the supervision is at the end of the phone
sometimes. That is a real concern for me.
Q57 Dr Naysmith: Do you want the
last word, Mr Murphy?
Mr Murphy: Yes. I think what you
are asking for can probably be done by contract. The compliance
levels can be put in the contract, as it was with the PPP. I do
not share Ruth's opinion of what happened. We did not do a PPP
at Charing Cross. I would be interested to find out who did it,
but we did not have that experience. We believe that within the
contract of the current PPP there is enough regulation and compliance
levels and targets for the NHS to get the service up they are
paying for. I think we have delivered it.
Q58 Chairman: With referrals to PPPs,
you normally refer on to the independent sector. Is that normally
done on the basis of the need of the patient? Obviously a medical
intervention would be in the hospital. Are there different levels
of referral? We had this debate last year, when we looked at the
Independent Sector Treatment Centres, as to whether they get all
the cherry picking.
Mrs Thomsen: There were very strict
criteria. It was the basic, direct referrals or the patients who
had been through the system already—because, as you can
imagine, every patient who had a hearing aid needed changing over.
A patient is a patient for life. We had their medical records,
their details, and if we knew it was a basic hearing loss due
to the ageing process then that would be generally quite straightforward
patient so they could test, fit, follow-up. If we had good GP
letters which gave us the proper details of the patient, we could
see no other underlying causes and they had followed our protocols
that had been sent out for referral, then we could triage those
letters and obviously put some new patients their way as well.
I would just like to say that I think it was unfair for PPPs in
a way because they were in short bursts. I think the contracting
is great, and if you have really stringent rules and regulations
when you put into place these contracts, that is great, but if
there are problems you need to give them time to be ironed out.
The PPP came and went when the ring-fenced money went and the
RNID stopped it. A lot of the anecdotal evidence I have gathered
on PPP—which is not great because people will always moan
rather than tell you the good stories—is stuff that could
possibly have been sorted out, but then the PPP contract was finished,
and you did not have time to put those checks and measures in
place and address the quality issues that you did not get when
you were running those contracts.
Q59 Chairman: The referral was your
referral, as opposed to the choice of the provider.
Mr Murphy: Yes. The referral came
from the hospitals. They decided who would be referred and they
referred through to us. Also, when the ring-fencing went and the
money was not available, the majority of hospitals continued to
use our service and gave it additional contracts, so that, from
the commercial point of view, proved that we were doing a good
job. As I say, the majority of hospitals carried on and found
the money from other sources, so they were motivated to find the
money from another source to carry out a contract that would reduce
their waiting lists.
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