Health and Care Bill

Written evidence submitted by the Royal National Institute for Deaf People (RNID) (HCB27)

Written Evidence to the House of Commons Public Bill Committee on the Health and Care Bill 2021-22

About Us

RNID is the charity making life fully inclusive for deaf people and those with hearing loss or tinnitus. We fund research to find a cure for hearing loss – driving the development of new technology; campaign to change public perception and policy for deaf people and those with hearing loss or tinnitus; and provide practical information and support.

Up until November 2020 we were known as Action on Hearing Loss, our engagement with individual members of this Committee will have taken place under that name.

Summary

In this submission we have made comments on two very narrow issues within the Bill; the need for the Secretary of State to make directions to enforce the implementation of NICE guidance, and the absence of measures around the development of technology within the NHS.

Implementation of NICE Guidance and CCG and ICB accountability – Clause 37

For several years, we have been concerned about the lack of accountability that exists for CCGs when they are making commissioning decisions, including decisions that directly and blatantly contradict NICE guidance.

On two occasions NICE have issued guidelines which have been ignored by a number of CCGs. This is on the provision of hearing aids for patients with mild and moderate hearing loss [1] and the provision of ear wax removal services [2] . Further details on the way in which these pieces of guidance are being ignored, and the detriment to patients, can be found on our website. [3]

We believe that the decision to ration hearing aids by North Staffordshire CCG is a particularly pertinent example of the lack of accountability for CCGs within the NHS. North Staffordshire took a decision in 2014 to remove hearing aids from those with a mild hearing loss and impose restrictions for those with a moderate hearing loss – mild and moderate are clinical terms which do not describe the impact on the patient, at the time there was no relevant NICE guidance. Since then NICE has published guidance on the treatment on hearing loss in adults, which clearly set out that hearing aids should be provided for patients with mild and moderate hearing loss who would benefit from them.

The ongoing rationing of hearing aids is a clear breach of the NICE Guidance. It has also been opposed by the local authority which has responsibility for scrutiny of the CCG and been shown not to meet local need on the basis on local consultations. The CCG recently responded to this scrutiny by reinstating the provision of hearing aids for patients for moderate hearing loss (although that will be little consolation to patients denied access for five years) but retains the policy of not providing them for patients with a mild loss.

We believe that the ability for CCGs to ignore NICE Guidance with impunity is a weakness in the current legal framework of NHS provision.

Therefore, whilst we welcome the clarity that the Secretary of State can issue directions where there is a breach of NICE guidelines we would like to see the Bill go further. We would like to see the Bill amended so that the Secretary of State shall issue directions where there is evidence services are being provided, or not provided, in a way which contradicts the relevant NICE guidance.

We will like to see the Committee bring forward an amendment to amend Clause 37, (13ZD)(3) to say:

"A direction under section 13ZC shall be given in relation to the provision of any drug, medicine or other treatment, or the use of any diagnostic technique, where the Secretary of State is satisfied that NICE has made a recommendation or issued guidance as to its clinical and cost effectiveness and services are not being provided in accordance with that recommendation or guidance."

We believe that such a measure would empower and even compel the Secretary of State to intervene where there is clear evidence that NHS England or local commissioning are breaching NICE guidance and not providing patients with the services they are entitled to. This will not only provide patients with short-term benefit, but long-term it will ensure that commissioners aren’t taking short-term decisions which stores-up long-term problems and increased demand on future health and social care services.

We hope that the Committee will consider the above amendment as a means of ensuring that NICE Guidance is implemented across the NHS.

New Technology – Absence from the Bill

In the Queen’s Speech the Government implied that the focus and rationale behind this Bill was about allowing the NHS to embrace new technology and innovations to improve the delivery of front-line treatments and services to patients. [4] This is something that we welcome and believe that there is a huge scope for utilising new technology across the audiology pathway.

NHS audiology is in a unique position to adopt existing technology as a means of improving patient choice and service efficiency. As well as video conferencing software to deliver certain appointments remotely, increasing numbers of NHS hearing aids have the capability to connect remotely with an audiologist allowing them to make adjustments without the patient being present. Many NHS hearing aids can also be adjusted by the patient themselves via an app on a smartphone, meaning they have more choice and potentially more engagement in management of their hearing loss.

Despite this technology being available prior to the Covid-19 pandemic, it was not widely used within the NHS. However, since March 2020 we have observed how some audiology services have successfully adapted to a digital first approach and used this technology effectively, therefore freeing capacity and addressing demand despite challenging circumstances. Most audiology providers that adopted this technology have indicated they will continue to use it, even when social distancing restrictions are no longer required in health and social care settings. This innovation and further commitment is welcome, considering the present and future demands posed to NHS audiology services.

However, despite a national directive, local inconsistencies across the fragmented healthcare system meant that some providers have not been able to use technology to the same extent, creating disparity in service provision. We would encourage the Government to acknowledge and consider the use of technology and innovation within the Health and Care Bill, paying attention to national or local barriers that could limit the use of technology, so that equal access to services is ensured across the country.

We are disappointed that the Bill does not include any mention of utilising technology to improve access to and efficiency of services. We hope that during their deliberations the Committee will find the chance to scrutinise the Government on why the Bill does not follow-through on the agenda outlined in the Queen’s Speech. We hope that the Government can, at the very least, offer reassurances over the role that ICBs will have in pioneering new technology and the way that NHS England can support the roll-out and piloting of new technology.

August 2020