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Your Lordships will recall how often, in other debates, we all, but especially the Government, have emphasised the need for inclusive social policies. One witness quoted by the RNID, Janine Roebuck, an opera singer, makes very clear just how important that concept is in this context. She says:
“My hearing aids are my lifeline. Long hearing aid waiting times means spending years struggling to hear and battling isolation and depression”.
That is the background to have in mind, as we react to the fact, whatever the long-term need, that as stated by the RNID no less than 250,000 people are currently waiting for a digital hearing aid.
How have the Government reacted? In May 2006, they set a target that by March 2007 no one should have to wait longer than 13 weeks for an audiology assessment—note those words carefully—and that by March of this year no one should be waiting longer than six weeks. However, the most recent figures, for October, show that almost 48,000 people were still waiting more than six weeks for an assessment, and more than 34,000 over 13 weeks. Furthermore, more than 13,000 patients have been waiting longer than a year for an assessment. I stress that these government targets and figures are for waiting times for an assessment only, and certainly not for actually being fitted with a hearing aid. Remarkably, the Government do not publish waiting-time data for what is called “the full patient journey”.
What then is the picture if one takes in that second period between assessment and supply—as clearly one must? Indeed, the Select Committee specifically recommended that. For the past four years the British Society of Hearing Aid Audiologists—BSHAA—has carried out an annual survey of waiting times for precisely that full patient journey from referral to supply. Its results are, therefore, much more meaningful than the Government’s official figures and the findings
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These BSHAA surveys have also highlighted serious regional discrepancies in waiting times. This has recently been underlined by a report from the RNID based upon freedom of information requests, delivered to every PCT, only two months ago. Out of the 100 trusts that have responded, no less than 11 have average waiting times of more than a year from GP referral to fitting of hearing aids. Some have waiting times of more than 18 months. In Kingston-upon-Thames, new adult patients wait an average of two-and-a-half years. Who knows how much worse the figures might be for the 50 or so trusts that have failed to reply to the RNID? What are the Government doing to address this? At one time we thought we knew. In July 2006, the then Minister, the noble Lord, Lord Warner, announced that 1.5 million patient pathways were to be procured from the independent sector at a rate of 300,000 per annum for five years. We have now passed that date and, alas, have seen no evidence of this happening. Instead, strategic health authorities locally have been tasked with filling their capacity gaps with,
- “a combination of greater efficiency in existing services where possible, and, where that is insufficient, new capacity”.
So what has happened to the national audiology action plan and why do we have no clear or continuous plan for effective engagement of the independent sector? The modernisation of hearing services—MHAS—project to equip the NHS with facilities to offer digital hearing aids began in 2003. It included a limited independent sector involvement through a PPP. Although only two independent sector companies were involved, no less than 68,600 patients were fitted with a hearing aid through that PPP until it ended last April. More significantly, it was accepted that the companies’ standards in providing fitting and follow-up service matched those of the NHS.
Despite all the current barriers to its involvement, the independent sector is, of its own volition, making a contribution towards alleviating pressures on waiting lists—for example, by helping to test patients’ hearing at their local GP surgery, thus speeding up the initial assessment and referral process. Some PCTs have also involved independent-sector providers in assisting with part of the full patient journey—for example the fitting of an aid and follow-up. But these are piecemeal approaches, wholly dependent on local initiatives and not part of any coherent policy by national government. The independent sector continues to invest in training of hearing aid dispensers who are fully qualified to carry out hearing assessments and fit hearing aids. Yet this significant capacity, a workforce of some 1,400, is virtually ignored in the Government’s calculations. Is it not high time to consider a more direct—indeed, a more actively participant—role for the independent sector?
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I invite the Minister and, indeed, the rest of your Lordships to study the evidence given to the Health Select Committee by Specsavers. From that, it is clear that developing a market for directly supplying audiology services financed by the NHS along the lines of the successful optical prescription model would offer the public greatly improved access, choice and quality.
In summary, the Government’s actions do not measure up to the scale of the problem. The Department of Health seems unable to ensure that the NHS works in partnership with the independent sector to develop a sustainable national audiology service. Consequently demand cannot be met and patients continue to suffer. I end by quoting the closing paragraph of the BSHAA report, Suffering in Silence2007, which states:
“BSHAA has for some time said it is puzzled why the Government does not recognise that the independent hearing care sector on the high street has the skill and expertise necessary to help solve the waiting list problem”,
- “offer patients real choice; choice of location, choice of time, choice of instrument, choice of dispenser and even choice of how many and which hearing aid they have fitted”.
I am much looking forward to this debate and, in particular, to hearing from the Minister when and how the Government will open the door that will enable us to start proceeding down the road that I have described.
7.45 pm
Lord Giddens: My Lords, we owe the noble Baroness, Lady Howe, our plaudits for setting up this debate on a topic that is unjustifiably low-profile in our thinking. It would be hard to dispute that audiology is one of the Cinderella areas of the NHS. This in some part reflects widespread cultural attitudes towards hearing loss in our society. If someone goes blind, it is universally regarded as a tragedy, but even people whose problems are of being very hard of hearing can be regarded with scorn, mirth and derision which is surely inapplicable, given the scale of the issues that we face in this area.
A recent study of the baby boomers generation in the US concluded:
“The reality is that hearing loss has a long way to go before it is considered a legitimate public health issue”.
I would suggest that the same applies in this country, too. That is pretty amazing when one considers the facts. According to the same study, 25 per cent of the baby-boom generation—people between 50 and 60 years old—suffer from serious noise-induced hearing loss, in addition to hearing loss brought about by ageing processes. Some observers in America have spoken of a hearing health epidemic and I do not think that that is an overstatement.
The issue is not just that people can be incapacitated in their everyday lives, but it can also have a significant impact on their work and capability to work. We live in a service-based society in which we spend most of our working days interacting with other people. Many kinds of jobs can be impossible for people who do not get effective assistance in such a situation.
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The other side of this issue is a tremendous and continuing wave of innovation in hearing-aid technology and, more generally, in technologies linked to those who are either deaf or seriously hearing impaired. At the cutting edge of this technology is nanotechnology; on the commercial market there is already a hearing device available which can be implanted, is invisible to the external observer and has a battery life of some five years. Tremendous technological revolutions are going on.
When I read the Government’s document, Improving Access to Audiology Services in England, and their response to the House of Commons Select Committee report, I felt that I was living in 1948 rather than 2008. I give three reasons for this: one is that digital aids were not introduced into the NHS until 2001, in spite of the fact that they existed for many years previously, although, of course, they were improving radically. That raises the issue of whether what is going on in the intersection between the NHS and the private sector is really at the leading edge of technological developments. Secondly, as the noble Baroness said, no reliable data are collected, or have been collected to date, on the wait between GP referral and treatment. As I understand it, the Government have now committed themselves to collecting that data. That is clearly a serious lapse. Thirdly, as the noble Baroness also said, the survey by the RNID found that many trusts had very long waiting times. This was based on a sample, rather than a universal survey, so to some extent it was guesswork. Like her, I picked up the case of Kingston, where there is a wait of 2.5 years, which translates into 125 weeks.
I have four questions for the Minister, which she might answer directly or subsequently. First, is this figure of 2.5 years for Kingston health trust valid? Is it really true? It seems quite incredible. Secondly, the person choosing open-ear technology today, and who goes privately, can get tested and fitted not only in one day, but within one hour of going to the practitioner. Yet the Government document says proudly that the Norfolk and Norwich University Hospital NHS Trust, using open-fit technology, has seen treatment waiting times drop from 28 weeks to 21 weeks. Could the Minister explain this yawning discrepancy? Thirdly, as the noble Baroness has said, surely there must be more effective ways of integrating the public and private sectors. She mentioned the case of opticians, where there is indeed very little waiting—where, because of technological innovation, you can get a pair of glasses within an hour. Here again the Government seem to have made only modest progress, especially in relation to the target that was also mentioned. According to the calculations I saw, only 116,000 people have been treated under a PPP arrangement. Fourthly, in his speech the other day, the Prime Minister rightly put an emphasis on prevention, rather than simply treatment. What are the Government doing in the area of prevention? It is not just the baby-boom generation who went to rock concerts; it is also the under-25 generation using iPods. A recent French study calculated that one in 10 of such users will have hearing deficiencies within two years, because they use these devices almost every day, and they play them at much too high volumes. Surely, prevention should be moved massively up the Government’s agenda.
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7.52 pm
Baroness Finlay of Llandaff: My Lords, I thank my noble friend Lady Howe for instigating this important debate. Her introduction demonstrated that she is certainly an expert in the field.
Hearing impairment is the most common sensory disability worldwide. Although deafness and loss of hearing are more common in the elderly population, many children and young people are also affected, with potentially devastating results on the development of language, communication and learning. There are estimates that in the UK, one in 1,000 children is deaf at the age of three. Currently, a staggering 17 per cent of the population have some deafness. As the noble Lord, Lord Giddens, said, in the younger age group that is likely to rise almost exponentially because of the sound technology they use on a daily basis. There are 20,000 children aged 15 and under who suffer from a degree of deafness, and 12,000 of them were born deaf.
Sufferers of deafness often experience isolation and depression. When deafness is of sudden onset, it is particularly devastating. The person with sudden onset deafness suddenly loses all orientation. Crossing the road or even pursuing activities in the home becomes incredibly hazardous. Even those with progressive deafness may find that they cannot pursue their previous employment, or find that employment opportunities wither, as their lives rapidly become narrower and more cut off. They are often acutely aware that their potential contribution to society is being wasted and that they cannot enjoy the same quality of life as they did when they had hearing or as those with good hearing can.
Two million people in the UK currently use a hearing aid, but it is estimated that a further 4 million might benefit from one. The Government are to be commended on their commitment to reducing waiting times for digital hearing aids. They certainly have recognised the failure of many PCTs to give audiology services the priority they deserve. To address this, the Audiology Advisory Board, chaired most capably by Professor Sue Hill, has produced the National Audiology Action Plan. But I would ask the Minister whether the current referral-to-treatment waiting time for a hearing aid has improved at all. Is the target of providing a diagnostic test for audiology within six weeks likely to be reached by its target date of March this year, since last year’s 13-week target was not met on time?
Hearing loss does not occur in isolation. The associated vestibular disorders cause dizziness, vertigo, nausea, fatigue and sometimes tinnitus and, sadly, they are commonly misunderstood both by the public and by healthcare professionals. These symptoms represent the most common reason for GP visits by patients over 65, and indeed 40 per cent of the UK population aged over 40 have experienced symptoms of dizziness and/or imbalance.
Let us make no mistake: the aftercare of those receiving an NHS hearing aid is inferior. After receiving an NHS aid, a patient will receive one phone call to assess whether problems are being experienced with the aid. If a hearing aid is purchased privately, the patient is able to arrange a personal consultation
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However, I hope that no one will be fooled into thinking that providing a hearing aid is the answer to issues around deafness. There is a real and urgent need for an increase in training numbers in audiological medicine if we are to cope cost-effectively with the increasing numbers of people with audio-vestibular disorders who will otherwise continue to be referred to the wrong NHS resources where their problem becomes compounded by inappropriate investigations and wrong treatments. Currently, services are variously provided by ENT surgeons, audio-vestibular physicians, audiologists, neurologists, geriatricians, paediatricians, physiotherapists and so on, depending on the complaint and the availability of professionals in that area, frequently determined by staffing levels and the equipment infrastructure. The majority of patients are referred to ENT and to neurology, even though only 5 per cent of hearing and balance disorders require surgical intervention or result from central nervous system pathology.
I know that the “good practice” documents produced following on from the framework are supported by the commissioning of 18-week patient care pathways, and there are other audiology transformation projects on education and training of the workforce and on the development of a workforce tool and a quality assessment tool. But all those require the availability of expertise to underpin them. Nationally, however, only a handful of services are able to provide state of the art, sophisticated auditory and vestibular investigations that patients need for accurate diagnosis of the underlying cause of their deafness and other problems. Unfortunately, much time and effort is therefore wasted on inappropriate or unnecessary and expensive investigations and referrals. With an ageing population, these problems are going to get greater. Provision of a hearing aid is only part of the management.
We need an increase in specialist medical audiology without which we risk more money being spent inappropriately. Hand in hand with that goes a requirement for more national specialist facilities too. The need for a rapid expansion in such services of expertise also puts an onus on the profession itself. Currently the training in audiological medicine is far too long. I ask the Minister what discussions have been had with the royal colleges to streamline and bring down the time spent training.
I am grateful for this debate, and I am pleased that the Government have demonstrated a commitment, but we have a long way to go.
7.59 pm
Baroness Wilkins: My Lords, I join other noble Lords in thanking the noble Baroness, Lady Howe, for initiating this very important debate. Few things are potentially more isolating than the onset of deafness, and I fully endorse the picture of need painted by my noble friend Lord Giddens and the importance of placing priority on this service. Like many of us I have been with my family over Christmas, and I was reminded anew of the crucial role that audiology equipment
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Sadly, that piece of equipment is not as well known as it should be; it would probably have reduced the tension in hundreds of households this Christmas. By contrast, the introduction of digital hearing aids has received wide publicity and become a victim of its own success. Given the history, it is hardly surprising that there are currently an estimated 250,000 people waiting for a free digital hearing aid.
Before 2000, the wearers of digital aids would have had to buy them for £2,000 or more. The NHS audiology clinics fitted only the outdated analogue aids and were chronically underfunded. The outstanding campaign by the RNID resulted in the unique partnership between government, the voluntary and independent sectors, and the modernising hearing aid services programme produced, in the RNID’s own words, the complete transformation of the service in less than five years.
More recently, the RNID has highlighted the unacceptably long waiting lists that still exist. Its latest figures revealed a shocking situation in some parts of the country, the worst, as we have heard, being in Kingston. But what is in danger of being overlooked is the fact that we are talking about pockets of poor provision. It is not the national picture. In fact, nationally there has been an enormous improvement and, while the unacceptably long waiting lists should and must be eliminated, the successes should be recognised and praised.
My local audiology department at Charing Cross Hospital is held up as an example for others to follow. That department’s reaction to the publicity given to the RNID’s figures was that it was grossly unfair. In its opinion, the figures do not reflect the overall reduction in waiting times, which have reduced radically. According to the Department of Health’s figures, last October roughly 80,000 people were waiting for an audiology diagnostic assessment; a year earlier, in November 2006, the figure was double that, at more than 166,000. Of these, roughly 47,000 had been waiting for more than a year, whereas last October this figure had been reduced to 13,000. Yes, that is still far too many, but the picture is not a uniform one. The staff at Charing Cross felt kicked in the teeth for all the hard work that their profession had undertaken over the past few years. They deny the description of Charing Cross as an “elite service”; in their judgment, theirs is a normal service, just hard working.
However, Charing Cross is worried by the draft tariff—the indicative tariff—which has been introduced to audiology services for the first time this year. It
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“If an independent sector company can provide a patient journey for the current tariff rate I would have serious concerns about the quality of that service; there will certainly be no money left for the shareholders if the job is done by a fully qualified audiologist”.
She provides the example of a current contract with a well known independent sector provider in Darlington, who charges £320 for a unilateral fit—I understand that that is not best practice—which is £90 higher than the NHS draft tariff.
The Health Select Committee’s report last May into audiology services highlighted its concerns about increased use of private sector provision and in particular its belief that there should be careful monitoring of the quality of care and that the private sector must not be allowed to undermine the capacity of the NHS to provide expert audiology services. I do not have time to go into these in detail, but I ask the Minister to assure the House that the Select Committee’s concerns will be acted on. Will she also assure me that the Department of Health will take on board the serious concerns that have been expressed about the level of the draft tariff? In reality, the audiology service is very cheap for the life-changing results that it achieves. Will she do all that she can to ensure that the Government build on its successes and not allow the service to deteriorate?
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