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8.05 pm

Baroness Richardson of Calow: My Lords, I, too, am grateful for the opportunity afforded by the noble Baroness to express the importance of audiology services and the need for greater priority to be given to them. Like many families, our family has its own sentences and catchphrases, which express our togetherness and which would be quite impossible for others to understand. In our family, most of them stem from a favourite grandmother, who was very deaf. She had a hearing aid—a huge orange thing that she held in tissue paper in the sideboard draw—which was kept for special occasions, although I must confess that I never witnessed such an occasion. Invariably in conversation, she used to get hold of the wrong end of the stick. Her wonderful non sequiturs have provided our family with endless amusement, although sometimes with a degree of annoyance.

As well as bequeathing to us these bon mots, our grandmother also bequeathed to me a genetic component that makes me very deaf. About 12 years ago, I began to realise that this was becoming a real disability, when the work that I was doing brought me to spend a lot of time with people for whom English was not their first language. I found conversation very

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difficult. I went to the local hospital and had, I have to say, a rather perfunctory test, after which I was given a hearing aid that amplified sound but did not clarify speech. I found it impossible to use. I was encouraged by a friend to go to a private clinic, where I had a test that was much more carefully done. I discovered that the kind of disability that I have relates to the middle range of sound, which means that I find it difficult to distinguish consonants in speech. If noble Lords remember some of those wonderful sketches that Ronnie Barker used to do, in which he had “trouble with worms” and kept getting his consonants mixed up, they will be able to appreciate some of the difficulties that I was having.

I believe that people who do not have hearing loss find it hard to appreciate what it means for those who do. I find it impossible to have a conversation on the telephone with my grandchildren. I can speak but I cannot hear what they are saying to me. Also on the telephone, when I have to get through to some officialdom and find that I am in a call centre, it is almost impossible to find communication between us and if I say to them, “I am deaf, will you speak slowly?”, they cannot resist the temptation to shout at me, which does not help at all. I find it difficult and almost impossible to eat with your Lordships at the long table in the dining room. I find it difficult to have a conversation with someone who is sitting alongside me. I need to see you in order to hear you. People leave voicemail messages and they think they have communicated with me but they have not done it clearly enough for me to be able even to hear who it is who has left the message, which causes quite a lot of embarrassment. I attend receptions and I do an awful lot of nodding and smiling and find that sometimes I have agreed to opinions I do not hold or even volunteered to do something I did not intend to do because I have not actually heard what was being said.

Hearing loss isolates, puts people at a disadvantage and damages confidence but it can be helped and the hearing aids that I now have do help. The first step, as other people have said, is to admit that there is a problem, and this is something that people find difficult. I have heard on more occasions than I can think of about people who say when they sit at the back of the church that the problem is that preachers are not trained to project their voices properly and refuse to admit that the problem might be within them. There is growing acceptance that help is available, and greater acceptance about the sophistication of the instruments which can help, but the capacity for dealing with the problem has not kept up with the expressed need. Only a year or two ago my nearest hospital was reporting that there were 22,000 people on its waiting list, and as has been said, there have been reports of waiting times of between 84 and 92 weeks in parts of the south-east. When we finally get round to admitting to a problem, the problem has to be diagnosed properly and quickly.

Where is the first port of call? When our eyesight fails we are used to going to a high street optician. Although we can be referred on from there if there is a health need, we can usually be provided for fairly quickly at a level which is appropriate to our financial

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ability, either with an NHS prescription or with very expensive designer frames. Many people find it easier to access the high street than to obtain an appointment with their GP and wait for a referral to a hospital, only to find that the waiting lists are long and the clinic is overstretched. The experience of using private practice must give some insight into the kind of opportunities made possible by using a mixture of private and NHS provision, not only in getting an appointment and finding an aid but in obtaining aid maintenance and repair and the provision of batteries, which is so often a source of irritation to so many people.

Hearing loss is not life threatening but the provision of aids is extremely life enhancing, not only for those with hearing loss but for all those who have to associate with them. It does not entail huge budget implications compared with the benefits to mental and social well-being. More help can be given. We need a clear insight into where the bottlenecks are and why they exist; an increase in audiology staff—I understand that there are more trained staff but that they are not being used effectively; a willingness to explore creative partnership with the private sector; and, above all, a commitment to a national programme.

8.12 pm

Baroness Barker: My Lords, I extend my congratulations to the noble Baroness, Lady Howe of Idlicote, and thank her most sincerely for the opportunity to take part in this debate. I do so for a particular reason. For over 60 years my mother has been profoundly deaf and she has been wholly dependent on the NHS for her lifeline—her hearing aids. That experience of growing up as the hearing child of a deaf person who lives in a hearing world with the TV turned up too loud and all that kind of stuff has had a profound effect on me. I shall give one example: most people my age can tell you all about “Doctor Who”—who played the Doctor, his assistants, and all that. In my house, “Doctor Who” consisted of the first three bars of that rasping, tinny music and an adult shouting, “Turn that noise off now”, as it cut through my mum’s ears. I know nothing about “Doctor Who”—I am scarred for life.

I shall tell my mother’s story briefly as it illustrates some important points. When I was little there was one clinic for the whole of the west of Scotland, where my mum used to go to get her batteries and cords. It was the same thing when we moved to Lancashire; she used to go to social services. She managed to get along with a pretty inferior system. During that time a friend died and in an act of generosity his family gave my mum his very expensive, private, behind-the-ear hearing aid, but it did not work. It was not until we moved to another place that, when she came under the audiology department of a district general hospital, on her first appointment somebody said, “We need to do a complete audiogram”. Because technology had changed and much more powerful behind-the-ear hearing aids were available, she finally got one. The change that it made to her, her confidence and her interaction with other people was phenomenal.

In the intervening period we as a family have gone through times when her hearing aid has not worked or she has not been very well, and we have appreciated

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the fact that she is getting older. She was told a while ago that she was getting old, that the nerves and so on in her ears were deteriorating and that she would not be able to hear any better. That was profoundly depressing for her and for all of us. Then there was a change, and last year she finally got a digital hearing aid. I asked her last week what it was like and she said that, apart from the relief of not having an inevitable descent into further deafness, she can hear things that she has never heard before. It may not be the biggest thing in the world, but to be able to differentiate noises is huge. In her words, it makes being in company altogether easier.

The point that I wish to make was alluded to by the noble Lord, Lord Giddens. When the Government count the cost of audiology services, they should include the savings made by people being able to continue working and to live independently without incurring caring costs.

We are in danger of going back to a fracturing of services rather than drawing them together. While that may be fine for somebody who has a slight hearing loss, who is young or familiar with technology and who can go to a private service, there will be those who are older and who have multiple conditions. They may be arthritic and cannot see very well and they are presented with a minute piece of machinery. They then panic because they do not know how to use it. It is important to note the point made by the noble Baroness, Lady Finlay, that maintenance and aftercare are an enormous part of a proper audiology service. The concentration on recording data, not just at the point of assessment but right through to fitting and beyond, to see how the person is living with a newly acquired deaf condition, is important.

The noble Lord, Lord Giddens, is right that we need to recognise that, as technology develops, the private and voluntary sectors have an enormous role to play in enabling deaf people to keep up with technological changes and go on with their lives more confidently. There needs to be coherence. Ophthalmology and optical services have changed by their reliance on there being a very good system of referral between the different parts—the voluntary sector, societies for the blind, the private sector and the NHS. That has enabled routine maintenance of people’s conditions to be contracted out to technicians, which has left precious specialist resources in ophthalmology—the same could be said for audiology—to be focused on those who really need them. I worry that, with the new system of commissioning from PCTs, we might be in danger of going back 40 years to when there was no coherence in provision, and deaf people will suffer as a result.

I shall abuse my position and say this: for those who are on tremendously long waiting lists—they are long in some places because PCTs do not have the resources—the RNID runs a telephone hearing check system. It wants more people to know about it; there is a telephone number on its website. Those people who are beginning to suffer can do something even if the NHS in their area is not particularly good.

8.19 pm

Earl Howe: My Lords, not for the first time, the noble Baroness, Lady Howe, has homed in on an extremely important topic, and I congratulate her on

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the case that she so ably presented. None of us should underestimate the social isolation and sheer human misery that deafness brings to large numbers of individuals in this country. The noble Baroness conveyed the scale of the issue. By any standards we are dealing with a major source of preventable disability.

The story of NHS audiology over the last eight years is an interesting one. In my view the Government are entitled to claim considerable credit for the decision they took in 2003 to roll out NHS provision of digital hearing aids across the whole country. That really did represent a quantum leap forward for many tens of thousands of people in terms of their quality of life. Unfortunately, as has been said, the very success of the MHAS programme sowed the seeds of the difficulties we are now experiencing. The benefits of digital hearing aids suddenly became more widely appreciated, demand for them shot up, and the NHS found itself without the capacity to cope. Indeed, audiology contains a paradigm of what has happened to the NHS as a whole since 1948. It is a classic instance of where an ageing population, improved technology and rising consumer expectations have combined to drive up demand for healthcare. If one were being critical of the Government, one could say that someone ought to have predicted this. As it is, there is not much indication that in 2003 anyone actually sat down to assess what capacity the NHS needed to meet future demand for audiology services in the short or medium term.

The result is what we see today: long average waiting times, as cited by the noble Baroness, to have a digital hearing aid fitted and of course, as we have heard, the average numbers conceal a huge variation between best and worst in different areas of the country. The target of a 13-week maximum wait between referral and assessment was meant to have been achieved last March but was missed by a wide margin. The six-week target, which is supposed to be met by March 2008, seems unattainable within that timeframe.

I say “unattainable” not simply in the light of the published figures but because of the numbers of people waiting whom the figures do not include. Those people waiting for a reassessment to see whether they need a digital hearing aid are only included in the official waiting list once a review has taken place to establish whether they might benefit from being reassessed. How many people are currently waiting to be reviewed in this way, and does the Minister not think that that hidden element of the waiting list makes the six-week target rather misleading?

The obvious way forward is for the NHS to draw upon the spare capacity that exists within the private sector. The problem here is that if you use the private sector there has to be demonstrable value for money, and how can you verify value for money unless you have a national tariff? A tariff is the only way there is to assess price comparability between different suppliers, yet there are very mixed messages emanating from Ministers about whether they see this as something that should be developed. The strategy document of last March simply said that the department would consider the introduction of a tariff as soon as practicable.

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I need therefore to ask the Minister what is happening here and whether the introduction of a national tariff is now seen as a priority.

Could I also ask the Minister about priority treatment for war pensioners? As from 1 January, all war veterans became entitled to priority access to NHS secondary care for any conditions which are likely to be related to their service, subject to the clinical needs of all patients. This could present a difficulty in relation to hearing loss. In the context of applying for a war pension, veterans have had to meet quite a high threshold of hearing loss—50 decibels in both ears—to be deemed eligible. For priority treatment on the NHS, on the other hand, the threshold is bound to be a lot lower, and we could well see a backlog of cases—perhaps as many as 100,000 according to the RNID—coming forward for priority treatment for deafness caused by service. What impact is that likely to have on waiting lists and what specific measures have been taken to ensure that the NHS can meet the potential increase in demand from those patients?

We are back to the capacity question. Like the noble Baroness, I wonder what happened to the commitment given by the noble Lord, Lord Warner, in July 2006 to source an additional 300,000 patient journeys per annum from the private sector for five years. Is that happening? In their answers to the recommendations of the House of Commons Health Select Committee, the Government admit that they are only now examining in any depth the medium and long-term demand for digital hearing aids and are only now developing a toolkit for workforce planning. Again, only very recently have the Government accepted that official data on referral to treatment times should be collected in relation to hearing aids. Better late than never, but one wonders how any policy decisions have been reached either in Whitehall or in PCTs in the absence of such fundamental information. What is not measured cannot be managed. I hope that the Minister will tell us that better and more detailed information will be the starting point for better and more joined-up policy in this vital area.

8.26 pm

Baroness Royall of Blaisdon: My Lords, I, too, am grateful to the noble Baroness, Lady Howe, for raising this very important issue, which affects the quality of life of a growing number of citizens. I agree that the debate is both necessary and timely, and I am sure that we are all indebted to both the noble Baronesses, Lady Howe and Lady Richardson, for their honesty about being deaf. It is very refreshing to hear about the problems confronting people who are deaf. My mother went deaf as she got older but for many years she refused to acknowledge it, and that caused problems for her and for us as a family.

In their White Paper, Our Health, Our Care, Our Say, the Government set out a vision to improve the independence, choice and control of those who receive services. The ability to communicate effectively is absolutely fundamental to achieving that vision, and the ability to hear is vital to the process of communication—an inclusive process. Perhaps for too long, audiology has

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been a Cinderella service but I can assure noble Lords that it is not a Cinderella service now, and we are working flat out to respond to the demand for improved audiology services.

Around 1.8 million people have NHS-provided and maintained hearing aids. These include the more recently introduced digital signal processing hearing aids, which have enhanced patient benefits. Those with more profound hearing loss, including children, are obtaining access to new implantable devices, such as bone-anchored hearing aids and cochlear implants. As people get older, they are more likely to develop a degree of hearing impairment, and with more people living longer, the demand on audiology services will continue to increase. The demand for audiology services has also increased because many people who currently use an analogue hearing aid naturally and rightly wish to switch to the improved performance provided by digital hearing aids.

Recognising the importance of early access to both diagnostic assessment and treatment for hearing difficulties, the Department of Health, as part of its 18-week physiological measurement programme, developed a national action framework for audiology services. From the outset, the department engaged with many key stakeholders to ensure that the process of developing the framework was inclusive. The national audiology framework, Improving Access to Audiology Services in England, was published in March 2007. It set out a programme of work aimed at helping local health systems to transform the experience of the audiology service for all their patients with a vision of delivering high-quality, efficient services closer to patients’ homes and responsive to the needs of local communities.

The framework also set out how the health reform levers could be brought to bear to achieve these aims and the national work that will be undertaken to support the process. It is now 10 months since publication and significant progress has been made—although as demonstrated this evening, clearly not enough progress yet. The number of people having to wait for an audiology assessment has fallen dramatically. A year ago, more than 114,000 patients waited longer than 13 weeks for their assessment. Now this figure has fallen to 34,000 and is still falling. By March 2008, no patient should have to wait longer than six weeks for their assessment.

The department is actively working with SHAs, PCTs and providers to tackle the current poor performance in some areas of the country. The noble Baroness and others cited the dreadful regional discrepancies and referred specifically to the problems in Kingston. As noble Lords will know, the department does not collect data on waiting times for treatment. However, we are working with the most challenged organisations to get this data and are committed to collecting them nationally by April.

We are constantly trying to improve the quality of data we collect. We have been working closely with the NHS to look specifically at how long patients wait if they are sent directly from their GP to the audiology service, which is not included in the 18-week target. The NHS is continuing to transfer services making the best use of innovation and new technology. A key

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example is open-ear technology which does not require individual ear moulds to be produced and provides more comfort, better cosmetic appearance and natural-sounding speech. This technology used in conjunction with digital hearing aids is effective in enabling a significant proportion of patients to be assessed and fitted with a hearing aid in the same appointment.

Training is currently being rolled out across the NHS to support both widespread adoption of this technology and to enable patients to benefit from treatment as quickly as possible. A patient’s pathway has therefore been reduced from five steps to one. This really is progress in the NHS. I know that it has been available in the independent sector for some time but now we have it in the NHS.

We published the good practice guide Transforming Adult Hearing Services for Patients with Hearing Difficulty in June 2007, which included the introduction of a new care pathway and case studies of NHS service improvements. Our aim is to drive innovative approaches to commissioning and to provision, including those of the independent and third sector, to which I will return.

We have set up the national Audiology Advisory Board to oversee the implementation of the framework, including representation from a broad range of key stakeholders. Whilst the majority of long waits are for adult hearing services, we are also in the process of developing further guidance for other services provided by audiology departments. We are working with stakeholders such as the National Deaf Children’s Society, to develop a new care pathway for children’s hearing problems and to embed best practice. We are developing new pathways and best practice guides for balance and vestibular function services, tinnitus and more complex hearing problems.

The noble Baroness, Lady Finlay, rightly referred to the need for more audiologists and to the need for increased numbers and type of training, not just for adult hearing and balance services, but for the whole of the audiology service. We are assessing that now. This will include the need to train GPs better, identify the problems, and communicate with paediatricians as well as audio-vestibular physicians.

We are training 300 new hearing aid audiologists to respond to the demand from high street hearing care practitioners. They will complete a foundation degree operated as an “earn as you learn” partnership with high street employers. Over two years, this degree programme will combine academic and workplace skills. This links in with the broader Department of Health policy to modernise strategic careers. We are also looking at non-degree-based new career structures for audiologists who can undertake functions for which they do not need a degree. That is rather exciting.

A workforce toolkit is being developed to support audiology services and profile their workforce to match the services that need to be delivered. This will include a range of e-learning modules to underpin the roll-out of new adult hearing care pathways.

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