INTRODUCTION

  1.  The Government welcomes the opportunity to set out its position on audiology services. This memorandum covers the five areas of particular interest expressed in the Health Select Committee's Terms of Reference together with detailed background on related issues.

TODAY'S AUDIOLOGY SERVICE

  2.  Audiology involves a wide range of hearing and balance services which include assessment, therapeutic intervention and rehabilitative strategies. These assessments determine the functional ability of the auditory and vestibular system, the effect of possible pathologies and the impact on related daily activities.

  3.  Following assessment, an appropriate care pathway is selected for treatment (eg surgery for cochlear implant) and for support. The most common audiology pathway is associated with the restoration of degenerative hearing loss in adults through the provision of digital signal processing (DSP) hearing aids. Pathways also include counselling and the provision of assistive listening devices.

  4.  Most services are based on acute hospital trust sites and range in the number and complexity of services provided but all offer direct access primary care services for adult hearing loss. Some offer outreach adult and paediatric services and there are a small number of primary care based services. There are an increasing number of private sector providers.

  5.  There is the potential for more services to be provided directly in primary care settings. Paediatric audiology services work in partnership with local authority services, who provide the major ongoing rehabilitative support for parents and their children.

  6.  Estimates based upon the Medical Research Council (MRC) and the Department of Health Survey of Audiologists in England 2004 suggest about 60% of audiology staff time is spent on adult patients, with the majority of time spent on care pathways associated with adult hearing aid services.

  7. The major elements of audiology services include:

—  Assessment of patient needs and selection of appropriate care pathways.

—  Hearing function (including pure tone audiometry) and tinnitus assessments.

—  Fitting of digital hearing aids to new and existing patients.

—  Diagnostic audio vestibular function tests (ie balance tests and electrophysiological tests of hearing and balance).

—  Assessment for implantable devices that aid hearing and communication (eg bone anchored hearing aids and cochlear implants) and for patients with central auditory processing disorders (provided by a small number of centres).

—  Hearing and tinnitus patient management and follow-up.

  8.  Most referrals to audiology services are direct referrals from GP for assessment of hearing loss and provision of digital hearing aids in adults. A small number of patients for this service are still referred via Ear Nose and Throat (ENT) consultants. In addition, there are intra-departmental referrals. Patients can also refer themselves back in for reassessment, maintenance and repair. Most other referrals for the complete range of hearing and balance services are traditional GP to hospital consultant usually via ENT (although for balance problems maybe via other hospital consultants). Children's referrals might arise via community paediatricians direct to audiology or from the Newborn Hearing Screening Programme (NHSP).

  9.  For some services offered by an audiology department, referrals are received late on in the patient pathway from specialties other than ENT, which can have a significant impact on the total patient journey. These referrals particularly impact on some of the lower volume tests offered by audiology departments. For example, many patients that require vestibular/balance assessments associated with dizziness or falls.

  10.  Audiology services work closely with a range of agencies, including education, social services and voluntary sector providers to support the provision of NHSP and services for children and adults with learning disabilities, dual sensory impairments and complex needs.

  11.  There are 158 audiology departments in England, 124 sites for Newborn Hearing Screening Programmes (NHSP) and 16 cochlear implant services.1[1]

  12.  Skill mix and the number of staff varies between organisations to reflect the services being provided but there is variable output in terms of service activity. The service is primarily delivered by healthcare scientists (clinical scientists and technologists). In paediatric audiology in particular, a proportion of staff are audiological physicians, who may undertake some assessments. In general practice, some GPs may undertake baseline hearing assessments and arrange for hearing aid services to be delivered within their practices. In paediatric audiology the service is often led by a consultant clinical scientist. There is scope for new roles to be developed and for skill mix to be reviewed to match the workforce to the main functions delivered as well as focus on greater productivity and efficiency.

  13.  Audiology requires specialist diagnostic equipment. Generally, audiology tests are undertaken in quiet clinical rooms, sound-proofed rooms or electrically shielded and sound-proofed rooms. However, newer technology means that requirements may change in the future.

  14.  Demand is increasing due largely to a combination of an ageing population and more people seeking to benefit from the advances in digital technology. In addition to the overall increase in hearing impaired people, recent initiatives have put further pressures on the capacity of audiology services to deliver the major care pathways within recognised quality guidelines:

—  Royal National Institute for Deaf People (RNID) reports and campaigns.

—  Introduction of Newborn Hearing Screening Programme (NHSP).

—  The MHAS programme ensured that all NHS audiology departments were able to routinely fit digital hearing aids by April 2005.

—  The replacement of analogue hearing aids with digital aids—digital hearing aids enable greater personalisation that requires more time for adjustment and more frequent replacement (as they are more likely to be used).

  15.  Approximately 20% of audiology staff time is spent managing referrals from ENT and providing pure tone audiometry and other hearing tests in ENT outpatient clinics. The increased demand on ENT services is also having a significant knock-on effect to audiology. In addition, reassessments of current patients also contributes significantly to the workload. This may include those patients switching to digital aids who require a new diagnostic workup and provision of rehabilitation support strategies, or those where hearing function is being reassessed and optimised after the provision of a new high power digital aid.

  16.  Audiology services are subject to pressure not only from direct referrals, unmet need and the increasing demand for adult hearing services but for all the services they provide. There are a range of steps which need to be taken to address these challenges. This includes issues such as the development of priorities and guidelines and ensuring that local commissioning and workforce planning is sufficient to address the need.

  17.  In order to provide digital hearing aids at an affordable cost to the NHS, contracts exist with certain manufacturers for a range of aids. The decision as to whether to purchase an aid on or off contract is made locally.

DEFINING THE PROBLEM

  18.  Historically there has been a lack of focus and understanding in the provision of audiology services in the NHS. The Audit Commission identified problems with the NHS hearing aid services in their report, Fully Equipped, (2000). The report examined five services from the user's perspective—orthotics, prosthetics, wheelchairs and specialist seating, community equipment, and audiology. The report found that the current level of services across these services was unsatisfactory in many respects:

—  there were unexplained variations in all aspects of service provision, bearing little relation to underlying levels of need;

—  the quality of services owed more to custom and practice, rather than to a considered view of the contribution that equipment services could make to the overall needs of the population; and

—  eligibility criteria were often unclear to users, carers, voluntary organisations and staff, and they were often applied inconsistently.

  19.  The report made a number of recommendations in relation to audiology, which included:

—  to reduce waiting times, health authorities should ensure that there are mechanisms in place to allow direct referral from GPs to hearing aid centres. They should also ensure that the capacity of the hearing aid clinics is adequate to manage an increased workload and range of tasks;

—  investigations into the provision of improved hearing aids should attempt to compare the opportunity cost of providing better hearing aids against the current cost to society of the isolation experienced by deaf and hard-of-hearing people;

—  health authorities, in conjunction with local trusts, should review their current service standards for the delivery of audiology services and the delivery of quality improvements;

—  health authorities and social services authorities should establish joint audiology services.

  20.  In response to the report the Government invested £125 million between 2000 and 2005 into modernising NHS audiology services through the Modernising Hearing Aid Services (MHAS) programme. The Royal National Institute for the Deaf (RNID) ran the programme on behalf of the DH.

  21.  The MHAS Programme successfully achieved the target that all 164 audiology services in England should be able to fit digital hearing aids routinely from April 2005. Other outcomes included:

—  the RNID estimate that 750,000 patients had been fitted with digital hearing aids through the MHAS programme by April 2006;

—  a reduced cost to the NHS of digital hearing aids; and

—  MRC findings of patients reporting a 40% increase in benefit with the new service.

  22.  Capacity initiatives through MHAS included:

—  the development of the National Framework Agreement for the supply of hearing aid services through a Public Private Partnership (PPP); and

—  the introduction of "Hearing Direct"—12 sites run by NHS Direct to provide follow-up care and advice for selected hearing aid users.

  23.  The NHS Improvement Plan (June 2004) set out an ambitious new aim that by 2008 no one will wait longer than 18 weeks from GP referral to hospital treatment. With the inclusion of all diagnostic tests and the initiation of treatment within the 18 week target definition a physiological measurement diagnostic programme was established within the Department of Health's 18 week programme. Audiology was one of the eight clinical specialities included. The work of this programme, and the lessons and information gained from it, have contributed in identifying the problems facing audiology services and finding solutions to those problems.

  24.  Despite the success of the MHAS programme, the physiological measurement programme has demonstrated that there is still a considerable challenge to be addressed with regard to those people on waiting lists for audiology services. The key challenges facing audiology services are:

—  unmet and increasing demand;

—  inadequate capacity;

—  workforce skills and competencies not matched to service functions;

—  inefficient service models and processes;

—  modern technology not encompassed; and

—  large waiting lists which have not been managed.

  25.  In order to address these challenges the Department of Health announced, in June 2006, that it would develop a national audiology action plan. In addition to this, on 25 July 2006, Lord Warner announced the central procurement of up to 300,000 audiology pathways from the independent sector, which was additional to the Wave 2 diagnostics procurement, which also included 40,000 audiology pathways.

  26.  The audiology action plan, or framework, is currently being finalised and has been developed drawing on the views of stakeholders, including audiologists. The framework will address the broad range of patients who suffer from audiology problems including:

—  adults with a hearing loss;

—  children with hearing and balance problems;

—  tinnitus sufferers;

—  patients with balance disorders;

—  bone anchored hearing aid users; and

—  cochlear implant users.

  27.  Linked to the publication of the audiology framework, and as part of the outcomes from the physiological measurement programme, will be plans to publish:

—  good practice guidance on new audiology service models based on findings from nine NHS pilot sites;

—  key information to support the commissioning of audiology services; and

—  a model pathway for adult hearing loss.

  28.  A stakeholder event took place on 1 February 2007 to discuss the challenges facing audiology services and the publication of the forthcoming framework.

  29.  The audiology framework will move towards the achievement of shorter waits by December 2008 and if this is achieved, will provide a solid base for the future sustainable delivery of audiology services.

INQUIRY TERMS OF REFERENCE AREAS OF INTEREST

Whether accurate data on waiting times for audiology services are available

  30.  The Department does not collect waiting times for hearing aid fitting. However, a trajectory has been set to deliver diagnostic tests within 13 weeks by March 2007 and six weeks by December 2008. Waiting time data has been collected for audiology diagnostic tests since January 2006 and is published on the Department's website at http://www.performance.doh.gov.uk/diagnostics/index.htm

  31.  The monthly diagnostic data for audiology consisted of waits for pure tone audiometry until October 2006 (published in December), when this was extended to cover all audiometry assessments.

  32.  As of November 2006, there were 166,740 patients waiting for an audiology diagnostic assessment. Of these, 108,628 were waiting over 13 weeks, and 80,941 over 26 weeks. The median waiting time was 25 weeks.

  33.  Regarding the quality of this data, this is a relatively new data collection, and there remain some problems in the accurate collection of audiology assessment waiting times. However, the published figures have been signed off by PCTs and should be seen as a realistic reflection of the waiting times experienced in the NHS.

Why audiology services appear to lag behind other specialties in respect of waiting times and access and how this can be addressed

  34.   The Department of Health acknowledges that there are long waits for adult hearing services compared to other specialties. These waits have largely built up because of the rapid increase in demand created by the MHAS programme and transition from analogue to digital hearing aids. The audiology framework will set out the plan for addressing these waits.

Whether the NHS has the capacity to treat the number of patients waiting

  35.  The audiology framework will help address the capacity challenges currently being faced by those patients waiting for audiology services.

  36.  Analysis and modelling of the limited data available indicates that there is a significant capacity problem. The framework will set out ways in which the NHS can address these challenges.

  37.  Initiatives to address the capacity issue include:

—  independent sector procurement; and

—  re-engineering the care pathway to increase efficiency in order to streamline the process and reduce the waiting times.

  38.  The November monthly collections suggests over 100,000 patients are currently waiting at least 13 weeks for the following audiology assessments:

—  Referral for hearing aid assessment (new patients).

—  Re-referral for hearing aid assessment.

—  Referral for complex needs hearing aid assessment.

—  Bone anchored hearing aid (BAHA) assessment.

—  Referral for cochlear implant candidacy assessment (adult).

—  Adult audio-vestibular assessment.

—  Tinnitus assessment.

—  Balance assessment.

—  Referral for cochlear implant candidacy assessment (paediatric).

—  Paediatric hearing services following newborn screening.

—  Audiological assessment at 2nd and 3rd tier clinic (pre-school and school-age).

  39.  The rate at which the population is ageing suggests that demand will increase in the coming years. To reduce waiting times to within 18 weeks and hold them there will require significant increases in capacity.

Whether enough new audiologists are being trained

  40.  The Department of Health recognises that in order to address the challenges currently being faced in audiology services we would need to increase capacity some of which will need to come from improvements in productivity. This is currently being investigated at a number of physiological measurement development sites, together with an assessment of their current workforce profile and the service output.

  41.  An integral part of this process will also be to ensure that there are sufficient staff, of the right skill mix, to address the capacity challenge. Some of which may include the use of administrative staff; the development of new roles at lower career pathway stages; the development of the audiology assistant role; and creating flexible roles to remove ear wax.

  42.  We have already taken a number of steps to increase the number of new audiologists being trained. In 2003-04, we introduced the new Bachelor of Science in Audiology. We have also implemented initiatives to improve recruitment and retention for all staff, including audiologists, by improving pay and conditions; encouraging the NHS to become a better, more flexible and diverse employer; providing help with accessing childcare; and running national and local recruitment campaigns.

  43.  Through a DH programme with Skills for Health we are working on the competencies and associated skill and knowledge requirements to support the introduction of an associate level practitioner in audiology to support the new care pathway. This will have synergy with the requirements of the independent sector providers for skilled practitioner who can undertake routine adult hearing service functions.

  44.  Additionally each year the Workforce Review Team in conjunction with the SHAs and other service representatives undertakes a workforce requirement review of audiology services, which is available to the whole of the NHS to direct and inform local workforce planning arrangements.

Background

  45.  A BSc course in audiology was introduced and commissioned by the NHS in 2003-04. Prior to that the NHS Non-Medical Education and Training (NMET) levy funded both Grade A clinical scientist training (which it continues to do) and a multiplicity of different training arrangements for audiology technicians, together with diploma programmes in hearing therapy. The first cohort of BSc (Audiology) students entered training in 2003-04 and graduated in 2006.

  46.  The most recent data on the audiology sector, states that at 30 September 2005 there were 1,651 (1,421 fte) qualified healthcare scientists working in audiology, an increase of 4% since 2004 when there were 1,582 (1,389 fte). Prior to 2004, it is not possible to separate healthcare science staff working in audiology from other scientific, therapeutic and technical staff.

  47.  As at 31 March 2006 the rate of three-month vacancies for qualified healthcare scientists working in audiology stood at 3.2%. This was a decrease of 1.6% from 31 March 2005. Prior to 2004 it is not possible to separate the vacancy rates for healthcare scientists from other scientific, therapeutic and technical staff.

  48.  Whilst the introduction of the new BSc is a positive step, we are aware from discussions with SHAs that there has been limited planning locally to increase posts at trust level, to take account of the increased output from training. The first cohorts graduated in 2006 and we are working with SHAs to address the planning issue.

How great a role the private sector should play in providing audiology services

  49.  Private sector provision for assessment, fitting of hearing aid devices, and follow-up does not represent an outsourcing of NHS audiology departments. In fact, it would lead to a significant increase in NHS capacity and is not intended to include any transfer of services to the independent sector. This should drastically reduce the waiting time for receipt of a first hearing aid.

  50.  It is intended that the independent sector procurement will help reduce the backlog without recourse to public capital investment funds. The NHS remains free to reconfigure and expand their services, although it is likely this procurement will bring innovative approaches to the delivery of these services and this will be a healthy challenge to the NHS.

  51.  The core benefits of a national independent sector procurement include:

—  Provide additional short and medium-term capacity and meet un-met demand to support the NHS in delivering adult hearing services.

—  Reduction in the significant waiting times for hearing aids.

—  Increase patient access and choice (patients will still have a choice between direct access in a community setting or GP referral to NHS trust audiology departments).

—  Increase the private-public mix of services.

—  Provide VfM solutions for the NHS; the involvement of the independent sector will drive a more commercial approach to the provision of audiology services. This could potentially increase efficiency and levels of innovation.

—  Shift care from hospital settings nearer to patients, in-line with the Our Health, Our Care, Our Say White Paper "Shifting Care" commitment.

Public Private Partnership (PPP)

  52.  Following a public tendering process, the National Framework Contract Public Private Partnership (PPP) with David Ormerod Hearing Centres and Ultravox Holdings plc was announced in October 2003. The contract was due to run until October 2005 but has now been extended until April 2007.

  53.  The contract allows NHS Trusts to use the two specific private hearing aid dispensers to see NHS patients. It ensures that the patient receives care to the same standard as used in the NHS, is provided with the same hearing aids and remains the responsibility of the NHS.

  54.  It is fundamental to the National Framework Contract that the quality of service, and hearing aid, that the patient receives mirrors those of the local department. Quality assurance is key in the initiative. Both companies have demonstrated their commitment to meeting these standards and have invested resources in terms of equipment, IT and staff training in order to do so.

NEXT STEPS: AUDIOLOGY FRAMEWORK

  55.  The Department of Health plans to publish its national audiology framework on 15 February 2007. The framework will set out the challenge and will provide commissioners with the tools to meet this challenge.

  56.  The Department will forward the Audiology Framework to the Health Select Committee upon publication.

The Department of Health

8 February 2007

THE MODERNISING HEARING AID SERVICES (MHAS)

  1.  In January 2000, Minister of State for Health, John Hutton MP, announced a pilot study to introduce digital hearing aids to the NHS, with details of the pilot sites confirmed in May of that year. Jacqui Smith MP, Minister of State for Health, announced expansion of the scheme beyond the pilot sites in 2001, with a commitment to full roll-out and modernisation by 2005, confirmed in February 2003. In 2002, the Minister announced the formation of the NHS Negotiating Team, comprising a partnership between the Department of Health (DH), the Royal National Institute for Deaf People (RNID), the NHS Purchasing and Supply Agency (PASA) and the Medical Research Council's Institute of Hearing Research (IHR) to support this programme and drive change.

  2.  The aim of the programme was to provide high quality digital hearing aids, as part of a modernised service, which was re-designed around the needs of people with hearing impairment. It recognised that people also need appropriate support and continuing care in order to use their hearing aids effectively and achieve a better quality of life. The MHAS programme was an important demonstration of the Government's NHS Plan commitment to modernise and improve the quality of services and to make them more accessible to patients.

  3.  The programme was managed by the Royal National Institute for Deaf People (RNID) on behalf of the Department of Health. The aims of the programme were:

Adult services

—  Introduction of modern digital signal processing hearing aids to all new and reassessment patients.

—  Introduction of uniform clinical protocol and patient journey.

—  Introduction of audiology patient management system to capture all patient demographic and clinical data, appointment, stock etc.

—  Introduction of routinely gathered data on outcomes for service management and individual patient rehabilitation.

—  Fostering an evaluative, modernising culture among the staff.

Children's services

—  Modern digital signal processing hearing aids to be routinely fitted to new cases, and offered to all existing aid wearers managed by the service within 24 months.

—  Aids to be fitted to an authorised software version of a paediatric fitting procedure with probe tube microphone verification.

—  Fitting to be followed by regular and ongoing reviews.

—  Impression and ear mould protocols to conform to new standards.

—  Close liaison with education services, including joint training, review appointments, and shared information.

—  Individual audiological management plans, agreed between parents, Health and Education services, with copies of all reports and assessments to parents.

—  The service across health, education and social services to be monitored by a multi-agency children's hearing services working group including parents.

REDUCING THE PRICE OF THE HEARING AID

  4.  Working together, the NHS Purchasing and Supply Agency (PASA) and RNID negotiated a favourable contract for procurement of digital hearing aids. The aids were sophisticated models similar to those sold on the high street for up to £2,000 each. They were made available to the NHS at around £70 each—very little more than the cost of analogue aids.

  5.  NHS PASA developed a new supply strategy in order to bring advanced technology to the NHS market. Detailed research was undertaken to understand the cost breakdown for digital hearing aids and the key drivers in reducing the cost to the NHS.

  6.  A tender process was carried out and a national contract was awarded to two suppliers for the key product line. The contract achieved an average reduction in the price of digital aids of 86%.

AUDIOLOGY AND 18 WEEKS

  7.  The 18-week pathway focuses on hospital pathways (and in particular hospital medical consultant pathways) as funded in the 2004 Spending Review agreement with HMT.

  8.  Audiology, and adult hearing services in particular, are mainly accessed directly by primary care and are therefore predominantly outside the scope of the 18-week pathway, which is focused on changing traditional hospital consultant pathways.

  9.  The Department considered the results of the listening exercise on the principles and definitions to govern the 18-week referral to treatment pathway, but because the majority of adult hearing services are accessed directly from primary care it would not be appropriate for them to be covered by 18 weeks.

  10.  The 18 weeks target focuses on hospital consultant pathways. Over time, patients with hearing problems who do not need to see a hospital consultant have increasingly been referred direct to audiology services, enabling services led by ENT consultants for example to focus on more complex cases. Direct access services should be quicker for patients because they cut out a stage of the potential pathway, and it would be perverse to reverse this.

  11.  It was recognised and identified within the 18-week implementation plan that direct access to audiology departments is the result of the introduction of innovation into the care pathway. This has led to a decrease in the number of patients who have needed to be seen by an ENT consultant, thereby freeing up the capacity of ENT to see patients with other problems.

FUNDING

2000-01—2004-05

  12.  £125 million was invested between 2000-01 and 2004-05 through the MHAS programme.

2005-06

  13.  In 2005-06 £12 million revenue and £26 million capital was allocated to NHS Trusts and PCTs for audiology services as part of the general allocations.

2006-07

  14.  In 2006-07 revenue allocations for audiology services were included in the SHA bundle. DH allocated approx £5.5 billion to SHAs as a single bundle of budgets, with the aim being to give SHAs as much flexibility as possible in the management of funding and delivery of services. It was the responsibility of individual SHAs to decide, in consultation with local stakeholders, how best to deploy the funding. In addition £26 million capital was allocated to NHS trusts and PCTs for their audiology services.

2007-08

  15.  There will not be any specific audiology allocations in 2007-08. Decisions about funding levels for audiology services will need to be taken locally, with consideration given to the need to have sufficient direct access activity to substantially reduce waits.

  16.   The NHS in England: Operating Framework for 2007-08 confirmed that there would be another SHA bundle of central revenue budgets for 2007-08 with a proposed value is £6,945.8 million. The bundle will be supplemented by a service level agreement between DH and SHAs. This agreement will include details of the services to be provided from the bundle.

  17.  A new capital regime has been put in place from 2007-08 under which NHS trusts can draw down as much capital as they can afford to service, rather than having it allocated to them. The new guidance for trusts, New Capital Regime for NHS Trusts, was issued on 13 December 2006. Allocation arrangements for PCTs remain unchanged, with a significant increase in the resources that are allocated for investment by the sector. This increase in resources to PCTs has removed the need to allocate additional capital specifically for many initiatives, including audiology.