Keeping the backlog under control is different to clearing it. To achieve a successful local dynamic balance between demand and supply use of accurate date is important. Quality control is of course very important for the patient but also contributes to controlling the backlog because unnecessary repeat visits are not generated.

  Some important aspects are listed here, not just to aim at sustainable solutions but also to identify false solutions.

1.  HOW IMPORTANT IS PROCESS INFORMATION?

  Process information has many aspects. But data which is accurate, relevant and timely is vital for understanding the process and then improving it sustainable.

  Lots of real-time data is readily available at local level and doesn't necessarily need to be aggregated across the whole of the NHS before it can be used. The essential information needed at this point is:

—  Diagnostic to fitting wait times.

—  Value for money in ISTC/PPP.

—  Quality assurance of both pathways.

  As the process improves, less data is needed because flexibility and responsiveness are built in at local level. The whole philosophy of "lean" thinking has a major contribution to make here, as it has already done in many other parts of the NHS.

2.  LOOKING AHEAD ON SKILL MIX

  If we invest in training graduates (or earn + learn associate grades) we should make sure that such valuable resources are rapidly put to work as soon as they can contribute.

  In the longer term the investment will continue to return value if career paths which give good job satisfaction are clear, and dead-end production line approaches—leading to high levels of early drop-out—are avoided. (As experienced during PPP)

  Associate grades are a key missing link in the skill mix, although urgent commitment is required to encourage more than the current small number of Universities offering limited places on the Foundation Degree courses. With the first courses starting in summer 2007, the earliest graduates will not be contributing full time until 2009.

  For PPP to add any capacity worth considering they need to be trained to state registration level via a minimum of foundation.

  Clear NHS commitment to use those who make the grade is the single biggest contributor to getting the supply line rolling for the benefit of both the NHS and PPP.

3.  MAINTAINING AND IMPROVING QUALITY FOR PATIENTS

  Digital hearing aids are complex and sophisticated. Skills of a much higher order are needed to ensure they contribute to the full in the patient's interest. Alongside that, there are many other factors in the patient's environment and behaviour which can impede true improvement.

  The Hearing Aid Council has made clear the challenges to be faced to ensure that Hearing Aid Audiologists are genuinely fit for purpose and are protecting patients' best interests. These challenges are real and won't go away just because the Council is phasing out.

  Strategic workforce planning that follows through the remit of training a workforce for the future needs to stay the course and deliver not only on education but in career pathways provision and remodelling of the recruitment process especially.

  Any PPP or ISTC should be audited for quality and value for money.

4.  LEARNING FROM ABROAD (REF EUROPEAN FEDERATION AUDIOLOGY SOCIETIES WWW.EFAS.WS)

  The main lesson to learn from abroad is that they expect and respect solid professional training in dealing with a complex technical and human problems such as required for an audiology patient journey.

  The digital hearing aid sits at the intersection of the technical and the human aspects and the voucher system works there because the audiologists have the full range of training and skills required to handle that joint complexity.

  A voucher system assumes that Pure Tone Audiometry results are prescriptive. No two hearing losses are the same—even if they do appear identical on an audiogram. So many other factors need to be considered. Essentially, hearing aid fitting and hearing rehabilitation is a holistic treatment that would be unlikely to respond well to a prescription or voucher system. It is not comparable to the provision of eye care, spectacles and contact lenses.

  Hearing aid fittings require access simultaneously to a sophisticated piece of digital equipment plus a properly qualified and trained specialist. The two go together. Software alone is no substitute for specialist skills. Far from deskilling the audiologist's role, in fact it calls for more demanding skills to achieve the much higher potential improvements possible.

5.  LOCATION, LOCATION ...

  The Hidden Hearing written evidence cites the use of local health centres and GP surgeries. This lesson could be developed and implemented more efficiently in the NHS.

  A very noisy shopping centre or high street can definitely compromise the quality of the testing and hearing aid verification which is at the heart of the process. Adequate sound proofing is costly and awkward to install correctly and would require massive capital investment. Not a financially attractive option when truly costing services on multiple sites.

  Mobile units sound attractive for a one-off need but some patients often the ones with the highest need may require regular appointments.

Ruth Thomsen

Audiologist, Charing Cross Hospital

March 2007