1.  We are pleased to submit evidence to the above Inquiry. The Royal College of Physicians (RCP) plays a leading role in the delivery of high quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the United Kingdom and overseas with education, training and support throughout their careers. As an independent body representing over 20,000 Fellows and Members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare.

  2.  A recent RCP Working Party on hearing and balance disorders included practitioners from a wide range of specialties including primary care, neurology, geriatrics and paediatrics, as well as audiological medicine and a representative from the Department of Health. In addition, evidence was given by societies for the deaf, those who provide specific services, and a patient representative.

BACKGROUND INFORMATION

  3.  Audiovestibular Medicine is the medical discipline concerned with the investigation, diagnosis and management of disorders of hearing and balance, including tinnitus, in both children and adults. In addition, some specialists are concerned with overall communication and the management of speech and language disorders in children (phoniatrics). Indeed, in some European countries, audiovestibular medicine and phoniatrics are one specialty.

  4.  Hearing loss can affect all ages—from congenital hearing loss in the newborn to late onset hearing loss in older people. The condition impacts on learning and development, is socially isolating and in addition has economic consequences for those of working age who suffer hearing loss often accompanied by balance disorders (which need to be considered in their own right and not just as an add-on to hearing loss). Yet the conditions causing hearing and balance disorders often remain undiagnosed or inadequately managed because of inappropriate referrals and the non-availability of a medically supported audiological/vestibular service.

  5.  The World Health Organisation has identified deafness as a non-communicable disease that is "a cause of enormous human suffering and a threat to the economics of many countries" and that "constitutes a major contributor to the burden of avoidable risk and disease" that require to be addressed with surveillance, health care and long-term care measures (WHO May 2004) http://www.who.int/ncd/mip2000/documents/key_areas_en.pdf).

  6.  Disorders of the ear represent 24% of all disabilities in the adult population in the UK. Of the UK adult population aged 18-60 years, 17% suffer significant hearing loss and this figure rises steeply with age (80% by 80 years). One in 1,000 children are born with a permanent hearing loss and this figure rises to two in 1,000 for children 9-16 years of age. The Newborn Hearing Screening Programme has identified some 50% more infants with permanent childhood hearing impairment at a much younger age than were previously diagnosed. Some of these infants will have potentially treatable conditions.

  7.  Forty per cent of people aged over 40 years experience symptoms of dizziness and/or imbalance. These symptoms are the most common reason for visits to a doctor by patients over the age of 65 years.

  8.  Demographic changes in the population will increase the medical need in hearing and balance disorders, as has been outlined in the National Service Frameworks (NSF) for Long-Term Conditions and for Older People (2001).

ROLE OF THE AUDIOVESTIBULAR PHYSICIAN

  9.  Consultant audiovestibular physicians form an integral part of the Multi Disciplinary Team, which aims to provide prompt, accurate, resource efficient and effective care to patients with audiological and vestibular disorders. The unique role of the audiovestibular physician is two fold:

(a)  generically, as a consultant physician supervising the holistic care of the patient; and

(b)  specifically, in the prevention and/or amelioration of pathology, aetiological diagnosis, interpretation of investigations in the context of medical care and medical treatment/management/rehabilitation.

  10.  This is particularly important with respect to the translation of basic neuroscience research advances in pathological mechanisms, neurochemistry and pharmacology into the clinical domain.

SERVICE PROVISION

  11.  Despite the prevalence of hearing and balance disorders (set out above), the provision of medical care has remained a relatively low priority for the NHS. There are inadequate numbers of medical and non-medical personnel, limited availability of test facilities and poor access nationally to the range of treatment and rehabilitation options. Thus in 2006 there was one audiovestibular physician per million population in UK. In Denmark the ratio is 1: 125,000 and Sweden 1:135,000. There is marked geographical inequality in service provision, with clustering of audiovestibular physicians/ paediatricians in specialist centres (London and Manchester) with no provision in the majority of the country (see figure 1).

  12.  Hearing and balance services have developed piecemeal across the UK dependent upon local expertise and resources. Only a handful of services provide complex audiological investigations/rehabilitation, for example for auditory neuropathy or auditory processing disorders and full vestibular investigation and rehabilitation. Specific deficits in the service are listed below:

—    here are no national audit figures as provision is fragmented, provided in diverse settings, and historically "audiology" has been seen as a low priority healthcare need;

—    here is a paucity of dedicated audiology, tinnitus or vestibular clinics, with limited access to an integrated multidisciplinary team (MDT) comprised of the relevant complement of professional skills;

—    despite the majority of patients suffering from conditions which are not surgically remediable, nor caused by central nervous system pathology, referrals are primarily directed to specialties recognised to be overburdened by the Department of Health (ie, ENT and neurology); [57]

—    here is no clear evidence to ensure appropriate medical as opposed to non-medical provision, and optimal use of available manpower and resources;

—    appropriate medical expertise may not be available to patients presenting with audiovestibular symptoms in a non-medical audiology service, leading to limited diagnosis and treatment of relevant medical conditions;

—    with the loss of community medical officers, there is a shortfall in provision of community medical/paediatric audiological services;

—    with the reorganisation of services, audiological experience amongst community medical officers is low; and

—    here has been inadequate medical and non-medical workforce planning for future hearing and balance services.

  13.  The public health and socioeconomic costs of auditory and vestibular disorders have not been recorded. However, the cost benefit of early identification and habilitation of infants with profound hearing loss, facilitating integration into education, society and a full range of occupations is well recognised. [58]

  14.  Adult auditory rehabilitation programmes are also recognised to be cost effective in enabling adults to continue functioning both in the workplace and socially with consequent effects on psychological wellbeing. [59]

  15.   Community based studies in England and Scotland have suggested that 20-25% of the population experience symptoms of dizziness/vertigo, with one quarter losing time from work in one study and one half reporting some disability in a second study. [60]

  16.  According to the US National Institutes of Health, the mean number of physicians a patient with peripheral vestibular pathology visits before receiving a correct diagnosis is 4.5. A similar finding is reported from specialist balance centres in the UK. [61]Frequently such referrals are associated with non-contributory expensive investigations such as MRI. The cost of delay in diagnosing the most common vestibular syndrome in older patients (BPPV) has been estimated at 253.62 Euros/patient.

NEW AUDIOVESTIBULAR PHYSICIANS AND TRAINING

  17.  The shortcomings of the audiovestibular service can be partly accounted for by the lack of training opportunities. Specifically:

—    here is virtually no training in audiovestibular medicine (the investigation, diagnosis and management of hearing and balance disorders and labyrinthine involvement in systemic disease) at the undergraduate level, in general practice training programmes or specialist training for physicians and paediatricians;

—    Neurologists, ENT surgeons and audiologists receive minimum training in the physiology and pathology of eye movement disorders, which are key to diagnostic vestibular assessment;

—    here is no overlap in training programmes between the professional groups leading to variability in standards of knowledge and competencies; and

—    here is only one academic unit of audiovestibular medicine in the country with a paucity of junior academic training posts.

NHS PROVISION

  18.  MDT working is essential in the future. Within this model, the focus of the work of the Audiovestibular Physician is directed at supporting and integrating with the skills of all members of the MDT. To meet the NHS targets of rapid, easy access to medical care, a three tier multidisciplinary managed network of care for hearing and balance disorders is proposed. A healthcare scientist/GP led primary care service will be developed and have access to and support from hospital centres, with audiovestibular physicians as part of the MDT. These centres, in turn, will be linked to tertiary centres with state-of-the-art facilities and medical and non-medical staff with subspecialty expertise. This will enable rapid, high quality care close to the patient's home for the large number of routine cases, with seamless, prompt and direct access to super-specialist care for complex cases, as required by current NHS directives.

RECOMMENDATIONS

Service provision

—    Clinical and academic audiovestibular physicians and paediatricians together with senior clinical and academic audiologists with a subspecialty interest and expertise, eg neuro-otology, electrophysiology, cochlear implantation should be based at the university/regional centres which have particular responsibility for teaching and research to both the medical and healthcare professions.

—    Consultant audiovestibular physicians and paediatricians together with audiologists as part of a MDT should provide a broad service across the discipline and be based in specialist centres serving 250,000 per consultant physician.

—    Audiologists should provide diagnostic auditory and vestibular services within the primary care/community service, while GPs, with additional training should continue to provide medical care of the patient within this service.

—    Given the current lack of training and knowledge in primary care, an audiovestibular service should initially be led in a top down manner with consultant audiologists and audiovestibular physicians training and supporting those working at the community/primary care level who will ultimately lead the service. It follows that there would need to be an increase in the number of consultant audiovestibular physicians and senior audiologists at every level of the network.

—    A national network of balance centres should be formed to address the current limited access to such services.

Training and Resources

—    We recommend that 10 new consultant audiovestibular physicians should be appointed over the next two years, in hospitals without medical support for audiovestibular services to lead the appropriate medical training and provide medical input to MDT. This figure takes account of the estimated 50% retirement of the current consultant workforce in next seven years. [62]

—    Five new funded training numbers at ST3 level should be allocated each year for next five years. This would lead to approximately 200 audiovestibular consultants in 2016 ie approx 1:300,000 population.

—    Dialogue with RCPCH should continue to ensure appropriate training of specialists providing paediatric service, and the development of integrated core modules of knowledge common to all healthcare professionals working in the field.

—    Audiovestibular training programmes and workshops should be developed for GPs (who it is envisaged will ultimately lead the service).

—    The development of additional academic departments to lead training and research should be supported.

—    Basic training in audiovestibular medicine should be introduced at both the under- and post-graduate medical levels, including foundation training, and in relevant healthcare curricula.

—    Basic principles of audiovestibular medicine should be included in the curricula for MRCP and MRCPCH examinations.

—    The development of common assessment of competencies for core skills should be provided by a professional working in the field.

  We hope you find this information useful to your inquiry. The RCP would be pleased to provide oral evidence as part of the next stage of this inquiry.

Lucy Widenka

Royal College of Physicians

8 February 2007

58   Barton G R, Stacey P C, Fortnum H M, Summerfield A Q. Hearing-impaired children in the United Kingdom, II: Cochlear implantation and the cost of compulsory education. Ear Hear. 2006 April; 27 (2): 187-207. Back

59   Joore M A, Van Der Stel H, Peters H J, Boas G M, Anteneunis L J The cost-effectiveness of hearing-aid fitting in the Netherlands Arch Otolaryngol Head Neck Surg. 2003 March; 129 (3): 297-304. Back

60   Yardley L, Owen O, Nazareth I and Luxon L M (1998), Prevalence and presentation of dizziness in a general practice community sample of working age people. British Journal of General Practice. 48, 1131-1135. Back

61   Personal communication: St George's Hospital London Audit, Dr Snashall and Dr Raglan. Back

62   RCP Working Party Report on Audiovestibular Medicine (2007). Back