EXECUTIVE SUMMARY

  1.  A transformation has taken place in NHS audiology services in the last seven years. In early 2000 every NHS audiology department was routinely providing adult patients with hearing aids based on technology that had not changed since the early 1970s. One third of aids were infrequently or never used by patients. Over five years the NHS audiology service was completely modernised by RNID working in partnership with the Departmet of Health. Since March 2005 every audiology department has routinely been providing high quality digital hearing aids. Yet, set against such a transformation there has been no real change in the capacity of the NHS audiology service to meet local needs. The absence of any central targets for waiting times has meant that the service has been starved of adequate funding by the majority of Primary Care Trusts. The failure to tackle the issue of capacity has meant that lengthy waiting times have been a long standing and escalating problem in many areas of the country.

INTRODUCTION

  2.  RNID is the largest charity representing the nine million deaf and hard of hearing people in the UK. As a membership charity, we aim to achieve a radically better quality of life for deaf and hard of hearing people. We do this by campaigning and lobbying vigorously, by raising awareness of deafness and hearing loss, by providing services and through social and medical research.

  3.  Until 2000 the NHS audiology service was routinely providing out of date (analogue technology) hearing aids to adults. The difference in benefit between the analogue hearing aids available on the NHS at that time and the advanced digital hearing aids available only on the high street, at a cost of over £2,000, was almost certainly the biggest example of health inequality between public and private sector provision in the UK. This view was reiterated by the Audit Commission in their report Fully Equipped (March 2000). The report stated: "Nowhere is the cost versus quality debate in public service delivery better exemplified than in the provision of hearing aids. Millions of people could benefit from reduced waiting times and the provision of better hearing aids".

  4.  Waiting times have been a significant problem for many years. In May 1999, before the modernisation of audiology services started, RNID published a report titled Waiting to hear. The information about waiting times was based on a survey of audiology services undertaken by RNID and revealed that the average time from direct GP referral to obtaining a hearing aid was then about five months, with waits of over a year in some parts of the country. The report highlighted the inadequate capacity and poor accessibility of the service and commented: "The low priority given to audiological services within the NHS is having a serious impact on quality of life, especially for older people."

  5.  Working with the NHS purchasing team RNID led the procurement process for digital hearing aids at the outset of the modernisation, fully exploiting the power of the NHS as the largest volume purchaser of hearing aids in the world. Following negotiations with multinational hearing aid manufacturers an agreement was reached that ensured a dramatic drop in the price of advanced digital aids for the NHS. RNID subsequently managed the Modernising Hearing Aid Services programme in partnership with the Department of Health from 2000-05, introducing the provision of cutting edge digital hearing aids in a phased roll-out across the country. This programme also included the provision of equipment for programming digital hearing aids, training of staff in the new techniques and improved service delivery protocols at every audiology department in England. This was the first example of a charity delivering a major Government programme of modernisation within the NHS.

  6.  The Medical Research Council's Institute of Hearing Research evaluated the effectiveness of a modernised hearing aid service. Its evaluation of the first 20 modernised audiology departments found that patients fitted in a modernised service with digital aids were reporting a 41% overall improvement in hearing benefit compared to patients with an analogue aid. There was also evidence of patients wearing their digital hearing aids for significantly longer each day.

  7.  It is estimated that since 2000 over a million people have received digital hearing aids from the NHS. While a significant achievement, there are nonetheless about half a million people in England who are in the system and still waiting for a modern digital hearing aid.

  8.  RNID is committed to changing attitudes towards hearing loss. Our vision is a world where wearing a hearing aid is considered no more surprising than wearing glasses. We are seeking to challenge the widespread misunderstanding and often stigma that relates to hearing loss. In particular we actively encourage more people to take an interest in their own hearing. In December 2005 RNID launched a nationwide campaign called Breaking the Sound Barrier. An integral part of this campaign was a telephone based hearing check (0845 600 5555) which has already been taken by well over 300,000 people.

Whether accurate data on waiting times for audiology services are available?

  9.  Comprehesive accurate data is not available. Since the beginning of 2006 the Department of Health have been collecting and publishing monthly data on waiting times for a range of 15 key diagnostic tests and procedures, including hearing tests (audiology assessments).

  10.  In relation to audiology services we understand that some PCTs have not submitted audiology returns. There has also been a lack of clarity as to how the data should be collected, with the result that even the partially collected data is unreliable. In particular the exclusion of people waiting for repeat tests has led to hearing reassessments not being included in returns from some PCTs. For people waiting to have their hearing reassessed, it is often many years since they were last fitted with a hearing aid and their hearing may have changed considerably. The waiting times for reassessments currently tend to be much longer than for people getting hearing aids for the first time.

  11.  Most fundamentally, there is total lack of data collection on the subsequent wait for having a hearing aid fitted after patients have had their hearing tested.

  12.  However, while there are no centrally held figures for the total wait between GP referral and actual fitting of hearing aids for new patients, or the time that people with hearing aids are waiting for reassessments, there is nonetheless extensive information from numerous surveys which have consistently revealed the existence of lengthty waiting times. Most recently the Freedom of Information requests made by the Grant Shapps MP have confirmed this situation. His survey of nearly 100 NHS Trusts revealed an average time from referral to fitting of 40 weeks and 64 weeks for reassessments.

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

  13.  Over many years health economies have not invested adequately in audiology services. Historically audiology services have had a low profile and have been neglected and marginalised in many hospitals. Evidence of such neglect is clearly demonstrated in RNID's report Waiting to hear and also the Audit Commission report Fully Equipped, published in March 2000. The Audit Commission report stated "There is a two-fold variation in the number of hearing aids issued per head of the hearing impaired population between regions, and an even greater variation between individual health authorities within regions for audiology services. In 1996-97, 22 health authorities issued hearing aids to less than 20% of the population who needed them, and the amount of money allocated by health authorities to these services appears to be unrelated to need or explicit local priorities."

  14.  The success of the modernisation project was partly related to the special funding arrangements, where the funding was in practice ring-fenced. Commenting on this the Audit Commission stated: "While little of the new money for community equipment serices reached frontline services, most of the new funding allocated to audiology services in England is being spent as intended. This is because it is allocated directly to trusts by a project manager at the Royal National Institute for Deaf People (RNID)."

  15.  Despite the inadequate funding of the audiology services it is the case that hearing aids are a relatively straightforward intervention with proven effectiveness, resulting in huge benefit in quality of life, social inclusion and employment opportunities. These benefits come at a very small cost per patient. Indeed, it is very difficult to think of any other form of expenditure in the health service where the benefits to individuals and society are so great, per pound spent.

  16.  The low priority given to audiology services has been reflected in the lack of any national targets. The absence of such targets has contributed to audiology services being a low priority for funding. Frozen posts and insufficient funds have meant departments have often been unable to properly meet the needs of their local populations. RNID has found that few commissioners are able to even identify how much they spend on audiology services, especially as audiology is often buried within blocks contracts for ENT and associated services. The limited national initiatives that have taken place to increase capacity have been very short term. There have also been inconsistent Department of Health policies in relation to audiology workforce and training.

  17.  In relation to the target 18-week pathway from referral to treatment it should be stressed this only applies to consultant-led services. Most people with age-related hearing loss are referred by their GP directly to the audiology department, avoiding the need for an ENT appointment first and therefore simplifying the pathway for these people. Only those who require further medical investigation are referred to ENT. Typically, around 80% of referrals are direct and around 95% of people referred directly to audiology need hearing aids. However, it is a bizarre consequence of the restriction of the 18-week target to consultant-led services that the 20% of people who are referred via ENT will get their hearing aids fitted within 18 weeks while the majority of people needing hearing aids are typically waiting a year or more.

  18.  In addressing the issue of waiting times it must be stressed that the centrally funded modernisation of the NHS audiology services from 2000 to 2005 was limited to improvements in technology and service delivery. Although it provided some modest funding for short-term capacity initiatives, while the changes were being implemented, it did not attempt to address in any fundamental way the issue of capacity.

Whether the NHS has the capacity to treat the numbers of patients waiting?

  19.  Until a full assessment of current and likely future demand has been undertaken, together with an analysis of workforce utilisation and skill mix, it would be misguided to make a judgement as to whether the NHS has sufficient capacity.

  20.  Many people who have a hearing loss actually wait many years before first raising their hearing loss with their GP, who are the gatekeepers to accessing NHS audiology services. Waiting lists for audiology services therefore only provide a partial picture of the number of people who would benefit from audiology services.

  21.  RNID understands that the Department of Health has never fully investigated the potential demand for audiology services. In producing the Action Plan for Audiology services it would appear that no consideration is being given to undertaking a rigorous analysis of the expected demand for audiology services.

  22.  The NHS could increase its capacity to see significantly more patients if staff vacancies and freezes in employment were ended. For example, 2006 saw the first graduates of the four-year BSc degree course in audiology. It is our understanding that about 40% have not yet found employment in the NHS. About 180 audiology BSc graduates are expected each year.

  23.  RNID does recognise there are limits to how quickly the NHS can expand its capacity and therefore accepts the need for some role for the private sector.

Whether enough new audiologists are being trained?

  24.  A proper assessment of staffing needs can only be made when a full assessment is first made of the actual demand for audiology services. Even the scant information that is available on waiting times reveals severe problems in many parts of the country, especially for people waiting for reassessments. However, there is also a great deal of further unmet need. Research from the Medical Research Council shows that there is typically a 15-year gap between the onset of hearing loss and patients taking the first step of raising the issue with their GP. At present around two million people in the UK have a hearing aid, but it is estimated that a further four million people could benefit from one. As a change in attitudes towards hearing loss takes place it is RNID's hope that many more people will present earlier for assessment.

  25.  Evidence of staff vacancies does exist. In answer to a written parliamentary question (24 July 2006) it was stated that there were 70 vacancies for audiologists remaining unfilled after three months or more in England (based on the March 2005 vacancy survey). This was a vacancy rate of 4.8%. While it is welcome that the vacancy rate has fallen to 50 in 2006, it should be stressed that a vacancy rate of 3.2% is still one of the highest vacancy rates for any medical profession.

  26.  RNID very much welcomes the agreement on the foundation degree being the basis for assistant audiology staff in the NHS as well as the independent sector, provided that both foundation and BSc degree course qualifications enable registration under the specific titles by the Health Professionals Council. However, it is disappointing that there has been lack of effective national workforce planning. For example staffing problems have been magnified by the decision to suddenly stop the BTec audiology qualification before students had completed the BSc degree course, leading to a gap in newly qualified staff.

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

  27.  There is already experience of the private sector being involved in the delivery of NHS audiology services. During the modernisation programme, RNID worked with the NHS purchasing team to set up a National Framework Agreement with two national hearing aid dispensing companies for a Public Private Partnership (PPP). Central funding was available for this scheme and in total 50% of NHS Trusts took part, enabling capacity to be obtained in a short period of time. In some locations the local health economies also contributed to the PPP as well. Now that PCTs have to exclusively fund extra capacity themselves, PPP activity has dwindled to a very low level. Evaluation of the use of the private sector has largely been positive. Professor Adrian Davis of the Medical Research Council (MRC) who has evaluated PPP has stated "Our research concluded that judicious, quality assured use of private sector hearing aid dispensers has substantial promise in delivering a major boost to capacity."

  28.  RNID has welcomed the announcement by Lord Warner in July 2006:

"I am pleased to announce today that as part of the second phase of the procurement of diagnostics from the independent sector, I have decided that an additional 300,000 patient pathways will be procured. That will start to produce services in the form of assessments, fitting and follow-up for people with hearing difficulties from the early part of 2007." [63]

  29.  RNID wishes to see the NHS directly increase its own capacity. However, we recognize that achieving a significant step increase in NHS provision will require involvement of the independent sector. In general we do not believe it is important where a patient is seen subject to the provision of digital hearing aids being free at the point of delivery and the service conducted by appropriately qualified staff working to nationally agreed service specification and standard protocols. It is vital that clinical governance is clearly defined and that a robust quality assurance mechanism is in place.

  30.  Any expansion in the use of the private sector by the NHS must include comprehensive safeguards for service users, many of whom are vulnerable people. It is vital that patients are not persuaded to buy products they do not need. Unlike with spectacles for correcting common visual defects, it can be difficult for people with hearing loss to identify if they are gaining optimal benefit with hearing aids. Choices are not purely aesthetic and pricing of features is not transparent or standardised.

  31.  NHS patients that are sent to the independent sector must be fully informed of what they are entitled to, what quality of service they can expect and how to complain if any problems arise.

RECOMMENDATIONS

  32.  Audiology services should be brought within the 18-week target for service delivery. The target should apply from the time between GP referral to final fitting of a hearing aid, or aids. The target should also apply to the length of time people wait from a request for reassessment to fitting of a new aid, or aids. A specific timescale should be set for reaching such a target, which should be no more than two years.

  33.  A full assessment should be made of the actual demand for audiology services and thorough workforce planning carried out to ensure that demand will be met in a reasonable timeframe.

  34.  Department of Health planning for audiology services should give greater consideration to the ongoing needs of hearing aid users in terms of continuing care.

  35.  The Department of Health should implement the Ministerial commitment, made in July 2006, to procure an additional 300,000 patient pathways.

  36.  The Department of Health's action plan to reduce waiting times should be published. The plan should include detailed proposals to ensure that in the longer term audiology services become more community based and accessible. The plan should further include rehabiliation and support that should be available for those living with tinnitus.

Royal National Institute for Deaf People

January 2007