Under pressure - Action on Hearing Loss

Transcription

UNDER PRESSURE:
NHS AUDIOLOGY ACROSS THE UK
By Christina Lowe
FOREWORD
We are publishing this report at a critical time for audiology
services. Demand from our ageing population is growing rapidly.
Yet despite the strong evidence that hearing aids and audiology
services should be provided for everyone who needs them,
commissioners in three areas in England have recently proposed
major cuts to NHS hearing aid provision.
This report goes further, showing how a failure to invest in services
in line with demand has left many audiology departments across
the UK struggling to cope. And all this at a time when support
from local councils has already been heavily stripped back. How
long before we recognise the impact that this is having on the ten
million people with hearing loss, and the many millions more who
communicate with them daily, at home or at work?
We must stop these cuts now – denying people the ability to
communicate is both cruel and senseless. It leaves people cut off
from the world, and at the same time it leads to higher costs for
the NHS, the government and the national economy, as people
are forced to leave work early, left unable to manage other health
conditions, and in greater need of more intensive support, all at the
expense of the taxpayer.
We can no longer shy away from this challenge. With the General
Election just around the corner, now is the time for governments
across the UK to step up and show decisive leadership – to commit
to proper investment in services, and to set and enforce national
standards. With co-ordinated plans and action, hearing loss can
be managed more effectively at a national, local and personal
level, and we can ensure that people with hearing loss are able to
communicate and live their lives to the full.
Paul Breckell,
Chief Executive
Action on Hearing Loss
January 2015
For more information about our campaign and about this research, please see:
www.actiononhearingloss.org.uk/underpressure
2 | www.actiononhearingloss.org.uk
Under pressure: NHS audiology across the UK | 3
Introduction
Hearing loss is a serious health condition that can have a profound
impact on a person’s health, wellbeing and overall quality of life
(Chisholm et al, 2007; Mulrow et al, 1990; Arlinger, 2003). There are
currently 10 million people in the UK with hearing loss. Prevalence
increases with age, with nearly three-quarters (71%) of people aged
over 70 affected. Since the population is ageing, the total number of
people with hearing loss is expected to rise to 14.5 million by 2031
(Action on Hearing Loss, 2011).
Without proper diagnosis and management, hearing loss can reduce
a person’s ability to communicate, stay socially active, maintain good
cognitive, mental, and physical health, and get and keep a job (National
Council on the Aging, 2000; Yueh et al, 2001; Genther et al, 2013; Lin
and Ferrucci, 2012; Lin et al, 2011; Arrowsmith, 2014). For example,
older people with hearing loss are more than twice as likely to develop
depression as their peers without hearing loss (Saito et al, 2010) and
at least twice as likely to develop dementia (Lin et al, 2011). Since most
people with hearing loss are older, many are likely to have other health
conditions. If not properly managed, hearing loss can reduce people’s
ability to communicate with health professionals and manage their care,
increasing the impact of other conditions and the cost of treatment
(NHS England, 2014). For example, one study showed that at least
£28 million of savings would be made in England alone if hearing loss in
people with severe dementia was managed properly (DCAL and Action
on Hearing Loss, 2013).
Contents
5 Introduction
6 Aims
6 Methodology
7 Findings
• increasing demand caused by an ageing population
• t he increased number of people with other health and care needs
alongside their hearing loss
• reductions to NHS funding, including audiology budgets
7 Part 1: The impact of budget cuts and
increased demand on service provision
•c
hanges to the way NHS services are provided and commissioned1.
art 2: Variation in provision along the
11 P
audiology pathway
Standards have been introduced in England, Scotland, Wales and
Northern Ireland, which aim to ensure consistent, high-quality audiology
services2. However, providers’ performance against these standards is
neither consistently evaluated, nor published, across the UK.
22 Part 3: Good practice
PHOTO: ISTOCKPHOTOS
NHS audiology services across the UK provide vital support for people
with hearing loss and many have developed innovative ways to improve
the quality and efficiency of their service. However, there are a number
of challenges facing audiology services that may be affecting their
ability to maintain or improve provision:
23 Conclusions
24 Our Recommendations
27 Bibliography
1
Key changes include the introduction of “Clinical Commissioning Groups” across England, and of the Any Qualified
Provider scheme (AQP) in some areas of England. Under AQP, any healthcare provider -including NHS, independent and
non-profit organisations- can deliver NHS services, providing they meet NHS quality requirements, prices and contracts.
2
In England 18 NHS providers have received Improving Quality in Physiological Diagnostic Services (IQIPS) accreditation.
In Scotland, Wales and Northern Ireland, Quality Standards for Adult Hearing Rehabilitation Services are in place.
Aims
Findings
In 2012 we carried out research in England and Wales to understand
the impact of budget cuts (Action on Hearing Loss, 2012a). Since
then, there have been further threats to audiology services,
including proposals to significantly restrict hearing aid provision in
particular areas.
Part 1: The impact of budget cuts and increased demand
on service provision
This research aims to identify how the current provision of NHS
audiology services varies across the UK. Where threats to good
service provision exist, we want to identify these – and understand
their impact. Where services are employing innovative approaches
to improve quality, capacity or effectiveness, we want to share and
promote this good practice.
Methodology
Budget reductions
First, we wanted to know whether providers’ budgets have been
reduced (or have failed to increase in line with inflation) since we last
asked about them in 2012 – and whether this is having a negative
impact on the service that patients receive.
Across the UK, 30% of NHS audiology providers who responded have
had their budgets reduced in real terms in the last two years. This
includes: 38 providers in England; 2 of the 4 trusts in Northern Ireland;
2 of the 13 health boards in Scotland; and no services in Wales.
In some cases, savings have been made that have had no direct
impact on the quality or scope of service provision.
30%
We issued our questions through a Freedom of Information request
to all NHS audiology providers in England, Scotland and Wales3, and
surveyed heads of NHS audiology services in Northern Ireland. The
results, collected between September and December 2014, included:
• 116 responses from the 129 NHS Trusts that provide adult
audiology services in England
of NHS audiology providers have had their
BUDGETS REDUCED in the last 2 years.
• 13 responses from the 14 NHS Health Boards in Scotland
• 7 responses from the 7 Health Boards in Wales
• 4 responses from the 5 Health and Social Care Trusts in
Northern Ireland.
More details of our findings are available at
www.actiononhearingloss.org.uk/underpressure
We didn’t ask questions of private or voluntary sector providers delivering audiology
services in England through NHS contracts, under Any Qualified Provider or other
local commissioning arrangements.
However, in the vast majority of cases,
budget cuts translated into a direct
impact on the service that patients are
offered – 71% of providers with reduced
budgets have seen a noticeable reduction
in the service they provide, with the most
common impacts being reduced follow-up
appointments and increased waiting times
(noted by 24% and 26% of providers with
reduced budgets respectively)4. Further
squeezes on budgets are expected over
the coming year – around one-fifth (19%)
of providers were already aware of budget
reductions planned for the next 12 months,
including one provider each in Scotland,
Wales and Northern Ireland, and 24
providers in England.
THE MOST COMMON
IMPACTS OF BUDGET CUTS
have been: INCREASED
WAITING TIMES and REDUCED
FOLLOW-UP APPOINTMENTS.
3
For more details about the ways in which services have been impacted by budget reductions and/or other factors over the last
two years please see Table 1 on page 9. Full details of the impact of budget cuts alone on services are available – please contact us.
4
Increased demand
Prevalence of hearing loss increases with age, so demand for
audiology services across the UK is growing due to our ageing
population. NHS audiology services must be properly funded to
meet this increasing demand. We wanted to know to what extent
services have been reduced over the last two years as a result of
increased demand.
One-third (33%) of providers indicated that increased demand
is directly impacting on the scope or quality of service that they
are able to provide. This includes: 32 (28%) of English providers;
9 (69%) of Scottish providers; 3 (43%) of Welsh providers; and 2
(50%) of Northern Irish providers.
Changes to service
We asked providers what specific impacts budget reductions,
increased demand or any other factors have had on services.
Table 1 shows the results from providers who responded.
INCREASED DEMAND
has forced 1/3 of audiology providers
to REDUCE THEIR SERVICE over
the last 2 years.
Table 1: Changes to service observed by providers who responded
Number (and %) of providers
Scotland
(of 13
providers)
Wales
(of 7
providers)
Northern
Ireland
(of 4
providers)
Change to service
UK-wide
England
(of 116
providers)
Increased waiting
times
26%
26 (22%)
5 (38%)
3 (43%)
3 (75%)
Increased time to
reassessment
16%
14 (12%)
4 (31%)
3 (43%)
2 (50%)
Reduced availability
of home visits
15%
15 (13%)
0 (0%)
3 (43%)
3 (75%)
Reduced overall
number of staff
15%
17 (15%)
2 (15%)
1 (14%)
1 (25%)
Reduced follow-up
appointments
14%
15 (13%)
3 (23%)
2 (29%)
0 (0%)
Reduced length of
appointments
8%
9 (8%)
1 (8%)
0 (0%)
1 (25%)
Reduced tinnitus
services5
6%
6 (5%)
1 (8%)
2 (29%)
0 (0%)
Reduced average
qualification level of
professional staff
6%
7 (6%)
1 (8%)
1 (14%)
0 (0%)
Reduced number or
qualification level of
specialist staff for
complex cases
6%
7 (6%)
0 (0%)
1 (14%)
0 (0%)
Reduced aftercare
service
4%
2 (2%)
1 (8%)
1 (14%)
1 (25%)
Change to policy on
bilateral hearing aids
3%
4 (3%)
0 (0%)
0 (0%)
0 (0%)
Reduced information
provision
1%
1 (1%)
1 (8%)
0 (0%)
0 (0%)
Change to hearing aid
candidacy
1%
2 (2%)
0 (0%)
0 (0%)
0 (0%)
5
In addition to asking whether their tinnitus service has been reduced, we also asked each provider what their tinnitus
service consists of. These findings will be published separately during Tinnitus Awareness Week in February 2015.
As Table 1 shows, the main changes to services have been longer
waiting times, increased time to reassessment, fewer home visits,
reduced number of staff, and reduced follow-up and length of
appointments. Each of these will be discussed in further detail in
Part 2 of this report, when we look in greater detail at what is being
provided at each stage of the audiology pathway.
Causes of changes
The two main factors prompting these changes were increased
demand and budget reductions (detailed above). For more than
two-fifths (41%) of providers across the UK, budget reductions
and/or increased demand have had a negative impact on their
service. Other causes were changes in service priorities (9%), and
staff shortages, due to recruitment difficulties (10%).
What is particularly worrying is that many of these cuts are
being made in places already struggling to cope with increased
demand. One in six providers (16%) faced budget cuts even though
increased demand was already forcing them to reduce the services
they provide.
BUDGET CUTS AND
OVERWHELMING DEMAND
Part 2: Variation in provision along the audiology pathway
The Audiology Pathway
PROMPT ACCESS
TO AN APPOINTMENT
ASSESSMENT AND FITTING
TO AGREED STANDARDS
PERSON-CENTRED MANAGEMENT PLAN
OUTCOMES MEASUREMENT
have forced TWO IN FIVE audiology
providers to REDUCE THEIR SERVICE.
SIGNPOSTING TO
OTHER SERVICES
FACE-TO-FACE FOLLOW-UP
EASY TO ACCESS AFTERCARE
REGULAR RE-ASSESSMENT
Prompt access to an appointment
It takes people with hearing loss, on average, 10 years to seek help.
And, when they do, GPs fail to refer 45% of them (Davis et al, 2007).
Yet, the sooner a patient receives hearing aids, the easier it is to
adapt – and the greater the benefit (Davis et al, 2007). Failing to
manage hearing loss promptly and effectively increases the risk of
social isolation, mental health problems, falls and communication
difficulties. It’s crucial, therefore, that audiology services make it as
easy as possible for people to get help, including ensuring prompt and
convenient access to appointments.
Each country in the UK has a target waiting time for audiology
patients. In England and Scotland, it’s 18 weeks – from referral to
treatment (typically a hearing aid fitting). In Wales, the target is 14
weeks. Northern Ireland divides it into two stages: nine weeks for
referral to assessment, and 13 weeks for assessment to treatment. Data
about waiting times is regularly published in England, Scotland and
Wales, but not in Northern Ireland.
Assessment and hearing aid provision
After an audiology assessment, most people with hearing loss are
fitted with hearing aids, which have been shown to increase quality
of life, help people manage and prevent other health conditions,
and improve self-confidence, social participation and employment
opportunities (Chisholm et al, 2007; Yueh et al, 2001; National
Council on the Aging, 2000; Kochkin, 2005).
Hearing aids should be offered to all those who could benefit,
not restricted through arbitrary and inflexible eligibility criteria,
which fail to take into account the full range of needs that a clinical
assessment should consider (Lustig and Olson, 2014).
There is extensive evidence of the benefits of fitting two hearing
aids, rather than one, for people with hearing loss in both ears.
Research shows that bilateral fittings:
•h
elp people identify which direction sound is coming from
(Stephens et al, 1991; Dreschler and Boymans, 1994)
We asked providers what percentage of patients were seen within their
country’s target waiting time, according to their latest available figures.
• suppress tinnitus (Brooks and Bulmer, 1981)
• r educe the risk of auditory deprivation (where a lack of
stimulation in the cochlea affects the brain’s ability to
interpret speech sounds) (Silman et al, 1984; Silman et al,
1992; Hurley, 1993)
All but five English trusts stated that 90% of patients or more
were seen within the target waiting time. This supports data
published by NHS England, which shows that, for the last two
years, the percentage of patients treated within the target
waiting time has not dropped below 98%6.
WAITING
TIMES
HAVE
RISEN
over the last
2 years for
MORE THAN
A QUARTER
of audiology
providers.
In Wales, all but one health board stated that 90% or more
of audiology patients were seen within the 14-week target
waiting time, confirming Welsh Government data showing that,
over the last two years, at least 96.5% of patients were treated
within 14 weeks.
In Scotland and Northern Ireland, however, our findings
suggest more cause for concern. Three of the 13 Scottish
providers and two of the four Northern Irish providers stated
that they were missing their country’s respective waiting-time
targets for more than one in 10 patients.
Despite targets generally being met, one-quarter of providers
noted that waiting times had increased over the last two years,
including 26 providers in England, five providers in Scotland,
three providers in Wales, and three providers in Northern
Ireland. Given increased demand, if budget reductions and
shortages of staff continue, we may see waiting times increase
further and targets being missed.
According to NHS England’s statistics, the average (median) waiting time for NHS audiology services has consistently been below
five weeks over the last two years. NHS England publishes its latest waiting-times data, every month, at www.england.nhs.uk/statistics/
statistical-work-areas/direct-access-audiology/daa-data/
6
Hearing
aids
should be offered
to all those who
could benefit –
not restricted
through arbitrary
eligibility criteria.”
• improve speech clarity and reduce listening strain (Köbler
and Rosenhall, 2002; Leeuw and Dreschler, 1991), which
can subsequently improve people’s ability to participate in
social situations, and their emotional wellbeing (Noble and
Gatehouse, 2006; Brooks and Bulmer, 1981).
Providers and commissioners should use this evidence to ensure
two hearing aids are prescribed to all those who can benefit.
We were pleased to find that 134 providers (96%) – in line with
evidence and standards7 – do always offer two hearing aids where
clinically appropriate.
96%
of audiology providers always offer two hearing
aids when someone has hearing loss in both ears.
Bilateral hearing aid fitting is stipulated as a requirement in the Welsh, Scottish and Northern Irish quality
standards, and is also required in the British Academy of Audiology Scope of Practice Document 2014 and
the International Society of Audiology’s Good Practice Guidance for Adult Hearing Aid Fittings and Services.
7
But four providers (two in England and two in Wales) only offer two
hearing aids if the person requests this. In addition, one provider
in England provides two hearing aids “by exception only, on an
Individual Funding Request basis”, and another is “tied by the
contract to provide 25% bilateral [fittings] only”. In these areas,
the majority of patients who have hearing loss in both ears will not
be receiving two aids, despite the evidence and national guidance
suggesting that this would benefit them.
Restricting provision of hearing aids will only result in higher costs
to the person’s health and wellbeing – and to the NHS in the long
term if they’re unable to hear or communicate effectively.
In order to deliver a service that meets quality standards, services
need to have enough qualified staff and the right specialist expertise.
Appointments must be long enough for audiologists to provide the
full treatment, information and support that patients require8.
Eight per cent of providers told us that, in the last two years,
appointment lengths had been reduced. Fifteen per cent noted
reductions in workforce numbers; and six per cent noted reductions
in the average qualification level of professional staff.
Many older people cannot get to audiology appointments because
they have other medical conditions, so home visits are increasingly
important. Fifteen per cent of providers said the number of home
visits had actually gone down. This alarming trend must be reversed
so that isolated, housebound people can access the support
they need.
Person-centred plan for management of hearing loss
Hearing loss can have a significant impact on a person’s quality of
life, including their physical health, mental health, employment and
social life, as well as how they cope with any other health conditions.
The way in which someone reacts to and manages their hearing loss
is influenced by a range of personal and social factors (Bowling,
2005). Audiologists must take into account all of an individual’s
health and care needs, their psychological response to the hearing
loss, and their occupational and social circumstances. Audiology
departments should make sure that they work in a ‘joined up’ way
to refer patients promptly to other useful support services9.
In a separate study, we asked 156 patients what they consider essential in an audiology service. Respondents
rated the provision of verified hearing aid fittings and information about hearing aid support as two of the top
three most important elements of the service. Deloitte Economics/Action on Hearing Loss (2013).
Patients tell us they would benefit from more information and
advice that recognises their individual needs (Matthews, 2011).
Audiologists should develop plans with patients to help them
manage their needs in a holistic manner, and provide information,
advice, and referrals to other professionals where appropriate.
Individual Management Plans (IMPs) are the most commonly used
tool to do this, and are required for all patients by the Scottish,
Welsh and Northern Irish quality standards, and by the British
Academy of Audiology’s Scope of Practice and the International
Society of Audiology’s Good Practice Guidance for Adult Hearing
Aid Fittings and Services10.
Restricting
provision
of hearing aids
will only result in
higher costs to the
person’s health and
wellbeing – and to
the NHS in
the long term.”
We asked audiology providers whether they develop Individual
Management Plans with their patients.
Two-thirds (66%) of providers from across the UK said that they
develop IMPs with all patients. A further quarter (26%) of providers
said that they develop IMPs with some patients. Two providers (1%)
stated that they do develop IMPs – but they do not involve patients
in the process. Ten providers (7%) do not develop IMPs at all,
including two of the four providers in Northern Ireland.
To provide a personalised and integrated service, we recommend that
plans should be developed with all patients – and updated regularly –
to maximise the service’s impact on patients’ quality of life.
Outcomes measurement
Patients have told us that they want services to measure outcomes
so that audiology services can prove they are having a positive
impact on patient satisfaction, confidence, and motivation to wear
aids, and improving people’s hearing, communication and ability
to engage in different activities (Deloitte Economics/Action on
Hearing Loss, 2013).
Measuring outcomes is required by quality standards across the
UK11. It helps providers to see if and how a service is responding to
patients’ needs, and whether they need to make improvements.
Outcomes data is also increasingly important in enabling services
to make the case for proper funding, and to demonstrate to
commissioners the impact they’re having if their value or costeffectiveness is put into question. Our evaluation framework may
help audiology providers and commissioners measure outcomes.
This is available at:
www.actiononhearingloss.org.uk/evaluationframework
Outcomes
data is
also increasingly
important in
enabling services to
make the case for
proper funding.”
8
This includes services to support people with other physical or mental health needs, as well as services to
support people with hearing loss with employment, education and finances.
9
A sample Individual Management Plan is available in Appendix 5 of Scotland’s
Quality Standards for Adult Hearing Rehabilitation Services.
10
Measuring outcomes is required by IQIPS in England and by the quality
standards of Scotland, Wales and Northern Ireland.
11
44%
OF AUDIOLOGY PROVIDERS ALWAYS MEASURE
OUTCOMES OF PERSON-CENTRED PLANS
42% sometimes measure outcomes
13% never measure outcomes
1% did not answer.
Our research found that, of the 128 providers that develop
Individual Management Plans with patients, 44% always measure
the outcomes of these plans, and a further 42% sometimes measure
outcomes. 13% of providers (17 in total) never measure outcomes –
two in Scotland and 15 in England. All services in Wales told us that
they always measure outcomes.
The main ways of measuring outcomes were the Glasgow
Hearing Aid Benefit Profile (GHABP), the Client Oriented Scale
of Improvement (COSI), the International Outcome Inventory for
Hearing Aids (IOI-HA), the Tinnitus Handicap Inventory, and patient
questionnaires assessing how well their needs have been met or
goals achieved.
Signposting to other services
All audiology providers must – and nearly all providers do – direct
patients to hearing aid repair and replacement services, to local
sensory services and to equipment and products designed to help
people with hearing loss12. Audiology providers should also ensure
that they direct people with hearing loss to wider support services
that might benefit them. We found that:
• 91% of providers across the UK signpost patients to
voluntary organisations that help people with hearing loss
• 88% signpost to lipreading classes
• 77% signpost to communication training
• 76% signpost to counselling
• 76% signpost to hearing therapy
• 69% signpost to peer support groups
• 67% signpost to benefits that people with hearing loss
may be able to apply for.
We did not ask providers how frequently they signpost to other
services, or in which circumstances they would consider this
12
Nearly all respondents to our survey said that they signpost patients to: a hearing aid repair and replacements service (97%), local
authority or council sensory services (95%), and equipment and products that can help people with hearing loss (98%).
appropriate. Previous research with patients suggests that providers
may not signpost all patients who could benefit. Four out of
five people fitted with hearing aids say they do not receive
information about other services or equipment that could help them
(RNID, 2008), and many do not know what services are available
(Action on Hearing Loss, 2012b; Northern Ireland Health
and Social Care Board, forthcoming).
In some cases, where a provider has indicated that they do not
signpost at all to a particular service, it may be because the service
is not available in that area. But, in other cases, signposting may not
take place because of a lack of awareness or time in appointments.
Four out
of five
people fitted
with hearing
aids say they
do not receive
information about
other services or
equipment that
could help them.”
Face-to-face follow-up
Follow-up appointments allow audiology providers to check
to see how well the person is adjusting to their hearing aid(s),
and to give additional information or support. As long ago as
1975, a Department for Health and Social Security report (1975)
summarised the importance of this follow-up support for patients
fitted with hearing aids:
“It is not sufficient simply to fit a hearing aid and assume that
all recipients will automatically and spontaneously acquire a
skill in its use…Where there is no or only a token follow up the
result is often severe disappointment for the patient whose
handicap could be ameliorated, a sad waste of his abilities and
an equally sad waste of public money in that much medical
attention is wasted and a high proportion of aids issued by
the NHS are only partially used or not used at all.”
British Academy of Audiology guidance
(2014) and quality standards in Wales,
Scotland and Northern Ireland state that
each patient should be given a followup appointment within 12 weeks after a
hearing aid fitting. Patients have told us that
good follow-up appointments are essential
(Deloitte Economics/Action on Hearing
Loss, 2013), and evidence shows that people
need continuing support and training to
get the most out of their hearing aids after
fitting (Upfold et al, 1990; Gianopoulos et al,
2002) – even if they do not realise they need
extra help (Sorri et al, 1984). Face-to-face
follow-up appointments give audiologists an
opportunity to observe the patient’s ability
to use the hearing aid, as well as to discuss
how they are coping and provide guidance
or make any alterations that can ensure they
continue to wear the hearing aids.
ONLY 49%
of audiology providers OFFER
FACE-TO-FACE FOLLOW-UP
APPOINTMENTS to all patients
fitted with hearing aids.
Table 2: Settings in which providers offer hearing aid repairs and
replacement services
Our research found that, 40 years on from the 1975 government
recommendations, only half (49%) of providers offer face-toface follow-up appointments to all patients as standard. This
includes six of seven providers in Wales, but less than half of
providers in Scotland and England (46% and 48% respectively),
and no providers in Northern Ireland offer face-to-face follow-up
appointments as standard.
Number (and %) of providers
Easy-toaccess,
ongoing support is
crucial otherwise
hearing aid users
may stop using
them completely.”
We asked audiology providers where they offer an aftercare (hearing
aid repairs and replacement) service, and whether this support is
available by appointment only or through a drop-in clinic.
LESS THAN HALF
of audiology providers offer hearing
aid support in care homes.
Scotland
(out of 13)
Wales
(out of 7)
Northern
Ireland (out
of 4)
137 (98%)
113 (97%)
13 (100%)
7 (100%)
4 (100%)
At a local health
centre/GP surgery
81 (58%)
70 (60%)
5 (38%)
6 (86%)
0 (0%)
At a non-healthcare
community setting
22 (16%)
19 (16%)
1 (8%)
2 (29%)
0 (0%)
In care homes
65 (46%)
53 (46%)
4 (31%)
6 (86%)
2 (50%)
At a person's home
89 (64%)
74 (64%)
6 (46%)
7 (100%)
2 (50%)
By post
105 (75%)
85 (73%)
11 (85%)
6 (86%)
3 (75%)
Via third sector
volunteers
54 (39%)
43 (37%)
5 (38%)
4 (57%)
2 (50%)
In a hospital setting
Our research found that follow-up is one of the most likely parts of
the pathway to be restricted when budgets are cut, with nearly a
quarter (24%) of providers with reduced budgets restricting access
to follow-up. Without proper follow-up to help them adjust, many
patients will not get the full benefit from their hearing aids, and
may stop using them (Gianopoulos et al, 2002). Cutting follow-up,
therefore, has a major, detrimental impact on patients – and reduces
the cost-effectiveness of the service.
Hearing aids require regular maintenance. They have to be cleaned
properly, they often need minor repairs, and the batteries and tubing
need to be replaced frequently. Many people need ongoing support
to help them with hearing aid maintenance. This is particularly the
case for new hearing aid wearers or older people with dexterity or
sight problems. In our research (RNID Cymru, 2009) we found that
66% of people had difficulties using their hearing aid when they
first received it. Getting timely, easy-to-access, ongoing support is
crucial, since hearing aid users who have difficulty in handling and
maintaining their aids often stop using them altogether (Oswal, 1977;
Gianopoulos et al, 2002). As we’ve outlined above, many older people
have hearing loss alongside other health or mobility problems, so
convenience and accessibility are important.
England
(out of 116)
Setting
A number of respondents who provide face-to-face follow-up told us
they work well – one provider said that they “have audited alternatives
[to face-to-face follow-up] in the past and found that they led to a
reduced quality in service and uptake and use of hearing aids”.
Easy-to-access aftercare
UK-wide
(out of 140
providers)
All providers offer an aftercare service in at least one of the settings
shown in Table 2, with over half (51%) offering an aftercare service
in four or more settings. Two-thirds (64%) of providers offer an
aftercare service through drop-in clinics, rather than requiring
patients to book an appointment in advance.
Less than half (47%) of audiology providers offer hearing aid
support in care homes, and only two-thirds (64%) offer support to
housebound people in their homes. All services should take steps to
reach these patients, who might otherwise struggle to access support.
Approximately two in five providers (39%) said that basic hearing
aid repairs and replacements were delivered via trained third sector
volunteers, such as through Action on Hearing Loss’s Hear to Help
service. One provider commented that Hear to Help was particularly
important in enabling the service to reach more vulnerable patients,
as well as reducing the pressure on audiologists’ capacity. See
www.actiononhearingloss.org.uk/heartohelp for details.
Regular re-assessment
ONLY 64%
of audiology providers offer hearing aid
support to housebound people in their homes.
Most people’s hearing will gradually deteriorate, so they may not
realise when they need a re-assessment or new hearing aids. It
is recommended that audiology providers automatically re-assess
each patient every three years13. We know that patients think
that they should automatically be called back for a hearing checkup (RNID, 2008). They should also be able to self-refer for review –
without needing another referral from their GP – if they notice
a problem.
We asked audiology providers if they automatically review patients’
hearing needs, or if this would only be scheduled on patient
request. Table 3, below, shows the alarmingly low proportion of
providers offering automatic re-assessment.
Table 3: Providers’ policy on re-assessment of patients’ hearing needs
UK-wide
(of 140
providers)
England
(of 116
providers)
Scotland
(of 13
providers)
Wales
(of 7
providers)
Northern
Ireland
(of 4
providers)
Automatically
44 (31%)
41 (35%)
2 (15%)
1 (14%)
0 (0%)
Only on patient
request
96 (69%)
75 (65%)
11 (85%)
6 (86%)
4 (100%)
Some providers, particularly in the devolved countries, are
delaying these review appointments – 16% of providers across
the UK noted that time to re-assessment has increased over the
last two years due to greater demand for the service, reduced
budgets and/or shortages of staff. This includes 4 of the 13
providers in Scotland, 3 of the 7 providers in Wales, and 2 of the 4
providers in Northern Ireland.
13
The Welsh, Scottish and Northern Irish quality standards require that a review appointment is
offered to all hearing aid patients every three years in at least 95% of cases. This is also advised by the
International Society of Audiology Good Practice Guidance for Adult Hearing Aid Fittings and Services.
Part 3: Good practice
Despite the challenges that NHS audiology services face, many
providers are continually striving to increase quality, capacity and
effectiveness. Below are some of the innovative examples of good
practice that providers shared with us, and which we hope others will
want to emulate14:
Identifying new ways to educate patients so that they can
better self-manage their hearing loss and hearing aids, for
example, through:
• web-based hearing aid help with pictures and
troubleshooting tips
• presentations on the TV screens in audiology waiting areas
• comprehensive hearing aid fitting packs for patients
• increased use of group hearing aid maintenance, tinnitus
and hyperacusis sessions, and peer support groups.
Better allocation of time and resources, for example, through
‘difficult to aid’ clinics for certain groups of patients, and more onestop assess and fit clinics (with screening beforehand to identify
suitable patients).
Allowing patients direct access (without needing to go via Ear, Nose
and Throat services (ENT)) from the GP to tinnitus services and
balance clinics, and from Audiology to Clinical Psychology and even
MRI scans, with stringent clinical guidelines in place.
Increasing outreach services, for example, through a mobile unit
to carry out hearing aid repairs in the community, or through more
community-based clinics. Several providers commented that they
have been able to deliver this more efficiently through third party or
trained volunteer support, such as our Hear to Help service.
Integrated working with Ear, Nose & Throat, for example, through
allocating pre-booked slots for Audiometry (hearing testing) support
to ENT, and training audiologists to offer aural care and wax removal.
Meeting demand through flexible working, for example, through
weekend clinics, and drop-off boxes in reception for 24-hour hearing
aid repairs.
Working with other hospital departments to better support
people with hearing loss alongside other conditions, for example, by
introducing pink hearing aid storage boxes15 on hospital wards
to reduce the number of lost aids, and by forming a local
For more examples of good practice please see www.actiononhearingloss.org.uk/underpressure
This is one of the recommendations developed in our Nursing Practice Project Toolkit, available at
www.actiononhearingloss.org.uk/supporting-you/gp-support/nursing-toolkit
14
Dementia Steering Group to improve care for people with
hearing loss and dementia.
Working with other local agencies to support people with hearing
loss, such as by jointly providing lipreading classes with the local
adult education service.
Involving patients in the design of services, for example,
through a patient panel or involvement group, or regular patientsatisfaction surveys.
Using robust, local evidence of increases in demand to secure
additional service funding from commissioners.
Conclusions
NHS audiology services are under significant pressure, with more
than two in every five providers (41%) offering patients a reduced
service as a result of budget cuts or increased demand, and another
one in five predicting further budgetary pressures in the next year.
One in six providers have endured double the pressure – being
faced with budget cuts when increased demand has already had
an impact on the service they can provide. These pressures have
made it impossible for providers to maintain their service, leading,
in particular, to increases in waiting times and reductions in followup appointments.
With demand continually growing, it is vital that there is proper
investment in audiology services to enable them to respond to the
ageing population’s needs. Short-term cuts such as restrictions
to hearing aid provision or follow-up appointments will only lead
to reduced quality of life for patients – and to higher costs in the
long term for the NHS and the social care system.
Providers have shared with us a number of the innovative
approaches that they’re employing in their determination to
increase quality, capacity and effectiveness in the face of increased
demand and reduced budgets.
But many providers are still failing to meet quality standards – or
follow national guidance – for core areas of service provision.
Contrary to the strong evidence for bilateral hearing aid provision,
several providers are not always offering two hearing aids where
clinically appropriate, and many areas are not developing personcentred management plans with their patients or providing proper
follow-up. This means that the quality of the service – and value for
money – varies greatly across the UK.
15
Alarmingly, 21 providers have responded to budget cuts, increases
in demand and other pressures by reducing the availability of home
visits; and far too few providers make aftercare services available in
people’s homes, care homes and the community. People who
are isolated or housebound should not be cut off from these
vital services.
Finally, particularly in light of the moves towards local decisionmaking in England, and pressures on NHS budgets across the UK,
there is an urgent need to improve outcomes measurement. This
would not only enable providers to address any weak areas in the
service, share good practice, and promote the service to patients,
but crucially it would allow providers to demonstrate their impact
and cost-effectiveness to commissioners and governments.
Our recommendations
Despite
increased
demand, 21
providers have
already cut down
on home visits.
People must not be
cut off from these
vital services.”
• Publish and implement national strategies that provide a
framework for person-centred, integrated support for people with
hearing loss.
In 2014, the Scottish Government launched ‘See Hear: A
strategic framework for meeting the needs of people with a
sensory impairment in Scotland’, but more effort is now needed
to make sure it’s implemented properly.
In Northern Ireland, the Physical and Sensory Disability Strategy
2012-2015 aims to improve outcomes, services and support
for people with hearing loss and other disabilities in Northern
Ireland. The Northern Irish Government must renew these goals
when the strategy reaches the end of its lifespan.
In England, a national Action Plan on Hearing Loss has
been developed, but its publication has been severely delayed.
It is vital that it is published immediately.
Audiology services provide cost-effective interventions, which greatly
benefit people with hearing loss (Access Economics, 2006; Chao and
Chen, 2008; Davis et al, 2007), and there is a growing demand for
services. To ensure that high-quality audiology services are provided
across the UK for all who need them:
• Ensure that sufficient training programmes are in place for
audiology professionals, to address local and national shortages
of staff.
The UK, Scottish, Welsh and Northern Irish governments, and NHS
England, should:
• Recognise the increasing need for and value of audiology
services, and invest properly in the service, in line with demand.
• Ensure that quality standards are in place and are enforced,
to provide evidence-based guidance to service providers and
commissioners.
• Make commissioning decisions based on the evidence, and local
need, in agreement with providers.
The National Institute for Health and Care Excellence (NICE) has
committed to produce a quality standard for adult-onset hearing
loss, but this has been delayed. NICE and NHS England should
prioritise the development of this quality standard, to enable
providers to make the case to commissioners for a high-quality,
comprehensive audiology service.
• Recognise and increase public and commissioners’ awareness of the
increasing prevalence of hearing loss – and the significant impacts
that it has on people’s physical and mental health, employment, social
participation and quality of life.
• Support commissioning bodies to invest properly in the provision of
audiology services to meet growing demand, and to not cut funding
for these vital, cost-effective services.
Organisations responsible for commissioning services should:
• Enforce quality standards through their contracts with providers,
and monitor compliance.
• Collect and share data on patient-centred outcomes and waiting
times to ensure high-quality services are being provided16.
Providers of NHS audiology services should:
• Follow national quality standards and guidance, particularly
around: waiting times; bilateral hearing aid provision; individual
management plans; follow-up appointments; and automatic
re-assessment.
• Ensure that all patients are able to access ongoing support that
is responsive to their needs. Given the increasing number of older
patients who experience hearing loss alongside other health and
16
Our evaluation framework may be useful to help providers and commissioners measure
outcomes. Please see: www.actiononhearingloss.org.uk/evaluationframework
care needs, it is particularly important that services find ways to
reach those who might struggle to attend appointments.
•M
easure patient-centred outcomes, to continually improve
service quality and secure continued funding.
•S
hare good practice within the sector and involve patients in
planning to continuously improve the service they provide.
At Action on Hearing Loss, we will:
•C
ontinue to work with Government, commissioners, providers,
professional groups and patients to secure proper investment in
audiology services.
•W
ork with governments and commissioners to ensure that quality
standards are in place and enforced, and that awareness is raised
of the impacts of hearing loss and the crucial importance of highquality audiology services.
•W
ork in partnership with those providing and commissioning
NHS audiology services, for example, to deliver our volunteerled hearing aid aftercare service, peer support groups, and
befriending programmes. Please contact us if you would like to
find out more about the services we can offer.
•P
roduce and share research findings and good practice to
help providers and commissioners improve the quality of
audiology services.
Bibliography
Access Economics (2006) Listen Hear: The economic impact and
cost of hearing loss in Australia
Action on Hearing Loss (2011) Hearing Matters
Action on Hearing Loss (2012a) Cut Off: Assessing provision of
adult audiology services and the impact of budget cuts
Action on Hearing Loss (2012b) Inaccessible: Access to social
services in Scotland
Arlinger, S. (2003) ‘Negative consequences of uncorrected
hearing loss – a review’. International Journal of Audiology 42(2):
17-20
Lin, F.R., Metter, E.J., O’Brien, R.J., Resnick, S.M., Zonderman, A.B.,
Ferruci, L. (2011) ‘Hearing Loss and Incident Dementia’. Archives of
Neurology 68(2): 214-220
Lustig, T.A. and Olson, S. (2014) Hearing Loss and Healthy Ageing.
Institute of Medicine and National Research Council
Matthews, L. (2011) Seen but not heard: People with hearing loss are
not receiving the support they need. Action on Hearing Loss
Bowling, A. (2005) Measuring Health: A review of quality of life
measurement scales. Berkshire: Open University Press
Mulrow, C.D., Aguilar, C., Endicott, J.E., Tuley, M.R., Velez, R., Charlip,
W.S., Rhodes, M.C., Hill, J.A., and DeNino, L.A. (1990) ‘Quality-of-life
changes and hearing impairment. A randomized trial.’ Annals of
Internal Medicine. 113(3): 188-94
British Academy of Audiology (2014) Scope of Practice
Document
Brooks, D.N. and Bulmer, D. (1981) ‘Survey of binaural hearing aid
users’. Ear Hear. 2:220-4
National Council on the Aging (2000) ‘The consequences of
untreated hearing loss in older persons’. Head & Neck Nursing.
18(1): 12-6
Chao, T.K. and Chen, T.H. (2008) ‘Cost-effectiveness of hearing
aids in the hearing-impaired elderly: a probabilistic approach.’
Otology and Neurotology 29(6): 776-83
NHS England (2014) ISB 1605 Accessible Information - Main
Submission (draft)
Chisholm, T.H., Johnson, C.E., Danhauer, J.L., Portz, L.J.P.,
Abrams, H.B., Lesner, S., McCarthy, P.A., and Newman, C.W.
(2007) ‘A systematic review of health-related quality of life and
hearing aids: final report of the American Academy of Audiology
Task Force on the Health-Related Quality of Life Benefits of
Amplification in Adults’. Journal of American Academy of
Audiology 18: 151-183
NHS Scotland (2008) Quality Standards for Adult Hearing
Rehabilitation Services (also in effect in Northern Ireland
and Wales)
Davis, A., Smith, P., Ferguson, M., Stephens, D., and Gianopoulos,
I. (2007) ‘Acceptability, benefit and costs of early screening
for hearing disability: a study of potential screening tests and
models’. Health Technology Assessment 11: 1–294
Northern Ireland Health and Social Care Board (forthcoming)
Survey of audiology patients
DCAL and Action on Hearing Loss (2013) Joining Up: Why
people with hearing loss or deafness would benefit from an
integrated response to long-term conditions
Department of Health and Social Security (1975) Report of
a Sub-Committee to consider the rehabilitation of hearingimpaired adults
Dreschler, W. A. and Boymans, M. (1994) ‘Clinical evaluation on
the advantages of binaural hearing aid fittings’. Audiologische
Akustik, 5, 12-23
Genther, D.J., Frick, K.D., Chen, D., Betz, J., and Lin, F.R. (2013)
‘Association of Hearing Loss with Hospitalization and Burden
of Disease in Older Adults’. Journal of the American Medical
Association 309(22): 2322
Gianopoulos, I., Stephens, D., and Davis, A. (2002) ‘Follow up of
people fitted with hearing aids after adult hearing screening: the
need for support after fitting’, BMJ, 325:471
Hurley R.M. (1993) ‘Monaural hearing aid effect: case
presentation’. J Am Acad Audiol. 4:285-95
Lin, F.R. and Ferrucci, L. (2012) ‘Hearing loss and falls among older
adults in the United States’. Archives of Internal Medicine 172(4):
369-371
Arrowsmith, L. (2014) Hidden Disadvantage: Why people with
hearing loss are still losing out at work. Action on Hearing Loss
Deloitte Economics and Action on Hearing Loss (2013)
Evaluation framework for Adult Hearing Services in England
For more information about our campaign and about this research,
please see www.actiononhearingloss.org.uk/underpressure
Leeuw, A. R. and Dreschler, W. A. (1991) ‘Advantages of directional
hearing aid microphones related to room acoustics’. Audiology
30(6): 330-344
Noble W. and Gatehouse S. (2006) ‘Effects of bilateral versus
unilateral hearing aid fitting on abilities measured by the Speech,
Spatial, and Qualities of Hearing Scale (SSQ)’. International Journal
of Audiology. Mar; 45 (3):172-181
Oswal, V.H. (1977) ‘The National Health Service and social services
link up for rehabilitation of hearing aid users’, British Journal of
Audiology, 11, 25-30
RNID Cymru (2009) Out of the Drawer
RNID (2008) Annual Survey Report
Saito, H., Nishiwaki, Y., Michikawa, T., Kikuchi, Y., Mizutari, K.,
Takebayashi, T., and Ogawa, K. (2010) ‘Hearing handicap predicts
the development of depressive symptoms after three years in older
community-dwelling Japanese’. Journal of the American Geriatrics
Society 58(1): 93-7
Silman, S., Gelfand, S.A. and Silverman C.A. (1984) ‘Effects of
monaural versus binaural hearing aids’. J Acoust Soc Am. 1;
76:1357-62
Silman, S., Silverman, C.A., Emmer, M.B. and Gelfand, S. A. (1992)
‘Adult-onset auditory deprivation’. J Am Acad Audiol. 3:390-6
Sorri, M., Luotonen, M., and Laitakari, K. (1984) ‘Use and non-use of
hearing aids’, British Journal of Audiology, 18, 169-172
Stephens, S.D., Callaghan, D.E., Hogan, S., Meredith, R., Rayment, A.,
and Davis, A. (1991) ‘Acceptability of binaural hearing aids: a crossover study’. Journal of the Royal Society of Medicine, 84(5), 267-269
International Society of Audiology. Good Practice Guidance for
Adult Hearing Aid Fittings and Services
Upfold, L.J., May, A.E., and Battaglia, J.A. (1990) ‘Hearing aid
manipulation skills in an elderly population: a comparison of ITE,
BTE and ITC aids’, British Journal of Audiology, 24, 311-318
Köbler, S. and Rosenhall, U. (2002) ‘Horizontal localization and
speech intelligibility with bilateral and unilateral hearing aid
amplification’. International Journal of Audiology, 41, 3905-400
United Kingdom Accreditation Service (2012) Improving
Quality In Physiological Services (IQIPS) Standards and
Criteria - Audiology
Kochkin, S. (2005) The impact of untreated hearing loss on
household income. Better Hearing Institute. Available at:
www.hearing.org/uploadedFiles/Content/impact_of_untreated_
hearing_loss_on_income.pdf
Yueh, B., Souza, P.E., McDowell, J.A., Collins, M.P., Loovis, C.F.,
Hedrick, S.C., Ramsey, S.D., and Deyo, R.A. (2001) ‘Randomized trial
of amplification strategies’. Archives of Otolaryngology – Head &
Neck Surgery. 127(10):1197-204
We’re Action on Hearing Loss, the charity
working for a world where hearing loss
doesn’t limit or label people, where tinnitus
is silenced – and where people value and
look after their hearing. We can’t do this
without your help.
To find out more about what we do
and how you can support us, go to
www.actiononhearingloss.org.uk
Action on Hearing Loss Information Line
Telephone 0808 808 0123
Textphone 0808 808 9000
SMS
0780 000 0360
(standard text message rates apply)
Email [email protected]
To find out more on anything contained in
this publication please contact the Action
on Hearing Loss Policy and Campaigns
team on
Telephone 020 7296 8003
Email [email protected]
Action on Hearing Loss is the trading name of The Royal National Institute for Deaf People.
A registered charity in England and Wales (207720) and Scotland (SC038926) A0924/0115

Under pressure - Action on Hearing Loss

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