Under pressure - Action on Hearing Loss
Transcription
Under pressure - Action on Hearing Loss
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 4 | www.actiononhearingloss.org.uk 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. Under pressure: NHS audiology across the UK | 5 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 6 | www.actiononhearingloss.org.uk 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 Under pressure: NHS audiology across the UK | 7 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. 8 | www.actiononhearingloss.org.uk Under pressure: NHS audiology across the UK | 9 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 10 | www.actiononhearingloss.org.uk Under pressure: NHS audiology across the UK | 11 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 12 | www.actiononhearingloss.org.uk 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 Under pressure: NHS audiology across the UK | 13 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 14 | www.actiononhearingloss.org.uk 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 Under pressure: NHS audiology across the UK | 15 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%). 16 | www.actiononhearingloss.org.uk 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. Under pressure: NHS audiology across the UK | 17 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. 18 | www.actiononhearingloss.org.uk 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. Under pressure: NHS audiology across the UK | 19 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. 20 | www.actiononhearingloss.org.uk Under pressure: NHS audiology across the UK | 21 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 22 | www.actiononhearingloss.org.uk Under pressure: NHS audiology across the UK | 23 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 24 | www.actiononhearingloss.org.uk Under pressure: NHS audiology across the UK | 25 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. 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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 Under pressure: NHS audiology across the UK | 27 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