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All-Party Parliamentary Group on Deafness

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All-Party Parliamentary Group on Deafness
House of Lords Debates
Health: Audiology
Date: 8 January 2008
Contact: Jonathan Isaac, Director UK Council on Deafness and Clerk to the APPG on Deafness - j.isaac@deafcouncil.org.uk

Verbatim Report

Baroness Howe of Idlicote asked Her Majesty’s Government what progress has been made in implementing the National Audiology Action Plan contained within the Department of Health report, Improving Access to Audiology Services in England; how they intend to ensure that audiology is regarded as a priority area by strategic health authorities and primary care trusts; and what specific role they envisage for the independent sector.

The noble Baroness said: My Lords, I begin by declaring an interest. I have used hearing aids of one kind or another for almost half a century. More recently, I have had the considerable benefit of the new digital aids, in both ears. Put bluntly, because I have been able to afford the independent sector’s excellent audiology services, I am able to remain a fully included Member of your Lordships’ House and the wider community.

My concern is that everyone with hearing needs should receive the same timely service from the NHS. Sadly, that is not the case at present, as capacity in the NHS is not keeping pace with demand. As your Lordships will recall, on 1 March last year, in order to address this problem the Government published their long awaited national audiology action plan. Your Lordships will note that this document was published on the same day that the Minister was due to appear before the House of Commons Health Select Committee, in order to respond to its concerns over audiology services in England. The very fact that that committee launched this inquiry underlines the seriousness of the situation. Yet neither the committee’s report nor the Government’s response, published, respectively, in May and July last year, has yet been debated in either House. Furthermore, most of the representative bodies at the inquiry have expressed their views on that response, and they are all very critical, so today’s debate is both necessary and timely.

There can be no doubt about the scale of the problem which, with our ageing population, is bound to become more pressing. The RNID estimates that 55 per cent of people over 60 are deaf or hard of hearing. In total, over 4 million people in the UK have a hearing difficulty that would be assisted through the use of properly prescribed hearing aids, and it is common ground, which I hope the Minister will confirm, that about 2 million people in need are not yet provided with a hearing aid or aids. So there is clearly a huge task still to be tackled.

Your Lordships will recall how often, in other debates, we all, but especially the Government, have emphasised the need for inclusive social policies. One witness quoted by the RNID, Janine Roebuck, an opera singer, makes very clear just how important that concept is in this context. She says:

“My hearing aids are my lifeline. Long hearing aid waiting times means spending years struggling to hear and battling isolation and depression”.

That is the background to have in mind, as we react to the fact, whatever the long-term need, that as stated by the RNID no less than 250,000 people are currently waiting for a digital hearing aid.

How have the Government reacted? In May 2006, they set a target that by March 2007 no one should have to wait longer than 13 weeks for an audiology assessment—note those words carefully—and that by March of this year no one should be waiting longer than six weeks. However, the most recent figures, for October, show that almost 48,000 people were still waiting more than six weeks for an assessment, and more than 34,000 over 13 weeks. Furthermore, more than 13,000 patients have been waiting longer than a year for an assessment. I stress that these government targets and figures are for waiting times for an assessment only, and certainly not for actually being fitted with a hearing aid. Remarkably, the Government do not publish waiting-time data for what is called “the full patient journey”.

What then is the picture if one takes in that second period between assessment and supply—as clearly one must? Indeed, the Select Committee specifically recommended that. For the past four years the British Society of Hearing Aid Audiologists—BSHAA—has carried out an annual survey of waiting times for precisely that full patient journey from referral to supply. Its results are, therefore, much more meaningful than the Government’s official figures and the findings are even more disturbing. The latest BSHAA survey published last September indicated that while there has been some fall in waiting times in the past year, patients are still having to wait an average of 36 to 38 weeks between referral and the actual fitting, at last, of a digital hearing aid. Moreover—and astonishingly for someone wanting only to upgrade from an analogue to a digital hearing aid—the average waiting time is even longer: between 44 and 47 weeks.

These BSHAA surveys have also highlighted serious regional discrepancies in waiting times. This has recently been underlined by a report from the RNID based upon freedom of information requests, delivered to every PCT, only two months ago. Out of the 100 trusts that have responded, no less than 11 have average waiting times of more than a year from GP referral to fitting of hearing aids. Some have waiting times of more than 18 months. In Kingston-upon-Thames, new adult patients wait an average of two-and-a-half years. Who knows how much worse the figures might be for the 50 or so trusts that have failed to reply to the RNID? What are the Government doing to address this? At one time we thought we knew. In July 2006, the then Minister, the noble Lord, Lord Warner, announced that 1.5 million patient pathways were to be procured from the independent sector at a rate of 300,000 per annum for five years. We have now passed that date and, alas, have seen no evidence of this happening. Instead, strategic health authorities locally have been tasked with filling their capacity gaps with,

“a combination of greater efficiency in existing services where possible, and, where that is insufficient, new capacity”.

So what has happened to the national audiology action plan and why do we have no clear or continuous plan for effective engagement of the independent sector? The modernisation of hearing services—MHAS—project to equip the NHS with facilities to offer digital hearing aids began in 2003. It included a limited independent sector involvement through a PPP. Although only two independent sector companies were involved, no less than 68,600 patients were fitted with a hearing aid through that PPP until it ended last April. More significantly, it was accepted that the companies’ standards in providing fitting and follow-up service matched those of the NHS.

Despite all the current barriers to its involvement, the independent sector is, of its own volition, making a contribution towards alleviating pressures on waiting lists—for example, by helping to test patients’ hearing at their local GP surgery, thus speeding up the initial assessment and referral process. Some PCTs have also involved independent-sector providers in assisting with part of the full patient journey—for example the fitting of an aid and follow-up. But these are piecemeal approaches, wholly dependent on local initiatives and not part of any coherent policy by national government. The independent sector continues to invest in training of hearing aid dispensers who are fully qualified to carry out hearing assessments and fit hearing aids. Yet this significant capacity, a workforce of some 1,400, is virtually ignored in the Government’s calculations. Is it not high time to consider a more direct—indeed, a more actively participant—role for the independent sector?

I invite the Minister and, indeed, the rest of your Lordships to study the evidence given to the Health Select Committee by Specsavers. From that, it is clear that developing a market for directly supplying audiology services financed by the NHS along the lines of the successful optical prescription model would offer the public greatly improved access, choice and quality.

In summary, the Government’s actions do not measure up to the scale of the problem. The Department of Health seems unable to ensure that the NHS works in partnership with the independent sector to develop a sustainable national audiology service. Consequently demand cannot be met and patients continue to suffer. I end by quoting the closing paragraph of the BSHAA report, Suffering in Silence2007, which states:

“BSHAA has for some time said it is puzzled why the Government does not recognise that the independent hearing care sector on the high street has the skill and expertise necessary to help solve the waiting list problem”,

and,

“offer patients real choice; choice of location, choice of time, choice of instrument, choice of dispenser and even choice of how many and which hearing aid they have fitted”.

I am much looking forward to this debate and, in particular, to hearing from the Minister when and how the Government will open the door that will enable us to start proceeding down the road that I have described.

Lord Giddens: My Lords, we owe the noble Baroness, Lady Howe, our plaudits for setting up this debate on a topic that is unjustifiably low-profile in our thinking. It would be hard to dispute that audiology is one of the Cinderella areas of the NHS. This in some part reflects widespread cultural attitudes towards hearing loss in our society. If someone goes blind, it is universally regarded as a tragedy, but even people whose problems are of being very hard of hearing can be regarded with scorn, mirth and derision which is surely inapplicable, given the scale of the issues that we face in this area.

A recent study of the baby boomers generation in the US concluded:

“The reality is that hearing loss has a long way to go before it is considered a legitimate public health issue”.

I would suggest that the same applies in this country, too. That is pretty amazing when one considers the facts. According to the same study, 25 per cent of the baby-boom generation—people between 50 and 60 years old—suffer from serious noise-induced hearing loss, in addition to hearing loss brought about by ageing processes. Some observers in America have spoken of a hearing health epidemic and I do not think that that is an overstatement.

The issue is not just that people can be incapacitated in their everyday lives, but it can also have a significant impact on their work and capability to work. We live in a service-based society in which we spend most of our working days interacting with other people. Many kinds of jobs can be impossible for people who do not get effective assistance in such a situation

The other side of this issue is a tremendous and continuing wave of innovation in hearing-aid technology and, more generally, in technologies linked to those who are either deaf or seriously hearing impaired. At the cutting edge of this technology is nanotechnology; on the commercial market there is already a hearing device available which can be implanted, is invisible to the external observer and has a battery life of some five years. Tremendous technological revolutions are going on.

When I read the Government’s document, Improving Access to Audiology Services in England, and their response to the House of Commons Select Committee report, I felt that I was living in 1948 rather than 2008. I give three reasons for this: one is that digital aids were not introduced into the NHS until 2001, in spite of the fact that they existed for many years previously, although, of course, they were improving radically. That raises the issue of whether what is going on in the intersection between the NHS and the private sector is really at the leading edge of technological developments. Secondly, as the noble Baroness said, no reliable data are collected, or has been collected to date, on the wait between GP referral and treatment. As I understand it, the Government have now committed themselves to collecting that data. That is clearly a serious lapse. Thirdly, as the noble Baroness also said, the survey by the RNID found that many trusts had very long waiting times. This was based on a sample, rather than a universal survey, so to some extent it was guesswork. Like her, I picked up the case of Kingston, where there is a wait of 2.5 years, which translates into 125 weeks.

I have four questions for the Minister, which she might answer directly or subsequently. First, is this figure of 2.5 years for Kingston health trust valid? Is it really true? It seems quite incredible. Secondly, the person choosing open-ear technology today, and who goes privately, can get tested and fitted not only in one day, but within one hour of going to the practitioner. Yet the Government document says proudly that the Norfolk and Norwich University Hospital NHS Trust, using open-fit technology, has seen treatment waiting times drop from 28 weeks to 21 weeks. Could the Minister explain this yawning discrepancy? Thirdly, as the noble Baroness has said, surely there must be must more effective ways of integrating the public and private sectors. She mentioned the case of opticians, where there is indeed very little waiting—where, because of technological innovation, you can get a pair of glasses within an hour. Here again the Government seem to have made only modest progress, especially in relation to the target that was also mentioned. According to the calculations I saw, only 116,000 people have been treated under a PPP arrangement. Fourthly, in his speech the other day, the Prime Minister rightly put an emphasis on prevention, rather than simply treatment. What are the Government doing in the area of prevention? It is not just the baby-boom generation who went to rock concerts; it is also the under-25 generation using iPods. A recent French study calculated that one in 10 of such users will have hearing deficiencies within two years, because they use these devices almost every day, and they play them at much too high volumes. Surely, prevention should be moved massively up the Government’s agenda.

Baroness Finlay of Llandaff: My Lords, I thank my noble friend Lady Howe for instigating this important debate. Her introduction demonstrated that she is certainly an expert in the field.

Hearing impairment is the most common sensory disability worldwide. Although deafness and loss of hearing are more common in the elderly population, many children and young people are also affected, with potentially devastating results on the development of language, communication and learning. There are estimates that in the UK, one in 1,000 children is deaf at the age of three. Currently, a staggering 17 per cent of the population have some deafness. As the noble Lord, Lord Giddens, said, in the younger age group that is likely to rise almost exponentially because of the sound technology they use on a daily basis. There are 20,000 children aged 15 and under who suffer from a degree of deafness, and 12,000 of them were born deaf.

Sufferers of deafness often experience isolation and depression. When deafness is of sudden onset, it is particularly devastating. The person with sudden onset deafness suddenly loses all orientation. Crossing the road or even pursuing activities in the home becomes incredibly hazardous. Even those with progressive deafness may find that they cannot pursue their previous employment, or find that employment opportunities wither, as their lives rapidly become narrower and more cut off. They are often acutely aware that their potential contribution to society is being wasted and that they cannot enjoy the same quality of life as they did when they had hearing or as those with good hearing can.

Two million people in the UK currently use a hearing aid, but it is estimated that a further 4 million might benefit from one. The Government are to be commended on their commitment to reducing waiting times for digital hearing aids. They certainly have recognised the failure of many PCTs to give audiology services the priority they deserve. To address this, the Audiology Advisory Board, chaired most capably by Professor Sue Hill, has produced the National Audiology Action Plan. But I would ask the Minister whether the current referral-to-treatment waiting time for a hearing aid has improved at all. Is the target of providing a diagnostic test for audiology within six weeks likely to be reached by its target date of March this year, since last year’s 13-week target was not met on time?

Hearing loss does not occur in isolation. The associated vestibular disorders cause dizziness, vertigo, nausea, fatigue and sometimes tinnitus and, sadly, they are commonly misunderstood both by the public and by healthcare professionals. These symptoms represent the most common reason for GP visits by patients over 65, and indeed 40 per cent of the UK population aged over 40 have experienced symptoms of dizziness and/or imbalance.

Let us make no mistake: the aftercare of those receiving an NHS hearing aid is inferior. After receiving an NHS aid, a patient will receive one phone call to assess whether problems are being experienced with the aid. If a hearing aid is purchased privately, the patient is able to arrange a personal consultation at a place of his own convenience, as stipulated in clause 11 of the Hearing Aid Council code of practice.

However, I hope that no one will be fooled into thinking that providing a hearing aid is the answer to issues around deafness. There is a real and urgent need for an increase in training numbers in audiological medicine if we are to cope cost-effectively with the increasing numbers of people with audio-vestibular disorders who will otherwise continue to be referred to the wrong NHS resources where their problem becomes compounded by inappropriate investigations and wrong treatments. Currently, services are variously provided by ENT surgeons, audio-vestibular physicians, audiologists, neurologists, geriatricians, paediatricians, physiotherapists and so on, depending on the complaint and the availability of professionals in that area, frequently determined by staffing levels and the equipment infrastructure. The majority of patients are referred to ENT and to neurology, even though only 5 per cent of hearing and balance disorders require surgical intervention or result from central nervous system pathology.

I know that the “good practice” documents produced following on from the framework are supported by the commissioning of 18-week patient care pathways, and there are other audiology transformation projects on education and training of the workforce and on the development of a workforce tool and a quality assessment tool. But all those require the availability of expertise to underpin them. Nationally, however, only a handful of services are able to provide state of the art, sophisticated auditory and vestibular investigations that patients need for accurate diagnosis of the underlying cause of their deafness and other problems. Unfortunately, much time and effort is therefore wasted on inappropriate or unnecessary and expensive investigations and referrals. With an ageing population, these problems are going to get greater. Provision of a hearing aid is only part of the management.

We need an increase in specialist medical audiology without which we risk more money being spent inappropriately. Hand in hand with that goes a requirement for more national specialist facilities too. The need for a rapid expansion in such services of expertise also puts an onus on the profession itself. Currently the training in audiological medicine is far too long. I ask the Minister what discussions have been had with the royal colleges to streamline and bring down the time spent training.

I am grateful for this debate, and I am pleased that the Government have demonstrated a commitment, but we have a long way to go.

Baroness Wilkins: My Lords, I join other noble Lords in thanking the noble Baroness, Lady Howe, for initiating this very important debate. Few things are potentially more isolating than the onset of deafness, and I fully endorse the picture of need painted by my noble friend Lord Giddens and the importance of placing priority on this service. Like many of us I have been with my family over Christmas, and I was reminded anew of the crucial role that audiology equipment plays in warding off that isolation. My eldest brother, a farmer, has acute respiratory disease and is now entirely dependent on oxygen. There is little that you can do when you are so breathless, so enjoyment with other people becomes all the more important. However, the one chance that his wife had to relax with him, watching television in the evening, was made excruciating by his increasing deafness. He needed the volume at such a level that it caused her acute pain, so they ended up spending the evening in separate rooms. A simple piece of radio equipment has solved that—he listens through headphones and she can have the volume at her usual level—and they enjoy the evenings together again.

Sadly, that piece of equipment is not as well known as it should be; it would probably have reduced the tension in hundreds of households this Christmas. By contrast, the introduction of digital hearing aids has received wide publicity and become a victim of its own success. Given the history, it is hardly surprising that there are currently an estimated 250,000 people waiting for a free digital hearing aid.

Before 2000, the wearers of digital aids would have had to buy them for £2,000 or more. The NHS audiology clinics fitted only the outdated analogue aids and were chronically underfunded. The outstanding campaign by the RNID resulted in the unique partnership between government, the voluntary and independent sectors, and the modernising hearing aid services programme produced, in the RNID’s own words, the complete transformation of the service in less than five years.

More recently, the RNID has highlighted the unacceptably long waiting lists that still exist. Its latest figures revealed a shocking situation in some parts of the country, the worst, as we have heard, being in Kingston. But what is in danger of being overlooked is the fact that we are talking about pockets of poor provision. It is not the national picture. In fact, nationally there has been an enormous improvement and, while the unacceptably long waiting lists should and must be eliminated, the successes should be recognised and praised.

My local audiology department at Charing Cross Hospital is held up as an example for others to follow. That department’s reaction to the publicity given to the RNID’s figures was that it was grossly unfair. In its opinion, the figures do not reflect the overall reduction in waiting times, which have reduced radically. According to the Department of Health’s figures, last October roughly 80,000 people were waiting for an audiology diagnostic assessment; a year earlier, in November 2006, the figure was double that, at more than 166,000. Of these, roughly 47,000 had been waiting for more than a year, whereas last October this figure had been reduced to 13,000. Yes, that is still far too many, but the picture is not a uniform one. The staff at Charing Cross felt kicked in the teeth for all the hard work that their profession had undertaken over the past few years. They deny the description of Charing Cross as an “elite service”; in their judgment, theirs is a normal service, just hard working.

However, Charing Cross is worried by the draft tariff—the indicative tariff—which has been introduced to audiology services for the first time this year. It believes that trusts will struggle to deliver at the current tariff rate and that, as a result, waiting times are bound to increase. Its main concerns are that the tariff is too low to cover the actual costs, that it does not reflect regional variations in the cost of provision and that it does not provide for the ongoing maintenance of hearing aids or for post-fitting adult rehabilitation. Nor is there provision for people who need bilateral aids—aids for both ears. Charing Cross fears that, at the current rate, the tariff will lead to increased contracting of independent sector provision at an inferior level of service. The head of department said:

“If an independent sector company can provide a patient journey for the current tariff rate I would have serious concerns about the quality of that service; there will certainly be no money left for the shareholders if the job is done by a fully qualified audiologist”.

She provides the example of a current contract with a well known independent sector provider in Darlington, who charges £320 for a unilateral fit—I understand that that is not best practice—which is £90 higher than the NHS draft tariff.

The Health Select Committee’s report last May into audiology services highlighted its concerns about increased use of private sector provision and in particular its belief that there should be careful monitoring of the quality of care and that the private sector must not be allowed to undermine the capacity of the NHS to provide expert audiology services. I do not have time to go into these in detail, but I ask the Minister to assure the House that the Select Committee’s concerns will be acted on. Will she also assure me that the Department of Health will take on board the serious concerns that have been expressed about the level of the draft tariff? In reality, the audiology service is very cheap for the life-changing results that it achieves. Will she do all that she can to ensure that the Government build on its successes and not allow the service to deteriorate?

Baroness Richardson of Calow: My Lords, I, too, am grateful for the opportunity afforded by the noble Lady to express the importance of audiology services and the need for greater priority to be given to them. Like many families, our family has its own sentences and catchphrases, which express our togetherness and which would be quite impossible for others to understand. In our family, most of them stem from a favourite grandmother, who was very deaf. She had a hearing aid—a huge orange thing that she held in tissue paper in the sideboard draw—which was kept for special occasions, although I must confess that I never witnessed such an occasion. Invariably in conversation, she used to get hold of the wrong end of the stick. Her wonderful non sequiturs have provided our family with endless amusement, although sometimes with a degree of annoyance.

As well as bequeathing to us these bon mots, our grandmother also bequeathed to me a genetic component that makes me very deaf. About 12 years ago, I began to realise that this was becoming a real disability, when the work that I was doing brought me to spend a lot of time with people for whom English was not their first language. I found conversation very difficult. I went to the local hospital and had, I have to say, a rather perfunctory test, after which I was given a hearing aid that amplified sound but did not clarify speech. I found it impossible to use. I was encouraged by a friend to go to a private clinic, where I had a test that was much more carefully done. I discovered that the kind of disability that I have relates to the middle range of sound, which means that I find it difficult to distinguish consonants in speech. If noble Lords remember some of those wonderful sketches that Ronnie Barker used to do, in which he had “trouble with worms” and kept getting his consonants mixed up, they will be able to appreciate some of the difficulties that I was having.

I believe that people who do not have hearing loss find it hard to appreciate what it means for those who do. I find it impossible to have a conversation on the telephone with my grandchildren. I can speak but I cannot hear what they are saying to me. Also on the telephone, when I have to get through to some officialdom and find that I am in a call centre, it is almost impossible to find communication between us and if I say to them, “I am deaf, will you speak slowly?”, they cannot resist the temptation to shout at me, which does not help at all. I find it difficult and almost impossible to eat with your Lordships at the long table in the dining room. I find it difficult to have a conversation with someone who is sitting alongside me. I need to see you in order to hear you. People leave voicemail messages and they think they have communicated with me but they have not done it clearly enough for me to be able even to hear who it is who has left the message, which causes quite a lot of embarrassment. I attend receptions and I do an awful lot of nodding and smiling and find that sometimes I have agreed to opinions I do not hold or even volunteered to do something I did not intend to do because I have not actually heard what was being said.

Hearing loss isolates, puts people at a disadvantage and damages confidence but it can be helped and the hearing aids that I now have do help. The first step, as other people have said, is to admit that there is a problem, and this is something that people find difficult. I have heard on more occasions than I can think of about people who say when they sit at the back of the church that the problem is that preachers are not trained to project their voices properly and refuse to admit that the problem might be within them. There is growing acceptance that help is available, and greater acceptance about the sophistication of the instruments which can help, but the capacity for dealing with the problem has not kept up with the expressed need. Only a year or two ago my nearest hospital was reporting that there were 22,000 people on its waiting list, and as has been said, there have been reports of waiting times of between 84 and 92 weeks in parts of the south-east. When we finally get round to admitting to a problem, the problem has to be diagnosed properly and quickly.

Where is the first port of call? When our eyesight fails we are used to going to a high street optician. Although we can be referred on from there if there is a health need, we can usually be provided for fairly quickly at a level which is appropriate to our financial ability, either with an NHS prescription or with very expensive designer frames. Many people find it easier to access the high street than to obtain an appointment with their GP and wait for a referral to a hospital, only to find that the waiting lists are long and the clinic is overstretched. The experience of using private practice must give some insight into the kind of opportunities made possible by using a mixture of private and NHS provision, not only in getting an appointment and finding an aid but in obtaining aid maintenance and repair and the provision of batteries, which is so often a source of irritation to so many people.

Hearing loss is not life threatening but the provision of aids is extremely life enhancing, not only for those with hearing loss but for all those who have to associate with them. It does not entail huge budget implications compared with the benefits to mental and social well-being. More help can be given. We need a clear insight into where the bottlenecks are and why they exist; an increase in audiology staff—I understand that there are more trained staff but that they are not being used effectively; a willingness to explore creative partnership with the private sector; and, above all, a commitment to a national programme.

Baroness Barker: My Lords, I extend my congratulations to the noble Baroness, Lady Howe of Idlicote, and thank her most sincerely for the opportunity to take part in this debate. I do so for a particular reason. For over 60 years my mother has been profoundly deaf and she has been wholly dependent on the NHS for her lifeline—her hearing aids. That experience of growing up as the hearing child of a deaf person who lives in a hearing world with the TV turned up too loud and all that kind of stuff has had a profound effect on me. I shall give one example: most people my age can tell you all about “Doctor Who”—who played the Doctor, his assistants, and all that. In my house, “Doctor Who” consisted of the first three bars of that rasping, tinny music and an adult shouting, “Turn that noise off now”, as it cut through my mum’s ears. I know nothing about “Doctor Who”—I am scarred for life.

I shall tell my mother’s story briefly as it illustrates some important points. When I was little there was one clinic for the whole of the west of Scotland, where my mum used to go to get her batteries and cords. It was the same thing when we moved to Lancashire; she used to go to social services. She managed to get along with a pretty inferior system. During that time a friend died and in an act of generosity his family gave my mum his very expensive, private, behind-the-ear hearing aid, but it did not work. It was not until we moved to another place that, when she came under the audiology department of a district general hospital, on her first appointment somebody said, “We need to do a complete audiogram”. Because technology had changed and much more powerful behind-the-ear hearing aids were available, she finally got one. The change that it made to her, her confidence and her interaction with other people was phenomenal.

In the intervening period we as a family have gone through times when her hearing aid has not worked or she has not been very well, and we have appreciated the fact that she is getting older. She was told a while ago that she was getting old, that the nerves and so on in her ears were deteriorating and that she would not be able to hear any better. That was profoundly depressing for her and for all of us. Then there was a change, and last year she finally got a digital hearing aid. I asked her last week what it was like and she said that, apart from the relief of not having an inevitable descent into further deafness, she can hear things that she has never heard before. It may not be the biggest thing in the world, but to be able to differentiate noises is huge. In her words, it makes being in company altogether easier.

The point that I wish to make was alluded to by the noble Lord, Lord Giddens. When the Government count the cost of audiology services, they should include the savings made by people being able to continue working and to live independently without incurring caring costs.

We are in danger of going back to a fracturing of services rather than drawing them together. While that may be fine for somebody who has a slight hearing loss, who is young or familiar with technology and who can go to a private service, there will be those who are older and who have multiple conditions. They may be arthritic and cannot see very well and they are presented with a minute piece of machinery. They then panic because they do not know how to use it. It is important to note the point made by the noble Baroness, Lady Finlay, that maintenance and aftercare are an enormous part of a proper audiology service. The concentration on recording data, not just at the point of assessment but right through to fitting and beyond, to see how the person is living with a newly acquired deaf condition, is important.

The noble Lord, Lord Giddens, is right that we need to recognise that, as technology develops, the private and voluntary sectors have an enormous role to play in enabling deaf people to keep up with technological changes and go on with their lives more confidently. There needs to be coherence. Ophthalmology and optical services have changed by their reliance on there being a very good system of referral between the different parts—the voluntary sector, societies for the blind, the private sector and the NHS. That has enabled routine maintenance of people’s conditions to be contracted out to technicians, which has left precious specialist resources in ophthalmology—the same could be said for audiology—to be focused on those who really need them. I worry that, with the new system of commissioning from PCTs, we might be in danger of going back 40 years to when there was no coherence in provision, and deaf people will suffer as a result.

I shall abuse my position and say this: for those who are on tremendously long waiting lists—they are long in some places because PCTs do not have the resources—the RNID runs a telephone hearing check system. It wants more people to know about it; there is a telephone number on its website. Those people who are beginning to suffer can do something even if the NHS in their area is not particularly good.

Earl Howe: My Lords, not for the first time, the noble Baroness, Lady Howe, has homed in on an extremely important topic, and I congratulate her on the case that she so ably presented. None of us should underestimate the social isolation and sheer human misery that deafness brings to large numbers of individuals in this country. The noble Baroness conveyed the scale of the issue. By any standards we are dealing with a major source of preventable disability.

The story of NHS audiology over the last eight years is an interesting one. In my view the Government are entitled to claim considerable credit for the decision they took in 2003 to roll out NHS provision of digital hearing aids across the whole country. That really did represent a quantum leap forward for many tens of thousands of people in terms of their quality of life. Unfortunately, as has been said, the very success of the MHAS programme sowed the seeds of the difficulties we are now experiencing. The benefits of digital hearing aids suddenly became more widely appreciated, demand for them shot up, and the NHS found itself without the capacity to cope. Indeed, audiology contains a paradigm of what has happened to the NHS as a whole since 1948. It is a classic instance of where an ageing population, improved technology and rising consumer expectations have combined to drive up demand for healthcare. If one were being critical of the Government, one could say that someone ought to have predicted this. As it is, there is not much indication that in 2003 anyone actually sat down to assess what capacity the NHS needed to meet future demand for audiology services in the short or medium term.

The result is what we see today: long average waiting times, as cited by the noble Baroness, to have a digital hearing aid fitted and of course, as we have heard, the average numbers conceal a huge variation between best and worst in different areas of the country. The target of a 13-week maximum wait between referral and assessment was meant to have been achieved last March but was missed by a wide margin. The six-week target, which is supposed to be met by March 2008, seems unattainable within that timeframe.

I say “unattainable” not simply in the light of the published figures but because of the numbers of people waiting whom the figures do not include. Those people waiting for a reassessment to see whether they need a digital hearing aid are only included in the official waiting list once a review has taken place to establish whether they might benefit from being reassessed. How many people are currently waiting to be reviewed in this way, and does the Minister not think that that hidden element of the waiting list makes the six-week target rather misleading?

The obvious way forward is for the NHS to draw upon the spare capacity that exists within the private sector. The problem here is that if you use the private sector there has to be demonstrable value for money, and how can you verify value for money unless you have a national tariff? A tariff is the only way there is to assess price comparability between different suppliers, yet there are very mixed messages emanating from Ministers about whether they see this as something that should be developed. The strategy document of last March simply said that the department would consider the introduction of a tariff as soon as practicable. I need therefore to ask the Minister what is happening here and whether the introduction of a national tariff is now seen as a priority.

Could I also ask the Minister about priority treatment for war pensioners? As from 1 January, all war veterans became entitled to priority access to NHS secondary care for any conditions which are likely to be related to their service, subject to the clinical needs of all patients. This could present a difficulty in relation to hearing loss. In the context of applying for a war pension, veterans have had to meet quite a high threshold of hearing loss—50 decibels in both ears—to be deemed eligible. For priority treatment on the NHS, on the other hand, the threshold is bound to be a lot lower, and we could well see a backlog of cases—perhaps as many as 100,000 according to the RNID—coming forward for priority treatment for deafness caused by service. What impact is that likely to have on waiting lists and what specific measures have been taken to ensure that the NHS can meet the potential increase in demand from those patients?

We are back to the capacity question. Like the noble Baroness, I wonder what happened to the commitment given by the noble Lord, Lord Warner, in July 2006 to source an additional 300,000 patient journeys per annum from the private sector for five years. Is that happening? In their answers to the recommendations of the House of Commons Health Select Committee, the Government admit that they are only now examining in any depth the medium and long-term demand for digital hearing aids and are only now developing a toolkit for workforce planning. Again, only very recently have the Government accepted that official data on referral to treatment times should be collected in relation to hearing aids. Better late than never, but one wonders how any policy decisions have been reached either in Whitehall or in PCTs in the absence of such fundamental information. What is not measured cannot be managed. I hope that the Minister will tell us that better and more detailed information will be the starting point for better and more joined-up policy in this vital area.

Baroness Royall of Blaisdon: My Lords, I, too, am grateful to the noble Baroness, Lady Howe, for raising this very important issue, which affects the quality of life of a growing number of citizens. I agree that the debate is both necessary and timely, and I am sure that we are all indebted to both the noble Baronesses, Lady Howe and Lady Richardson, for their honesty about being deaf. It is very refreshing to hear about the problems confronting people who are deaf. My mother went deaf as she got older but for many years she refused to acknowledge it, and that caused problems for her and for us as a family.

In their White Paper, Our Health, Our Care, Our Say, the Government set out a vision to improve the independence, choice and control of those who receive services. The ability to communicate effectively is absolutely fundamental to achieving that vision, and the ability to hear is vital to the process of communication—an inclusive process. Perhaps for too long, audiology has been a Cinderella service but I can assure noble Lords that it is not a Cinderella service now, and we are working flat out to respond to the demand for improved audiology services.

Around 1.8 million people have NHS-provided and maintained hearing aids. These include the more recently introduced digital signal processing hearing aids, which have enhanced patient benefits. Those with more profound hearing loss, including children, are obtaining access to new implantable devices, such as bone-anchored hearing aids and cochlear implants. As people get older, they are more likely to develop a degree of hearing impairment, and with more people living longer, the demand on audiology services will continue to increase. The demand for audiology services has also increased because many people who currently use an analogue hearing aid naturally and rightly wish to switch to the improved performance provided by digital hearing aids.

Recognising the importance of early access to both diagnostic assessment and treatment for hearing difficulties, the Department of Health, as part of its 18-week physiological measurement programme, developed a national action framework for audiology services. From the outset, the department engaged with many key stakeholders to ensure that the process of developing the framework was inclusive. The national audiology framework, Improving Access to Audiology Services in England, was published in March 2007. It set out a programme of work aimed at helping local health systems to transform the experience of the audiology service for all their patients with a vision of delivering high-quality, efficient services closer to patients’ homes and responsive to the needs of local communities.

The framework also set out how the health reform levers could be brought to bear to achieve these aims and the national work that will be undertaken to support the process. It is now 10 months since publication and significant progress has been made—although as demonstrated this evening, clearly not enough progress yet. The number of people having to wait for an audiology assessment has fallen dramatically. A year ago, more than 114,000 patients waited longer than 13 weeks for their assessment. Now this figure has fallen to 34,000 and is still falling. By March 2008, no patient should have to wait longer than six weeks for their assessment.

The department is actively working with SHAs, PCTs and providers to tackle the current poor performance in some areas of the country. The noble Baroness and others cited the dreadful regional discrepancies and referred specifically to the problems in Kingston. As noble Lords will know, the department does not collect data on waiting times for treatment. However, we are working with the most challenged organisations to get this data and are committed to collecting it nationally by April.

We are constantly trying to improve the quality of data we collect. We have been working closely with the NHS to look specifically at how long patients wait if they are sent directly from their GP to the audiology service, which is not included in the 18-week target. The NHS is continuing to transfer services making the best use of innovation and new technology. A key example is open-ear technology which does not require individual ear moulds to be produced and provides more comfort, better cosmetic appearance and natural-sounding speech. This technology used in conjunction with digital hearing aids is effective in enabling a significant proportion of patients to be assessed and fitted with a hearing aid in the same appointment.

Training is currently being rolled out across the NHS to support both widespread adoption of this technology and to enable patients to benefit from treatment as quickly as possible. A patient’s pathway has therefore been reduced from five steps to one. This really is progress in the NHS. I know that it has been available in the independent sector for some time but now we have it in the NHS.

We published the good practice guide Transforming Adult Hearing Services for Patients with Hearing Difficulty in June 2007, which included the introduction of a new care pathway and case studies of NHS service improvements. Our aim is to drive innovative approaches to commissioning and to provision, including those of the independent and third sector, to which I will return.

We have set up the national Audiology Advisory Board to oversee the implementation of the framework, including representation from a broad range of key stakeholders. Whilst the majority of long waits are for adult hearing services, we are also in the process of developing further guidance for other services provided by audiology departments. We are working with stakeholders such as the National Deaf Children’s Society, to develop a new care pathway for children’s hearing problems and to embed best practice. We are developing new pathways and best practice guides for balance and vestibular function services, tinnitus and more complex hearing problems.

The noble Baroness, Lady Finlay, rightly referred to the need for more audiologists and to the need for increased numbers and type of training, not just for adult hearing and balance services, but for the whole of the audiology service. We are assessing that now. This will include the need to train GPs better, identify the problems, and communicate with paediatricians as well as audio-vestibular physicians.

We are training 300 new hearing aid audiologists to respond to the demand from high street hearing care practitioners. They will complete a foundation degree operated as an “earn as you learn” partnership with high street employers. Over two years, this degree programme will combine academic and workplace skills. This links in with the broader Department of Health policy to modernise strategic careers. We are also looking at non-degree-based new career structures for audiologists who can undertake functions for which they do not need a degree. That is rather exciting.

A workforce toolkit is being developed to support audiology services and profile their workforce to match the services that need to be delivered. This will include a range of e-learning modules to underpin the roll-out of new adult hearing care pathways.

In order to address the areas that are experiencing the most significant challenges, the Department of Health recently established a transforming audiology services project. The team, working closely with the 18 weeks intensive support team, are working directly with the most challenged local health services and spreading best practice and learning throughout the NHS. That approach will be supplemented by the introduction of a quality monitoring tool to enable audiology services to become self-improving. The impact of the project is already improving performance in these areas. My noble friend Lord Giddens referred to the example of Norfolk and Norwich using open-ear technology and the new model. We have seen overall waiting times fall because of the way in which that trust has moved to assessment and fitting in one appointment. However, it is still trying to get rid of a backlog that developed over a number of years, so there are still long waiting lists in Norwich, but they are dealing with the situation.

Many noble Lords referred to the need for us to work more closely with the independent sector. Critical to achieving sustainable audiology services is strengthening commissioning capability. The department has established a national audiology commissioners group to look for innovative ways of ensuring that there is appropriate local capacity to deliver. In some instances, that will require procurement from the independent sector working in partnership with local health economies to provide solutions that cater for local requirements. Like patients, we want services in the community, close to home, with effective and efficient follow up. I assure noble Lords that we have effective engagement with the independent sector, but at local rather than national level because we believe that PCTs are best able to identify local needs and capacity. Some PCTs engage with high-street providers, often to provide certain parts of the patient pathway, sometimes in much needed areas such as routine maintenance, which was mentioned by the noble Baroness, Lady Barker.

The most complex patients under the care of a consultant will be treated within 18 weeks by the end of 2008. The operating framework for the NHS has made clear the priority of delivering 18 weeks this year, and we have made it clear that no organisation will be able to claim credible success in delivery of the 18-weeks target without making excellent progress on reducing long waits, even those waits that are technically outside the target.

The noble Earl, Lord Howe, spoke about war veterans. While I understand his natural concern, they are not currently seen as a priority by audiology departments.

In response to the points made about the indicative tariff, specifically the points made about Charing Cross Hospital, the tariff can be agreed locally and cover all aspects of the patient pathway. The national commissioning group, which includes representatives from every SHA, will discuss whether amendments to the tariff are required prior to the publication of the national tariff. I hope that that will address some of the problems that Charing Cross Hospital is anticipating.

I have not dealt with the problem of prevention, and I will return to that in writing. While I hope that I have been able to outline some of the significant progress that has been made since the publication of the framework, there remains a real challenge if we are to continue to drive down waiting times for audiological assessments and ensure that the six-week milestone is delivered. I should assure the noble Earl that the figures for the assessment of six weeks do include reassessments. Is the target of six weeks by the end of March attainable? Every SHA has guaranteed that it will hit its target, and the Department of Health continues to support the most challenged organisations to do so. I am an optimist, and there is great determination in the department to try to ensure that the target is reached. I trust that this excellent short debate will have acted as a catalyst for those SHAs.

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