Audiology good practice_June07

Transforming Adult HearingServices for Patients withHearing DifficultyA Good Practice Guide

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Transforming Adult HearingServices for Patients withHearing DifficultyA Good Practice Guide

June 2007

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DH INFORMATION READER BOX

Policy EstatesHR/Workforce PerformanceManagement IM & TPlanning FinanceClinical Partnership Working

Document purpose Good Practice Guidance

Gateway reference 8426

Title Good Practice in Transforming Adult HearingServices for Patients with Hearing Difficulty

Author Department of Health

Publication date 29 June 2007

Target audience PCT CEs, NHS Trust CEs, SHA CEs,Foundation Trust CEs, Medical Directors,Directors of HR, Directors of Finance, GPs,Communications Leads, Audiologists, ENTand Audiology Consultants, Heads ofAudiology Services

Circulation list

Description Further to the publication of ‘ImprovingAccess to Audiology Services in England’ inMarch 2007, this document provides goodpractice and evidence to help commissionersand service providers to make changes to theway that adult hearing services are delivered,in particular, to reduce waits for patients withthe most common hearing difficulties.

Cross reference Improving Access to Audiology Servicesin England

Superseded documents N/A

Action required N/A

Timing N/A

Contact details Becky FarrenPhysiological MeasurementCommissioning Directorate4N14 Quarry HouseLeedsLS2 7UEwww.18weeks.nhs.uk/public/default.aspx?main=true&load=ArticleViewer&Articled=557

For recipient’s use

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http://www.18weeks.nhs.uk/public/default.aspx?main=true&load=ArticleViewer&Articled=557

Foreword 1

Vision for Audiology and Adult Hearing Services 2

1 Achieving the Vision 5Systems and Processes 5

• Understanding the scale of the challenge locally 6

• Improving and consistently applying referral criteria 7

• Waiting list management and better scheduling 9

• Utilising all the benefits of Audiology Patient Management Systems 11

• Adopting Lean Processes 12

Technology 14

• Digital Hearing Aids 14

• Universal Open Ear Tip Technology 15

• Triage Equipment 18

• Automated Audiometry 19

Workforce 20

• New roles and expanded roles 20

• Volunteers 23

• Leadership 23

2 A new model pathway for commissioning audiology services for patients with hearing difficulties 24

Commissioning 27

Acknowledgements 29

AnnexesAnnex 1 – Summary of case study evidence referenced in the good practice 30

Annex 2 – References 31

Transforming Adult Hearing Services for Patients with Hearing Difficulty – a Good Practice Guide

iii

Contents

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FiguresFigure 1: High level pathway for adults with hearing difficulties 4

Figure 2: An integrated audiology service 5

Figure 3: Primary care questionnaire to assess hearing difficulty 8

Figure 4: Suggested referral management 9

Figure 5: Patient grouping for adult hearing services 10

Figure 6: Summary of lean solutions 13

Figure 7: Open ear tip technology 15

Figure 8: Comply ear tip technology 15

Figure 9: Percentage of people with ‘open ear’ hearing aid fitting by age group 16

Figure 10: Percentage of people with ‘open tip’ and ‘open tip + comply tip’

as a function of better hearing ear threshold category (averaged 0.5, 1, 2, 4kHz) 16

Figure 11: GHABP benefit from open ear technology 17

Figure 12: Assessment using audiology triage equipment 18

Figure 13: Triage equipment 19

Figure 14: Automated audiometry 20

Figure 15: Workforce solutions 22

Figure 16: Process pathway for hearing difficulty 24

Figure 17: Commissioning 28


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Professor Sue Hill – Hon MRCP, OBE:Chief Scientific Officer & National Clinical Lead for Physiological Measurement, Department of Health

Professor Adrian Davis – OBE:Clinical Champion for Audiology, Director New Born Hearing Screening Programme, MRC Hearing and Communication Group

Improving Access to Audiology services in England published by the Department of Healthin March 2007 set out the vision for people with hearing and balance problems and how theNHS needed to respond to the challenge.

Integral to improving access and reducing waits, particularly in adult hearing services, is the needfor services to be transformed applying all the tools and techniques of service improvement andredesign.

This good practice guide provides practical evidence based advice and introduces a new carepathway designed to provide speedier access to assessment and treatment and to fundamentallychange the patient experience. It is intended to support both commissioners and providers infinding and implementing solutions to capacity constraints and reducing waits to a sustainableposition.


1

Foreword

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1. The vision for people with hearingand balance problems is for them toreceive high quality, efficient servicesdelivered closer to home, with low waitsand high responsiveness to the needs ofindividual patients, which are free at thepoint of access.

2. The levers and incentives introduced bythe health reforms provide the opportunityfor more effective commissioning ofaudiology services, including practicebased commissioning and Tariffs.Each NHS audiology service should beencouraged to become self-improvingand deliver a quality service that aims toachieve, year-on-year, a better patientexperience.

3. Improving Access to Audiology Servicesin England1 sets out the context forthe transformation of adult hearingservices in England in relation to thekey patient outcomes of improving healthand well being, through the provision ofsafe, effective and responsive serviceswhich are efficient, affordable andequitable. In particular it seeks to improveresponsiveness to the needs of individualpatients and to make a maximum wait of18 weeks from referral to treatmentpossible for all audiology referrals.

4. The Care Closer to Home ENTdemonstrator sites2 have taken forwardthe White Paper, ‘Our Health, Our Care,Our Say’, vision for people to havegreater independence, choice, controland empowerment. A report from thiswork will be produced shortly, whichtouches on audiology services.

5. The Health Select Committee Enquiryreport into audiology3 also supports theneed to improve audiology services.Whilst this document addresses some ofthe issues raised in the report, it does notattempt to pre-empt the Government’sformal response to this document.

6. Improving Access to Audiology Servicesin England sets out the DH commitmentto produce a range of materials thatwill support the NHS in delivering onthese priorities.

7. This document represents the firstpart of this supporting information.It provides evidence and advice to helpcommissioners and service managers makechanges to audiology services, in particularto reduce waits for patients with the mostcommon hearing difficulties. It does notaddress more complex hearing need (suchas for bone anchored hearing aids or


2

Vision for Audiology andAdult Hearing Services

1 www.18weeks.nhs.uk/public/default.aspx?main=true&load=ArticleViewer&ArticleId=5702 www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Modernisation/Ourhealthourcareoursay 3 www.publications.parliament.uk/pa/cm200607/cmselect/cmhealth/392/392.pdf


http://www.18weeks.nhs.uk/public/default.aspx?main=true&load=ArticleViewer&ArticleId=570

http://www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Modernisation/Ourhealthourcareoursay

http://www.publications.parliament.uk/pa/cm200607/cmselect/cmhealth/392/392.pdf

cochlear implants), balance conditions,tinnitus or paediatric care, which will beaddressed though further materials to beproduced later in the year. The documentis split into two sections.

• The first focuses on the benefits thatcan be gained through getting thesystems and processes right, usingthe best technology that is availableand planning an effective andaffordable workforce,

• The second section introduces a newpatient pathway for the majority ofpatients with hearing difficulties, withsuggestions about an effective wayto deliver each stage of care.

8. The evidence on which this document islargely based is from the experience ofsix DH NHS Physiological MeasurementDevelopment Sites4, which testedinnovative delivery models and solutionsto reducing waiting times, predominantlyto NHS provided adult hearing servicesduring 2006/07. Some of the evidence isbased on early findings and requiresongoing refinement, testing, analysis andevaluation. The experience from thesesites is presented in a series of casestudies which will be available on the18 weeks website, these are listed atannex A. This evidence is supplementedby evidence from other NHS sites and

services provided by other organisationsthat have demonstrated improvementsin the delivery of their services.

9. New information is provided on a modelcare pathway for adults with hearingdifficulties, a high level overview ofwhich is outlined at figure 1 and whichwill be described in detail later in thisdocument. Additional pathways will bedeveloped and published during 2007 tocover a more comprehensive range ofhearing and balance disorders includingthose affecting children.

10. Good practice in providing care foradults with hearing difficulties as outlinedin this document and using this patientpathway will:

• Challenge existing practice andpathways so that patient outcomesand experience are improved

• Maximise transformational changeopportunities so that services meetpatient needs

• Minimise risks to patients in takingforward change

• Utilise service improvementtechniques

• Support commissioners to deliver18 weeks across all care pathways


3

4 Referred to as the NHS Development Sites, case studies listed at annex A will be made available onhttp://www.18weeks.nhs.uk/Public/default.aspx?main=true&load=ArticleViewer&ArticleId=557#1


http://www.18weeks.nhs.uk/Public/default.aspx?main=true&load=ArticleViewer&ArticleId=557#1

11. A more comprehensive pathway for alladults with hearing difficulties is alsoembedded within a ‘symptom based’commissioning pathway5 published asone of a series of commissioning

pathways to support delivery of18 weeks. The good practice in thisdocument refers mostly to the columnheaded ‘primary assessment’.


4

Figure 1: High level pathway for adults with hearing difficulties

Wax removal, for some,

by GP or in One Stop Model

Self ManagementHigh Street shops

PharmacyEmployers

Third SectorNHS Direct and Online

Primary Care: Review hearing impact and ongoing need

*

People with Hearing Difficulty

Access to Scheduled

NHS Services

Quality Control viaKey PerformanceIndicators, plussample of cases

seen in depth

Primary careAdults with the most common hearing difficulties triaged

using standard referral criteria which could include hearingscreening test and otoscopy. All referrals made to an audiology

provider or to unscheduled care eg sudden hearing loss.

Assessment and Fitting

assessment of hearing impairment e.g. PTA and wherepossible agree and start care plan, including fitting

of hearing aid

Follow up

Outcomes Assessment (e.g. GHABP) via phone,if appropriate

On going care close to home

Provide repairs, batteries, tubing and advice

5 http://www.18weeks.nhs.uk/public/default.aspx?load=ArticleViewer&ArticleId=645


http://www.18weeks.nhs.uk/public/default.aspx?load=ArticleViewer&ArticleId=645

12. Improving Access to Audiology Servicesin England describes the audiology servicetoday. Audiology services have commonlybeen commissioned from the acute sectorwith highly variable accessibility, patientwaits and outcomes. By using existingknowledge about improving NHS Systemsand Process, evidence about InnovativeTechnology and planning and introducinga competent, productive Workforce todeliver the right processes at the rightskill level, services can be transformedto deliver the vision.

13. This section triangulates evidence tosupport these essential componentsof integrated service improvementfor delivering services to adults withhearing difficulties.

Figure 2: An integrated audiology service

Systems and Processes14. Waiting times for adults with hearing

difficulties can be radically reduced bygetting the basic systems and processesright through:

• Understanding the scale of thechallenge locally and collectingappropriate information to plancapacity

• Improving referral criteria andensuring that they are consistentlyapplied by well informed primarycare practitioners

• Better waiting list management andefficient scheduling, includingmanaging DNAs

• Managing variation in capacity anddemand and maximising added stepsin the patient pathway

• Utilising all the benefits of theaudiology Patient ManagementSystems and linking where possiblewith broader NHS PatientManagement Systems

• Adopting lean processes and otherservice improvement methodologiesthrough a systematic approach tounderstanding local services

PATIENTImproving the patient

experience and providingbetter access to audiology

services

Realising thebenefits ofnew technology

Matchingworkforce skills& competencies

to improvingworking practices

Making systems& processeslean and efficient


5

Part 1Achieving the Vision


15. A wide range of good practice materialsin the general management of systemsand processes have been produced by theModernisation Agency and more recentlyby the NHS Institute for Innovation andImprovement, which may provide usefulreference material6. These materials willhelp to improve the efficiency andproductivity of pathways, but need to becoupled with a transformational approachwhich results in services looking verydifferent from the present.

Understanding the scale of the challengelocally and collecting appropriate informationto plan capacity

16. It is estimated that the prevalence ofhearing loss among adults in England is20%. Age is a major predictor of hearingimpairment so as the population agesmore people will be affected. There islittle effect of prevention strategies forpeople aged 50 years and older, althoughnoise exposure at work and at leisure(clubs, concerts, DIY, power tools etc)is the major preventable risk factor forthose under 50 years7. About 10% of theadult population have hearing difficultiesand could benefit from hearing aids

associated with a significant andsubstantial improvement in their qualityadjusted life years (QALYs)8.

17. Improving Access to Audiology Servicesin England estimates that nationallyaround 300,000 extra pathways areneeded between April 2007 andDecember 2008 to make a maximumwait of 18 weeks from referral totreatment possible for all adult patientswith hearing difficulties, including thoserequiring reassessment of their needs andan appropriate hearing aid upgrade. EachSHA will have its own estimated capacitygap associated with its long waits andthe needs of its population.

18. The NHS development sites illustrated thebenefits that can be achieved throughunderstanding their local demand andhistorical activity levels and estimating thecapacity needed for sustainable serviceswith reduced waiting times. This has insome way been helped by the need forsystems to be put in place to generateinformation for the DH monthly datareturns and quarterly census whichinclude a requirement to provide waitinglist and activity information9.


6

6 www.modern.nhs.uk/improvementguides/capacity/www.wise.nhs.uk/cmsWISE/Cross+Cutting+Themes/capacity/planning.htmwww.modern.nhs.uk/improvementguides/capacity/7.htmwww.institute.nhs.uk/ServiceTransformation/Lean+Thinking/www.nodelaysachiever.nhs.uk/

7 www.hse.gov.uk/pubns/indg322.pdf and www.hse.gov.uk/noise8 Davis 1995; Davis et al 20079 www.performance.doh.gov.uk/diagnostics


http://www.modern.nhs.uk/improvementguides/capacity

http://www.wise.nhs.uk/cmsWISE/Cross+Cutting+Themes/capacity/planning.htm

http://www.modern.nhs.uk/improvementguides/capacity/7.htm

http://www.institute.nhs.uk/ServiceTransformation/Lean+Thinking

http://www.nodelaysachiever.nhs.uk

http://www.hse.gov.uk/pubns/indg322.pdf

http://www.hse.gov.uk/noise

http://www.performance.doh.gov.uk/diagnostics

19. In order to understand the scale of thechallenge for NHS services, commissionersshould ensure that providers:

• Collect and analyse demand data forall stages of the pathway, againstagreed lists, in order to determinethe rate of referral, and any changesto this

• Maintain data sets, which record thetype of referral, referral sourceincluding speciality, referral date,appointment dates, attendance record,waiting and/or clearance times

• Understand and plan the capacity ofthe service (encompassing all sessionsand different types of referrals) andhow this needs to alter to meetcurrent demand and any fluctuations,including through use of theaudiology Patient ManagementSystems (see para 33)

• Utilise data to inform service redesignand models of provision to ensurethat access is improved and thatpatient flow is balanced into andout of the service associated, forexample, with variations in demandand capacity

20. To assist NHS service providers, theNational Physiological MeasurementProgramme has developed a simplecapacity planning and scheduling toolthat is currently being tested by NHSpartners and will be available shortly10.

21. Commissioners should also review howthe independent sector can be utilised asa flexible resource to meet additionalcapacity requirements.

Improving and consistently applyingreferral criteria

22. Clear and consistently applied referralcriteria into health services are a keyelement of service transformationprocesses, supporting not only equitableprovision but also ensuring that patientswith defined symptoms flow into themost appropriate service.

23. The level of hearing loss is tested bydetermining the intensity of a sound(in dBHL) that can be heard at differentfrequencies (kHz). It is usuallyacknowledged that there is a problemwhen hearing loss in any ear is 25dBHLor greater across a mid range offrequencies (0.5, 1, 2 and 4 kHz)11.


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10 http://www.18weeks.nhs.uk/public/default.aspx?load=ArticleViewer&ArticleId=55711 Davis, 1995



24. The validated questionnaire at figure 312

will help primary care and otherpractitioners to make a decision aboutwhether a new patient has a hearing lossthat can benefit from using hearing aidsand whether it affects one or both earsas part of the initial assessment13: Thequestionnaire could be carried out bya range of primary care professionals,including practice nurses, healthcareassistants and GPs or could be selfadministered and interpreted by ahealthcare professional.

25. Assessment of other factors, which areoutlined at figure 4 (based on goodpractice from open ear fitting trial), willhelp to make a judgment about the mostappropriate referral for the individual andshould be based on information providedby both the patient and carers/relativesand taking account of patient choiceand preferences. This includes assessmentof the medical symptoms that couldaccompany hearing difficulty, such asvision and manual dexterity. At this earlystage it is important to ascertain whetherthe patient is likely to choose treatmentwith a hearing aid if they do havesuspected or demonstrated hearing loss,however, this should not preclude furtherassessment of hearing difficulty.

Figure 3: Primary care questionnaire to assesshearing difficulty

Q1. Do you have any difficulty withyour hearing? No/Yes

Q2. Do you find it very difficult to followa conversation if there is backgroundnoise (such as TV, radio, childrenplaying? No/Yes

Q3. How well do you hear someone talkingto you when that person is sitting onyour RIGHT SIDE in a quiet room?With no difficultyWith slight difficultyWith moderate difficultyWith great difficultyCannot hear at all

Q4. How well do you hear someone talkingto you when that person is sitting onyour LEFT SIDE in a quiet room?With no difficultyWith slight difficultyWith moderate difficultyWith great difficultyCannot hear at all

If the answer to Q1 or Q2 is yes and theresponse to both Q3 and Q4 are at leastslight then hearing aids would give benefitand would be more likely to be used.


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12 Validated in the national study of hearing Davis 1995 and Davis et al 200713 The mean hearing threshold level associated with a YES to Q1 or Q2 is about 30 dB HL and for Q3 the answers

no, slight, moderate, great difficulty and cannot hear at all are associated with about 20, 35, 45, 70, 85 dB HLrespectively across the average of 0.5, 1, 2 and 4kHz thresholds in people age 50-80 years.


26. Informed primary care staff will becritical to the success of introducing thequestionnaire, a more streamlined servicemodel and needs based referral systems.

Waiting list management andbetter scheduling

27. The national diagnostics data collectionhas highlighted long waits and clearancetimes in audiology services and particularlythose associated with adult hearingdifficulty. Waiting list management wasvariable in the NHS development sites.The following principles provide a guidefor NHS audiology services to achieveconsistency but also an expectation ofservice providers by commissioners:

• As far as possible adopt existing localprovider waiting times policies andprocedures that reflect 18 weeks

• Carry out administrative andpatient based validation to excludeunnecessary cases e.g. peoplewho are on the list more than once,those that have already been seen,those who no longer need care orhave died

• Maintain as few separate waiting listsas possible

• Group together and maintain clearguidelines for patients who needbroadly similar services14


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14 www.modern.nhs.uk/improvementguides/capacity/1.htm

Hearing difficulty and problem Suggested referral

• Younger age group 50-80 (70% of � Refer for an assess and fit appointment current first time referrals) where possible

• Visually impaired/problems with � Refer for primary assessment with the dexterity/communication difficulties/ audiology service unless GP thinks assess older age group and fit appropriate

• Slight difficulty with hearing in one ear � Watchful waiting, with counseling and and/or unwillingness to have an aid information

• Tinnitus that lasts for more than 5 minutes � Refer for primary assessment with the and is not only after loud sounds audiology service

• Other symptoms reported and/or under � Refer to medical consultant led ENT/Audio-50 years old vestibular medicine outpatient service

• Sudden hearing loss � Refer to emergency ENT/Audio-vestibularmedicine outpatient where appropriate

Figure 4: Suggested referral management


http://www.modern.nhs.uk/improvementguides/capacity/1.htm

• Register patients as they enterthe service

28. The importance of adopting goodwaiting list management is demonstratedin a number of NHS development sites.For example, by validating their waitinglists, Leeds Teaching Hospitals NHS Trustachieved a reduction of 894 patients(27% of the list) and Stoke on TrentNHS Trust reduced lists by 245 patients(5.2%). Stockport PCT reduced theirlist by 254 patients (10%) througheliminating duplications and list basedmistakes and then by up to 25% whenwritten confirmation letters were sent outasking for a reply to whether the patientwanted an appointment or re-assessment.

29. The first stage in achieving an effectiveapproach to waiting list management andin moving towards fully booked audiologyservices is to break the appointment listdown by triaged needs and to make anassessment of the available capacity toassess and manage clinical prioritypatients and all other patients currentlyreferred for each care pathway15.

30. Experience from the NHS DevelopmentSites suggests an effective grouping forestablishing and maintaining lists foradult hearing difficulty after adopting thereferral management outlined earlier(paragraph 22), this is set out at figure 5:


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a. Urgent patients including those with sudden hearing loss or associated concurrentsymptoms that are referred from medical services

b. New patients with hearing difficulty

• Referred to Audiology for “assess and fit” pathway service with universal open eartip device or comply ear tip devices

• Referred to audiology for a two stage pathway with an assessment appointmentwhen an earmould is taken and information provided, followed by hearing aid fittingat a further appointment.

c. Existing patients with discontinued analogue hearing aids to be upgraded to new models

d. All other existing patients

15 http://www.healthcarecommission.org.uk/_db/_documents/04018762.pdf

Figure 5: Patient grouping for adult hearing services


http://www.healthcarecommission.org.uk/_db/_documents/04018762.pdf

31. NHS and other audiology services areencouraged to introduce a patienttracking list (PTL) to prospectivelymanage their waiting lists on the basisof referral to treatment, this will ensurethat a focus on improving access todefinitive treatment is both establishedand maintained irrespective of the routeof referral and provision of service.Guidance on implementing an 18weeks PTL is provided on the 18 weekswebsite16. This will be mandated for18 weeks pathways from July (e.g. thosevia ENT). Four NHS pilot sites are alsocurrently trialling a PTL for non 18 weekaudiology pathways.

32. Integral to the introduction of a PTL isensuring that scheduling or bookingarrangements are as efficient as possibleand all available capacity is appropriatelymanaged and utilised. For audiologyservices (see case studies for individualexamples, average figures given here)this could include:

• better management of DNAs througha clear and consistently applied DNApolicy, which can reduce DNA to wellbelow 5% of appointments

• cancellations handled consistentlyand in line with the Trusts access orwaiting list policy eg by booking atshort notice into cancelled slots,which can improve capacity by 5%

• applying innovative (and ethical)ways of both calling patients forappointment and reminding themof the date of their appointment

• offering a booked in advanceaudiology service to consultant ledENT outpatients rather than an adhoc on demand service, which isan inefficient use of staff time, whichdemonstrated huge reductions invariation of workload and an increasein efficiency of audiology staffinvolved in ENT clinics of about 20%

• offering specific slots and/or sessionsfor particular activities (eg repairs,telephone follow up) instead ofoffering drop in or ad hoc provision,which demonstrated large reductionsin variability of demand for services

• offering extended hours of operationand using staff flexibly to enable morepatients to be scheduled using thesame physical resources, whichdemonstrated 20 – 25% increase incapacity

Utilising all the benefits of Audiology PatientManagement Systems

33. The audiology patient managementsystem is domain/audiology specific asit has to work with NOAH. NOAHis designed specifically for the hearingcare industry. It can measure a patient’s


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16 www.18weeks.nhs.uk/public/default.aspx?load=ArticleViewer&ArticleId=947



hearing loss and transfer resultsautomatically to a common database,record journal notes regarding the sessionand automatically save these in thepatient’s record, either in NOAH or in aNOAH-compatible office managementsystem such as AuditBase or PracticeNavigator. NOAH comes with modulesfor performing basic fitting, measurementand office management functions.

34. To maximise the benefits of IT, servicemanagers should ensure that theiraudiology department:

• Engages with the Trust’s ITdepartment and ensure that audiologyservice requirements are reflected inexisting and new strategies goingforward e.g. National Programmefor IT

• Understands how their audiologyPatient Management System works

• Ensures that there is appropriate andearly segmentation of lists and thatlocal PTLs are established

• Understands how PMS interfaces tothe local IT infrastructure and chooseand book and plan to ensure thatthe NHS trust and PCT can sharemanagement information acrosssystems in line with NHS Connectingfor Health policy17

• Ensures the capabilities of the localPMS are being used to putappropriate workflow and localprocedures in place

• Receive adequate training to ensurethey use the system to its maximumeffect with recognition that local ITsupport may be required, wherepossible contracts should be in placeto ensure that local services are ableto receive system upgrades

Adopting Lean Processes

35. Service model improvement stems fromadopting a lean system design approach,removing unnecessary steps in thepatient journey and fully using theresources that are available in audiologyservices. An effective way to attain thislevel of understanding is to undertake alocal process mapping exercise18. Thisshould lead to better understanding ofthe entire patient pathway by all teammembers and thus improved workflowand greater efficiency of all staff, withbetter team working. A Medical ResearchCouncil workflow report19 suggests thatorganisational efficiency could increaseproductivity by about 10% in gooddepartments and that in others this gaincould be greater especially if waiting listsare poorly maintained and DNA ratesare high.


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17 http://www.connectingforhealth.nhs.uk/18 http://www.institute.nhs.uk/ServiceTransformation/Lean+Thinking/19 http://www.mrchear.info/cms/Resources.aspx?ResourceId=403


http://www.connectingforhealth.nhs.uk

http://www.institute.nhs.uk/ServiceTransformation/Lean+Thinking

http://www.mrchear.info/cms/Resources.aspx?ResourceId=403


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Lean solution Benefits Site Impact on waiting timesand/or capacity

Reduced variability inproductivity

East Kent HospitalsNHS Trust

Patients seen before ENT,which releases clinical time

Service ENT clinics moreefficiently

Reduces poorly used clinicappointments by 5-10%

Royal Bolton HospitalNHS Trust

Extension of audiologistrole; reduction in numberof wasted appointments

Remove ear wax on thespot during audiologyappointment

20-25% extra capacityusing same infrastructure

40 additional patients seeneach week for assessmentfor first hearing aid

Leeds Teaching HospitalNHS Trust

Norfolk and NorwichUniversity HospitalsNHS Trust

Extra capacity bystaggering existing staffover the extended day

Extend working day

Between 66%-70%discharged usingteleaudiology; 50% ofthe patient populationcovered by the service

Norfolk and NorwichUniversity HospitalsNHS Trust

More convenient forpatients, reduce thenumber of visits that thepatient makes to the clinic,saving time for bothpatients and staff

Establish a teleaudiologyfollow up service

20-30% capacity gainNorfolk and NorwichUniversity Hospitals NHSTrustEast Kent Hospitals NHSTrust

Leeds Teaching HospitalsNHS Trust

Time saving, andmorale/social involvementfor the patients

Group instructionsessions

100% capacity increase

10-15% capacity increase

Royal Berkshire HospitalNHS Trust

Royal Bolton HospitalNHS Trust

Increased capacity asworkflow is moreefficiently managed

Use of audiology PMS

5% capacity increaseEast Kent Hospitals NHSTrust

Fewer letters, effectivemeeting and greeting,information, travel plansand associatedbureaucracy

Minimise duplication

36. NHS audiology departments have madesignificant changes to their delivery

models as a result of lean thinking andthese are detailed in figure 6:

Figure 6: Summary of lean solutions



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Technology37. Embracing the benefits of new technology

has been highlighted by the Governmentas critically important in delivering servicesfor 21st century healthcare. This appliesequally to audiology services whereinnovations in current and emergingtechnology that support the assessmentand treatment of hearing difficulty meanthat audiology departments need toconstantly evolve and reap the benefitsof new technology, in line with recentreviews20 such as by the audiology supplygroup and by the Clinical AudiologicalResearch Network (CARnet).

38. A number of new pieces of equipmenthave been introduced into the marketwith several others in the pipeline, whichcould help to improve patient experience,productivity in audiology departmentsand outcomes for patients, including:

a. Digital signal processing (DSP)hearing aids

b. Open ear tips and comply tips

c. Triage equipment/Hear Screenequipment

d. Automated audiometry equipment

39. Information is provided in the followingparagraphs on a number of very newtechnological developments and whilst

these may not constitute a major part ofthe current solution to audiology services,providers and commissioners areencouraged to keep these solutions andevidence on the benefits they canprovide, under review.

Digital Hearing Aids

40. Digital signal processing hearing aidsprovided a major technological advancein the provision of audiology serviceswhen they were first introduced to theNHS in 2000. DSP hearing aids haveenormous benefits over the olderanalogue aids for patients, providingoptimised treatment and enablingpatients to experience majorimprovements in quality of life21.

41. Some patients still need to be upgradedfrom older analogue to digital technology,given the benefits and as spares on many ofthe analogue models are being phased out.Those that already have a digital hearing aidwill benefit in the future from the improvedmodels that the NHS will procure as theycome onto the market. This together withthe ‘3-4 year half-life’ of a DSP hearing aidmean that patients will require the devicesto be replaced and the patient’s needsreassessed to optimise and maintainsupport at regular intervals. Replacementneeds should be taken into account indemand and capacity planning.

20 DH Strategic Implementation Group, Health Industries Taskforce ‘Innovation for health: making a difference’ 21 Smith et al


Universal Open Ear Tip Technology

42. Earmoulds couple hearing aids to a patientsouter ear so that appropriately amplifiedsound can be presented to the middleand inner ear. Traditional earmoulds needan impression of the ear to be made andthen for a customised earmould to bemade from that impression. This involvestwo separate appointments forassessment and fitting of the hearing aid.

43. Open ear tip technology has beendeveloped in a universal format that canbe used as a good alternative to thetraditional custom made earmoulds inappropriate cases. The modular elementmeans that, providing the right size tip isused, it will support an assess and fit in asingle appointment, remove unnecessarysteps in the patient journey and reducethe time from referral to provision.

Figure 7: Open ear tip technology

44. Comply ear tip (CET) technology is similarto the open ear tip technology but usesheat sensitive foam tips closely coupled tothe ear tube that delivers sound from thehearing aid to the ear canal. Comply tips

can also be used (on a permanent ortemporary basis) where open ear fittingsare not possible such as for patients withgreater hearing loss than the currentfitting range.

Figure 8: Comply ear tip technology

45. The NHS Development Sites, have shownthat open ear or comply tip fittings canbe a solution for between 60 to 70%of patients who are directly referredfrom primary care to NHS audiologydepartments who need hearing aids aspart of their treatment and can also beused for existing patients22.

46. Open ear technology brings a range ofother benefits:

• Low frequency sounds, including thepatients’ own voice, sound morenatural. This naturalness, coupled withsome cosmetic improvement meansthat the hearing aids, especially when


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22 Kuk et al 2005; Wynne et al 2006; Davis et al 2007


fitted in both ears (bilaterally), aremore acceptable to patients

• The open ear technology can be usedacross a range of patient age groupswith the approach being suitable in75% of those patients in the agerange 50 to 74 years (50% of thosereferred for the first time) and 40%of patients aged 85 years and over.This is illustrated overleaf:

• Greater patient choice is provided aspatients can choose whether theywould prefer a conventional earmould fitting or the new technology,which is less intrusive

• Open ear or comply tip technologycan be used across a wide rangeof hearing severity levels includingin the form of an assess and fitservice model, as illustrated in thediagram overleaf.

Figure 9: Percentage of people with ‘open ear’hearing aid fitting by age group

• A percentage of patients with moresevere hearing difficulties can havehearing aids (treatment) earlier on inthe patient pathway and can receivebenefits earlier

Figure 10: Percentage of people with ‘opentip’ and ‘open tip + comply tip’ as a functionof better hearing ear threshold category(averaged 0.5, 1, 2, 4kHz)

• Technology is available in sizes to fitmost ears

• Importantly, patient outcomes asmeasured by the Glasgow Hearing AidBenefit Profile (GHABP) from open ear

0

10

20

30

40

50

60

70

80

90

100

<35 35-49 50-59 60+Better ear average threshold category (dB HL)

Open % Open + comply %

Figure 10 highlights the additional benefitthat can be gained from using open fit witha comply tip. It illustrates the differencebetween the number of people fitted withopen tip alone (purple) and the total numberfitted with open tip or comply tip (burgundy).This shows that comply tip can be adoptedacross hearing severity levels, but as hearingimpairment becomes more severe thenumber of patients that benefit reduces.

Age Group

100

80

60

40

20

050-64 65-74 75-84 85+

Perc

enta

ge


16



17

technology with DSP hearing aids aresimilar, if not better, to those thatmight be expected from theconventional ear moulds with DSPhearing aids as illustrated in figure 11.

47. Further evidence is needed to fullyevaluate the utilisation of the assess andfit approach and in particular the openear technology including:

• Whether the number of patients thatcontinue to use their aid increases

• The proportion of patients who willneed customised ear moulds at a laterdate either as hearing impairmentprogresses or if the outlined benefitsare not sustained

• The continued degree of additionalbenefit given by the aids

• How often the technology needs tobe repaired and replaced

• The extent to which this approachmay be easier for staff

• The number of patients who mayrequire follow up assistance to getthe full benefits including help withblockages of the tip or with excessivehearing aid feedback. It is estimatedthat this could be 20% of patientsand this is similar to those patientswho currently receive and haveproblems with conventional earmoulds in NHS services.

Figure 11: GHABP benefit from open eartechnology

Figure 11 provides the GHABP score on thevertical axis. The higher score relates tobetter benefit. On the horizontal axis scoresare provided for a sample of patients whoreceived either one or two DSP hearing aids(ie for one or two ears) with a conventionalear mould (MHAS 1 or 2) compared toa sample of patients who received eitherone or two DSP hearing aids with openfit technology (open ear trial 1 and 2), n = gives the number of patients whocompleted assessment.

In this sample the evidence suggests thatopen ear technology provided better patientoutcomes for both one or two ear fittingscompared to the conventional approachusing similar behind the ear hearing aids.

O

1 2 1 2

GH

ABP

ben

efit

dom

ain

scor

e (%

)

50

60

70

_

n= 521

_

n= 194

_

n= 101

_

n= 49

MHAS Open Ear Trial

1 2 1 2

Hearing Aids (1 or 2)

50

60

0

_

n 521

_

n= 194

_

n= 101

_

n= 49


• Cost effectiveness, including takingaccount of the increased number ofpatients that can be treated

Triage Equipment

48. A hearing screening device test has beendeveloped based on using different tonesat three intensity levels, it has been shownto be effective in identifying people whomay benefit from hearing aids23. Thisdevice is not currently available on themarket but is due to be launched insummer 2007. It enables a screen to bemade of a patient’s hearing loss before a

formal diagnostic assessment, to identifythose individuals below a certain thresholdwho do not need to be referred to anaudiology service24.

49. The equipment can be used by non-audiological staff such as GPs andpractice nurses. It is anticipated that thedevice could be used to effectively triagepatients and to streamline referrals asoutlined in figure 12, however, furthertesting and evaluation will be requiredafter its introduction.


18

Outcome from triage device Action/referral

Can hear all 6 tones – unlikely to need further hearing assessment

– may be discharged after an explanation and advice, ifnecessary, that many people have problems hearingspeech in noise or have tinnitus and if this persistsbeing a problem may need further investigation

Can hear 3,4 or 5 tones – likely to have a hearing difficulty that would benefitfrom fitting of an assess and fit hearing aid productsuch as an open ear tip or a comply tip as appropriatefor the patient

Can hear less than 3 tones – referred for comply tip or for assessment and fitting intwo sessions

Cannot hear any tones – referred for assessment in a clinic that canappropriately assess severe hearing impairment

Different results for each ear – referral for full audiometric assessment

Figure 12: Assessment using audiology triage equipment

23 MRC HARC and an industrial partner24 Davies et al 2007


Figure 13: Triage equipment

50. The device has been used in a numberof sites, including Stockport PCT where,through a trial, all 157 re-assessmentpatients involved were effectivelydirected to the correct appointment. Thedevice has been found, in an early pilotstudy, to be in the region of 90%sensitive and 85% specific25.

Automated Audiometry

51. Still in the early stages of developmentand testing, automated audiometry canbe used to carry out pure toneaudiometry (air conduction and boneconduction with masking) using anautomated procedure which gives patientinstructions in English and requires a highdegree of patient co-operation andconcentration. It has been developed inthe USA and elsewhere26. Work is

underway in the UK to fully understandwhether this technology could be usedappropriately in a wider range oflocations in the NHS and in theindependent sector, although it will stillrequire a sound-proofed room or area.The benefits will be dependent on localfacilities, work flow and skill mix, as wellas a range of patient related factors.

Figure 14: Automated audiometry


19

25 Davis et al 200726 Margolis et al 2006



20

Workforce52. As outlined in Improving Access to

Audiology Services in England and therecent Health Select Committee report onaudiology services, workforcetransformation is critical in achievingreduced waits for patients with hearingdifficulties. Workforce development plansneed to be affordable and supported bysignificant role redesign, skill mix andproductivity gains to produce asustainable workforce of the future.

53. The delivery of the complete range ofhearing and balance services for adultsand children will require an audiologyworkforce spanning the whole careerframework, inclusive of medical staff.It should be supported by appropriateeducation and training. Key to deliveringthe adult hearing difficulty pathway,however, is the introduction of anassociate practitioner role, which wouldbe recognised in terms of scopeof practice in both the NHS andIndependent Sectors.

54. The introduction of new technology andof streamlining systems and processesas outlined earlier in this document,together with new models of care,provide opportunities in themselves forreprofiling of the current workforce,

defining and utilising skill sets andintroducing new ways of working27.

New roles and expanded roles

55. A range of redesigned and newworkforce roles have emerged at the NHSdevelopment sites to support innovativesolutions to the long waits for adulthearing services. These are summarisedoverleaf and related to the new pathwayoutlined at the beginning of thisdocument. They do not cover thepathway as a whole but demonstrate afunction and competence based approachto achieving the aim of utilising skill mixto meet the pathway requirements. Theyrepresent a combination of expandingthe roles of the current workforce, newadministrative roles and a potential newrole to support the new model of care.

56. Figure 15 illustrates that significantworkforce transformation could beachieved within audiology services. Thereis potential for greater efficiencies, withskills and competences required to deliverservice outputs being more closelymatched to the healthcare scientist careerframework28 level descriptors. The NHSdevelopment sites have highlighted theimportance of administrative duties ofaudiology staff being kept at a minimum.Efficiency of audiologists was greatly

27 Executive Summary: Workflow analysis project – Adult Hearing Serviceshttp://www.mrchear.info/cms/Resource.aspx?ResourceId=408

28 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4123204


http://www.mrchear.info/cms/Resource.aspx?ResourceId=408

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4123204

improved when highly skilled andcompetent administrative or clerical staffwho are trained to understand thepatient flow, scheduling and listing ofpatients and waiting list managementwere introduced into departments.

57. In common with making services morelean, by process mapping and redesign, isthe need to undertake a similar processfor workforce redesign and profiling bymapping the functions that need to beundertaken, then identifying the skillsand competences required to undertakethe task/s and defining the supportingeducation, training and assessmentneeds. This can be done locally, and hasbeen undertaken in part by some of theNHS development sites, however workfor the complete 18 week adult hearingpathway will be undertaken nationallyin the near future to develop a nationaldata set of competences to support thelocal commissioning of a competentworkforce for delivery.

58. The opportunities for the roles outlinedat figure 15 to be nationally transferableand defined to support localimplementation will be explored. Workwill continue on the definition of theassociate practitioner role to undertakeroutine adult hearing assessment andfitting, which would support both the

NHS and IS sector requirements. Theworkforce capacity in this high volumetask area could be increased relativelyquickly, affordably and safely through thenew models of education and trainingprovision. Within the NHS such a rolewould exist within a team comprising ofa range of different professionals androles undertaking the breadth of hearingand balance disorders, including forpatients with more complex needs.

59. As outlined in Improving Access toAudiology Services in England, a toolkitof materials will be produced to supportlocal health systems in adjustingworkforce profiles to reflect newpathways and volumes of activity. Thiswork will, where relevant, be undertakenin conjunction with the DH ModernisingScientific Careers programme. This willidentify nationally transferable rolestogether with supporting education andtraining programmes to assist localworkforce planners and commissioners,together with modernised pre and postregistration education and training. It willprovide a more comprehensive and fit forpurpose audiology career framework tosupport the delivery of all care pathwaysas they emerge. The workforce in boththe NHS and IS will be considered andopportunities for cohesive developmentopportunities explored.


21

29 Improving Access to Audiology Services in England



22

Pathway stage Role Impact Site where itwas developed

East Kent Hospitals NHSTrust

• Increase number of free slots forAudiologist led clinic

• Triage at time of booking

• many patients directed to the robustvolunteer network for retubing

Assistant led clinic –expanded role of anassistant audiologist

Maintenanceand repair

Norfolk and NorwichUniversity Hospitals NHSTrust

Since April 2006,

• reduced the number of clinicappointment slots available forfollow-up by 120 a month

• corresponding gain of 15 hours ofclinic time a week for a qualifiedaudiologist

• This capacity has been reinvestedinto hearing aid assessment andhearing aid fitting slots and is helpingto drive down waiting lists

Expanded role ofsecretarial andadministrative staff inpotential follow up

Telephone follow up

Pennine Acute HospitalsNHS Trust

• Reduced administration time foraudiologists

• Increased knowledge for whole teamof ear mould processes, pitfalls andproblems

• Skill mix by using the relevant skills atthe relevant place along the pathwayhas given value for money

• release audiologists to do other tasks

Assistant audiologist Ear mould impressions


• Practitioner dedicated to assessingand fittings digital hearing aids

• Patients referred on to audiologistswhere required

• Can be trained on the job undersupervision

New associate practitionerfocused on routinepatients

Assess and fit for mildto moderate patients

Leeds Teaching HospitalsNHS Trust


• Efficient and consistent administrativehub

• All telephone calls handled in oneplace

• Repetition of administrative tasksreduced

• Efficiently equitably managed waitinglist

• Activity reports’ quality andconsistency has improved

Office Manager/Administration Co-ordinator

Improved scheduling tomost appropriate list

Norfolk and NorwichUniversity Hospitals NHSTrust

• Extension of the audiologist role.

• A reduction in the number of wastedappointments.

• Fewer journeys for patients – theydon’t have to come back to theaudiology department for arescheduled appointment followingtheir earwax removal.

Expanded role ofaudiologist

Wax removal

Figure 15: Workforce solutions



23

Volunteers

60. The use of volunteers was highlightedin a case study from Hearing Concern29

which has a network of volunteers tosupport NHS audiology services acrossthe country. The volunteers providerehabilitative advice to help patients livewith and manage their hearing difficulty.Whilst currently small scale, this projectillustrates the role that the voluntarysector can play to provide similar input.

61. Reflecting the benefits of this approach,NHS audiology services have begunto develop their own volunteerarrangements, for example at theShrewsbury and Telford NHS Trust, whichis supported by a locally developededucation and training programme. Theseexamples show how services can bedelivered in partnership which needs tobe an integral part of local planningarrangements. The capacity of the NHSaudiology service can be enhanced byworking with the Third Sector and optionsshould be explored through workforceplanning to support local delivery.

Leadership

62. To achieve the major change in workforcetransformation strong clinical leadership isessential together with support when it isrequired and a can do attitude from thewhole delivery team and a ready toembrace change philosophy.

63. An effective pathway will maximise theway that services are delivered so thatpatients presenting with hearing difficultyare managed effectively and in a timelymanner. The aim for every patient is toreceive services according to need and ina way whereby they can benefit fromtreatment options quickly and efficiently.

64. The high level pathway shown at thestart of this document (figure 1) is furtherbroken down into its component parts infigure 16, this provides an opportunity tocommission elements differently and in away that may ensure, for example, thatNHS capacity is used in a focused wayand that care for some parts of theprocess can be provided closer to home.



24

Part 2A new model pathway forcommissioning audiology servicesfor patients with hearing difficulties

Figure 16: Process pathway for hearing difficulty

Possible hearingdifficulty

Hearingdifficulty

OptimiseHearing for

every day living

Routine andcomplex cases ofhearing difficulty

Ear wax andaural hygiene

Provide localon goingsupport

Patientself management

Primary Care/GP

Follow up – varietyof provider models

Hearing servicesproviders: 1 stopmodel or 2 stage

for complex

In primary care orone stop model

Maintenance/advice-variety of

provider models

Screen

Triage: Questions,otoscopy, screening test

Outcome assessed GHABP/GHADP plus HD questions

by phone, face toface or internet

Wax removal andaural hygiene

Provide batteries, tubesand repair andrehabilitation

Patient/othersidentify level of

hearing difficultyneeding attention

Discharge/Ear wax/refer for possible

DSP aid

Degree of Hearingand communication

improved withhearing aid use

Watchful waiting orDSP hearing aid

fitted orother support

Hear better sodischarge or still

difficulty – continuerefer for DSP aid

Successful hearing aiduser achieving benefit

in everyday living

Clinical issue Stages Process Patient Outcome

Hearing loss assessed, explainedand fit hearing aids. If patient

chooses, group instruction,deal with patient problems

Hearing aid review

– telephone, face to face, using structured questions


65. The pathway essentially comprises of sixmain stages, identified in the green boxesin the diagram and detailed in thefollowing paragraphs:

• Patient self management

• Primary care

• Assessment and fitting

• Follow up

• Maintenance, advice and support

• Review

66. Patient’s will take some responsibilityfor self management of their hearingcondition by:

• Consulting with their doctor if theyexperience hearing problems, possiblyleading to a hearing screening test(in person or on the phone)

• Ensuring appropriate aural hygienei.e. that the problem is not a build upof wax (which should be managed inprimary care)

• Ensuring that any aids they alreadyhave are appropriately andhygienically maintained, withearmoulds and tubes regularly cleanedand the right stock of batteries kept

67. There should be greater focus on theinvolvement of primary care by:

• Utilising triage questions andassessment of needs/difficulties andwhen available use a screening device

• Removal of wax done or planned inprimary care or commissioned fromthe audiology service provider in aone stop appointment model withassess and fit

• Where there is a need, patients withanalogue should be prioritised overpatients with DSP hearing aids

• Implementing standardised referralcriteria to identify correct pathwaywith all patients with sudden hearingloss going to A&E and/or ENTduring outpatient hours or to audio-vestibular physicians

• Reviewing patient’s ongoingrequirements every 4-6 years orearlier on a needs basis

68. All of the above will require a greaterawareness and understanding ofhearing difficulties among primarycare practitioners, which will need tobe built into any commissioning plan.

69. Where possible, and when clinicallyappropriate, the patient should beassessed and fitted with a digital hearingaid in a single appointment or be seenin a streamlined two stage process:

• Assess and fit with open eartechnology should be used forpatients with mild to moderatehearing loss, usually delivered by anassociate audiologist


25


• Those not suitable for assess and fittechnology, and those with severehearing loss, should be assessedagainst a suitable protocol, includinga review and full needs assessmentby an audiologist

• Ear moulds should be taken on theday of the appointment for patientsthat are not suitable for open eartechnology

• Potential reductions to be made inproducing earmoulds should becapitalised using new technologyeg 3D scanning of ear impression andlaser manufacturing of ear mouldswhich could reduce the time betweenimpression and ear mould beingdelivered to patient in three workingdays

It should be noted that some patientsfitted with open ear tips may need tocome back into the system for an earmould at a later date.

70. Follow up after fitting should be triagedand handled initially by phone wherepossible and/or face to face based onpatient need and choice:

• Follow up should initially be byphone, using a structuredquestionnaire and an outcomeassessment of whether hearingneeds have been met. This may beface to face according to patient

need and choice or based on anassessment by the audiologist orassociate audiologist when theirhearing aid is fitted

• Patients who cannot be followed upover the phone and who are notderiving expected benefits should beseen in a dedicated face to facefollow up clinic

• Follow up could be provided by theNHS audiology department orexternal provider e.g. Hearing Direct(part of NHS Direct) or the ThirdSector.

71. Patients who have received an aid shouldget non urgent or routine maintenanceand advice and support from locationsconvenient to them:

• Maintenance and repairs – such as forbatteries or tubing – should beprovided in locations convenient forthe patient and where appropriate bythe independent sector or third sector

• Support and advice may be providedby telephone and, if a need isidentified, the patient may berequired to revisit an audiologyprovider

• Provision could involve the thirdsector or IS provision on the highstreet


26


• Patient records need to be maintained,wherever care is provided

72. Patients should be advised to return toprimary care to be referred for a reviewon a needs basis:

• It is suggested that patients arereviewed after a period of time,to check that their hearing aid isdelivering optimum benefits

• The frequency of such a reviewshould be determined locally inconjunction with audiology providersand based on patient need

• If a patient’s hearing deterioratesand/or they feel their hearing aid isno longer fit for purpose, they shouldbe advised to return to primary carewhere support may be provided.If appropriate, the patient will bereferred to an audiology providerfor assessment and treatment, ifrequired, this would represent a newepisode of care.

Commissioning73. Audiology services for the NHS should be

commissioned to provide patients withservices that are responsive to their needsand that empower patients to be partnersin achieving those needs. The high leveloverview shown in figure 1 and the 18week commissioning pathway promotedelivery of a service in which:

• primary care provide a more activerole in assessing patient need andpreparation for hearing care (e.g.removal of earwax)

• referral criteria are uniformlyimplemented to the main referralstreams

• appropriate new and returningpatients receive one-stop assessmentand fitting based on availabletechnology

• follow up, including reassessment ofpatient needs, is conducted bytelephone

• patients who have received hearingaids get maintenance, batteryreplacement and ongoing advicefrom locations convenient to them,including in primary care

74. The version of the pathway at figure 17shows the different elements that needto be commissioned. Each colourrepresents potentially different serviceproviders, although one provider couldprovide all services. Particular attentionneeds to be given as to how the interfacewith ENT and other scheduled andunscheduled care is taken forward.Other care pathways will be publishedlater this year.


27


75. As part of the PCT commissioning cycle,all current and potential providersof audiology services should be consultedin relation to adoption of the suggestedreferral criteria and new pathwayoutlined in this document and to engagein broader local implementation plans.Developing a PCT and/or SHA widenetwork may be useful in helping toimplement this pathway and in spreadinggood practice and making best use ofall of the available capacity.


28

Access toScheduled

NHS Services

Commissioned work streams in scheduled patient pathwayCommissioned work streams in scheduled patient pathway

On goingSupport variety ofprovider models

Self managementand review

Follow upVariety of provider

models

One stopmodel

Hearingdifficulty

Self assess

Screen identifyif problem

viaPhoneInternet

Digital TVIn personBy post

ProvidersHigh Street

shopsEmployers

Third SectorNHS Direct

Online

Selfmanagement

Primary care /GP

Peoplepresenting with

hearingproblems

triaged basedon clear

referral criteriathat mayinclude a

screening testof hearing

plus otoscopy.

Make allreferrals

to AudiologyProvider, ENT

or A&E

Assess Needs Hearing / ENT

Involve patient

Discharge or Start Care Plan

Programme fit and verify

as assess needs unless difficult

case, when take mould and patient

returns for fit

Group instructioncan help efficiency

and understanding

Follow-up

Outcome Assessment via phone for all suitable

eg GHABP

Clinic inputonly if needed to

adjust Care plan

Primary Care

Initiated Review

Hearing

~3-4 years

Support

Triage needby phone,assistant, Internet

Use 3rd

Care PlanProvide

Repairs, Batteries,

Tubing, New aids

Rehab

To ENT as required ( In parallel)

Other scheduled pathways (eg severe HL, tinnitus, balance)

Wax andaural hygiene

To unscheduled care pathways (eg A&E, sudden hearing loss)

Wax removalin PrimaryCare Or

One-Stop-Model

Self m

anagementS

elf m

anag

emen

t

hearing aids insame session

sector to helpunderpin

Aid Review

Figure 17: Pathway for Commissioners


Audiology Working Group (Nov 2006 – April 2007)Adrian Davis, MRC Hearing & Communication;Alan Torbet, BSHAA; Graham Day, WithingtonCommunity Hospital; Jan Yeates, WestMidlands SHA; Jonathan Parsons, BritishAcademy of Audiology; Neil Griffiths, PASA;Nick Setchfield, Leeds Teaching Hospital NHSTrust; Paul Montgomery, Norfolk & NorwichUniversity Hospital; Paul Sinden, Barking &Dagenham PCT; Tony Sirimanna, GreatOrmond Street Hospital; Tali Mendelshon,RNID.

Department of Health – Wendy Brown;Chris Walker; Peter Grummitt; John Brittain;Rob Alexander; Andrew Rostron;Hilary Osborne; Jim Timpson.

Audiology Advisory Board (June 2007 – March 2008)Adrian Davis, MRC Hearing & Communication;Alan Torbet, BSHAA; Bunty Levene, HearingConcern; Ewa Raglan, Great Ormond StreetHospital; Jan Yeates, West Midlands SHA;Lesley Bachelor, Royal College of Paediatricsand Child Health; Linda Luxon, Royal Collegeof Physicians; Martin Burton, ENT UK; NickSetchfield, Leeds Teaching Hospital NHS Trust;Paul Sinden, Barking & Dagenham PCT;Pauline Beesley, British Academy of Audiology;Philippa Palmer, RNID; Ros Davies, BSA;Sandra Verkuyten, Hearing Aid Council; SusanDaniels, The National Deaf Children’s Society;Sue Hitchenor, East Midlands SHA.

Physiological Development SitesEast Kent Hospitals NHS TrustLeeds Teaching Hospital NHS TrustNorfolk & Norwich University HospitalNHS TrustRoyal Devon & Exeter NHS Foundation TrustRoyal Free Hampstead NHS TrustPennine Hospitals Acute Trust


29

Acknowledgements



30

East Kent Hospitals NHS Trust• Service ENT clinics more efficiently

• Commit to continuous serviceimprovement

• Create clinical capacity by strippingout administrative and non clinicaltasks from clinical roles

• Consolidate and validate waiting lists

• Introduce positive booking

Leeds Teaching Hospital NHS Trust• Relocate hearing aid assessment

and fitting services into primarycare settings

• Encouraging patient management offollow-up care

• Using dynamic IT based tools forclinic planning and staff management

• Actively managing waiting lists

• Introduce fully booked follow-upand repair services

• Increase productivity by introducingan extended working day

Norfolk & Norwich University HospitalNHS Trust

• Minimise waster appointments:remove ear wax on the spot duringan audiology appointment

• Use telephone follow-up

• Use Fit and Go open mould eartechnology for a one-stop hearingassessment and hearing aid fittingservice

Royal Devon & Exeter NHSFoundation Trust

• Introducing new technology –Assess and Fit

Royal Free Hampstead NHS Trust• Bundle diagnostic tests at one

appointment to reduce waiting timesfor patients

• Validate waiting lists on an ongoingbasis

Pennine Hospitals Acute Trust• Setting up an in-house service to

manufacture ear moulds

Annex 1Summary of case study evidencereferenced in the good practice


1. Adrian Davis, Pauline Smith, MelanieFerguson, Dafydd Stephens, IoanisGianopoulos (2007). Acceptability,benefit and costs of early screening forhearing disablity. HTA monograph inpress.http://www.hta.ac.uk/project/1025.asp

2. Davis AC, Mencher GT (eds). Specialsupplement on Binaural Hearing andBilateral Hearing Aid Provision. Int JAudiol. 2006 Jul; volume 45

3. Hannaford PC, Simpson JA, Bisset AF,Davis A, McKerrow W, Mills R. Theprevalence of ear, nose and throatproblems in the community: resultsfrom a national cross-sectional postalsurvey in Scotland. Fam Pract. 2005Jun;22(3):227-33.

4. Davis A. Population study of the abilityto benefit from amplification and theprovision of a hearing aid in 55-74-year-old first-time hearing aid users. Int JAudiol. 2003 Jul;42 Suppl 2:2S39-52.

5. Gianopoulos I, Stephans D, Davis A.Follow up of people fitted with hearingaids after adult hearing screening: theneed for support after fitting. 2002 BMJ,Vol 325, page 471.

6. Kuk F, Keenan D, Ludvigsen C. Efficacyof an open-fitting hearing aid TheHearing Review 2005;12(2);26-32.

7. Wynne Ch, Sparkes C, Jones H, Tyson S,Pilot study to evaluate hearing aidprovision for mild/moderate highfrequency, permanent hearing loss inadults and the ability to use a one stopfitting technique, BAA conf Nov 2006.

8. Davis AC (1995). Hearing in Adults.London: Whurr pp 1010

9. Pauline Smith, Alison Riley, Adrian Davis,Wendy Davies, and Ellen Jeffs. The useof compliant ear tips with digital hearingaids. The Hearing Journal (in press)

10. Margolis RH, Saly GL, Le C, Laurence J.Qualind: A method for assessing theaccuracy of automated tests. J Am AcadAudiol. 2007 Jan;18(1):78-89.


31

Annex 2References


http://www.hta.ac.uk/project/1025.asp


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