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The false economy of rationing hearing aids in CCGs

The false economy of rationing hearing aids in CCGs

Action on Hearing Loss fought cuts to hearing aid provision, Dr Roger Wicks explains why.
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In October 2015, North Staffordshire CCG made history by becoming the first area since the NHS’s inception to restrict its provision of hearing aids. It did this contrary to all clinical evidence,  public opinion, and government advice.

As the UK’s leading charity supporting people who are deaf or have hearing loss, Action on Hearing Loss fought these and other cuts proposed by CCGs across the country. A petition signed by more than 5,000 people triggered a county council meeting in Stafford, where the cuts were unanimously condemned and it was decided that the matter should be referred to the Secretary of State. As it stands, these cuts remain in place.

Despite that ongoing disappointment, we’ve successfully fought 14 similar proposals by other CCGs, who have welcomed the strength of evidence we provided against the cuts – so far, only North Staffordshire CCG has gone ahead and made them.

After a brief respite from the threat of cuts, in February this year Milton Keynes CCG announced plans to stop providing hearing aids to thousands of people with mild and moderate hearing loss. Hot on its heels was Enfield CCG, which made similar proposals. Happily, Milton Keynes CCG engaged positively with the evidence we presented in the consultation and will not be cutting hearing aids, stating instead that it will improve its commissioning of hearing services to deliver improved value from existing contracts and seek to introduce other improvements. We are still waiting to hear the results of Enfield CCG’s consultation.

What concerns us as a charity, however, is an emerging trend towards ignoring clinical evidence and government advice in the urgent need to cut costs. And some CCGs clearly aren’t engaging in the recently published Commissioning Framework for Adult Hearing Loss Services.[1]

In July 2016, NHS England launched the framework after years of seeking advice. It provides clear guidance on commissioning cost-effective services, and sets out why addressing hearing loss is so important. Crucially, when implemented properly, the framework nullifies any arguments that savings can’t be made without unfairly rationing or cutting provision altogether.

No one denies that the NHS is under enormous strain, and that huge savings need to be made if we are to ensure its survival. The pressure on CCGs to find savings must be immense. We want to work with CCGs to help them find effective ways to save money without cutting or rationing.

The reasons not to cut hearing aid provision were robust even before the commissioning framework was published. Over nine million people in England currently have hearing loss. Cuts affecting those with ‘mild’ and ‘moderate’ hearing loss are effectively targeting the vast majority of people who could benefit from hearing aids: around two-fifths (38.4%) of people over 50 years old and almost two-thirds (63.8%) of over-70s have hearing loss at these levels.[2]

The terms ‘mild’ and ‘moderate’ are clinical, and do not reflect the fact that evidence demonstrates that these are not minor conditions. There are, in fact, significant consequences for individuals and the health and social care system when they are not addressed. The additional burdens on health and social care would negate any savings made.

Unaddressed hearing loss can result in reduced access to services and increased communication difficulties, and is linked to comorbidities including increased levels of isolation, depression and dementia, all of which reduce independence.  The World Health Organization lists hearing loss in the top 20 leading causes of burden of disease (in terms of disability-adjusted life years) and estimates that by 2030 it will be in the top 10.[3]

Hearing aids reduce these risks for all levels of hearing loss,[4] and are the only viable treatment currently available.

Evidence also shows that if hearing aids are fitted soon after a patient starts to experience hearing loss, they adapt much more readily to them and benefit for longer. A significant Health Technology Assessment overlooked by these CCGs found that fitting hearing aids earlier was more cost effective, and stated that ‘those identified early had greater benefit than those of the same ages and hearing impairment who were fitted with hearing aids later’.[5]

By denying people with mild and moderate hearing loss this treatment, these CCGs would be preventing them from benefitting fully from the devices by the time their loss becomes ‘severe’.

There is a myth that hearing aids are ineffective and live in people’s drawers. But research has consistently found that hearing aid wearers, including those with mild to moderate hearing loss, show high levels of satisfaction with their hearing aids.[6] Nine out of 10 people continue to use and benefit from them. UK Data shows us that in 2012, 501 hearing aid users surveyed wore them for an average 8.3 hours a day.[7]

As our population ages, the prevalence of hearing loss will increase, with the number in the UK expected to rise to 15.6 million by 2035 (one in five of the population). And because many of us will be continuing to work later in life, it’s more vital than ever to protect NHS hearing aids.

In March 2015, NHS England and the Department of Health demonstrated their recognition of this by publishing the Action Plan on Hearing Loss, stating that urgent action is required to improve awareness of the impact of hearing loss and improve services.[8] The National Institute for Health and Care Excellence (NICE) is following suit, and is currently developing clinical guidance on adult onset hearing loss, due next year. In other guidance, NICE has noted the significant impacts of hearing loss and the need to address it properly.[9]

Meanwhile, the commissioning framework provides extensive guidance and tools, including case studies of flexible commissioning models, local prevalence data, model service specifications and outcome measures to support CCGs to commission services that are high quality and cost effective - and provides ample alternatives to cutting hearing aid provision.

For instance, North East Essex CCG briefly consulted on cutting hearing aids but decided not to after we intervened and it realised that the implementation ‘could adversely impact the quality of life of a large proportion of individuals with mild hearing loss’. This CCG was used as a good practice case study in the framework, both for its procurement of a single ‘lead’ provider accountable for a number of community services and for its volunteer-led aftercare support. It successfully implemented methods in the framework to make savings and prevent cuts to hearing aid provision.

Without NHS provision, hearing aids could be out of reach for most people in the UK who need them. All CCGs have a duty to ‘secure continuous improvement in the quality of services and outcomes for patients’ and ‘reduce inequalities in the services and outcomes achieved’.[10] Furthermore, the NHS constitution says that all patients have the right to expect local decisions on the funding of drugs and treatments ‘to be made rationally following a proper consideration of the evidence’[11]. Limiting access to hearing aids is contrary to the weight of evidence.

The fact is, there is a vast difference in price between private and NHS provision. A hearing aid costs the NHS £90, and it costs the NHS on average £390 for all of a person’s appointments, two hearing aids and repairs for three years.[12] This small cost per person has enormous benefits to both quality of life and the need for more costly future interventions.

Private hearing aids, on the other hand, are not a viable alternative for the vast majority of people. Research by consumer group Which? found that it costs £3,000 on average to purchase a set of hearing aids privately[13], a sum beyond the savings of 55% of UK households.[14] The CCGs that propose hearing aid cuts suggest that patients use private alternatives ‘widely available on the high street’ – but these are prohibitively expensive. Costs as high as this will introduce large health inequalities, which contravenes the CCGs’ duty to actively reduce such inequalities.

From all angles, restricting the commissioning of hearing aids is bad practice. Ultimately, the short-term savings will be far outweighed by the costs created by poorer mental health, isolation and difficulty remaining in gainful employment. If we are to ease the burden age will continue to have on the NHS, we must use everything at our disposal to enable everyone to have the best quality of life and health they can, for as long as they can. Commissioners can play a vital role here: by properly examining the evidence and using tools to formulate long-term, clinically robust plans, future generations can benefit from a health and social care system that enables them to continue to thrive.

It’s no exaggeration to say that hearing aids are a lifeline to people with hearing loss. As a charity we come across countless people whose lives have improved dramatically since getting them. NHS hearing aids and the peace of mind they give to millions benefit all of us, and we look forward to working with CCGs to enable them to do this in the most cost-effective and efficient way possible.

[1] NHS England (2016) Commissioning framework for adult hearing loss services, available at www.england.nhs.uk/wp-content/uploads/2016/07/HLCF.pdf

[2] Action on Hearing Loss (2015) Hearing Matters, available at www.actiononhearigloss.org.uk/hearingmatters

[3] World Health Organisation (2008) The global burde of disease, 2004 update

[4] Action on Hearing Loss (2015) summarises all the evidence relating to the needs of people with hearing loss, www.actiononhearingloss.org.uk/hearingmatters

[5] Davis et al (2007) Acceptability, benefit and costs of early screening for hearing disability: A study of potential screeing tests and models. Health Technology assessment 11: 1-294

[6] Fellinger et al (2007) Metal distress and quality of life in the hard of hearing. Acta Psychiatrica Scandinavica 115:243-245

[7] Eurotrak data 2012. Available at: www.anovum.com/publikationen/Anovum_EuroTrak_2012_UK_EuroTrak%20212.pdf

[8] Department of Health and NHS England (2015) Action Plan on Hearing Loss, available at: www.england.nhs.uk/2015/03/23/hearing-loss

[9] NICE quality statement on mental wellbeing of older people in care homes, available at www.nice.org.uk/guidance/QS50/chapter/Quality-statement-4-Recognition-of-sensory-impairment.

[10] Health and Social Care Act (2012): www.legislation.goc.uk/ukpga/2012/7/pdfs/ukpga_2012_en.pdf

[11] NHS England (2013) The NHS Constitution, available at https://www.gov.uk/government/publications/the-nhs-constitution-for-engl...

[12] Monitor/NHS England (2013) National tariff information workbook 2014/15, available at: www.gov.uk/government/publications/national-tariff-information-workbook-201415

[13] Which? website. www.which.co.uk/home-and-garden/staying-independent-at-home/guides/how-to-get-the-best-hearing-aid/how-to-buy-your-hearing-aids

[14] Department for Work and Pensions (2014): Famiy Resources Survey: financial year 2013/14. Available at www.gov.uk/government/statistics/family-resources-survey-financial-year-201314

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