New guidance suggests how CCGs can improve the provision of audiology services
In July 2016, NHS England launched the commissioning framework for adult hearing loss services. After years of clinical commissioning groups (CCGs) seeking advice on how to meet the needs of adults with hearing loss, the framework provides clear guidance on commissioning cost-effective services, and sets out why addressing hearing loss is so important.
Over nine million people in England currently have hearing loss; this includes 42% of over-50s and 71% of over-70s. Despite this prevalence, it takes people an average of 10 years to seek help after they first notice symptoms.
Just two-fifths of people who need hearing aids have them, yet evidence shows they improve quality of life. After being given hearing aids, nine out of 10 people continue to use and benefit from them.
Health benefits of hearing aids
The framework makes clear the significant impact of unaddressed hearing loss. Without help, people with hearing loss often have difficulty communicating with friends, family, colleagues and health professionals. There is evidence of how it can reduce quality of life and independence, and how this increases the risk and impact of other health problems.
Depending on the severity, people with unaddressed hearing loss are between two and five times more likely to develop dementia.
People are also at much greater risk of developing depression because of social anxiety and isolation, and this greatly affects their ability to live independently and work. The burden this places on the NHS and social care is unnecessary given the effective treatment available.
For those who use them, hearing aids become a lifeline. The framework states that they have been shown to improve quality of life and economic prospects, reduce loneliness and improve mental health by reducing the psychological and social effects associated with hearing loss.
As well as the impact that hearing aids have on people’s ability to communicate, stay in work, avoid depression and manage other health conditions, there is recent evidence suggesting that hearing aids reduce the risk of developing dementia. This shows once and for all that hearing aids are well worth the investment.
The framework cites studies from the UK and other countries that have shown hearing aids to be a cost-effective healthcare intervention.
Various UK studies have estimated the cost per quality-adjusted life year (QALY) to be around £1,300 - £1,500.
Overall, given the impact hearing loss has on quality of life and health, hearing assessments and hearing aids represent very good value for money.
Hearing aid provision
NHS hearing aid provision has been put at risk in some parts of the country, with a few CCGs considering decommissioning some audiology services, including hearing aid provision.
The framework makes it clear that restricting hearing aids is a false economy. On average it costs the NHS around £390 for all a person’s appointments and two hearing aids and repairs for three years. However, hearing aids cost on average £3,000 if bought privately - an amount that is beyond 55% of households. If hearing aids weren’t available on the NHS, most sufferers would be denied the only viable treatment.
After laying out the case for CCGs taking serious action on hearing loss in adults, the framework goes on to provide practical guidance on how to work with providers. It sets out a number of tips for CCGs:
1. Involve patients, families and carers
Patients, the framework finds, ‘provide valuable insight into how services can be improved and can be involved in a variety of ways’. Suggestions include involving patients in ‘informing and shaping the service specification including outcomes, key performance indicators and quality requirements, tender shortlisting and interview panels, and forming part of the performance steering groups with the providers of hearing services’.
2. Review and analyse local needs and service provision to plan for the future
CCGs are advised to use estimates of the numbers with hearing loss provided in the framework to plan services, along with patient feedback, clinical evidence, local information and service data. Case studies of innovative service models are provided to help CCGs work with providers to find a model that works best locally.
3. Use an outcome-based commissioning approach
The framework finds that commissioning services on the basis of outcomes for patients will ‘have a positive impact in terms of access, choice, quality and other related outcomes’, and importantly ‘assure CCGs that services are providing good value for money’. Stakeholders involved in the production of the framework suggest some outcomes that are easy for providers to measure:
4. Improve access, choice and quality
People wait an average of 10 years before addressing their hearing loss – and there is strong evidence that the earlier a person gets hearing aids the sooner they adjust and the more they benefit.
Therefore it is essential that CCGs encourage more people to seek help. The framework recommends that older people’s hearing should be checked regularly, and that hearing services should be easily accessible.
5. Develop service specifications for all hearing services
To enable CCGs to hold all providers to account, evidence-based service specifications are ‘essential in setting out what services to deliver and the planned outcomes to be reported and monitored by the service’. The framework includes a model service specification that commissioners can tailor locally with their providers.
6. Implement robust reporting and monitoring systems
CCGs should use the formal processes, incentives and sanctions available through the NHS standard contract to set ‘high standards for providers and to make sure that referral pathways are working and commissioned hearing services deliver the expected outcomes and quality’.
7. Make exit arrangements in local contracts
Clear arrangements should be made in contracts to ensure that when they expire or are terminated, ‘continuity of service can be maintained, payments made in advance for elements of care not yet delivered can be recouped, and duplicate provision of hearing aids can be avoided’.
8. Adhere to NHS regulations and hold all providers to account
CCGs should follow regulations and use the guidance from NHS England and NHS Improvement, which have been developed specifically to maximise outcomes and value for patients.
9. Share learning on commissioning hearing services
CCGs should talk to each other and share examples of best practice for adult hearing services. Some have started to share what they are doing through case studies included in the framework.
The framework includes a model service specification, outcome measures, data and evidence as well as sources of further information and support. It cites a number of case studies that illustrate what CCGs are doing to offer a ‘seamless and integrated’ service.
The case studies offer great examples of how CCGs can, having properly evaluated the need in their area, work with providers to deliver accessible, integrated and high quality services in a cost-effective way.
North East Essex CCG is one such case study. This CCG has moved hearing services from acute hospitals to community settings, reducing costly activity while improving the experience for patients.
After being fitted with hearing aids by qualified audiologists, provide support and hearing aid repairs are provided by trained local volunteers, many of whom have hearing loss themselves.
For people with hearing loss, the benefits of a community-based service include a focus on prevention and early intervention, with rapid access to one-stop clinics, enhanced integration with wider care services for patients with co-morbidities and better access to information, equipment and support.
This kind of community-based service has huge benefits for people with hearing loss – particularly in areas with a higher percentage of older people. By also actively promoting a detection and early intervention strategy this CCG will be making huge long-term savings.
10. Encouraging sufferers to come forward
The framework encourages CCGs to be proactive about identifying and managing hearing loss. To encourage older adults to seek help rather than gradually withdraw from social life and become isolated, the
framework recommends that GPs and
other NHS and social care professionals regularly check patients’ hearing as they get older.
GPs, being on the front line of patient care, are best placed to encourage this proactive attitude, and to normalise the idea of getting hearing checked – just like eyesight. By looking out for signs of hearing loss in older people, such as asking them to repeat themselves or appearing to misunderstand, communication is improved and the numerous health risks associated with hearing loss are greatly reduced.
There is no doubt that CCGs have good cause to make the most of this framework.
Ensuring that hearing services for adults meet local needs is clinically and economically prudent.
The framework points out that examining local services and implementing the suggestions can save money – savings that can allow commissioners to treat more patients.
Action on Hearing Loss would be happy to help CCGs develop commissioning strategies that focus on local need and improve cost effectiveness.
Ultimately, if we work together we can ensure that the millions with hearing loss can get the help they need.