§ 8.1 p.m.
§ Lord Cullen of Ashbournerose to ask Her Majesty's Government whether they will take steps to improve the availability of choice and service for adults who are hard of hearing and can be assisted by the use of hearing aids.
The noble Lord said: My Lords, in asking Her Majesty's Government the Question standing in my name on the Order Paper, the only interest I have to declare is that I am one of those 3.9 million adults who find it necessary to use a hearing aid. Therefore, my remarks are addressed to the needs of that group of people rather than to the really deaf or those people who have ear conditions which can be remedied by surgical operation.
At the moment someone who is hard of hearing has two quite separate and distinct routes available to him or her. The first option is the NHS route. First you go to see your GP who refers you to an ENT specialist, and from there you are referred to the audiology department of an NHS hospital. I understand that around 80 per cent. of people who are hard of hearing tread this somewhat lengthy and inconvenient route with its attendant travel and waiting list delays which may vary from weeks to years. At the end, however, they obtain an NHS hearing aid from a somewhat 336 limited range, all of which are either body-worn aids or of the behind-the-ear type. Exceptions are so few as to be irrelevant.
Each year the NHS supplies approximately 350,000 new hearing aids of this type, all supplied completely free of charge to the patient. The alternative is to obtain a hearing aid privately, supplied by a registered hearing aid dispenser. That route is much more convenient since you can either go to a high street branch or have the dispenser make a domiciliary visit. By taking the private route you have access to an unlimited range of all the latest hearing aid technology. It can be seen and tested instantly and the aid supplied after a delay of no more than a few weeks. Approximately 65,000 hearing aids are supplied by the private sector each year at an average cost to the client of £450 paid for in full by the purchaser. The private hearing aid sector represents just under 20 per cent. of the total hearing aid market.
It seems to me that the present set-up whereby 80 per cent. of a limited range of NHS hearing aids are supplied at no cost to the patient, whereas 20 per cent. of a much wider range of hearing aids are supplied privately at full cost, does not appear to be the most efficient use of limited resources; nor does it, I believe, offer the majority of people the best available service. That should not be seen as an attack on the staff working within the NHS. Many of them do an excellent job. The effectiveness of the system within which they operate must be challenged.
On the point of service, it is important to appreciate that hearing aids are delicate and intricate instruments and require service from time to time. They also need batteries. So the convenience and service aspect for the consumer is very important. Another matter which concerns me is the waste involved in the present arrangements. I understand that as many as one-in-five NHS hearing aids can end up being put in a drawer and not used. Further, of those who end up buying an aid privately, about one-in-three previously had an NHS hearing aid. All that must involve some considerable waste of resources, and I wonder whether the Government have given any consideration to the possibility of undertaking a survey to look into the extent of any such wastage.
However, there is also the wider question of whether it is wasteful of hospital resources to be fitting hearing aids to people with a condition requiring no medical or surgical treatment. As I understand it, only about one-in-140 of NHS patients fitted with a hearing aid have any recognisable condition which could justify the attention of an ENT surgeon. The vast majority of these patients could perfectly well be fitted with hearing aids without any need to attend hospital.
The NHS Management Executive published a paper in February last year entitled Integrating Primary and Secondary Health Care. In paragraph 23 that paper provided most welcome recognition that ophthalmic services offer great scope for developing an integrated approach and pointed to the fact that high street optometrists already play a major part in detecting diseases such as diabetes and glaucoma and in referring patients through their GP to hospital. As 337 my noble friend is aware, I have been interested in optics for a number of years so I particularly welcome the way in which the NHS Management Executive appears to have recognised that there may well be scope for farming out to ophthalmic opticians in the high street much of the managing and monitoring of eye conditions which has previously been done within the hospital eye service. Strangely. however, the paper makes no reference to the NHS supply of hearing aids which I would suggest is a service which could be transferred and largely delegated to the private sector.
That brings me to three questions which I hope that my noble friend will be able to answer when she comes to reply. First, what is the true overall cost annually of the NHS hearing aid service, including not merely the actual appliance costs, but also the overhead costs including an element for the use of hospital premises and the time of NHS staff? I asked this Question some time ago for a Written Answer. I was told that the cost was not known. I am hoping this evening that perhaps my noble friend will be able to give an estimate of the costs. It has been suggested to me that it is something like £100 per hearing aid unit, but that may be wide of the mark.
Secondly, I should like to inquire what the position will be as regards the supply of hearing aids in Europe. What will happen after 1992? I hope that people will not find it necessary to go to France for their hearing aids, rather like the gentlemen from Kent who went to France for a cataract operation in order to beat his local hospital waiting list. Thirdly,—and I believe that this is the key question—if one takes an overall view of the hearing aid market, why should all public funding be channelled exclusively to the NHS hospital supply?
I believe that there is an analogy to be drawn here with the spectacle voucher scheme, which the Government introduced in 1986. Between 1951 and 1986, everyone was entitled to NHS spectacles. As with hearing aids, the NHS range was very limited. But unlike the NHS hearing aid, the patient obtaining NHS spectacles had to make a patient's contribution towards the frame and lenses at a price fixed by the Government.
NHS spectacle dispensing resulted in a total distortion of the optical market and severely restricted patient choice. Nowadays however NHS-eligible groups are entitled to a voucher which helps with their spectacle purchase. As from 1st April 1991 the most commonly prescribed spectacle voucher, band A, provides the patient with £19.30 which he can put towards the price of his spectacles, and he can choose from the full range of what would previously have been regarded as "private" spectacles. That system has worked well, and I should like to urge the Government to give serious consideration to the implementation of a voucher system for the hard of hearing. As with the spectacle voucher scheme the hearing aid voucher should cover the cost of the supply and service of the basic product. Both sources of supply would offer the full range of what are now NHS-type hearing aids and private hearing aids.
A voucher scheme for hearing aids could have much to offer. First, it could save the NHS money by 338 reducing waste. Secondly, it would reduce pressure on the NHS hospital service and reduce waiting lists. Thirdly, it would enable state funds allocated to the NHS to be targeted on primary health care and assisting those who can be helped by the particular attention of ENT specialists and audiology departments of hospitals. Fourthly, it would remove a major distortion in the hearing aid market. Fifthly, it would offer the person who is hard of hearing—the consumer —much wider choice and access to the best hearing aid technology, whether they chose to go to the hospital department of audiology or preferred the service and convenience obtainable in the private sector. Above all, speed of availability would lessen the chance of the hard of hearing becoming isolated from society for two years or more, often at a time when they can ill-afford to lose their hearing for such a significant proportion of the remainder of their lives. Isolation also becomes a habit hard to break when the hearing aid is eventually fitted.
In conclusion, so far as concerns the role of the Government in relation to the hearing aid industry, there appears also to be a division of responsibility which no doubt reflects the sharp division which exists between NHS and private hearing aids. I am referring to the fact that the private sector of the hearing aid industry is regulated by the Hearing Aid Council for which the Department of Trade and Industry has overall responsibility. On the other hand, the Department of Health has responsibility for the bulk of hearing aid supply made through the NHS hospital service.
I seriously question whether this present rigid division between NHS and private supply is helpful to those in need. Would it not be more sensible and rational for the entire supply of hearing aids to he brought within the responsibility of one department; namely, the Department of Health? I hope that the Government will give some careful future consideration to that possibility and ask that department to examine ways of achieving a better integrated service that would be more cost-effective for the Government and more convenient for the consumer.
§ 8.14 p.m.
§ Lord DesaiMy Lords, I am sure we are all grateful to the noble Lord, Lord Cullen of Ashbourne, for raising the important problem of those who are hard of hearing. Given the age structure of the population and the fact that we shall have a large proportion of the elderly in our population in the future, this issue will become more, rather than less, important.
The noble Lord has made a number of interesting suggestions about how to tackle the problems in this area. I should like to respond to a few of them. Clearly, in the NHS sector the problems have to do with waiting times—both before a patient can see an ENT surgeon and afterwards when waiting for the hearing aid to be supplied. These delays—which are some 16 weeks before a patient can see an ENT surgeon and about eight weeks before a hearing aid can be supplied—are clearly too long. We should like 339 to know whether there has been any recent decrease in these waiting times, and how can we speed up this process?
The NHS has an advantage in that the service is available free of charge. Not only are hearing aids available free of charge, but they can be repaired and renewed. What one might call the after-sales service is much more efficiently and cheaply done within the NHS.
Before taking up the suggestion of the noble Lord, Lord Cullen, about letting the high street hearing aid dispenser play a major role, one should like to know how the after-sales service problems will be tackled for those NHS patients who will not be taking advantage of supplementing with their own money their hearing aid needs. That is clearly an important problem. This is a matter of judgment rather than any certainty. If there is to be a guarantee that an NHS voucher will be paid for anyone obtaining a hearing aid, will that lead to a general increase in prices all round because a floor is established? I should especially like to be quite sure that there will be no undue pressure on patients whose intention it is to have an NHS hearing aid, and that there would be no overt or covert sales pressure to go the private route. People get embarrassed and might end up spending more money than they had intended. Of course, they are free to spend more money, but I should like to know that they will not be embarrassed into spending.
Currently, if they do not want to spend more money, they wait and they pay the price in terms of time. I should like to know that if they do not pay the price in terms of time, that we can avoid the possibility that they will have to pay too much money.
Having said those things, the suggestion made by the noble Lord that the high street private sector hearing aid dispenser be given a major role, is a welcome one. Clearly an ENT surgeon should be much too busy to look at every person who needs a hearing aid. He or she should have better things to do. That will be one saving.
I am not sufficiently sure that this requires the creation of an intermediate category of specialist who can be licensed and trusted to give the service that currently the ENT surgeon gives. I am not at all medically literate. I should like to know whether this would require a special class of intermediate medically-qualified people to do this. If so, who will license them? Where will they be trained and how many people do we need? I see that analogy of the optometrist is a good one; but I should like to know whether there is a possibility of people who are not full scale ENT surgeons carrying out these tasks. Perhaps the audiologists will perform these functions, and they can be trained quickly. The problem is how to give the 80 per cent. of consumers who resort to the NHS a better service with shorter waiting times. In addition, if we move to these other arrangements the NHS may save on resources. It would be helpful to know how much would be saved. If resources were saved one might be able to give a better deal to the person who wants a NHS hearing aid.
340 This is not a matter on which there is any great party political divide. I certainly do not pretend to have any great expertise in this area.
§ 8.20 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health (Baroness Hooper)My Lords, I am most grateful to my noble friend for drawing the attention of the House to the problems of people who are hard of hearing. My noble friend is not unique in the House in having the problem to which he referred. I feel that there is considerable sympathy for what he has to say.
Hearing loss is a hidden disability which often goes unrecognised and is poorly understood by those who are fortunate enough to enjoy good hearing. We appreciate how important it is for people who are hard of hearing to be able to obtain a hearing aid that meets their individual needs. That is why the range of NHS hearing aids is under continual review. We are taking steps to improve the service and reduce waiting times for consultations and fittings where those are unacceptably long. Far from moving in the direction of changing what my noble friend called a rigid separation between the National Health Service and the private sector, as in all areas of NHS provision our aim is to ensure that the National Health Service is the best possible service available. Perhaps I may say a little about what we are doing to ensure that.
We know that some people may be deterred from seeking help through the NHS because they are daunted by the traditional referral chain, to which my noble friend referred, of GP, ear, nose and throat consultant, and hearing aid centre. That process can sometimes involve long delays, a point to which the noble Lord, Lord Desai, referred and over which the Royal National Institute for the Deaf led a vigorous campaign for change.
As a result of that campaign, we set up 12 pilot projects at a variety of centres throughout England to compare the advantages of using a direct referral procedure with the traditional referral via the ENT department. There are, of course, built-in safeguards to ensure that patients are not placed at increased clinical risk. Those projects are being independently evaluated by a team of researchers from the University of Manchester who will look at the costs and benefits of the different referral systems as well as at the level of satisfaction of patients and staff, the clinical safety factors and what the effect is on waiting times. A final report is expected in the spring and we hope to learn useful lessons. I trust that the noble Lord, Lord Desai, is willing to accept that we are dealing with the problem to which he referred and that we hope to come forward with a useful response.
In addition to piloting an accelerated referral system we have recommended that health authorities should consider locating all or part of their hearing aid services in community settings to make them more accessible to people, some of whom may live a long distance from the hospital.
We are also working in a variety of other areas. A shortage of technicians can affect some of the problems that have been referred to. We have 341 addressed the problem of delays in two ways. First, we are, through the pilot projects, encouraging health authorities to harness the resources and expertise available in the private sector by entering into contracts with private dispensers to provide NHS hearing tests and fit NHS hearing aids. That may go a little way to breaking down the rigid separation to which my noble friend referred. Secondly, we are actively seeking to improve the recruitment of audiology technicians. As a result of a review in 1988 of the terms and conditions of service of NHS audiology technicians, we have introduced improvements in both their salary and career structure. We are also working on training and qualifications. We are working towards the introduction of an improved training package leading to a national vocational qualification. It is clear that structured training and a nationally recognised, portable qualification can be powerful factors in drawing people into a profession.
My noble friend referred on a number of occasions to the private sector. He will appreciate that it is the Hearing Aid Council rather than the Department of Trade and Industry that regulates the private hearing aid sector. The department appoints the council's chairman and members. The members are drawn equally from the trade, representatives of consumers and people with medical or technical knowledge. The council has an independent chairman. It is the council which sets the training requirements and examinations for private hearing aid dispensers. I have already referred to a common interest in this respect with the NHS. However, the council also operates a code of practice which covers the sales and advertising needs of private dispensers. Clearly, this is not a matter for the Department of Health or the NHS but should remain the responsibility of the Department of Trade and Industry through the Hearing Aid Council.
As to the question of overall cost, as we have said before it is not possible to identify the service costs which are part of the wider hospital service though we can of course quantify the cost of the aids themselves.
Having dealt with the way we are promoting improvements in the service, to some extent at least, I should like to say something about the choice and availability of hearing aids.
§ Lord Cullen of AshbourneMy Lords, did I understand my noble friend to say that she can give an idea of the cost of the hearing aid? Did I hear her correctly?
§ Baroness HooperNo, my Lords, I am afraid that my noble friend did not hear me correctly. I said that it is not possible to identify the service costs and therefore the unit costs in the way that my noble friend requested. If it is helpful, perhaps I may undertake to look at the point and perhaps reply to him in writing if I have more information.
I should now like to move on to the question of choice and availability of hearing aids, which was referred to by my noble friend and the noble Lord, Lord Desai. The standard range of hearing aids supplied through the National Health Service has been considerably extended in recent years and meets the clinical needs of the great majority of patients. The 342 range includes three types of post-aural or behind-the-ear hearing aids, each having different power and amplification levels. Each type is represented by several different models, usually from different manufacturers, which gives a choice of peripheral facilities. Moreover, as manufacturers update their products, older models are withdrawn and new ones introduced. That is the way in which the NHS standard range is kept up to date.
Patients can obtain replacement and support services for standard range hearing aids anywhere in the country. In the few cases where a hearing aid standard range does not meet a patient's clinical needs, health authorities are able to supply any other suitable hearing aid under National Health Service arrangements. Nevertheless, we clearly want to encourage National Health Service clinics to make wider use of existing powers to supply aids outside the standard range because, like my noble friend, we wish to avoid any possible suggestion or perception that there is wastage as regards the aids which are available.
My noble friend also made specific reference to the question of vouchers and the possibility of introducing a system for hearing aids similar to that which exists for spectacles. I know that is something in which the private hearing aid sector has been interested for some time. Indeed, those concerned have raised the matter with my honourable friend the Parliamentary Under-Secretary of State for Health in the other place.
As to the issue of vouchers, we have considered this very carefully and listened with interest to the proposals put to us by representatives of the private sector. While there may be some superficial similarities between the supply of hearing aids and spectacles, they entail very different clinical, technological, administrative and financial considerations. There are also major differences in the way that the private optical and hearing aid sectors organise and deliver their services.
Those considerations confirm our belief that the National Health Service should continue to provide a comprehensive hearing aid service that is available to all on equal terms. We also wish to see a flourishing and well-regulated private sector so that people can exercise their right to choose. However, it is a fundamental principle that patients who choose private treatment as an alternative or in addition to a service which the NHS provides free of charge must expect to pay the whole cost of the private treatment. We see no grounds for making an exception in the case of services for hearing impaired people by subsidising the cost of private treatment whether through a voucher system or by any other means.
My noble friend also asked about the situation in Europe in the future. I believe that he probably had in mind the period after 1992. Of course, the single market legislation affects only manufacturers' or suppliers' ability to sell their wares in member states; in other words, by the removal of technical barriers to trade. It does not bear upon service delivery systems. So far as I am aware, the medical device directives currently proposed by the European Commission will 343 result in harmonisation of essential minimum requirements for hearing aids and other medical devices in support of the single market.
I have described a number of ways in which the Government have demonstrated their commitment to maintaining and improving the quality and choice of services for people who are hard of hearing. In so doing, I hope that we shall provide considerable assistance for the private sector so that it, too, continues to improve its services for the benefit of its customers. I hope that I have answered most, if not all, 344 of the points raised by my noble friend and the noble Lord, Lord Desai. However, if I find that there are any points of detail to which I have not responded, I shall be happy to write to the noble Lords.