1. Audiology Overview
1.1 Audiology services are focussed on the assessment, prevention, and treatment of disorders of hearing and balance. Audiologists and Hearing Aid Dispensers (HADs) use a range of diagnostic tests and tools to assess the functioning of the auditory system and determine the nature and extent of a patient's hearing loss or vestibular disorder. Audiologists often work closely with Ear, Nose and Throat (ENT) departments. Audiology is delivered in a variety of settings, including hospitals and in the community.
2. Commissioning Arrangements
2.1 NHS Sussex commissions audiology through both acute hospital services and community services.
Acute Audiology Services
2.2 Acute hospital-based audiology services are commissioned as part of wider acute contracts with East Sussex Healthcare NHS Trust and University Hospitals Sussex NHS Foundation Trust. These services cover everything from paediatric audiological disorders to adult patients with complex complaints such as severe tinnitus, balance disorders, hearing loss treatments such as Bone-Anchored Hearing Aids and Cochlear Implants, as well as hearing aid services for patients with severe and profound hearing loss or patients with special needs.
2.3 Our commissioning of acute audiology also includes the provision of routine hearing aids services by East Sussex Healthcare NHS Trust, from their sites in Eastbourne, Hastings and Bexhill. This hearing aids service is very similar to the community service (see paragraph 2.6), but forms part of a contract with the trust that operates to the national waiting times framework.
2.4 University Hospitals Sussex NHS Foundation Trust provide complex adult and paediatric audiology services. The Trust does not provide routine hearing aid services after the services in Brighton ceased in 2013/14 and in West Sussex in 2021/22. In these areas, services are commissioned in the community.
2.5 Surrey and Sussex Healthcare NHS Trust has not had audiology provision since 2013/14 and NHS Sussex commissions a bespoke complex audiology service in the Crawley area.
Community Audiology
2.6 Community Audiology is centred on the provision of hearing aids to patients aged 55 and above. Since 2013/14 this has been commissioned across the whole of Sussex under an ‘Any Qualified Provider’ scheme, which is open to any provider that can meet the service specification and accepts our contract terms. The range of organisations that deliver these services is diverse, spanning a mix of ‘high street’ commercial entities such as Specsavers and Scrivens, small or specialist organisations such as Hidden Hearing and Outside Clinic, an NHS social enterprise in the form of First Community Health, and a local charity in the form of Action for Deafness (formerly known as West Sussex Deaf and Hard of Hearing Association). They all provide exactly the same service to exactly the same minimum standards.
2.7 The scheme is closely monitored by the NHS Sussex commissioning and contracting teams, including regular contract monitoring meeting with each provider to review provider performance, activity, service quality, service issues, complaints and plaudits.
2.8 Since inception, there have been 5 – 6 contracted community providers, delivering the service in up to 60 - 70 locations across Sussex. The service delivered approximately 18,000 hearing aid fittings in 2023/24 and at any point in time there are typically around 50,000 patients being cared for by providers. This represents around 80% of all audiology patients.
2.9 A key feature of the service delivered by community audiology providers is a typical 3–4 weeks’ timeline from referral to assessment, which often includes fitting as a one-stop function.
2.10 There are no known gaps in audiology commissioning across Sussex, including East Sussex. All age groups and patient profiles are fully commissioned for. Audiology commissioning covers the complete pathway from initial referral to treatment, follow-up and ongoing care. Hearing Aids pathways cover the entire pathway from referral through to audiological assessment, fitting, follow-up, ongoing aftercare, periodic review and re-assessment/re-fitting where appropriate.
2.11 NHS hearing aid services are one of the most widely distributed NHS services. Within East Sussex there are approximately 20 sites from which services are provided, including the 3 acute audiology service sites. Across Sussex as a whole, services are provided from around 60 sites.
3. Audiology Pathways
Age-Related Hearing Loss
3.1 Bilateral, age-related hearing loss (presbycusis) accounts for around 80% or more of all audiology referrals and, typically, the ‘treatment’ is provision of hearing aids. All providers deliver against a service specification and pathway that is based on a national-level specification published by the Department of Health in 2012:
· Patients are referred by their GP (who needs to ensure their ears are free of occluding wax).
· The patient is offered an assessment appointment.
· At assessment, if the patient needs hearing aids and is suited to a ‘one stop’ pathway, they are fitted with aids in the same attendance.
· If the patient is not suited to open fit and needs ear moulds, impressions are taken, and a fitting appointment is arranged.
· At fitting, a follow-up check is arranged for a point within the next 10 weeks or so. This is to check that the patient is adapting to using aids and, if necessary, to arrange an attendance for adjustment to the aids.
· The patient is supported with free batteries, other consumables and any other aftercare needs for the lifetime of the hearing aids.
· The provider should periodically review the patient’s needs.
Other Pathways
3.2 Acute audiology pathways cover a much wider spectrum of hearing issues than age-related hearing loss, such as unilateral hearing loss, tinnitus, vertigo, hereditary hearing loss and so on. In these instances, the patient will be referred, by their GP, to either the Audiology or ENT department for investigation of their issue. The pathway from that point onwards depends on the condition. It can involve additional diagnostic tests, rehabilitative interventions, collaborations with ENT or with other teams such as Paediatrics and Speech and Language Therapy.
3.3 There is an overlap with the community pathways in so far as the acute service may also address the determined hearing issue by prescribing and fitting hearing aids. The hearing aids pathways tend to be similar to those in the community except that patients may be referred on to audiology or for hearing aid assessment consequent to referral or examination by the ENT department or following a complex audiology assessment.
4. Earwax Services
4.1 Earwax removal has historically been part of primary care (GP) provision and this continues through the NHS Sussex commissioned Locally Commissioned Service (LCS) arrangement with primary care practices. Under the current LCS, patients are either treated by their practice or, if the practice is unable to provide this service, through inter-practice referral to a different GP practice. Across Sussex, there are currently 132 practices providing ear irrigation, of which 36 also provide microsuction. For East Sussex 42 of the 52 practices offer ear irrigation and 15 offer microsuction.
4.2 Best practice for earwax removal is that patients are taken through a tiered pathway as follows:
· Self-care
· Irrigation
· Microsuction.
4.3 Under this scheme, 5,899 Sussex patients underwent ear irrigation in 2023/24 and 1508 also or alternatively proceeded to have microsuction. These figures do not include earwax removal undertaken within acute hospitals as part of an ENT attendance.
4.4 Earwax removal is a relatively simple intervention that nevertheless requires special training. The Care Quality Commission advises that “earwax removal is a regulated activity if the person and a listed health care professional both agree there is a problem that needs an intervention; and the treatment is carried out by a listed healthcare professional”. All practices in Sussex offering NHS-funded irrigation and microsuction are required to be CQC registered. Earwax removal through the LCS scheme is provided free of charge.
4.5 Many private sector organisations, such as high street optician chains, private audiologists and private hearing aid providers, offer fee-paying earwax removal including microsuction. There are several non-NHS providers offering a fee-paying service in the Eastbourne area, including East Sussex Hearing Resource Centre and many more across Sussex as a whole. The NHS is not involved with these private services and holds no information on their training, qualifications or CQC registration status.
5. Issues of note
Hearing Aid services
5.1 A factor of the AQP system is that it is market driven i.e. providers seek to provide from locations that generate higher demand. This means that rural, low-population-density areas are generally less well covered. All parts of East Sussex however are covered by domiciliary services if the patients qualify and are unable to travel to appointments.
5.2 A large proportion of patients still choose the hospital service for provision of their routine hearing aids needs. Hospital delivered services, including for hearing aids, were severely impacted by the COVID pandemic and waiting times became quite long. However, the hospital service waiting times in East Sussex have been addressed and once again comply with national standards (6 weeks for diagnostic assessment, 18 weeks for first definitive treatment). Waiting times in the community service were also adversely affected but have been back to pre-COVID levels for more than a year.
5.3 There is a need for clear communication to support patient understanding of the services available. There is a common misconception that hearing aids have to be replaced every three years. Modern digital hearing aids can be adjusted to accommodate progressive hearing loss, up until more powerful aids are required. Most manufacturers publish an expectation that their hearing aids will last around 5 – 7 years.
Earwax Removal
5.4 As an aerosol-generating process, earwax removal by GP practices was also severely affected by COVID and suspended during lockdown. Post-COVID, practices needed to prioritise other services and access to this service was quite limited during the recovery period. However, the Locally Commissioned Service was refreshed in 2023 and, as described above, provision is now widespread with accessible to the Sussex population.
Concerns raised by East Sussex Hearing Resource Centre (ESHRC)
5.5 In March 2024 ESHRC raised a range of concerns with NHS Sussex to which we responded to, providing clarification on how earwax removal services are delivered in line with best practice guidance including NICE and the audiology pathway. We also offered to engage further with ESHRC with regard to how we might further improve signposting for patients on the audiology pathway to support services, how we might have a greater focus on prevention measures in the pathway and how we could further enhance hearing assistive equipment and staff training with regards to hearing communication within Primary Care and acute services.
East Sussex Healthcare NHS Trust (ESHT) Audiology and ESHRC
5.6 Up until recently, the ESHT Audiology department provided 1.5 days per week of audiologist support for the East Sussex Hearing Resource Centre services in Chantry House, Eastbourne. This was a long-standing arrangement wherein NHS patients would be seen, by appointment, by the NHS audiologist, who was also able to provide ad hoc support to the walk-in repairs and maintenance clinics offered by ESHRC.
5.7 ESHT has had to take the decision to relocate this role to the ESHT base at Eastbourne Park Primary Care Centre following introduction of a private microsuction service by ESHRC using the same room. This relocation was primarily related to the impact of aerosol generating procedures on NHS audiological equipment and clarity for patients around colocation of paid for services alongside NHS provision. ESHT continues to provide consumables such as batteries and tubing to ESHRC for distribution to ESHT patients on their behalf.
Impacts on the system
5.8 Community audiology was particularly impacted by the COVID pandemic, and this led to some providers re-appraising their position. Two of the smaller AQP providers terminated their NHS contracts: Hidden Hearing in mid-2022 and Sussex Health Care Audiology in mid-2023. In both instances, this necessitated NHS Sussex to manage and deliver a large-scale transfer of patients to alternative providers. NHS Sussex and providers responded swiftly to manage the safe transfer of 7000 patients to ensure continuity of care.
5.9 For the Sussex Health Care Audiology transfer, the caseload of 5,000 patients was subsequently too large for absorption by the other providers and NHS Sussex brought on board, at short notice, a new provider called The Outside Clinic. This provider specialises in domiciliary audiology but has adapted to the face-to-face model for Sussex.
5.10 While the transfer process was relatively seamless for most patients, we recognise that this was not the case for a relatively small number of people. The reasons varied by individual, from out-of-date contact information to needs for care at short notice, and NHS Sussex worked hard to address any issues that arose. Provider withdrawals from the market is an indication of fragility in the community audiology system that NHS Sussex is seeking to address.
6. Interface with Voluntary, Community and Social Enterprise (VCSE)
6.1 The acute audiology departments have a long history of working with local VCSE organisations, typically signposting patients for additional social support and in some instances providing supplies of ‘spares’ such as batteries and tubing to enable easier access for patients.
6.2 The community audiology sector engages with VCSE’s differently. Within the range of providers, we contract with Action for Deafness, who are themselves a local VCSE and combine being one of the largest providers of NHS-funded hearing aids with extensive charitable activities in support of people with hearing loss across Sussex. First Community Health is to some extent similar, in that it is a social enterprise, and also operates on a not-for-profit basis. Equally, private companies such as Specsavers and Scrivens are both engaged at a corporate and local level with the VCSE community, from their national support of particular VCSE organisations and liaison/signposting patients and, in some instances, provision of spares and supplies in much the same way as the acutes audiology providers.
7. Future Commissioning
7.1 The introduction of AQP Audiology in 2013/14 was a ground-breaking initiative that transformed access to hearing aids services. However, the system has certain attributes that have come to the fore during recent years. Hearing Aids services require long term provider stability and continuity. Once a patient is fitted with aids, they will normally need hearing aids for the rest of their hopefully long life but more immediately, they need ongoing aftercare for these specific aids for anything up to 6 or 7 years.
7.2 An AQP system can drive a level of competition which may discourage providers from locating service points in low-density rural areas. Smaller providers may not have the resources or marketing ability of larger commercial organisations. Equally, even larger organisations can fail to secure their desired market share where there are a number of other providers operating. In 2014 one national-level company terminated their Sussex contract for this reason. Similarly, both providers who terminated their Sussex contracts in 2022 / 2023 cited low market share as one of the drivers for withdrawal.
7.3 This market fragility can be both challenging and less cost effective and NHS Sussex has been in discussion with providers, looking at different options to mitigate the risks. As a consequence, we are considering how best to develop our approach to the commissioning of these services in the coming year. This will ensure we seek to retain and improve upon those features that are most valued, such as the wide distribution of access points and short waiting times whilst enabling better transferability, through standardising the range of aids, and strengthening the quality of aftercare provision.
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