Recommendation		Page
1	The Board recommends that NHS Sussex works with GP practices and Primary Care Networks to improve information, public communications and signposting both in surgeries and online, on how and where to access free NHS earwax removal services in East Sussex.	11
2	The Board recommends that NHS Sussex issues communications to all GP practice employees in East Sussex to make staff aware of the earwax removal pathway and confirm that they should not be referring patients to private provision.	11
3	The Board recommends that NHS Sussex responds (if it has not already) to the recommendations made by Healthwatch in its report ‘Experiences of Earwax Removal’, published in July 2024, and that the responses are shared with HOSC.	12
4	The Board recommends that NHS Sussex confirms with all GP practices in East Sussex that if they are unable to provide earwax removal services that they should be referring patients to other nearby GP practices that do provide regular earwax removal appointments.	12
5	The Board recommends that that NHS Sussex explores benchmarking of activity and uptake of earwax removal services to monitor if it reflects local age profile and expected activity levels and take appropriate action to address any identified gaps in provision.	14
6	The Board recommends that NHS Sussex works with Primary Care Networks and Integrated Community Teams to explore the viability of earwax removal ‘hubs’, while recognising the limitations of such a delivery model in some parts of the county, particularly rural areas.	15
7	The Board recommends that NHS Sussex facilitates cooperation between GP practices, PCNs, VCSE organisations and the new contract holder to create simple and effective referral pathways for patients needing earwax removal prior to a hearing assessment.	18
8	The Board recommends that NHS Sussex works with Public Health to further understand barriers to people using hearing aids once they have been provided with them, including access to aftercare and maintenance.	21
9	The Board recommends that specific Key Performance Indicators (KPI) are included within the new contract to monitor and assess hearing aid maintenance and ensure regular reviews of hearing are undertaken.	22
10	The Board recommends that NHS Sussex develops digital and non-digital patient communications, including leaflets, that provide patients with information on areas including: a) a summary overview of the hearing aid pathway; b) the importance of hearing aid maintenance and where patients can access it; c) that patients cannot mix provision and maintenance for their hearing aids; d) signposting to other available support for living with hearing loss.	22
11	The Board recommends that NHS Sussex works with the new provider to explore whether it could deliver a same day drop off and maintenance and repair service for hearing aids.	23
12	The Board recommends that patients are automatically recalled for a hearing assessment on a regular basis and when they are due to receive a new hearing aid.	23
13	The Board recommends that NHS Sussex continue to work with relevant commissioners in ESCC Adult Social Care as part of contract implementation and ongoing monitoring.	24
14	The Board recommends that NHS Sussex works with Public Health to validate assumptions of future demand for the new age-related hearing loss contract.	25
15	The Board recommends that NHS Sussex work with Healthwatch East Sussex and other patient representative groups to monitor the new contract to ensure it meets the specific needs of the population of East Sussex.	26
16	The Board recommends that NHS Sussex carefully evaluates the impact a single provider model has on the availability and provision of hearing aid services to the population of East Sussex and ensures it provides high quality continuity of care for existing patients.	26

Introduction

1. On 30 July 2024 the Health Overview and Scrutiny Committee (HOSC) considered a report from NHS Sussex on the provision of audiology services in East Sussex. This followed concerns being raised about the provision of audiology services, including earwax removal, which were brought to the attention of the Committee by a number of sources, including Healthwatch.

2. The Committee agreed to establish a Review Board to examine the provision of audiology services in order to understand the issues and make recommendations for improvements to these services.

3. The Review took place over a series of meetings held during the period of November 2024 to February 2025, which examined a range of evidence, including from NHS Sussex, East Sussex Hearing, Healthwatch, South Downs Health & Care GP Federation, East Sussex County Council officers and Audiology staff from the East Sussex Healthcare Trust (ESHT). The scope of the review included:

· Issues related to the current provision of, and access to, NHS audiology services, including earwax removal and hearing aid services.

· How communication of audiology pathways and local NHS provided services can be improved.

· Future commissioning arrangements, particularly related to the ongoing commissioning of the over-55s age related hearing loss contract, and how identified issues and barriers to access can be addressed through this.

4. During the review, the Board found that the commissioning intentions of NHS Sussex were varied from activity levels and patients’ perception of access to audiology services. Despite a commitment by the local NHS to provide both earwax removal and a complete hearing aid pathway from referral to ongoing aftercare, the evidence heard by the Board suggested that the audiology services in East Sussex were not working as intended and that there was a lack of clarity for patients on where and how they could access these services. While the Board is hopeful that the recommissioning of the over-55s age related hearing loss contract in Sussex will address some of the issues in the services, it has reservations that there is sufficient funding to support the expanded service specification of the new contract.

5. Having considered evidence from a range of witnesses and sources, the Review Board has made a number of recommendations to NHS commissioners which it considers will help improve the provision of audiology services in East Sussex for age related hearing loss, the provision and maintenance of hearing aids, and earwax removal treatment services.

Background

6. Hearing loss is an invisible and under-recognised health issue. The Royal National Institute for the Deaf (RNID) estimates that 1 in 3 adults in the UK are deaf, hard of hearing or suffer from tinnitus, including over half of people over 55 years old. Estimates by East Sussex Public Health suggest that there are currently 136,751 adults in East Sussex living with some level of hearing loss.

7. Unsupported hearing loss can have an adverse impact on a person’s quality of life and their general health, as it impacts on people’s work, social and family lives and can lead to a decline in physical activity. People with hearing loss are more likely to experience social isolation, emotional distress and loneliness. Hearing loss doubles the risk of developing depression.

8. Despite the significant knock-on implications for people’s health, there is an average 10-year delay in people seeking help for their hearing loss. Often this is related to the stigma associated with hearing loss, particularly around hearing aids and especially in the workplace.

Earwax removal

9. Earwax usually falls out on its own, but it can build up and block ears, causing temporary hearing loss and requiring clinical intervention. Earwax blockages can have significant wider physical and mental health implications for a patient’s health, impacting on peoples’ education, employment, social and home lives. Earwax blockages can affect people of any age, although prevalence is higher in people aged 50 and over.

10. Earwax removal is a service provided by the NHS in primary care (General Practice - GP) settings. Not all GP surgeries remove earwax as it is not a part of the nationally defined core GP contract, and it is commissioned by NHS Sussex through the Locally Commissioned Services (LCS) arrangement. It is therefore a voluntary service that GP practices can choose to sign-up to, however if a practice is not signed up to deliver the service, it is obliged to refer the patient to an alternative practice where they can access free earwax removal under the NHS.

11. National Institute for Health and Care Excellence (NICE) guidance provides clinical best practice for treating patients whose earwax should be removed. It recommends that patients are first advised to use ear drops to soften wax and aid removal, and that, should symptoms persist, consideration be given to ear irrigation (syringing), to flush the wax out with water, or microsuction, to use a vacuum to suck the wax out under a microscope.

12. Of the 52 GP practices operating in East Sussex, only 3 (Fairfield Surgery; Sedlescombe House; and The Lighthouse Medical Centre) are not signed up to deliver earwax removal services as an LCS. A full list of GP practices in East Sussex offering earwax removal services as an LCS is included at Appendix 2.

13. Many private sector organisations, such as high street optician chains, private audiologists and private hearing aid providers offer paid for earwax removal, as do some non-NHS not-for-profit organisations. The NHS is not involved with these services and does not commission or fund them, nor does it provide oversight of these services. The provision of non-NHS audiology services was outside the scope of this review.

Current Services – Community Audiology

14. 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’ (AQP) scheme, which is open to any provider that can meet the service specification and accepts the terms of the contract. 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, Action for Deafness. They all provide exactly the same service to the same minimum standards.

15. Referral by a GP is required to access the over-55s hearing aid pathway. A patient must have an appointment with a GP, who would agree with the patient which AQP to refer them to, including discussing the most appropriate AQP for a patient’s ability to access. From referral a patient should have a hearing assessment within 6 weeks. The national standard from referral onto the pathway to definitive treatment and having hearing aids fitted if necessary is 18 weeks.

16. East Sussex Healthcare NHS Trust (ESHT) also provides AQP hearing aid services for age related hearing loss. Although it was initially commissioned as an AQP, hearing aid services are now incorporated as part of the ESHT’s main provider contract with NHS Sussex. ESHT is not treated as an AQP, but it aims to meet the same waiting time requirements as community AQPs; currently the average waiting times for a first assessment is 3-4 weeks and for fitting a hearing aid 10-11 weeks compared to the AQP target of 18 weeks from first referral to treatment.

17. Audiology commissioning covers the complete pathway from initial referral to treatment, follow-up and ongoing care. Age related hearing loss 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.

18. As with earwax removal, private hearing aid provision is available from a number of high street providers where individuals can pay to have their hearing assessed and hearing aids fitted privately.

Future Commissioning – Community Audiology

19. While the introduction of AQP commissioning for community audiology initially expanded access to hearing aids services, in recent years some drawbacks to the commissioning model have become apparent. Hearing aid 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 life and will need ongoing aftercare for these specific aids for anything up to 6 or 7 years depending on the make.

20.An AQP system can drive competition and requires sufficient patient numbers to be financially sustainable 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. During the COVID-19 pandemic and number of providers stopped operating, which led to service interruptions for patients. This market fragility can be both challenging and less cost effective and in recognition of this NHS Sussex has been in discussion with providers, looking at different options to mitigate the risks.

21.NHS Sussex is in the process of developing a new service model and recommissioning the over-55s hearing aid service. It intends to move away from the AQP model as it does not provide a sufficient level of service coverage across East Sussex.

Acute Audiology

22. Hospital-based audiology services are commissioned by NHS Sussex as part of wider acute contracts with East Sussex Healthcare NHS Trust and University Hospitals Sussex NHS Foundation Trust. Maidstone and Tunbridge Wells NHS Trust also provide acute audiology services. Any patient in East Sussex who experiences hearing loss who is under the age of 55, or has more complex hearing issues (e.g. also has tinnitus), will automatically be referred according to their preference to an acute Ear, Nose and Throat (ENT) Department, as there is a higher chance that hearing loss in under-55s is caused by a more complex issue that cannot be managed in a community setting. Acute audiology services were outside the scope of this review.

Review Board Findings

Earwax Removal

Access and communication

23. The Review Board received confirmation from NHS Sussex that everyone who is a patient of a GP practice in East Sussex should be able to access free NHS earwax removal. NHS Sussex was committed to continuing to provide the service free at the point of access to eligible patients.

24. Despite this commitment from NHS Sussex, the Board heard evidence that this was not well understood by patients, and did not seem to be the reality in practice. A survey conducted by Healthwatch East Sussex found that a significant proportion respondents reported it was difficult to access appointments for earwax removal. There was confusion for patients as to why different surgeries provided earwax removal and others did not, particularly where GP practices no longer provided services they had previously offered. Healthwatch suggested there was a pattern of variation across the county and inconsistent messaging from GPs and other health professionals as to what treatment people could expect to receive. Healthwatch also found that when patients asked where they could access free NHS earwax removal, the answer was not always easily available, and it was unclear where patients should be signposted.

25. Some respondents to the survey run by Healthwatch indicated that they had been signposted by GPs to private alternatives where they would be charged for the same service. The Board also had personal experience of trying to access earwax removal at a GP surgery in East Sussex and being told that it was no longer available at that practice, and it would be necessary to have the treatment done privately. The Board also noted that NHS Sussex was unable to comment on the CQC registration of private providers or professional qualifications of those undertaking procedures, as it did not have oversight of these services.

26. The Healthwatch survey found that that the average price quoted for a private earwax removal procedure was between £50 and £75. The Board commented that this was a particularly significant cost to incur for patients on low incomes and frequent users of the service.

27. The Board was concerned about the health inequality implications of patients paying for a service that they were entitled to under the NHS. The Board was also concerned about patients who had been unable to access earwax removal from their GP and were unable to afford private provision. The examples of this which Healthwatch was aware from its works suggested that in most cases patients either had to have the procedure done privately, or not have it done at all.

28. Healthwatch concluded that there is a lack of a clear and consistent approach to earwax removal across the local health and care system, which makes it challenging for patients, the public and some health professionals to navigate. Healthwatch suggested there should be clearer guidance to patients and the public on earwax management and treatment options, eligibility for NHS treatment, and why provision is changing. It also raised concerns about the impact a reduction in free earwax removal may have on health inequalities. To this end, Healthwatch produced 12 recommendations in its report, including a number for NHS Sussex and for GP practices and PCNs, which the Board was supportive of. The recommendations of the Healthwatch report are included in full in Appendix 3.

29. When asked by the Board, NHS Sussex confirmed that GP practices should not be signposting patients to private provision of earwax removal. The Board heard evidence that there could be particularly long waiting times for earwax removal procedures, and that some practices may have capacity problems. Representatives from NHS Sussex suggested that it may be quicker for patients to have their earwax removed privately than wait for a GP appointment, and so practices may mention to patients that alternative provision was available if they were unwilling to wait for an appointment. NHS Sussex said it was important for all GP practice staff, both clinical and non-clinical, to have a knowledge of the pathways, in order to suggest alternatives to patients where it would be helpful and appropriate.

30. The Board concluded that if earwax removal continued to be an NHS funded service, there should be better communication of this, such as through posters in all GP surgeries signposting to the service. NHS Sussex noted that it encourages GP practices to put information about access to services on their websites, but there is significant variation between practices. NHS Sussex also works with patient participation groups on how best to communicate to the wider public. NHS Sussex cited the example of Bexhill Primary Care Network (PCN) as being forward thinking in the work it did to hold community events and provide patients with a better understanding of the primary care offer. The Board heard from NHS Sussex that it was encouraging other GP practices and PCNs in East Sussex to take a similar approach, although it was often much more challenging to run community events in rural areas.

Recommendation 1

The Board recommends that NHS Sussex works with GP practices and Primary Care Networks to improve information, public communications and signposting both in surgeries and online, on how and where to access free NHS earwax removal services in East Sussex.

Recommendation 2

The Board recommends that NHS Sussex issues communications to all GP practice employees in East Sussex to make staff aware of the earwax removal pathway and confirm that they should not be referring patients to private provision.

Recommendation 3

The Board recommends that NHS Sussex responds (if it has not already) to the recommendations made by Healthwatch in its report ‘Experiences of Earwax Removal’, published in July 2024, and that the responses are shared with HOSC.

Inter-practice referral

31. The Board understands that where GP practices do not provide earwax removal as a Locally Commissioned Service (LCS), they are still obliged to direct patients to where they could access those services on the NHS. Where a practice is signed-up to provide the LCS, it may provide ear irrigation only, microsuction only, or both.

32. In East Sussex there are only 3 practices not signed up to provide earwax removal as a LCS, however, patients at these practices are still able to access the service from a different neighbouring practice. The Board heard from NHS Sussex that every practice should have a list of local practices that offer the service and that there should be practices within all Primary Care Networks (PCNs) that can provide the service as a first alternative. The patient’s own practice should refer them to another practice on their behalf.

33. The Board heard concerns from Healthwatch that inter-practice referral between GPs did not seem to be working as intended. This correlated with what Board members had heard from their constituents. Healthwatch noted that it may be the case that GPs signposting to another practice were not fully aware of what services that practice offered. Equally, if multiple practices were signposting to a single practice, that put demand pressures on that one practice, which it may not have the capacity to meet.

Recommendation 4

The Board recommends that NHS Sussex confirms with all GP practices in East Sussex that if they are unable to provide earwax removal services that they should be referring patients to other nearby GP practices that do provide regular earwax removal appointments.

Activity levels

34. The Board received evidence from NHS Sussex on the level of earwax removal activity that took place in GP practices in Hastings in 2023/24. It showed that some practices that were signed up to deliver both ear irrigation and microsuction delivered very little or no microsuction treatments in that time period. The Board heard that most patients were treated through irrigation only and it was not necessary for there to be an escalation to microsuction, so it would be expected that many fewer people would have that procedure.

35. The Board learned that one GP practice, despite being signed up to deliver earwax removal as an LCS and provide both ear irrigation and microsuction treatments, had undertaken no procedures over the period the data covered. The Board heard that, because earwax removal is a voluntary service for GPs, they could stop providing it for a time even if they were signed up to deliver it. As it was a specialist service, this may occur where practitioners are off sick or otherwise absent for an extended period. Where this was the case, GP practices should be directing patients to alternative NHS providers. The Board concluded that the number of GP practices signed up to deliver earwax removal as a LCS provided no indication of the frequency or availability of appointments, nor the volume of activity that was undertaken.

36. The Board heard from South Downs Health & Care GP Federation that the funding envelope provided by NHS Sussex for LCS earwax removal might not fully cover the cost of providing the service, and consequently the number of GPs providing earwax removal services may have reduced.

Service	Area	Q1 23/24	Q2 23/24	Q3 23/24	Q4 23/24	Q1 24/25	Q2 24/25
EAR WAX – Irrigation (one ear)	HWLH	344	463	392	310	315	328
	EHS	264	313	317	308	357	302
	H&R	289	329	351	331	392	451
EAR WAX – Irrigation (two ears)	HWLH	635	712	625	470	448	478
	EHS	336	326	347	318	362	436
	H&R	417	434	447	328	530	494
EAR WAX – Microsuction (one ear)	HWLH	33	40	45	43	52	49
	EHS	110	98	88	49	84	69
	H&R	68	58	44	73	63	48
EAR WAX – Microsuction (two ears)	HWLH	129	128	119	108	147	79
	EHS	337	299	342	197	294	130
	H&R	183	190	190	164	137	107
EAR WAX – Domiciliary ear irrigation	HWLH	17	6	4	1	4	2
	EHS	9	8	6	9	5	5
	H&R	4	1	7	5	0	16
Total		3175	3405	3324	2714	3190	2994

37. NHS Sussex provided data on the overall activity levels for different types of earwax removal across the county. This is broken down into three areas: High Weald and Lewes-Havens (HWLH), Eastbourne, Hailsham and Seaford (EHS), and Hastings and Rother (H&R).

38. The data from NHS Sussex showed that earwax removal services remained available and were being utilised across the county, and that the level of activity had not been declining, although there was some level of quarterly fluctuation. NHS Sussex suggested that perceptions that the service was no longer available were likely a result of well-known and wider challenges related to accessing primary care services generally, and dissatisfaction that there may be high waiting times for the service.

39. Although the level of activity had not declined, the Board had concerns that there appeared to be insufficient capacity in the primary care system to provide enough earwax removal appointments to meet the population need. Evidence from the contacts and inquiries Healthwatch and East Sussex Hearing received from members of the public indicated that, regardless of the commissioning intentions of NHS Sussex, there is a level of unmet need in the county for earwax removal. The Board concluded that NHS Sussex does not currently have a accurate picture of how practices which are signed up to deliver earwax removal as an LCS are actually doing so in practice, including how often they run clinics or carry out the treatments, and what the waiting times are like for treatment.

40. The Board commented that given the aging population in East Sussex, it expected that demand for, and therefore activity levels in earwax removal services, to be increasing. The Board heard from NHS Sussex that the data it held on earwax removal activity was not routinely broken down by age. The Board therefore felt that NHS Sussex needed to further explore how it was using data to understand where there were issues of access and demand. NHS Sussex was open to exploring benchmarking the volume of activity against expected uptake reflecting their local age profile to see if there was variation between practices in the level of activity they deliver.

Recommendation 5

The Board recommends that that NHS Sussex explores benchmarking of activity and uptake of earwax removal services to monitor if it reflects local age profile and expected activity levels and take appropriate action to address any identified gaps in provision.

Alternate delivery models

41. As the Board was concerned that there was insufficient capacity to meet demand for earwax removal, Members explored whether there were alternate means of delivery.

42. The Board discussed with NHS Sussex whether it was possible to establish dedicated, high-capacity ‘hubs’ for earwax removal that could deliver the service on behalf of multiple GPs. The Board understands that both ear irrigation and microsuction require staff with specific training, and that microsuction also requires specialist equipment which is expensive and requires specialist staff to operate. Staff absence was one of the reasons why a GP practice that was signed up to deliver earwax removal may not actually be undertaking it. The Board heard that it might be possible for PCNs to staff hubs using Additional Roles Reimbursement Scheme (ARRS) funding.

43. The Board therefore suggested there may be a case for staff with the necessary specialisms to be centralised into hubs that provided a dedicated earwax removal service. This would also have the benefit of being an obvious centre for patients to access the earwax removal treatment, and for practitioners to signpost patients to.

44. NHS Sussex told the Board that it had no current plans to create dedicated hubs to provide earwax removal, due to the dispersed nature of the patient population. However, NHS Sussex could explore a dedicated hub model of service delivery should there be a case that it could improve patient access requirements in an affordable and sustainable way.

45. The Board heard that the payment GPs receive from the NHS for earwax removal services was based on a payment for each treatment provided and the volume of activity they undertook. Therefore, if a GP was signed-up to provide earwax removal under the LCS scheme, but undertook no procedures, it would receive no funding. Under a hub service delivery model, where one practice undertook all earwax removal procedures on behalf of multiple practices, that practice would receive all the funding.

46. The Board also heard that a potential issue with a hub service model would be travel distances and times for some patients, particularly those in rural areas. The Board accepted that the hub service model would only help improve access for larger urban centres with a high population density, such as Eastbourne and Hastings.

47.The Board concluded that earwax removal hubs were a possibility for urban areas where the travel distances would not be too great and population density was higher. However, this would require GP practices within the PCNs to co-operate around providing joint services and would require agreement on how funding for the service was distributed.

Recommendation 6

The Board recommends that NHS Sussex works with Primary Care Networks and Integrated Community Teams to explore the viability of earwax removal ‘hubs’, while recognising the limitations of such a delivery model in some parts of the county, particularly rural areas.

Treatment methods

48. The Board heard from East Sussex Hearing that microsuction is the safest method of earwax removal and was preferable to ear irrigation. The Board also heard from Healthwatch that it had received no specific safety concerns regarding ear irrigation instead of microsuction. It is the Board’s understanding that the NHS Sussex treatment pathway for managing and removing earwax follows NICE guidelines and best practice.

49. Based on the evidence it received, the Board had no particular concerns about the safety or efficacy of microsuction versus ear irrigation as methods of removing earwax.

Community Audiology and Hearing Aids

Any Qualified Prover model (AQP)

50. The Board examined the current AQP model for providing community audiology services, which focuses on the provision of hearing aids to patients aged 55 and above.

51. The Board understands that the entry point to the over-55s age-related hearing loss pathway is through referral by a GP to an AQP. The Board recognised that the requirement for a GP referral to access the pathway was the first barrier to access for people seeking support, given well-known difficulties people experience in accessing GP appointments.

52. As it is a diagnostic test, AQP providers are required to undertake an assessment within 6 weeks of referral, and the Board heard that they are all currently achieving this target. AQP community providers aim to assess and fit patients with hearing aids within 5-6 weeks.

53. A map showing where community audiology providers (AQPs) are based in East Sussex. The map shows that AQPs are based only in larger towns and urban areas, with no coverage in a number of smaller towns, including Lewes, Heathfield and Rye, or rural parts of the county.
The Board understands that AQPs do not have a guaranteed level of income, so providers have no incentive to ensure there was comprehensive coverage of the service across the county and tend to base themselves in areas where there is a higher footfall. As a result, AQPs tend to be based in town centres with limited coverage in rural parts of the county, as indicated by the map below which shows where all the AQPs in East Sussex are based.

54. As well as the poor coverage it delivers in rural areas, the Board also heard that the AQP model did not provide market stability. NHS Sussex informed the Board that in 2014 one national-level company terminated their Sussex contract for this reason. Similarly, two providers terminated their Sussex contracts in 2022 and 2023, citing low market share as one of the drivers for withdrawal. AQPs withdrawing from the market necessitated NHS Sussex to manage the transfer of patients to new providers, ensuring continuity of care.

New contract

55.Having heard some of the issues with the existing AQP commissioning arrangements the Board explored the recommissioning of the over-55s age related hearing loss contract.

56.Work to recommission the over-55s hearing aid contract originally began in 2019. NHS Sussex carried out a lot of engagement with patients when the process started, however the recommissioning had been interrupted with the outbreak of the COVID-19 pandemic, and subsequently by the reorganisation of NHS commissioning bodies.

57.NHS Sussex informed the Board that the recommissioning would allow the Integrated Care Board (ICB) to be specific about where the services should be based, as well as to explore satellite and hub sites in areas where there were currently gaps in the service. Self-referral would also be a key component of the new service.

58. While it had been intended that the tender for the new over-55s hearing aid contract would go out in January 2025, the timescales for the procurement and issuing the new contract have been delayed. This is due to the need to resolve some outstanding queries regarding the specification. These mainly relate to the support provided to people with a learning disability and whether they are best supported in acute rather than community settings.

59. The Board heard evidence from NHS Sussex and SDHC that the current commissioning arrangements did not have a clear and consistent specification for AQPs, as well as having slightly different funding for each. The Board heard that NHS Sussex intends to move away from the AQP commissioning model and award a contract for the new over-55s hearing aid service to a single provider for the whole of Sussex. By commissioning the contract in this way, it would allow NHS Sussex to be more specific in what it would expect from the delivery of the contract, including to specify where services should be based.

60. Although the Board has not seen the service specification for the new contract in full, NHS Sussex has provided an outline summary, and Members heard that it will provide holistic and patient-centred assessment, care and maintenance. NHS Sussex believes that the new contract will make it clearer to patients what they could expect and what providers should be delivering. The Board heard that the new contract will include 4 main elements:

· Hearing Assessment

· Fitting and Provision

· Maintenance

· Annual Review

The Board explored each of these areas of the new contract.

Hearing assessment

61. The Board heard evidence from South Downs Health & Care GP Federation (SDHC) that its member practices felt the current requirement for GPs to refer patients onto the pathway was a box-ticking exercise, and they did not add any value in being the access point for the hearing aid pathway.

62. NHS Sussex has confirmed that self-referral will be an element of the new contract. The Board welcomed this as the right way forward to improve access to the pathway, provided it is made clear that patients will need to check and remove earwax if it is blocking their ears prior to self-referral.

63. The Board explored the relationship between earwax removal and hearing aid services. The Board learned that although hearing aid provision and earwax removal are distinct services delivered in separate settings, they are nonetheless linked. Earwax removal is a key component of the age-related hearing loss pathway; it is not possible to have your hearing assessed or re-assessed if your ears are blocked. Earwax checks and removal are also important for patients who have already been fitted with a hearing aid but are experiencing further problems with their hearing.

64. The Board heard evidence from East Sussex Hearing and SDHC that there are currently no automatic checks ahead of a hearing assessment appointment to see if a patient has an earwax blockage. This can result in failed appointments and is a waste of both patients’ and clinicians’ time as any patient that has an earwax blockage that would prevent them having a hearing assessment would need to have it removed in a primary care setting.

65. The Board heard that earwax removal would not be included in the service specification of the new hearing aid contract, and the service would remain within primary care. However, NHS Sussex has confirmed that the new contract holder will be expected to refer people to primary care for earwax removal where it is required prior to undertaking a hearing assessment. The new provider will be expected to develop effective referral pathways and handover arrangements between the two services. The Board also heard that it would also be important for the new provider of the age-related hearing loss contract to work closely with GPs and PCNs once the new services are commissioned.

66. NHS Sussex also confirmed that under the new service specification, although patients will be able to self-refer to the service, this will require them to check for earwax first. This would be built into the self-referral form which will be co-produced with the provider and patients.

67. The Board agreed that it was important that NHS Sussex recognise the links between accessing earwax removal at GP level and the new hearing aid contract and the importance of robust and streamlined referral methods between the two services.

Recommendation 7

The Board recommends that NHS Sussex facilitates cooperation between GP practices, PCNs, VCSE organisations and the new contract holder to create simple and effective referral pathways for patients needing earwax removal prior to a hearing assessment.

Fitting and Provision

68. At a fitting appointment, patients should be instructed on how best to use their hearing aids and ensure that their aids are correctly moulded to the ear. The Board learned that patients receive a large amount of information at the fitting appointments. Under the current service a follow-up appointment should be arranged within 10 weeks of first being fitted with their hearing aids to check that the patient is adapting to using aids and to arrange for adjustment if necessary.

69. The Board heard from East Sussex Hearing that prior to the COVID-19 pandemic the NHS also offered group meet and learn sessions 12 weeks after fitting to receive information about hearing aid maintenance, but these had since stopped and only seemed to be available from non-NHS commissioned organisations such as East Sussex Hearing and similar organisations.

70. East Sussex Hearing had received a number of reports from people who felt rushed during their fitting appointments, which had increased the likelihood that hearing aids were not fitted correctly first time. The Board heard from NHS Sussex that during the pandemic there had been a shift to providing what had previously been face-to-face provision virtually instead, but that this has not shifted back since.

71. The Board heard from NHS Sussex that the new contract service specification will set out a list of matters that should be covered during a fitting appointment. This will include how to replace the tubes and batteries, using Bluetooth facilities, connecting hearing aids to mobile phones and where to access maintenance support. To assist patients and remind them what had been covered in previous appointments, the new service will also provide patients with a personalised care and support plan, which will be co-designed with service users and the new provider.

72. The Board also heard that the new service specification will include the use of an International Outcome Inventory for Hearing Aids (IOI-HA) tool to capture patients’ experience of using the services. It will include questions such as:

· Are you using your hearing aid and if not, what are the reasons for this?

· Are you feeling less isolated as a result of using your hearing aid?

· Are there situations/places where you find it difficult to use your hearing aid?

73. After the hearing assessment and fitting appointments, there will be a requirement for the provider to arrange a follow up appointment in 6-8 weeks with the patient to check everything is satisfactory and to complete the follow up IOIHA questionnaire. NHS Sussex is keen to ensure that people use their hearing aids once they have been prescribed and to understand how to address issues if patients are not using them.

74. The Board welcomed that the new service specification would clearly set out the support and advice that should be offered to patients in fitting and follow up appointments. The Board agreed that if they were successfully delivered, there would be an improvement in services, and a return to some of the support that had been available prior to the pandemic.

75. The Board heard evidence from Public Health on inequalities in relation to hearing loss. Inequalities as a result of poverty can begin at a young age and compound throughout a person’s life course, increasing the likelihood that they will experience hearing loss. However, these inequalities also mean that people are less likely to seek help for their hearing loss and use hearing aids if prescribed them.

76. Board members and witnesses who were themselves hearing aid users, also noted that it took time to adjust to wearing hearing aids, including an understanding of ‘softer’ things, such as how to make best use of hearing aids in different settings. The Board heard that support was crucial for ensuring patients continued using their hearing aids once they had been provided with them.

77. Public Health believes more can be done to prevent hearing loss and associated inequalities. Hearing aids are a cost-effective intervention and recommended for adults with mild to moderate hearing loss to improve quality of life and listening ability. With only around 40% of people who need hearing aids having them, there is a need to increase awareness that hearing aids are available on the NHS. It is important to ensure that information and support is available to everyone following the supply of a hearing aid, helping people to continue to use them. There is also a need to address the stigma associated with hearing loss and the wearing of hearing aids, especially in the workplace, and to educate the workforce on simple adjustments that help communication for people with hearing loss.

78. The Board concluded that there were opportunities for joint working between NHS Sussex and Public Health to explore these issues further, particularly to understand more about why some people do not use the hearing aids that are made available.

Recommendation 8

The Board recommends that NHS Sussex works with Public Health to further understand barriers to people using hearing aids once they have been provided with them, including access to aftercare and maintenance.

Maintenance and ongoing aftercare

79.The Board learned that the regular maintenance and ongoing aftercare of hearing aids is essential for them to function as intended. Currently when people receive hearing aids on the NHS, they should be informed at the fitting appointment what maintenance is required and where they can access it. If hearing aids are not properly maintained, they will not function as they ought to, which increases the likelihood of patients not using them. If hearing aids are not being used it represents a waste of resources and risks people experiencing the impacts of hearing loss for longer. The Board noted that it was very important that hearing aids were well-maintained, and that ongoing maintenance support was a vital part of the pathway.

80. Although AQPs are commissioned to deliver the entire hearing aid pathway from referral, including ongoing maintenance and re-fitting of hearing aids where necessary, the Board heard evidence that this was not widely happening in practice. East Sussex Hearing noted that it regularly supported individuals who were unaware that regular maintenance was needed (such as replacing the plastic tubes) and unsure of where they could access support. East Sussex Hearing suggested that the significant increase in people contacting the charity for advice and support on how and where to access maintenance services for their hearing aids indicated that the level of support available had declined. East Sussex Hearing felt that some providers offered little more aftercare than the provision of replacement batteries for hearing aids. The Board heard that AQPs receive funding to deliver ongoing maintenance and aftercare support, and had concerns as to how this was being delivered. NHS Sussex does not currently have a specific Key Performance Indicator (KPI) to assess the maintenance aspect of AQP commissioned services.

81. The Board heard that maintenance is required regularly and, if this was not available locally, it raises health inequality concerns, particularly for people with limited mobility, on lower incomes and without access to private transport. At present some AQPs patients were required to leave their hearing aids for maintenance, and these were not returned for a week. Slow turnaround times and travel distances for maintenance could disincentivise people from having their hearing aids maintained as required, increasing the likelihood they would not work as intended. The Board noted the importance of maintenance for hearing aids being both local and timely.

82. The Board heard from ESHT (which has a large number of AQP patients), that it used to offer drop-in maintenance service in both Eastbourne and Hastings, but this had stopped during the pandemic and that the service was now appointment only, in order to manage demand. Appointments were available every day and patients should be able to get one either the same or the next day. Volunteers had also been recruited to welcome patients and support them with routine queries.

83. NHS Sussex informed the Board that the new contract service specification will require patients to be able to access aftercare services, both face-to-face and non-face-to-face within 5 working days of a request. There was no requirement in the new specification that there should be a walk-in maintenance service. A postal repair service must also be available to patients, with a guaranteed return time of 7 days from the provider receiving the devices. Patients would also be able to walk-in to collect their aids without prior notice. NHS Sussex had tested this maintenance model with patient representatives who were satisfied with the offer.

84. The Board heard that all follow up and aftercare related to hearing aids has to be delivered by the same provider who supplied and fitted the hearing aid to the patient. For example, if a patient gets their hearing aid from Specsavers under the NHS, they could not go to ESHT or another provider for aftercare. Additionally, if a patient has their hearing aid fitted and supplied privately, they could not then receive aftercare on the NHS.

85. The Board raised concerns as to whether this was well understood by patients, who might be willing to have their hearing aid fitted privately but expected to be able to receive aftercare support on the NHS. NHS Sussex said that GPs should be very clear to patients that they cannot mix providers when they make the first referral to an AQP. The Board felt that it was important that patients are provided with clarity and had a complete understanding of the hearing aid pathway.

86. The Board concluded that the new contract represented an opportunity to further embed maintenance as a core part of the hearing aid pathway. The Board were hopeful that this could result in a return to the level of service that had been available prior to the pandemic but had since fallen away.

Recommendation 9

The Board recommends that specific Key Performance Indicators (KPI) are included within the new contract to monitor and assess hearing aid maintenance and ensure regular reviews of hearing are undertaken.

Recommendation 10

The Board recommends that NHS Sussex develops digital and non-digital patient communications, including leaflets, that provide patients with information on areas including:

a) a summary overview of the hearing aid pathway;

b) the importance of hearing aid maintenance and where patients can access it;

c) that patients cannot mix provision and maintenance for their hearing aids;

d) signposting to other available support for living with hearing loss.

Recommendation 11

The Board recommends that NHS Sussex works with the new provider to explore whether it could deliver a same day drop off and maintenance and repair service for hearing aids.

Annual Review

87. The Board understands that the length of time a patient is on the hearing aid pathway through the AQP service is currently 3 years. East Sussex Hearing explained that prior to the pandemic patients would automatically be invited back for a hearing test every three years but suggested that this was not happening in practice anymore. The onus was therefore currently on patients to know how long it had been since their last assessment and to make contact to have their hearing assessed again. Patients who did not proactively make contact with the service could then risk falling off the pathway, and needing to go back to their GP to be re-referred. The Board were concerned about people who dropped out of the pathway and how they were provided with continual support.

88. The Board heard that as part of the new contract there will an annual review for patients. Having not seen the full service specification, the Board has been unable to fully understand how the annual review element of the new contract will work in practice, including whether patients will need to be re-referred onto the pathway after a certain length of time or whether they will remain on it indefinitely. However, the Board felt it was important that automatic recall was included within the new contract, so that at the end of the pathway patients were automatically prompted to have their hearing reassessed. In this way, hearing would be treated similarly to vision, where patients receive regular reminders to have their eyes retested.

Recommendation 12

The Board recommends that patients are automatically recalled for a hearing assessment on a regular basis and when they are due to receive a new hearing aid.

Commissioning process

89. As part of the development of the new contract, NHS Sussex had worked with a commissioner who specialised in sensory impairments in the East Sussex County Council (ESCC) Adult Social Care and Health Department. Their role had been to review the service specification for the new service as well as the questions that would be asked of prospective bidders for the contract and assess whether they met the expectations of the department and the needs of its clients. There was a particular focus on ensuring equity of access, equality, the sustainable use of resources and the social benefits of the new contract.

90. The Board heard from the ESCC commissioner that they had been able to comment on and make a number of suggestions to amend the service specification, including to strengthen the support for adults with learning disabilities, people with dementia and digitally excluded people. The Board welcomed the fact that Adult Social Care (ASC) had had an opportunity to provide feedback and suggest changes to the service specification, given the overlap of users for both services.

91. The Board heard from the commissioner that there had been no indications that ASC would have any ongoing involvement with the contract management. Given the importance and impact of the service on ESCC commissioned services and its clients, the commissioner was hopeful that there would be a mechanism for ASC to continue to feed into the provision and monitoring services on an ongoing basis.

Recommendation 13

The Board recommends that NHS Sussex continue to work with relevant commissioners in ESCC Adult Social Care as part of contract implementation and ongoing monitoring.

Funding

92. The Board explored the future funding arrangements for the new over-55s age-related hearing loss contract.

93. The Board understands that the funding set aside for the new contract will be based on the outturn cost of the service for 2023/24. The Board heard concerns from SDHC (a prospective bidder) that capping the funding at the previous year’s outturn would be insufficient to meet the widened service specification of the new contract. The Board was concerned that if the funding was not enough to deliver the service specification, then there was a risk that the new contract may fail. In response, NHS Sussex confirmed that it was taking a number of steps to mitigate the risk of contract failure throughout the procurement process, and there had been significant work early on in the commissioning process to check that any future provider was able to deliver the services required.

94. The Board also heard from NHS Sussex that it expected to make savings in the new contract because people’s hearing aids should last longer. Modern digital hearing aids function for longer than most people expect, as there was a common misconception that hearing aids have to be replaced every 3 years. Most manufacturers now indicate that their hearing aids will last around 5 – 7 years.

95. NHS Sussex indicated that the new service had been planned based on an assumption of 1% per annum growth in demand. This was based on census data that showed a population growth of 9% in the over 55 age group over the next 10 years. As part of the procurement process, prospective providers will be asked to submit their activity levels in line with the contract value and the assumption of 1% growth in demand per year.

96. The Board heard evidence from Public Health, which had produced a briefing on hearing loss as part of the Joint Strategic Needs Assessment. Included within this was modelling of future prevalence of hearing loss in the East Sussex population for 2023 – 2040. This showed that the number of working age people in the county with some level of hearing loss was projected to remain steady and decline slightly over that period. However, the number of people in the county with hearing loss over the age of 65 was projected to substantially increase, from 95,865 in 2023, to 132,506 in 2040. This was as a result of the well documented aging demographic of East Sussex which would mean there would be many more people over the age of 65 projected to be living in the county by 2040.

97. The Board was concerned that this would result in far greater demand for age-related hearing loss services. The broadened service specification that the new provider would be required to deliver could also represent an increase in costs from the current level of provision, given the gaps in the service the Board had already noted, particularly around ongoing aftercare.

98. In order to mitigate the risk of the contract failing or not being delivered as expected, the Board noted that the funding for it must be set at a level to reflect likely future demand. The Board commented that this should also consider projected housing growth in the county, and the age profile of the people likely to be moving into the area.

Recommendation 14

The Board recommends that NHS Sussex works with Public Health to validate assumptions of future demand for the new age-related hearing loss contract.

Future delivery

99. The Board learned that the new contract will be held by a single provider for the whole of Sussex. South Downs Health and Care GP Federation noted that, given the widened service specification it was unlikely that a single organisation would be able to deliver the entire service. It was therefore likely that the provider awarded the contract would need to subcontract other organisations to deliver elements of the service across different parts of Sussex.

100. The Board heard evidence that VCSE organisations including East Sussex Hearing, currently provide significant support to patients such as information and signposting and routine maintenance, although they are not commissioned by nor receive funding from the NHS. The Board considered there were opportunities to formalise the role that local VCSE organisations in the county have in the audiology pathway. This was thought to be particularly important if the new provider was not East Sussex based.

101. The Board heard from ESHT that it was in the process of evaluating the service specification and costings of the new contract, before determining whether it would bid. The Board observed that ESHT, as well as other AQP providers, are currently responsible for a significant proportion of patients in the county, but that it was not currently clear which of these would continue to provide NHS services under the new contract. The Board had concerns that where current providers might not be contracted to deliver the new service there may be a reduced level of coverage in parts of the county. The Board were also concerned about the continuity of care implications for patients that may need to switch providers under the new service.

102. Given these concerns, the Board considered that it would be important that the performance of the new service is monitored carefully to ensure that services are provided in the way they are intended to be. It will be important that the patient’s voice, including through Healthwatch East Sussex and other patient representative groups, is heard in any monitoring arrangements.

Recommendation 15

The Board recommends that NHS Sussex work with Healthwatch East Sussex and other patient representative groups to monitor the new contract to ensure it meets the specific needs of the population of East Sussex.

Recommendation 16

The Board recommends that NHS Sussex carefully evaluates the impact a single provider model has on the availability and provision of hearing aid services to the population of East Sussex and ensures it provides high quality continuity of care for existing patients.

Conclusions

103. Overall, having considered a range of evidence in detail, the Board recognises the significant impact that hearing loss can have on individuals, for both their physical and mental health, and increased likelihood of social isolation. Age-related hearing loss is however treatable and manageable through the use of hearing aids, provided patients receive the right support from assessment through to ongoing maintenance. This is particularly important in East Sussex, which has a significant proportion of older people living in the county

104. The Board concluded that community audiology and earwax removal services in East Sussex are currently unsatisfactory and have substantially diminished since before the COVID-19 pandemic. In particular the Board considers that there is a lack of clarity on the services people are entitled to receive on the NHS for both earwax removal and hearing aids, and confusion about how to access these services. The Board has therefore made a number of recommendations to NHS Sussex intended to improve patient communications and access to earwax removal and hearing aid pathways.

105. The Board concluded that the new community hearing aid contract represents a chance to significantly improve the access and provision of hearing aids in the county if the service specification is delivered. However, the Board has concerns that the funding NHS Sussex has made available for the new service may not be sufficient to meet expected future demand, and that the single Sussex provider model may risks further reduction in services in East Sussex if current providers have no involvement with the new contract.

Appendix 1:

Scope and terms of reference of the review

The Review was established to consider and make recommendations on the following.

The areas of concern raised with HOSC and Healthwatch predominately relate to NHS Sussex commissioned primary and community audiology services, which focus on hearing tests, hearing aid pathways and earwax removal services. Therefore, the services within the scope of the review include community audiology commissioned under the Any Qualified Provider (AQP) scheme; earwax removal services delivered by GP practices; and East Sussex Healthcare NHS Trust (ESHT) audiology services.

The lines of enquiry for the review included:

What are the current access issues to community and GP based audiology services and how can these be improved?

Where are the current gaps in the provision of primary audiology services in the county?
What are the impacts for people not able to access ear wax removal via the NHS or those unable to access non-NHS services due to cost?
How can accessibility to community and GP provided audiology services be improved in rural areas and deprived areas of the county?

How can communication of audiology pathways and local NHS provided services be improved?

Are GP practices effectively communicating whether they offer earwax removal services and signposting to other NHS services where they don’t?
Are patients being effectively signposted and referred to NHS services rather than paid-for providers?
How are NHS Sussex monitoring inter-practice referral?
Is the three-tiered pathway for audiological care clear and well understood by patients?
How can simplified and consistent communications on the treatments available for ear wax removal be made available to patients and the public?

How will the future commissioning arrangements ensure that identified issues and barriers to access are addressed?

How will future commissioning ensure that availability to services such as hearing tests, hearing aid provision and maintenance services is widened?
How will current patient experiences feed into future commissioning plans?
Could self-referral be a part of the new service model?
What role will the voluntary sector play under a new commissioning model?
Can future commissioning involve more preventative work that reduces the need for people to access primary or acute services?
Will the funding provided under the new contract be sufficient to deliver on the widened service specification?
What patient monitoring will feature under the new contract to limit barriers to access and ensure that patients remain on the pathway?

Desired Outcomes

Identify gaps or inequalities in access and provision of audiology services across East Sussex.
Provide recommendations to inform the new hearing aid commissioning arrangements.

Matters Outside the Scope of the Review

Acute hospital-based audiology services provided by Ear, Nose and Throat (ENT) Departments of ESHT and University Hospitals Sussex NHS Foundation Trust.
Provision of audiology services provided by non-NHS Sussex commissioned bodies.

Board Membership and project support

Review Board Members: Councillors Christine Robinson (Chair), Abul Azad, Colin Belsey, Sorrell Marlow-Eastwood and Alan Shuttleworth.

The Project Manager was Patrick Major, Scrutiny & Policy Support Officer with additional support provided by Martin Jenks, Senior Scrutiny Adviser.

Review Board meeting dates

11 November 2024
25 November 2024
16 December 2024
13 January 2025
12 February 2025

Witnesses providing evidence:

The Board would like to thank all the witnesses who provided evidence to the review:

NHS Sussex officers

Ashley Scarff, Director of Joint Commissioning and ICT Development (East Sussex)

Wendy Young, Director of Acute Services Commissioning and Transformation

Fiona Kellett, Deputy Director of Primary Care

Karen Sallis, Head of Primary Care Commissioning: General Practice and Community Pharmacy

Cecily Hollingworth, Deputy Head of Planned Care and Cancer

East Sussex County Council (ESCC) officers

Ben Brown, Public Health Consultant

Thomas Skilton, Commissioning Manager (Technology Enabled Care), Adult Social Care

East Sussex Healthcare Trust (ESHT) officers

Nadia Cruddis, Divisional Director of Operations (DDO)

Ian Woodward, Head of Service for Head & Neck, Professional Lead for Audiology

Voluntary, community sector and not for profit organisations

Glynwen Chetcuti, Operations Manager, East Sussex Hearing

Karen Norwood, Trustee, East Sussex Hearing

Kirstie Ingrams, South Downs Health and Care GP Federation

Simon Kiley, Head of Insight and Evidence, Healthwatch East Sussex (HWES)

Evidence papers

Item	Date
Provision of Audiology Services in East Sussex. NHS Sussex. HOSC 30 July 2024.	July 2024
HOSC minutes from the meeting held on 30 July 2024.	July 2024
Experiences of Earwax Treatment report. Healthwatch East Sussex.	July 2024
East Sussex Joint Strategic Needs Assessment Briefing on Hearing Loss. ESCC Public Health.	May 2024
Provision of Audiology services in East Sussex - Follow-up report to the East Sussex HOSC: November 2024. NHS Sussex	November 2024
Provision of Audiology services in East Sussex - Follow-up to the East Sussex HOSC Review of Audiology Services Group meeting 25 November 2024, and the Committee meeting 3 October 2024. NHS Sussex	January 2025
Written submissions from East Sussex Hearing	Various

Contact officer: Patrick Major, Scrutiny & Policy Support Officer.

Telephone: 01273 335133
E-mail: patrick.major@eastsussex.gov.uk