Independent Review of Audiology Services in Scotland

Education and Training Sub-Group

Key points

• Four priorities were identified by the Sub-Group: CPD; foundation education; advanced practice; and leadership.
• A CPD champion or training officer in every department, as well as a national project role, would help define responsibility and accountability.
• An accountable training lead and core training register would help in the continuous process of checking competency.
• There are currently three potential training providers of audiologist professional status.
• A disconnect between supply from these programmes and demand from the audiology service may account for staff shortages but the intermittency of the programmes is also a factor.
• The diversity of pathways to access audiology training is a positive feature and must be properly managed.
• Leadership preparation is mixed.
• Leaders need to be comfortable with external scrutiny.

Introduction

Of 36 recommendations in the BAA’s Lothian report, 11 related to training – particularly in CPD, assurance of competency and specific leadership skills relating to assurance of standards. Recommendations were deemed urgent (i.e. immediate action) in relation to training for visual reinforcement audiometry (VRA) and auditory brainstem response (ABR), and leadership skills for key staff. Other recommendations deemed of high importance (i.e. within 12 weeks) included training in new and existing protocols such as real ear coupler difference measurement, child protection awareness, peer review networks, clinical audit training and critical appraisal for senior staff including root cause analysis.

The BAA’s recommendations did not reference workforce supply in Scotland and impact on capacity. Nor did they reference the healthcare science workforce’s profile in a Board. The Sub-Group’s view is that the limited oversight by Boards amplifies the solitary nature of the service, with a risk to training and service quality.

Shortly before publication of this report, the BAA conducted a further survey (7) of the audiology workforce in Scotland covering:

• training and career development;
• governance and leadership;
• raising concerns;
• quality of service;
• strengths, improvements and demonstrating value to stakeholders.

The survey is entirely consistent with the findings of the Education and Training Sub-Group.

Methodology

The Education and Training Sub-Group was convened on 11 August 2022. Membership was drawn from across the profession and included practitioners, trainees, heads of service and senior staff from around the UK, NHS workforce planning, and higher educationalists from the Scottish universities. Draft recommendations were formulated for each aspect of the Sub-Group’s work and reported to the National Review Group for comment and feedback. The Review website lists the Sub-Group participants (1).

The first meeting of the Sub-Group identified priorities for consideration:

• CPD;
• foundation education;
• advanced practice;
• leadership.

Speakers from the group presented an expert view on the topic and there was a corresponding overview paper from the Sub-Group Chair that outlined the key issues. Emerging recommendations were debated and feedback taken from the Review Group as the recommendations developed. The Sub-Group’s fifth meeting considered all the recommendations in the round.

Ahead of publication of this report, two early recommendations have been made through the Review Chair to the Cabinet Secretary for Health and Wellbeing. This encouraged availability of BSc foundation training provided by Queen Margaret University and Glasgow Caledonian University. The recommendations were made early to the Scottish Government in the light of academic planning cycles and the urgency of securing undergraduate training in audiology.

Also, ahead of publication of this report, NES Healthcare Science offered fee support for eligible experienced audiology staff to sit the BAA Higher Training Scheme (HTS) exam, Paediatric Assessment 6 months+. BAA closed this exam-only pathway at the end of March 2023. By early March, 14 staff from Scotland had applied for fee support.

In parallel with this National Review, the team from the Scottish Government CNOD, led by the Chief Scientific Officer, commenced a high-level review of the education and training landscape for healthcare science in which audiology sits. Any future changes to education and training are not yet identified by that Review.

In framing these recommendations, the scope of the Sub-Group’s work has been the immediate audiology profession. It is acknowledged that other groups play a pivotal role in the patient pathway, most notably the newborn-hearing screener. The recommendations are equally applicable to these wider groups. Any implementation of these recommendations must include consideration of the screener workforce.

Findings – CPD

Why does CPD matter? The Sub-Group framed its response in terms of the safety-critical nature of the services audiologists provide. An observation of the NHS Lothian situation by the BAA was of no internal or external oversight of local competences. There was no challenge in the system or routine inspection of team members’ essential skills. There was no clear idea of how those skills were kept up to date.

CPD applies to all levels in the team. To that end, a CPD champion/training officer in every department would help address the risk of training in isolation to give:

• defined responsibility and accountability;
• point-of-contact for all – the status of training as a team activity is elevated, thereby enhancing patient safety;
• strengthening of mutual support between larger and smaller departments, reinforcing the professional network. This would be particularly important for small/single-handed units where the obligate support of a larger neighbouring department could be established.

A fixed-term national project role to coordinate and drive all aspects of the recommendations is also recommended.

A departmental core training register of safety-critical diagnostic investigations by the team should be established to clearly define a department’s capacity to conduct tests and individuals’ capacity and competence. It would record:

• who is rated/competent to do what test;
• how that individual is qualified to do such tests;
• the validity period of an individual’s competence before revalidation;
• the recurrence interval for competency to conduct a test;
• a schedule of reapproval of competence for each member of the team.

Improving the wider system

Checking an individual’s competency and annual appraisals should include inspection of the core training register.

An accountable training lead and core training register could help address the competency issues identified in the Lothian report. They could intercept any unknown yet similar risks in other departments. A core training register, as a professional norm, would emphasise the safety-critical nature of the department’s work and, importantly, lay the groundwork for further safety-related development of the system. This is the intersection between the Education and Training Sub-Group’s work and that of the Structure, Governance and Leadership and Quality Assurance Sub-Groups.

In other branches of healthcare science, external audit/inspection of service is well-established. For example, hospital laboratory services are subject to inspections by the United Kingdom Accreditation Service (UKAS) (15) as a necessary part of their licence to operate. UKAS accreditation inspections include examination of staff training records and, effectively, a cross-check of who is competent to do what.

Accountability and system oversight were implicated in NHS Lothian. Medical and nursing oversight, at executive director level, are statutory components of NHS Scotland’s Health Boards. Despite the complexity of the healthcare science workforce, its central role to the patient pathway and the safety-criticality of its activities, there is no lead healthcare scientist or authority to drive the above improvements. A similar sized commercial organisation could not operate without a director of science or engineering. NHS Wales (16) has executive directors of therapy and healthcare science; NHS England (17) has a network of scientific directors in the regions. The NHS Lothian incident is a microcosm of a wider systemic organisational shortcoming.

An accountable scientific lead should be a healthcare scientist empowered to support and oblige all healthcare science departments, including audiology, in a Health Board to engage with appropriate quality systems to give credible assurance. The post should be line-managed directly by a Board executive director, but it should be promoted as the senior responsible officer to direct robust systems of CPD/skills tracking and – by extension – any associated quality auditing of service. Lead posts have been piloted by Greater Glasgow and Lothian. There is a strong case for a nationally evaluated job description at a harmonised and senior Agenda for Change band.

Findings – foundation education

What is needed to secure the workforce now? While the NHS Lothian review did not highlight audiologist training pathways as a cause of failings in the service, the shortage of staff is perennial. The supply of trained audiologists is detached from the actual workforce shortages: service is left to hope that a qualified person can be found or that local Board decision-making will permit departmental training posts if an in-house traineeship is chosen.

What are the demand and supply numbers?

Scottish Government workforce estimates (18) indicate there are 260 NHS audiology professionals in Scotland. Of these, the service reported, in late 2022, 26 WTE vacancies, or just over 9% of its workforce. The concentration of roles across the service is in band 6, senior practitioner, followed by band 3, assistant.

For a small workforce such as audiology, a single vacancy can have a catastrophic impact on patient flow and service know-how, both potentially leading to delays, burnout and error. Patient safety lurks behind the vacancy situation. This is the connection with the National Review.

At present there are three potential training providers of audiologist professional status in Scotland. These pathways will be explored next, but to summarise the prospective supply side:

• Glasgow Caledonian University (GCU) has 12 audiologists on its BSc programme. These are NHS employees and will graduate between 2023 and 2025;
• Queen Margaret University (QMU) expects a total of 14 graduates between 2023 and 2024 from its pre-registration MSc programme and 66 from its hearing aid dispenser programme between 2022 and 2024. The likelihood for NHS Scotland employment is lower as these are unattached self-funded postgraduate students;
• there is one clinical scientist known to be in training via the Scientist Training Programme (STP)-equivalence pathway.

What are the current training pathways?

QMU offers a DipHE for hearing aid dispenser (Health and Care Professions Council-accredited) and a pre-registration MSc that is accredited by the Registration Council for Clinical Physiologists (RCCP)/Academy for Healthcare Science (AHCS). The MSc is self-funded. The university also has an RCCP/AHCS-accredited BSc undergraduate audiology programme, but it is not listed on the University and College Admissions Service (UCAS) (19) system as it has not been offered since about 2006. The hearing aid dispenser programme is an important supplier of the retail sector (out of the scope of this Review) and of the bands 3 and 4 component of the NHS workforce. As a blended learning programme, it allows NHS staff to access this level of training while remaining in post, provided the service can release the individual for the academic component. The department has close links with speech and language therapy academic provision.

GCU offers a BSc in clinical physiology that combines generic academic elements with learning for specialisms in audiology, neurophysiology, cardiac physiology and respiratory physiology. The programme runs every second year for NHS staff only. It is not listed on the UCAS system. Delivery is at the institution and in the workplace. Essentially it is, in all but name, an undergraduate apprenticeship model. Crucially, the programme offers a “year 0” starter phase at a partner further education college to allow access to the degree programme for candidates without Higher/A-Level qualifications. The uncertainty as to whether it will run in 2023 has been overcome since the Review commenced.

The STP is for able science graduates to join the NHS and acquire Health and Care Professions Council (HCPC) clinical scientist registration in a specialty such as audiology. Except for the nationally commissioned cochlear implant service, the wider audiology service in Scotland has not requested clinical scientist trainees in over a decade. Demand for NES-funded supernumerary clinical scientist training posts from service is around one third higher than resources allow for all healthcare science disciplines. There is an urgent need for clinical scientist training post investment, particularly if the audiology community also adopts this pathway.

“Equivalence” pathways exist to allow alternative routes to registration, largely via in-house development, to RCCP/AHCS (practitioner) registration or HCPC (clinical scientist) registration. Audiology services have avoided this pathway. For other specialties, the driver for training via “equivalence” has been workforce shortages.

What needs to happen to stabilise supply?

The intermittency and disconnect between audiologist supply from these programmes and the demand from the audiology service explains the workforce shortages.

The GCU programme is wholly dependent on service creating or converting establishment posts to training posts: the programme has no control over the intake. Service tends to recruit existing science graduates into what should be school-leaver (non-graduate) candidate posts. Service is probably driven to recruit graduates who, in theory, are faster learners, more mature and who will probably yield lower attrition than a school-leaver cohort. Prediction of the intake every second year is guesswork.

The QMU pre-registration MSc programme is entirely dependent on individual ability to self-fund. There is no deeper contractual attachment to a department beyond the programme placement; there is no obligation or incentive to seek NHS employment in Scotland after graduating. Similarly, NHS Board willingness to release staff onto the dispenser programme is beyond the university’s control.

Diversity of training pathways to secure supply

A positive feature of the Scottish training landscape for audiology is more accidental than by design. Properly managed, it could reinforce multiple pathways into audiology and help secure the workforce. Diversity reinforces access and inclusion, so by its nature is desirable.

Effectively, the GCU model is an undergraduate apprenticeship that combines the four principal clinical physiology disciplines for employers if an in-house apprentice-type trainee is wanted. Emphasis should be on non-degree-holding entrants, such as school-leavers, as other (quicker) postgraduate pathways like STP are available: it makes no sense to expect degree-holders to repeat undergraduate training which is both time-consuming and a disincentive to retention. Incentivising service to recruit would be helpful.

The QMU pre-registration MSc is a route into audiology for able science graduates. It could be the springboard for completers to go on to acquire HCPC clinical scientist registration via equivalence. Improvement in the connection to Scottish service of such postgraduates could enhance retention; for example, selective sponsorship could be a route to achieving this. A restart of the BSc programme is highly desirable; it would boost the supply of audiologists both for the NHS and retail sector. The DipHE could be further enhanced by an articulation with the undergraduate programme to give a clear career pathway for these staff. The export opportunity for Scotland of training such undergraduates and from all programmes should not be overlooked and placements not confined to Scottish centres.

Placements and connection with service

Regardless of the academic models, some form of agreement relating to placement could be an improvement. This goes beyond audiology to the wider healthcare science sector. NES has experience in formalising such memoranda of understanding. Indeed, current healthcare science trainees, including NHS audiology staff, are assigned a national training number and tracked throughout training as part of NES’s quality assurance of training function (20). This function includes recognition of NHS training centres via an assessment process traceable to HCPC Standards of Education and Training.

Leadership and training in quality systems

Awareness of leadership principles, quality systems and regimes of external inspection should become the norm as early as practicable in the training cycle. This awareness will be the foundation on which effective advanced practice and leadership can be developed.

Findings – advanced practice and leadership

The Sub-Group’s final themes propose responses to the specialist skills and leadership challenges exposed in the Lothian review. The discussion took account of a parallel discussion in the Quality Assurance Sub-Group, which identified considerable variation in the application of accredited higher learning and current best practice in the profession.

The impact of specialist skills preparation

The BAA highlighted concerns around understanding and application of specialist audiological test protocols, the external oversight of those competencies, and the leadership underpinning maintenance and development of skills. The guiding principle in our deliberations was “no-blame/learn from error”: the deficiencies observed were clearly systemic rather than individually malign.

The impact of deficient specialist skills on a patient can be for life, which places added importance on the correct understanding and application of those skills. This need is accentuated when the practitioner is independent or with sole responsibility in the clinic. What specific competencies must be faultless? How should training in them be delivered? Who oversees that training?

Understanding and application of specialist protocols

The BAA report cites an urgent need to improve ABR testing both in newborn and older children and in VRA testing. Specialist skills in audiology such as these are developed after initial registration. The BAA’s HTS addresses these and has been available for 15 years. The training is in-house under an accredited supervisor, with compulsory secondments, external assessment prior to examination and external assessment at the exam undertaken in the workplace and supported by accredited local trainers. Verified completion of the module results in a BAA HTS certificate. The current suite of HTS modules includes (21):

• adult assessment and rehabilitation with additional needs;
• advanced adult assessment and rehabilitation;
• balance assessment;
• balance rehabilitation;
• paediatric assessment (6 months+);
• paediatric assessment (newborn);
• paediatric habilitation;
• therapeutic skills;
• tinnitus and hyperacusis;
• cochlear implants.

In advance of publication of this National Review, NES Healthcare Science offered direct sponsorship of assessment fees for able staff wishing to sit the HTS paediatric specialty exams. The BAA pathway for this equivalence recognition was open until March 2023.

The BSA provides a comprehensive suite (22) of evidenced practice guidance documents, including specific protocols recommended for neonate and child examination. The caveat, of course, is that obtaining such information is not the same as showing understanding and then correctly applying it.

The Review’s Quality Assurance Sub-Group conducted a survey of service in October 2022 that included questions about the state of higher training/master’s-level specialisation. To date, BAA colleagues on this Sub-Group report that Scottish service engagement with the HTS is very limited, with time, cost and trainer availability the limiting factors.

Clearly, quality assured specialist learning resources are available to develop competencies. Accessing such material would be the logical next step. It is recognised that the capacity of the BAA to operate the HTS is limited; a Scottish solution, perhaps involving the NHS Scotland Academy, may help but with the short-term inconvenience of diverting staff away from the frontline. Notwithstanding service pressures, there is a clear contradiction that the system faces with the potential reluctance of staff (who deliver specialist tests) to undergo an assessment that could reveal competence shortcomings. It is a bullet that must be bitten. Transition and supportive environments are essential.

A final observation on postgraduate training is the distinction between the clinical STP and the advanced practice specialist training listed above. Pre-registration clinical scientist training is a postgraduate pathway for able science graduates to join service on a three-year programme. However, it is not immediate preparation for those specialist skills, but rather it is the foundation on which they can be acquired.

Trainers and verifiers: external oversight of competencies

Safety-critical specialist practice cannot be self-taught and enabled. Not only is evidence of attainment important, but so is independent verification of that attainment. The role of trainers and verifiers of such practice is paramount if there is to be uniformity and consistency across service of the safe and effective standards needed. If priority areas are ABR testing both in newborn and older children and VRA testing, then we need to ensure that competent trainers and verifiers of ABR and VRA are available.

In recommending system-wide improvements to the CPD of audiology staff, we suggested a local training champion with oversight from a national project officer. Such a role could extend to ensuring consistency of verifier standards.

NES Healthcare Science gives system-wide assurance of the state of training for healthcare science, including which training centres are recognised as compliant with its standards. The self-assessment process is well established and designed to be light-touch. The NES Healthcare Science core team is ready to assist with compliance.

Audiology leadership underpinning the maintenance and development of specialist skills

There are leadership preparation programmes at Board and national level that audiology leaders can undertake such as Leading to Change (23) in Scotland. Continuous improvement depends on an engaged leader to drive change and challenge norms. Appreciation of the critical role of external scrutiny is the hallmark of a high-functioning system; a leader needs to be comfortable with this and embrace the improvement opportunities that follow.

External scrutiny – the connect with quality systems and audit

Specialist skills are well-defined and are available through the BAA and BSA. Confirming those skills are in place and are open to external monitoring is the necessary assurance that was absent in Lothian.

The wider enquiry into service standards and quality systems is about assurance-building. The UKAS Improving Quality in Physiological Service Standard Awareness course (24) is an example of a quality management training programme specifically for clinical physiology services including audiology services. Engagement with it or similar would seem timely.

Summary

Investigation of the four priorities that the Sub-Group identified – CPD, foundation education, advanced practice and leadership – revealed a number of challenges that services need to address if service quality is to be upheld.

CPD needs champions at local and national levels and a core register of training will help ensure that competencies are being maintained.

Supply and demand in terms of audiology professionals are currently mismatched but the diversity of access to training is a benefit and should be managed to the advantage of the service and patients.

Finally, greater focus on the acquisition and regular testing of specialist and leadership skills is important in the context of ensuring safe and effective services.

Recommendations 19 to 41 are especially relevant to the work of this Sub-Group.