Independent Review of Audiology Services in Scotland

Conclusion

This Independent Review has identified a range of concerns in all the areas we have scrutinised. A combination of factors is responsible, but in particular there has been a lack of strategic and workforce planning, poor quality assurance of services and staff training, and an absence of national oversight and responsibility.

The ALLIANCE engagement work (2) has given us crucial insights from patients, parents and other professions that use audiology services. We have learned that from the patient and parent perspective, there is considerable variation in the patient experience and perceptions of quality of service. The following comments from patients and parents quoted in the ALLIANCE report demonstrate this variation.

"I feel they should listen more to parents. We know our children best and hopefully they will pick up on hearing loss quicker so no more children have to wait 10 years for help.”

"Audiology services should have a holistic approach to their patients. They should recognise that hearing aids (while they work very well for many and I would not be without mine) are not the final and total answer. Every individual should be treated as such – how they manage their hearing loss is unique to them and this should be acknowledged and supported.”

"We even had a follow-up call from the consultant a week or two later to make sure we had digested the diagnosis and to check if we had any more questions.”

"Once I received my hearing aids I have had no more communication with the audiology department. Perhaps I am supposed to contact them again but I have had no reminders or info. As there was a great deal to take in at my fitting appointment I think that there should be some follow-up info.”

Patients and parents are concerned about the “customer service” aspects of audiology services and in particular poor communication. They would like to see services that are patient-centred, understand the patient voice, promote self-management, empower patients, and quickly address and respond to needs. It is crucial that patients and parents feel they are listened to and believed – i.e. that hearing loss is present until proven otherwise. Patients and professional groups using audiology services have highlighted the vital role that co-ordinated multi-agency working plays in patient care. This must become the norm.

The Structure, Governance and Leadership Sub-Group identified significant problems with the current audiology workforce, both in terms of numbers of vacancies and skill mix. The national organisation of structures is complex, with varying lines of reporting, no national oversight and poor visibility of the specialty. Similarly, in Health Boards audiology lacks visibility and governance arrangements lack clarity. There is a need to raise the profile of audiology services, in particular to promote their impact on health and for resourcing to reflect the benefits of interventions. The establishment of a Audiology Specialist Advisory Group and appointment of healthcare science leads in each Health Board are central tenets of our recommendations. Healthcare science leads would benefit not just audiology, but the wider healthcare science community.

The Education and Training Sub-Group highlighted the current mismatch between supply of and demand for audiology professionals. Current routes into audiology training are intermittent and lack coordination, and the specialty would benefit from a wider range of training routes. The Sub-Group identified that core training registers, overseen by departmental training officers are essential for effective CPD and maintenance and development of knowledge and skills. The Sub-Group also confirmed the need for registration of trainees, recognition of trainers and accreditation of training centres. Leadership development and clear descriptors of leadership skills in audiology posts were also identified as being of crucial importance.

Quality assurance activities within audiology departments are extremely limited. The only information routinely collected relates to performance against 18-week referral-to-treatment access targets, but it is unclear who monitors this data in Health Boards. Little regular clinical audit is conducted either within departments or between specialties. In particular, joint audit with UNHS or SCIP does not occur. In terms of KPIs sampled, there were shortfalls across all Health Board audiology services. This indicates a need for robust, external audit of services against existing national quality standards through which quality of care can be assured and improvements achieved. This will require an openness in approach, recognising the benefit of external scrutiny of practice.

Patient sampling audits of diagnostic ABR tests and hearing-aid fitting highlighted the need for urgent additional education and training of audiologists, for further audit and establishment of an external peer review process.

Audiologists felt that training and career development opportunities were limited by lack of funding, workplace pressure and staff shortages. High-quality training and work-based learning were seen as priorities. They recognised that workload and patient complexity are increasing, but that staffing levels and skill mix have failed to keep pace. There was a perception of lack of support by Health Boards for service development, and lack of national leadership and visibility of the specialty were viewed as key issues. It is a concern that audiologists, and other stakeholders involved in the Review, have noted that morale in the specialty of audiology is low. This may have an impact on retention of staff in the workforce and buy-in from the audiology community which will be of such vital importance in implementing change.

An opportunity to build services for the future

There are multiple, systemic problems within audiology services in NHS Scotland. Resolving these requires a whole-system approach. This is a once-in-a-generation opportunity to aim not just for safe, acceptable services, but for excellence, and to develop the services patients deserve.

The wide-ranging recommendations in this report provide the foundation for improvements which will ensure high-quality, joined-up, patient-centred services. It is stating the obvious to say that the recommendations can only have this effect if they are implemented. A fundamental requirement of this report is the urgent establishment of an Implementation Group, with stakeholders that include patients and the third sector, and with the necessary project management support, resources and delegated authority, reporting directly to the Scottish Government.

This is not the time for a half-hearted response or for a sticking-plaster approach. This is a time to acknowledge the systemic issues and to use this report as the catalyst for a transformation process, which will require vision, national leadership and accountability. It will require planned investment in the education and training of our audiology professionals to ensure the right numbers are available with the required skills. In parallel, it will require the establishment of robust, quality assurance processes for services to affirm the delivery of high-quality care.

The right to effective language and communication is enshrined in Article 19 of the United Nations (UN) Universal Declaration on Human Rights. Furthermore, the UN Convention on the Rights of the Child recognises the right of every child to “the highest attainable standard of health” and to the development of “mental and physical abilities to their fullest potential”. We will do patients a great disservice if there is a failure to implement the recommendations from this Review. Consigning it to the “too difficult” box is not an option. There is a need for improvement and a huge appetite for change within the audiology community. In particular, there is recognition from stakeholders of the need to work more collaboratively to achieve common goals.

If we return full circle to the catalyst for this Independent Review, it was the identification of serious failings in the care of 155 children. We must learn from the situation in Lothian and from the extensive work of this Review. Implementing the recommendations in this report, and in particular establishing the suggested structures and governance, will help to ensure that such failings in care are not repeated.