Independent Review of Audiology Services in Scotland

Recommendations

Introduction

The Reference Group engagement report, engagement with NHS audiology staff and thematic reviews across 1) structure, governance and leadership, 2) education and training and 3) quality assurance informed and supported the development of the final recommendations.

The findings from the work of the Review and its Sub-Groups point to a number of important issues that require urgent action to deliver change and improved outcomes for the people of Scotland. Fundamental to service improvement is cultural change that focuses on patient-centred care and which listens to patients, empowers them and places them at the heart of their coordinated, multidisciplinary care.

The overarching aims across the findings and recommendations are:

• to reduce variation and ensure the delivery of safe, high-quality, patient-centred care across Scotland, with clear accountability;
• to build a sustainable pipeline of talent and ensure that patients are cared for by professionals with the right knowledge and specialist skills, within services with effective, skilled leadership;
• to ensure a culture of continuous improvement of quality and outcomes of care across the patient journey, with external assurance of patient safety, clinical effectiveness and patient experience;
• to ensure that national structures are in place to provide strategic oversight and assurance of audiology services.

Timescales have been described as:

• short term – within three months;
• medium term – within six months;
• long term – within 12–24 months.

Implementation and continued oversight of NHS audiology services

The absence of continued oversight and leadership of audiology has been a major feature of the Review’s varied deliberations; left unresolved, this is a potential future failure point in both the sustained change required within audiology services and the governance of the healthcare science workforce.

1. Establish a time-limited National Implementation Group with a Project Lead to provide the necessary project management leadership to produce and monitor a plan to implement the Review’s recommendations. It is advised that Group membership is multidisciplinary, including patients and third-sector representatives, reporting directly to the Scottish Government.

While it will be for the Scottish Government to set the Group’s terms of reference, appoint its members and determine specifically how the recommendations should be taken forward, it is advised that this Group should play a vital role in:

• defining national audit and peer review processes;
• supporting the establishment of local working groups;
• ensuring all relevant stakeholders are represented in the national and local groups’ structures and activities;
• coordinating any actions nationally, regionally and locally;
• ensuring the recommendations are applied consistently across Scotland in line with the “Once for Scotland” approach (14), but also supporting adaptation of the recommendations as necessary to reflect local needs.

It would be prudent to ensure that opportunities are taken during the implementation phase to share learning through collaborative effort at Governmental and professional levels.

Responsibility: Scottish Government

Timescale: Short term

2. Establish an Audiology Specialist Advisory Group, a single body with oversight of paediatric and adult audiology services which reports to the Scottish Government.

An indicative description of responsibilities for this Group is below;

• To provide scientific and technological advice on NHS audiology matters to the Scottish Government.
• To advise on policy matters relating to the provision of safe, cost-effective, high-quality NHS audiology services.
• To ensure national oversight of quality assurance and review audit and performance data across the clinical pathway.
• To advise on matters relating to workforce planning, education and training of those involved in the provision of NHS audiology services.
• To enhance the reputation and profile of NHS audiology.
• To enhance the identity, culture and morale of NHS audiology services.
• To advise on strategic planning and development of NHS audiology services.
• To encourage a collaborative approach, with representation from NHS audiology services, medical audiology, specialist services, higher education institutions and the Scottish Government.

Responsibility: Scottish Government

Timescale: Short to medium term

3. Establish a single policy home for audiology within the Scottish Government.

Responsibility: Scottish Government

Timescale: Medium term

4. Appoint a Healthcare Science (HCS) Lead in each Health Board. While we are specifically interested in Board-level oversight of audiology, director-level leadership, as currently applies to other major clinical groupings, would also benefit audiology and the wider HCS community. The absence of such HCS leadership has been a major feature of the Review’s varied deliberations; left unresolved it is a potential future failure point in the governance of the wider HCS workforce.

The following remit for an HCS leader would benefit audiology, helping to assure safe care and outcomes for the population served by this and other specialist HCS disciplines;

• Support and monitor education, training and registration of clinical staff, including oversight of core training registers.
• Responsibility and accountability for clinical governance issues – alerting the Health Board Chief Executive to service issues that may impact on safety and the reputation or performance of the organisation.
• Ensure quality assurance programmes are in place and that the organisation complies with specific quality requirements and accreditation schemes.
• Receive external audit reports/reviews on behalf of the organisation, providing challenge and support for the delivery of quality assured HCS services.
• Encourage organisational support for service improvement informed by patient feedback, outcomes of audit/review and technological innovation.
• Ensure organisational support for implementation of national strategies and policies.
• Promote and provide high-level support for the needs of the service within the organisation, as a healthcare discipline.
• Encourage an identity and a culture of collaboration across HCS services in the organisation.
• Support HCS leadership development.
• Participate in national strategic and collaborative efforts, with counterparts in other Health Boards.

Ideally, to have authority to achieve the above, a Healthcare Science Lead should hold an executive level position and responsibility at each Health Board. This may be more viable in association with a wider professional partnership grouping, but always with a post-holder who has clear responsibility for and knowledge of HCS.

Responsibility: Scottish Government

Timescale: Medium term

Structure

Enabling delivery of high-quality audiology services wherever you are in Scotland

The foundation of safe, effective and timely audiology service delivery is having the right number of appropriately trained and skilled staff in place to meet the needs of patients. These staff should be able to record all patient interaction to ensure seamless delivery of care and outcomes.

5. Conduct a comprehensive workforce review with a particular focus on skill mix with reference to professional best practice guidance and linking in with professional bodies.

Responsibility: Health Boards

Timescale: Short term

6. Develop a robust workforce plan to ensure appropriate safe-staffing levels and equitable patient-staff ratios.

Responsibility: Scottish Government

Timescale: Short-medium term

7. Develop a suite of national job descriptions to improve consistency across all job descriptions particularly of those at band 7–8, Head of Service and Deputy Head of Service level. This work should link with professional best practice guidance and be informed by the Academy for Healthcare Science (AHCS) Good Scientific Practice document (26) and for Heads of Service posts to the AHCS Standards of Proficiency for Higher Specialist Scientists document (27).

Responsibility: The Scottish Terms and Conditions Committee and Health Boards

Timescale: Medium term

8. Review and formalise collaborative arrangements with neighbouring Health Boards to ensure sustainable service delivery for specialist audiology services.

Responsibility: Health Boards

Timescale: Medium term

9. Use the most updated version of the Audiology Patient Management System to enable consistent data recording and reporting and ensure delivery of effective, high-quality patient care across all Boards.

Responsibility: Health Boards

Timescale: Medium term

Service design

Audiology services should be accessed and delivered by, and involve, multidisciplinary agencies consistently across Scotland.

10. Define and ensure adoption of a consistent patient pathway for adult and paediatric audiology, with reference to best practice guidance and national service quality standards, which is responsive to innovations over time. This will enable consistency of care, comparative audit and reporting of performance between Health Boards.

Responsibility: Health Boards, National Services Scotland National Services Division and the Scottish Government

Timescale: Short to medium term

11. Design services based on demographics, geography and local needs ensuring that stakeholders are a key contributor to the process as per the Scottish Government’s Scottish Approach to Service Design (28).

Responsibility: Health Boards

Timescale: Medium term

Governance

Accountability for safety and improving standards of care

Audiology, like other NHS disciplines, should sit within tried and tested policy and corporate, clinical and care governance structures at both Health Board and Scottish Government level.

12. Undertake a review of NHS Board internal governance arrangements to ensure strong accountability links for audiology reporting within NHS corporate and clinical and care governance structures.

Responsibility: Health Boards

Timescale: Short term

13. Review the Audiology Heads of Service Group’s terms of reference to ensure alignment with local and national guidance around NHS Scotland good governance (29).

Responsibility: Health Boards

Timescale: Short term

14. Review and define professional accountability for the audiology service within Scottish Government and NHS Board governance structures.

Responsibility: Scottish Government

Timescale: Medium term

Leadership

The foundations for better leaders and better care

Strong leadership for audiology in Scotland will encourage cultural change and drive improvements in services. The right leaders will balance the clinical demands of the service with those of patient-centredness; they will promote and value collaborative working with the whole multidisciplinary team and will understand and exploit audiology’s position in the policy and wider health service landscape.

15. Clearly specify the need for healthcare science leadership skills development in job descriptions for all posts, proportional to the level of seniority. If candidates are less developed formally on appointment, then an unequivocal commitment must be given to engage with a programme suitable for the role. Health Boards may offer such support through organisational development and learning.

Responsibility: Scottish Government and the Heads of Service Group

Timescale: Medium term

16. Ensure recruitment panels for NHS leadership posts for audiology, as a healthcare science service, include external senior audiology and local healthcare science professionals.

Responsibility: Health Boards

Timescale: Medium term

17. Ensure that advanced and ongoing leadership development of those in senior positions (healthcare science band 7 and above) is understood to be the norm and recorded as part of an individual’s ongoing personal development utilising national programmes such as Leading to Change with the option to develop bespoke leadership development programmes if required.

Responsibility: Health Boards

Timescale: Medium term

18. In line with the Health and Care (Staffing) (Scotland) Act 2019, ensure all individuals with lead clinical professional responsibility for a team of staff receive sufficient time and resources to discharge that responsibility, along with their other professional duties. They should have opportunity to engage and contribute with healthcare scientists in other disciplines to foster mutual support on matters related to the delivery of healthcare science services.

Responsibility: Health Boards

Timescale: Medium term

Education and training

Ensuring patients are cared for by professionals with the right skills and knowledge now and in the future

We want to maximise the supply of audiology staff and ensure a flexible approach, offering a range of access routes to entry and training.

The workforce must be grown at pace; workforce shortages jeopardise current service delivery and will impact on the ability of services to implement the Review recommendations. Given the urgency of the need for workforce supply, the quickest, most logical approach is to use current and previously designed courses in Scotland.

The export potential of programmes rests on the expectation that they can cater for learners employed outside NHS Scotland. Programme viability is enhanced and should also be recognised as a key export opportunity that draws, where it can, on the placement, wisdom and experience of the Scottish service.

19. Posts requiring specialist skills must only be open to candidates formally qualified to the agreed national standard. Examples of such include existing specific UK-level healthcare science routes available such as the Scientist Training Programme and Higher Scientist Training Scheme. The BAA’s Higher Training Scheme (HTS) modules are an industry-standard that could be adopted in Scotland with eligible staff registering to do HTS within 18 months and complete three years thereafter.

Responsibility: Health Boards

Timescale: Medium term

20. Staff in post should gain a qualification or equivalent recognition to demonstrate clinical competence in a specialty area. For example, the BAA’s HTS modules currently provide a scheme to develop competency and allow for competency assessment. It is recommended that the Scottish Government works with that professional body on capacity to throughput candidates and to develop local examiners in Scotland to assess competency.

Responsibility: Health Boards

Timescale: Medium term

21. In readiness for promotion opportunities and to build workforce capability, the Scottish Government should encourage Health Boards to pursue equivalency to secure Clinical Scientist Registration and Higher Specialist Scientific Registration for consultant level leadership.

Responsibility: Scottish Government and Health Boards

Timescale: Medium term

22. Define minimum education and training needs and minimum ongoing continued professional development and reaccreditation arrangements to maintain competencies for those:

• performing auditory brainstem response assessment of children, including peer review;
• leading two-person assessment of pre-school-age children;
• fitting hearing aids to children;
• performing tinnitus assessment of adults;
• leading vestibular assessment of adults;
• undertaking adult assessment and rehabilitation.

Responsibility: Health Boards and Scottish Government

Timescale: Short-medium term

23. Establish a Core Training Register for safety-critical diagnostic testing performed by the team.

Responsibility: Health Boards

Timescale: Medium term

24. Establish a Continuing Professional Development Champion or Training Officer in every department offering audiology services. The individual must practise evidence-based training and include external training as well as internal. It is advised that this is reflected in the relevant job description.

Responsibility: Health Boards

Timescale: Short term

25. Ensure annual appraisals include regular review of an individual’s competency and training record.

Responsibility: Health Boards

Timescale: Medium term

26. Ensure all services are connected to a network of trainers and verifiers to ensure uniformity of high standards of specialist skills and to provide evidence of training assurance to external auditors, thereby cementing a quality culture.

Responsibility: Health Boards

Timescale: Medium term

BSc programmes

27. Current undergraduate BSc programmes should run annually, and previously run courses should be restarted. They should prioritise school-leaver/non-degree-holding entrants.

Responsibility: Scottish Government and Health Boards

Timescale: Short to medium term

28. Urgent consideration should be given to the sustainable funding of programmes.

Responsibility: Scottish Government and Health Boards

Timescale: Short to medium term

29. Consideration should be given as to how programmes could be formalised, if desired by service, into degree apprenticeships, and how Boards could be assisted to embrace the model.

Responsibility: Health Boards

Timescale: Medium term

MSc programmes

A two-year MSc generates a qualified practitioner able to join the accredited register. An additional benefit is that the M-level qualification is a useful springboard to clinical scientist equivalence and fulfils part of the BAA higher training scheme requirements.

30. There should be direct sponsorship of selected students to undertake the pre-registration MSc as it stands. NHS Scotland placements should be prioritised for students who are directly sponsored.

31. Consideration should be given as to how to recruit and retain such sponsored trainees.

Responsibility: Health Boards and the Scottish Government

Timescale: Medium term

Dip HE

A Dip HE in Hearing Aid Audiology is a two-year work-based diploma currently available in Scotland for staff employed in service. It provides education and training to support a role as Associate Audiologist (band 4), providing a foundation for further education and training.

32. The existing programme should run an intake as planned in 2023.

33. Promote and support access to the Dip HE in Hearing Aid Audiology as an element within the NHS career pathway, also ensuring that the course offered reflects the evolving needs of the NHS.

34. Consideration should be given as to how NHS departments can be incentivised to place staff on the Dip HE in Hearing Aid Audiology course and retain them.

35. Articulation is required between the DipHE and BSc top-up modules to allow Boards to accelerate workforce supply, both in Scotland and beyond.

Responsibility: Health Boards

Timescale: Medium term

Enhancing care through skills development, registration and recognition

36. All NHS trainees regardless of programme pathway should be mandated to acquire a National Training Number from NHS Education for Scotland which would ensure monitoring of training progress.

Responsibility: Health Boards

Timescale: Short term

37. All trainees entering NHS Scotland employment must, on completion of their training, be eligible for registration either with Health and Care Professions Council or Registration Council for Clinical Physiologists – Academy for Healthcare Science (AHCS) registers.

Responsibility: Health Boards

Timescale: Long term

38. All NHS training departments should be registered as a training centre with NHS Education for Scotland.

Responsibility: Health Boards

Timescale: Medium term

39. Boards should ensure that all audiology staff eligible for registration are professionally registered either with the Health and Care Professions Council or Registration Council for Clinical Physiologists – Academy for Healthcare Science to demonstrate professionalism and public protection.

Responsibility: Health Boards

Timescale: Medium term

40. All audiology staff involved in delivery of training must be trained by the university provider, professional bodies and encouraged to engage with the wider healthcare science training community via NHS Education for Scotland trainer courses.

Responsibility: Health Boards

Timescale: Medium term

41. Trainers should be formally trained and recognised to deliver and verify training across all levels. This should be harmonised across Scotland with training formally incorporated into job descriptions. Consideration should also be given to developing a cadre of key trainer-verifiers for specialist skills in Scotland who can cover multiple Health Boards. A collaborative approach to training should be encouraged to share training capacity across Health Boards through a training consortium approach.

Responsibility: Health Boards and the Scottish Government

Timescale: Medium term

Quality assurance

Quality standards, audit and external assurance

Audiology service delivery requires the right balance of clinical competence and “customer service” to ensure a patient-centred experience and good outcome measures. Good communication skills, strong deaf awareness, the ability to empower patients, encouraging self-management, and an understanding of the social impact of hearing loss all contribute to the experience and outcomes.

Effective quality assurance and improvement of audiology services requires all of the following elements to be in place: development of nationally recognised service standards and performance measures that are fit for purpose; robust and regular external audit against such standards; reporting of outcomes of audit; escalation of outlier performance and pursuit of action plans to improve performance where shortfalls are identified. This approach requires a culture of openness from those responsible for service delivery, to accept challenge of performance and presentation of outcomes in the public domain.

To help improve outcomes, collaboration and benchmarking with professional counterparts in other countries should be built upon and encouraged.

42. Develop, implement and report on a mandatory basis against an agreed set of robust national key performance indicators (KPIs) for annual audit, with suitable governance arrangements. These should be informed by the outcomes of the KPIs survey conducted as a part of this Review.

It is advised that the Audiology Specialist Advisory Group (see earlier) should oversee the review and development of this list of KPIs to reflect changes to practice and any national shortfalls or elements of service quality in need of improvement.

Wherever possible, there should be collaboration with professional counterparts across the four nations to support country comparison of common KPIs.

The following KPIs are suggested as priority for regular benchmarking:

• patient reported experience measures (PREMs);
• patient reported outcome measures (PROMs);
• bone anchored hearing aid (BAHA) provision/head population/year;
• continuing professional development/head population/year;
• paediatric pathway indicators (for significant milestones in the diagnosis and management pathway);
• positive predictive value (PPV) measurement;
• multidisciplinary team working;
• aetiological investigation of children with permanent hearing loss.

Responsibility: National Services Scotland National Services Division and Health Boards

Timescale: Short-medium term

43. Establish KPIs for routine monthly, discrete (non-aggregated) referral to treatment waiting times performance reporting through Health Boards. This should include:

• waiting times for all adult audiology procedures (aggregated);
• waiting times for first assessment of hearing for children (other than those referred from the Universal Newborn Hearing Screening Programme).

Responsibility: Scottish Government

Timescale: Short-medium term

44. Develop evidence-based national service quality standards for NHS audiology services in partnership with third-sector organisations, service users, professional counterparts in the other UK countries, professional bodies and Healthcare Improvement Scotland. Review and update them on a regular basis.

Development should reflect the multidisciplinary nature of services, include views of those with lived experience identified through the work of the Reference Group and any further lived experience engagement, with appropriate governance arrangements in place.

Responsibility: Health Boards and the Scottish Government

Timescale: Short-Medium term

45. Establish a local service-level quality assurance and improvement plan which describes roles and responsibilities, resourcing and reporting outputs. The plan should be updated regularly, reflecting outcomes of audit and performance against KPIs.

Responsibility: Health Boards

Timescale: Short term

46. Introduce an accountable post-holder in the audiology service to oversee and drive local quality improvement initiatives and ensure senior staff develop quality systems thinking awareness for themselves and their teams.

Responsibility: Health Boards

Timescale: Medium term

47. Define and adopt a robust external audit process for the service quality standards, in partnership with professional bodies, third sector partners, service users and professional counterparts in other UK countries. This should feature site visits and observation of clinical practice.

Explore partnership working opportunities with other UK countries to establish a reciprocal audit process for scrutiny external to Scotland. The Scottish Government should mandate Health Board participation in the audit process, ensuring the release of clinical staff to participate as assessors. Outputs should include audit reports to be sent to Health Board Chief Executives and a collective national audit report to be provided to the Advisory Group (see earlier).

Responsibility: Scottish Government

Timescale: Short-medium term

48. Explore opportunities and identify the best approach to achieve external accreditation of NHS audiology services with external agencies such as the United Kingdom Accreditation Service and counterparts in other UK countries. Thereafter, Health Boards should pursue external national accreditation of audiology services as indicated and collectively agreed.

Responsibility: Health Boards and the Scottish Government

Timescale: Short-medium term

49. Develop and deliver an annual reporting and escalation process for audit against service quality standards, with agreed governance arrangements in place. Outcomes should be presented in the public domain. Annual publication should develop a better public understanding of local and national outcomes to encourage contribution to any national solutions where required. To deliver on this work, it is crucial all Boards have robust data and digital infrastructure.

Responsibility: Health Boards and Scottish Government

Timescale: Short-medium term

Improving care through collaborative working across the patient journey

Collaboration and multidisciplinary working are key within audiology, and the KPIs and quality standards referred to above will reflect that, through effective collaborative engagement with other stakeholders such as education, the third sector and other professionals.

Specifically, the relationship between audiology and the Scottish Cochlear Implant Programme (SCIP) and audiology and the Universal Newborn Hearing Screening Programme should be addressed.

50. Ensure recommendations from the most recent review report around the Universal Newborn Hearing Screening Programme in Scotland are addressed at pace.

Responsibility: National Services Scotland National Services Division, Health Boards and the Scottish Government

Timescale: Short-medium term

51. As commissioners of the SCIP, National Services Scotland National Services Division and Health Boards should establish a collaborative working group, working to defined terms of reference and with appropriate governance arrangements.

This group should be tasked with conducting an annual joint audit/benchmarking coordination event to review audit outcomes across all partners.

This should routinely explore whether cases meeting criteria are referred in a timely way and the appropriateness of referrals. The group should consider variations in implantation (by Health Board area) as a high-level indicator of combined (Health Board and SCIP) performance. It is advised this group should explore introduction of measures to reduce variation and optimise onward referral, such as Cochlear Implant Champions.

Responsibility: National Services Scotland National Services Division and Health Boards

Timescale: Short to medium term

Specific quality assurance areas for action identified by the Review

The following recommendations (52-54) were submitted in advance of final reporting in February 2023, in recognition that they needed to be expedited given the findings of the peer review-based audit exercise of current practice.

52. Commission national-level training for ABR assessment of infants. This training should be mandated for all audiologists performing such work. The format should include one-to-one assessed sessions and face-to-face training sessions. Content for this training should be guided by the learning from the case sampling audit exercise.

Responsibility: Scottish Government

Timescale: Short term

53. Support the establishment of a national external peer review scheme for ABR assessments with mandated participation across NHS Scotland for all audiologists performing ABR assessments. It is recommended this could be taken forward as a mini project with consideration of best practice across the UK.

Responsibility: Scottish Government

Timescale: Short term

54. Conduct a wider audit of ABR cases referred from the Universal Newborn Hearing Screening Programme, with defined scope: i) review of cases to identify where management can and does need to be revised; ii) further identification of training needs at individual audiologist level; and iii) obtain information to guide changes to service delivery model for the ABR assessment.

It is advised that the Implementation Group should determine the scope of the audit and if there is a period of time before this is established, the Heads of Service Group for Audiology should be tasked with this.

Responsibility: Health Boards and the Scottish Government

Timescale: Short term

55. Ensure implementation of local action plans to mitigate and minimise risk to patients against the KPIs surveyed as a part of the work of the Review. This will support readiness for formal external audit.

Responsibility: Health Boards and the Scottish Government

Timescale: Short term