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MHAS – Modernisation of Hearing Aids Services

Published Date: 10 April 2008

The RNID (Royal National Institute for Deaf People) was keen to address the fact that new technology was not reaching up to 2 million NHS hearing aids users. People who wanted digital hearing aids (Digital Signal Processing or DSP) were paying as much as £2,500 to purchase them privately.

RNID identified the potential of the NHS to use its bulk purchasing power to drive down the cost of digital hearing aids and supply them to NHS patients. Prior to modernisation, people in need of hearing aids were fitted with analogue models that had developed little since the 1970s. In addition, lack of technical expertise and patchy follow-up support meant that at least one third of patients fitted with old analogue hearing aids did not use them because they offered little benefit. The RNID argued that there was no existing opportunity in the NHS to change so many lives so radically at such a low per capita cost (£75 ; less than a day in hospital or a week in care). Idea Research conducted by the RNID in 1999 and work done around the same time in the professional community suggested that a wholesale change in the provision of hearing aids was required both in terms of the technology that was available and the way in which it was delivered.

The RNID proceeded to launch a large scale lobbying campaign to encourage the Government to provide more funding for audiology services, and particularly for the development and provision of advanced digital hearing aids. They used national and local press and direct mail appeals to 300,000 supporters. 50,000 postcards and letters were sent to Ministers and MPs, and efforts generated major media coverage on the long waiting lists for poor hearing aids, provoking questions about the issue during two parliamentary debates. Through negotiations with the Department of Health (DoH), RNID succeeded in securing £125 million to ensure large scale modernisation of services over a five-year period.

The next step in this initiative was very unusual; RNID was asked by the government to manage the process of modernisation, alongside the DoH. This was the first time a voluntary organisation had been asked to co-manage such a large-scale project with a government department. The Modernising NHS Hearing Aid Services (MHAS) programme was launched by the DoH in the spring of 2000. The cost of digital hearing aids at the time was £2,500 per unit – a prohibitive cost for most patients that prevented widespread public provision. More efficient procurement methods implemented by the RNID resulted in a substantial cost reduction to as little as £55, which meant that digital hearing aids could be provided free of charge through the NHS. This was a major achievement but it became apparent that wider changes were needed to maximise social impact. Providing the hearing aids required significant staff training in fitting and supplying, and investment in technology to support the aids. This, in turn, exacerbated the need for greater capacity to meet increased demand for the new hearing aids in a timely manner, and waiting lists grew significantly. Similar audiology modernisation has taken place in Wales and Northern Ireland and the process in Scotland will be complete by the end of 2007.

A sum of £11 million was dedicated to 20 pilot areas offering services for both adults and children. The pilot areas were set up to test whether it was possible for the NHS to provide digital hearing aids combined with more up-to-date rehabilitation and fitting services. Given the previous lack of investment in audiology services, these pilots were also intended to give the DoH an understanding of how much these additional and necessary services were likely to cost if rolled out on a large scale. The pilots were found to provide significant benefits to both adults and children. There was long-standing evidence suggesting that taking time to fit and support users led to significantly improved experiences, and one of the successes of the new programme was that time was set aside to do this. This MHAS pilot was monitored through rigorous data collection and was independently evaluated by the University of Manchester and the Medical Research Council’s Institute of Hearing Research in Nottingham. Evidence gathering was an important part of the process of scaling up, because without adequate evidence the government would not have been prepared to invest in the next stage of the programme. The wider political context and timing for the programme’s introduction was important to its success.

The initiative came at a time when the government was keen to test the concepts of third sector involvement in the provision of public services and of private-public partnership. The hearing aids initiative also fit into a wider ethos at the time of not just addressing a specific health problem (hearing loss), but also enabling those previously disadvantaged by disability to lead more independent lives. Diffusion/scaling up In 2002-03, the DoH made a further £20 million available to continue the original pilot sites and to modernise a Second Wave of 45 additional sites. In February 2003, an additional £94 million was provided to complete the programme in England by the end of March 2005. By the end of October 2003, just over 100,000 people had digital hearing aids fitted under the MHAS programme. At the end of the modernisation process in April 2005, when RNID management of the programme ceased and funding had been incorporated into general NHS allocation, 165 Trusts had been modernised including over 350 audiology clinics and £520,000 worth of digital aids had been fitted for over 400,000 people. Today, more than one million people have been fitted with digital aids. In June 2004 the RNID won the Best Charity Award for the modernisation of hearing aids services,

The most important challenge faced in the programme’s expansion was a direct result of its success. Because of the publicity surrounding it, there was a hugely increased demand for the new hearing aids, and MHAS struggled to maintain the capacity to deliver them. In fact, some audiology departments complained of patients demanding DSP aids when they were not medically appropriate. Further complaints were made about patients’ raised expectations, through word of mouth, of the aids’ effectiveness. A further challenge for the programme was the increased amount of time patients spent in the clinic ensuring that their new hearing aids were fitted correctly. Unfortunately, there was at the time an inadequate number of trained audiologists available to provide this service, and given the huge growth in demand for the aids, an increase in waiting times was inevitable. Professor Adrian Davis, who was involved from the start in evaluating the programme, highlights the lack of graduates employed at that time in the audiology service and the difficulties this presented in the training process. One method of addressing this was to increase the role of audiology assistants, who took over some of the more routine tasks normally undertaken by audiologists. Two innovative solutions were found to address the lack of capacity, the first via a Public Private Partnership (PPP). Capacity in the private sector was used to meet some of the demand created by the programme’s success. This was piloted in Shropshire and Leeds under a scheme involving four hundred patients. The guidelines that had been developed under the MHAS programme were used to train existing private hearing aid dispensers. NHS patients on the waiting lists were offered the opportunity to see a private dispenser at no cost. These pilots were evaluated and found to be successful, and paved the way for a National Framework Agreement between the NHS Purchasing and Supply Agency and two private hearing aid dispensing companies.

As a result, negotiations were not necessary at the local level every time an NHS patient needed to access private hearing aid services. The second solution to capacity challenges involved NHS Direct. Telephone support was provided to patients by specially trained advisors through a new service called Hearing Direct. Patients could call in and ask questions about hearing services locally and receive after-care support 8-12 weeks after initially being fitted with their aid. The telephone advisors could assess whether or not patients needed to return to a clinic, thus reducing pressure on audiology departments and shortening waiting times. Finally, completing the modernisation process threw up other important dilemmas. One of the fundamental questions given funding limitations, was who should be eligible for the services. A decision was made that those who had been fitted with a new hearing aid within the last three years would not be eligible and those who already had the old style hearing aids would also not be eligible (unless they were reassessed and found to have an urgent need for a new hearing aid). According to Professor Adrian Davis, this was a difficult but necessary decision given the funding context in which the MHAS was operating. Training audiology staff in the correct protocols for fitting the hearing aids was a very important element of the programme’s success. Many staff had had very limited training in the past due to the same lack of investment in the service that had resulted in the problem that they were trying to overcome. Training programmes were standardised to ensure that staff were able to provide the same level of care to all patients. Notably, adhering to the protocols of the programme also contributed to lengthening the waiting lists that were preventing it from delivering hearing aids to more patients.