Hearing Loss: Action Plan and Commissioning Framework

Diane Abbott Excerpts

Thursday 30th June 2016 Westminster Hall

[Ms Diane Abbott (Hackney North and Stoke Newington) (Lab)]

It is a pleasure to serve under your chairmanship, Ms Vaz. I congratulate my fellow east end MP, my hon. Friend the Member for Poplar and Limehouse (Jim Fitzpatrick), on securing this important debate; I also congratulate my hon. Friend the Member for Nottingham South (Lilian Greenwood) on her thoughtful speech.

As we have heard in the debate, hearing is at the heart of the human experience. I think we will all have seen online the short films of babies who, through hearing aid devices, suddenly hear their mothers’ voices for the first time. Those babies’ faces are transformed, and that reminds us how important hearing is.

There is much to welcome in the Department of Health’s action plan on hearing. The aim of reducing the stigma related to hearing loss is important. I think that sense of stigma is the reason for people waiting so long before they get the help they need. Designing public services and public spaces to support good communication is also important. Here, and certainly in the Chamber of the House of Commons, the design is good and hearing loss need not stop any Member following what is going on; but there is more to be done in other public spaces, such as cinemas, theatres and so on.

The action plan also seeks to provide better communication support and understanding in the workplace. That is important, because for people of working age I think the worst thing is the feeling that hearing loss is cutting them off from the workplace. The workplace is not just source of income; it gives people a sense of identity, self-worth and importance. For that to be cut off through hearing loss is tragic. The things that are wanted in the workplace are timely access to assistive devices, language support—such as learning British Sign Language or sign-supported English—and speech to text. Another aim of the action plan is that there should be more research into the causes and management of hearing loss and tinnitus. Tinnitus is a particularly alarming issue. It is sometimes written and talked about as if nothing can be done. It can be as bad for people’s ability to function in society as absolute hearing loss. It is important that we have more research on its management, rather than just accepting that nothing can be done about it.

An important aspect of the action plan is the promotion of strategies for the prevention of hearing loss, and an understanding of hearing awareness. Some hearing loss is workplace-related, and my hon. Friend the Member for Poplar and Limehouse said that his may be related to his working life as a fireman. Some hearing loss happens as people get older. However, we need strategies to prevent it, if that is possible. Early awareness, diagnosis and management is vital. That is why we think the issue of stigma is so important. We want person-centred planning that is responsive to information and social needs and that reaches out into all communities.

We should not assume that communities whose first language is not English will be able to get access to all the things that are made available. Many communities, particularly in the east end of London, are wary of approaching the authorities—even their GP. A lot of thought needs to be given to the sort of information outreach programmes that will reach people of every age in every community. In big urban centres in particular, if thought is not given to outreach and an understanding of early awareness, diagnosis and management, thousands of people in a given area will not be able to get the help they need. So we need person-centred planning, and timely access or signposts to communication support, lip-reading classes, hearing therapy, counselling, support groups, befriending services and assistive technologies. I reiterate that we must consider that we are not in a mono-cultural society. It should be as easy for a Bengali widow in Poplar and Limehouse to get access to lip-reading classes, befriending services or support groups as it is for a retired man in Nottingham. Finally, one of the aims of the Department’s action plan is to promote inclusion and participation, through ensuring that all public services are accessible, and to support language and communication needs. Those are excellent aims.

The purpose of today’s debate is to consider how far the aims are being achieved, and my colleagues have touched on two major issues that are worth considering again. The question of hearing aid rationing arises in the context of pressure on NHS resources. One way in which the NHS and CCGs are seeking to manage the pressures is by raising the bar before someone can get access to a service or to help. One of the most alarming aspects of that approach is its effect in mental health, where people must manifest more extreme symptoms before they can get help. It might seem to CCGs that rationing hearing aids is a less obvious form of rationing, because only the patients know or understand what has happened. Thus, as we have heard, since October 2015 one CCG—North Staffordshire—has stopped providing hearing aids to patients who have mild hearing loss, and it subjects those with moderate hearing loss to a questionnaire before it decides whether to provide them with a hearing aid.

As the Minister heard from my colleagues, it is not acceptable to ration hearing aids in that way. There is a danger that people’s hearing loss will get more severe before they can get the help they need. There are some exemptions, such as for people with dementia; hearing loss can make people more susceptible to dementia, physical disability or tinnitus. However the approach in question is not good enough. If the Government feel that we must have rationing in the NHS, we need clarity about that—it must be transparent and there must be debate. It cannot happen just because the Government feel that somehow they can get away with it.

Ten further CCGs have consulted on proposals to stop the provision of NHS hearing aids to patients with mild to moderate hearing loss, although none, as we have heard, has gone ahead with the proposals. Some are seeking alternative cost savings and others await the publication of the commissioning framework. As the Minister has heard, hearing aids are good value for money. The cost to the NHS of a pair of hearing aids and three years’ support is under £400, but the average price for an individual purchasing them privately is £3,000. In the part of the world that I come from— the east end of London—£3,000 for a hearing aid is prohibitively expensive. Furthermore, the sad fact is that 30% of audiology providers have had their budgets reduced in real terms over the past two years, and 33% said that increased demand is directly impacting on the scope or quality of the service that they can provide.

The other point, apart from the notion of hearing aid rationing, is to do with routine health checks. The charity Action on Hearing Loss commissioned a cost-benefit analysis of hearing screening, which found that screening everyone and providing support to those who need it at the age of 65 would save £2 billion over 10 years, for a cost of only £255 million. Low levels of diagnosis mean that two thirds of people are not getting the treatment and support they need. The research suggests that there is an average 10-year delay in people seeking help for their hearing loss and that, when they do, GPs fail to refer fully 45% of those reporting hearing loss to hearing services.

Hearing loss can be a gradual process. The stigma around hearing loss might make people reluctant to get the help they need, in particular as they get older and feel it is a sign of ageing to which they do not want to admit. Imagine, though, the reality for people who gradually and incrementally find their hearing going, and find themselves increasingly shut off from the world, the workplace, family and friends. Some excellent work has been done on the issue, and I await with interest the Minister’s response to the points that have been made.

--- Later in debate ---

[Alistair Burt]

Absolutely. Again, there may be more to be done through charities, the third sector, the Royal College of General Practitioners and perhaps the British Medical Association, certainly about the thing that people have in the back of their mind and do not always raise. Clearly, if there has been a sudden change, people may mention it. I suspect that part of it may be that people’s hearing loss is gradual. Perhaps there is an earlier stage.

All colleagues mentioned early intervention and perhaps there is a point at which it should be stated that hearing loss is not necessarily a natural thing that people should accept; it is something that they could and should do something about. My father is a GP and he always said that the most important part of any consultation was when the patient had taken their coat from the chair and put it on and was just leaving the room and said, “Oh, there’s one more thing, Doctor.” At that point, he always brought them back. I wonder whether, for a number of patients, that one more thing that they think they might not bother the doctor with is actually that: “I’ve just been getting a little bit hard of hearing. Maybe it is something and nothing” and so on. Perhaps that is something we could promote and say, “If that is your circumstance, do let someone know, because there is support available.”

Let me develop the discussion. We spoke about rationing services. I am aware that NHS England supported a recent decision from North Staffordshire CCG because it was able to demonstrate that its commissioning policy was evidence-based and had followed extensive public engagement. The hon. Member for Nottingham South was right to say that I am extremely wary of rationing early intervention and hearing aids at the very early stage. I fully accept all the evidence that says that it is doing something at that early stage that prevents something else later on. As colleagues have said, no one else has yet followed that. There has been a lot of challenge. It remains possible for NHS England to intervene if it thinks that commissioning has gone badly askew, but for now that has not been followed.

I will make a general—if slightly light-hearted—remark about resources in the national health service. Due to the decision taken by the nation last week, those who promoted a decision to leave the EU have promised, I think, £350 million a week—or maybe it is £100 million a week—to come to the NHS. My understanding is that that will not happen immediately, but perhaps in two or three years’ time we might see that money written into the health service’s baseline. It would be nice if that were to be. That remains to be seen. Certainly if that comes to pass, it would be one silver lining in the clouds of last week, but I suspect that that will not be a decision for me to take.

[Ms Abbott]

I want to press the Minister on the issue of rationing—I was involved in the discussions on the current reorganisation in my earlier incarnation on the Front Bench. Is he saying that nothing can be done until a CCG announces that it plans to ration, or is there any way—even under the reorganised NHS—of giving central direction to CCGs about that?

[Alistair Burt]

There is not a way of giving a central direction, because the whole direction of travel in the health service in recent years, as we know, has been to allow decisions to be made as close to people as possible. CCGs and the areas covered by them vary in the nature of their provision—there is variation in services, as we know—and if we were to go back to giving national direction on virtually everything and taking decisions that amount to micromanagement, as this one would, we would be moving away from that.

I will come on the commissioning framework and the action plan in a moment, but the commissioning framework should set out what the expectations are. However, it is right to leave local decision making to those working locally. Indeed, the recent decision and the pressure in other places have reminded CCGs of the importance of early provision, which has probably been far better than any directive from the centre.

[Ms Abbott]

So the Minister is saying that, in respect of the rationing of hearing aids, all we can really do is cross our fingers.

[Alistair Burt]

No, in all fairness I am not, because it has happened in only one CCG. It has not spread everywhere, and I think that is because the concerns that have been raised in the NHS and elsewhere have persuaded CCGs that they would not like to make that restriction.

To come back to the issue of resources, and to be a little more serious, the NHS remains under significant financial pressure. We have committed to making an extra £10 billion available to the NHS by 2020, as the chief executive has requested, but money will remain tight. Unless we want to go back to a situation in which everything is directed from the centre, we must leave local decision making to those closest to an area—that idea will remain in place. To characterise that as crossing our fingers is not entirely fair, and it has not proved to be the case.

The forthcoming commissioning framework will support CCGs to make informed decisions about what is good value for the populations they serve, using an evidence-based methodology to determine policy. NHS Improvement has received expressions of concern about commissioners reducing prices for audiology services, causing firms to exit those services, and reduced access and choice for patients. So far, except in one case, those allegations have not been substantiated and no formal complaint has been made to enable NHS Improvement to consider taking regulatory action.

NHS England could consider any immediate concerns about a CCG’s behaviour at local level under the assurance framework, and there may be scope for NHS Improvement to consider them under the National Health Service (Procurement, Patient Choice and Competition) (No.2) Regulations 2013, under the pricing rules contained in the national tariff.

Hon. Members raised the issue of screening. I am aware that the “Hearing Screening for Life” campaign has called for hearing screening to be introduced for everybody at the age of 65. However, advice from the UK national screening committee—the expert group that advises Ministers on all aspects of screening—suggested that the evidence did not demonstrate that screening would provide any hearing-related improvement in quality of life in comparison with the identification of hearing loss in other ways.

That is different from screening for newborn children—I have seen some of that work in action. I went out to Hounslow, where I will always recall the three-week-old baby who was cradled in her mother’s arms and being tested by the lady responsible, who was watching for the brainwave patterns. The hearing test could only be done when the baby was asleep and the brainwave patterns were absolutely level. The care and consideration taken with that baby was really quite remarkable. We should be proud that that programme exists. Seeing such things in action—even in one individual example—really cuts through all the statistics. In that instance, screening is the right response.

There are, however, a number of other policy solutions under active consideration by NHS England and CCGs, such as better training as part of the ongoing work to support the uptake and dissemination of the action plan and framework, including better training for GPs to identify and improve the response to hearing loss in adults. That will feed into what we discussed earlier about better recognition at an earlier stage.

The hon. Member for Poplar and Limehouse raised the subject of BSL and sign language in general. My hope is that access to personalised information in appropriate formats and support for communication will improve because of the new accessible information standard, which is mandatory. All organisations that provide NHS or publicly funded adult social care must implement and conform to the standard by 31 July this year. More generally, responses to the Department for Work and Pensions review of the market for BSL and communication support for people who are deaf, deaf-blind or have hearing loss are currently being analysed, and the results will be reported this autumn. From my previous work on disability, I know how important British sign language is. It is a culture and a language that is capable of expression, of drama, of comedy and of all sorts of things. We discussed earlier the life and culture of people who are hard of hearing or deaf, which is very important, and we look forward to the conclusions of that DWP review.

NHS England, along with patient groups, charities, CCGs, providers and professional groups, set out to respond to some of the challenges I have mentioned with the forthcoming commissioning framework. The framework ensures that first and foremost, CCGs have a clear guide to what good commissioning looks like. It is designed to ensure that CCGs are properly supported not only to provide more consistent, high-quality integrated care to meet the needs of local people, but to make informed decisions about what represents good value for the populations they serve. A golden thread throughout the publication is action to be taken to help reduce inequalities in access and outcomes. The framework is a real attempt to deal with the issues of variation that we come across.

The framework underscores the value of co-ordination and integration. In a climate of financial constraint, improved understanding of prevention means that effective measures can be taken to improve services and save money. The framework encourages CCGs to utilise outcome-based commissioning to incentivise change and advocates improving patient access to and choice of services. Implementing contracting, pay and monitoring outcomes and referrals from all providers should ensure fair choice and drive up quality. That shows that we are moving in the right direction, but a lot more work is needed to encourage action and promote the change we all want to see across the public sector and across the age range.

System partners have shown demonstrable commitment to working together to ensure that progress is made to achieve the goals set out in the action plan. Although there is no one perfect model, NHS England and the sector need to continue to collaborate to support CCGs to improve value, innovate and build sustainable services. I also think that lessons can be learned and applied across the system from the valuable work of NHS England and system partners.

It is clear, as this debate has demonstrated, that there are passionate advocates out there who are eager to achieve the improvements in outcomes, experience and services that we all want to see. The publication of the framework provides us with the opportunity and the incentive for action. We all need to be on the front foot on prevention. We will only achieve gains through concerted action across all the partners in the hearing landscape.

I will continue to play my part in holding system partners to account for commitments made. Collaboration and partnership working at national, regional and local level are key, and the work of colleagues here in the House and the all-party group in ensuring that interests are constantly represented here will also be of great importance. On behalf of the Department, I am very grateful to the Backbench Business Committee and to colleagues for raising such an important subject and contributing to the debate.