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How to...set up a hearing aid clinic that sees patients in a week

Dr John Neden and Ian Macdougald explain how their PBC group set up a community clinic that means patients now have a hearing aid fitted in weeks instead of years

Dr John Neden and Ian Macdougald explain how their PBC group set up a community clinic that means patients now have a hearing aid fitted in weeks instead of years

For those hard of hearing, a simple aid can make the world of difference. But in east Kent, it was taking up to two years for patients to have one fitted. Not only was this bad for patient care, it was also frustrating for GPs who were constantly having to chase follow-up appointments. We at East Cliff PBC group believed we could offer a better service.

Three years on, the group has developed a hearing aid clinic that ensures a patient can have an NHS digital aid fitted within just four weeks of a decision being made that they need one.

We are also taking referrals from 10 other neighbouring practices to our clinic, and three other PBC groups covering some 20 practices across east Kent are following what we have done and are commissioning their own services from the audiologist who works at our clinic.

41225742Traditionally, East Kent Hospitals Trust has been responsible for delivering the hearing aid service to patients. But because the service was dealing with patients with complex hearing problems as well those who simply needed a hearing aid fitted, simple cases were being put to the bottom of the list. As a result, these patients were faced with absurdly long waiting times.

Most of them were older people and many were frail, and they had to deal with the inconvenience of making several visits to the hospital for a hearing assessment, a fitting and follow up. A lot of unnecessary effort was being made to deliver what should have been a simple service. After all, people don't go to a hospital to get new glasses, so why were they being asked to go there for a hearing aid?

Unlike some patient groups, those with a hearing impairment are not particularly empowered. Some may be so desperate to get a hearing aid that they end up going to a provider who may give them an aid that is not fit for purpose.

Strong patient need

East Cliff PBC group is a single-practice PBC cluster. Our practice has 14,000 patients of whom more than 2,500 are aged over 65, so we were particularly affected by the long waiting list for the secondary care hearing aid service.

It was a visit to the surgery by representatives from the local training college for the deaf that really inspired us to take action. They talked to us about the problems of those who are hearing impaired, and stressed how having a decent hearing aid fitted can make an enormous difference to people's lives.

Our experience of PBC had already convinced us we could make a difference to primary care services. At that time we were delivering smaller schemes in-house such as an orthopaedic integrated clinical assessment treatment service.

By holding a weekly hearing aid clinic, we believed we could clear the backlog of patients who we estimated were waiting in excess of 78 weeks for a hearing aid to be fitted.

Our previous PBC experiences had taught us that PBC requires perseverance, as the initial response to new schemes from the NHS tends to be negative and you have to overcome a lot of red tape. However, we are fortunate that Eastern and Coastal Kent PCT's medical director and chief executive are determined to make change happen.

Early problems

Our initial attempt to bring a hearing aid service to the community was unsuccessful. We used a commercial provider, but it soon became obvious that they seemed more interested in selling expensive private aids than performing the assessment service the PBC group wanted. So we decided to employ an audiologist who would work in the interests of patients. The audiologist is paid for by the PBC group and works for us two days a week.

Initial discussions about the proposed clinic with secondary care proved difficult. Staff were anxious we were going to take their work away. A lot of time was spent on the phone trying to reassure them that we weren't trying to destabilise their service. We just wanted to ‘take the simple stuff' that didn't need to be in secondary care; to create a hearing aid service delivered by the right person in the right place.

Patients also needed convincing about the proposed benefits of the service. People may be fed up with the service they have, but often they are not prepared for wholesale change and they have questions such as ‘Will the person treating me have the right qualifications?' and ‘Will I have to pay?'. Again, we needed to offer reassurance.

The group also had to convince practice staff who had witnessed the problems with the commercial provider that a hearing aid clinic was not only doable, but sustainable.

The pilot

We approached the PCT with a proposal designed to cut waiting times and reduce the inconvenience of hospital visits for older people, and it agreed to finance the service on a pilot basis, which lasted for about 18 months. Start up costs were around £2,000, including a £1,500 investment in an audiometer, and audiologist supplies.

Initially the PCT funded the set-up costs, hearing aids and audiologist's time, who initially worked one day a week.

Working with the PCT and secondary care staff, we were able to identify suitable patients for the clinic, held at the practice. Referral criteria had to be clarified – it was important to make sure we were not referring patients to the clinic who had, say, new acute balance problems or whose tinnitus had not been fully investigated. We cherry pick simple cases, such as patients with clear eardrums and no perforations, and continue to send patients with complex problems to secondary care.

Branching out

After about 18 months we moved to a service level agreement with the PCT which means we receive £282 per patient to pay for the complete patient journey – from the assessment to the hearing aid fitting, plus aftercare for the next three years.

The sum includes the hearing aid itself, which costs about £60.

Referrals are now being taken from up to 10 other practices and this PBC group is the listed provider on Choose and Book community services for the whole of east Kent. Around 50% of referrals now come from other practices.

We are paid per patient so there is no guarantee on weekly patient numbers, and if there is a particularly quiet week the audiologist might take the odd day off.

He will also visit housebound patients.

The GPs decide if a patient needs to see the audiologist. They then write a note to the practice's secretary, who puts the patient on the clinic list.

Later that same week, sometimes even the same day, they will be seen by the audiologist, who tests the patient's ear to decide whether they would benefit from a hearing aid.

Six months ago the clinic started offering an ‘open fit' hearing aid, a relatively new product, suitable only for patients with moderate hearing loss. This has streamlined the pathway even further because unlike the secondary care service, the patient does not always need to have a mould of their ear made before the aid can be fitted – a process that can take two to three weeks.

The open ear fitting is also smaller and easier for patients with arthritis or rheumatism to handle as they are less complicated to fit in the ear and are more cosmetically discreet.

Results

Three other PBC groups have replicated our service and are commissioning our audiologist, Andrew James, to provide a service to their patients from two other clinic sites. As a result Andrew has had to employ three other audiologists.

In one respect, the objectives we had for patients have ultimately created a new provider.

Andrew was working for a multinational private organisation on a PCT project when we approached him, and three years on he is running his own audiologist service company.

We were lucky to find him and we would advise those seeking similar services to seek advice from the Hearing Aid Council, the Government body that regulates the private hearing aid market.

Having raised the profile of the hearing aid service, demand has increased, so we are now seeing patients who would not have come to us for a hearing assessment before.

Our ENT referral rates are only 50-75% of other practices, while figures on savings achieved have yet to be collected. For the PBC group it's not about reducing admissions and cutting costs, it's about making sure the right treatment is provided to patients as quickly as possible, and improving their quality of life. Patient feedback about the service, which includes a questionnaire, has been extremely positive. And GPs tell us their workload has reduced and they are no longer constantly writing letters to the hospital to chase up referrals.

Reflections

If you are thinking of setting up a similar service, make sure the audiologist you recruit is someone you can work with. They will be a regular visitor to your practice, so it's essential to build up a good relationship with them to make the service work.

You also need to persevere and not get disheartened when you face your first hurdles. People will present you with barriers, but remember you're trying to change things to a ‘can do' culture.

Many GPs are frustrated by the slow speed of change in PBC, and PCTs are reluctant to let them have a hand in new services. We need a more mature attitude on both sides. But we should also remember that ultimately we are measured by our successes. Our PCT, our colleagues and patients can see the hearing aid clinic is making a difference.

We've taken this service as far as we can now – it works, it's the right size and we want to keep it working by not overreaching ourselves. Patients are now seen within a sensible time frame. They no longer come back to us asking: ‘When am I going to get a hearing aid, doctor?'

Recently a patient came to see us after having his hearing aid fitted, complaining that he didn't like his deaf wife shouting at him anymore! Then there are those who come back to say having a hearing aid fitted has been ‘a good experience'. And that's what makes this work so satisfying.

Dr John Neden is chair of East Cliff PBC group and a senior partner at East Cliff Practice, Ramsgate, Kent. Ian Macdougald is managing partner of East Cliff practice

Dr John Neden and Ian MacDougald 60-second summary

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