While vision and hearing care have much in common, the rollout of community pathways offers further evidence that light travels faster than sound.
Nevertheless, the wheels are in motion for more audiology services, such as hearing tests, the dispensing of hearing aids and replacement of batteries, to be commissioned away from overstrained NHS hospitals.
Last month, the sector embraced the publication of Commissioning Services for People with Hearing Loss – a framework for clinical commissioning groups, which followed up an initial Action Plan on Hearing Loss report in 2015.
The framework calls on commissioners to review and analyse local needs so they can use an outcome-based approach to audiology services.
Central to its implementation will be Mark Georgevic, legal director of major community provider Scrivens Opticians & Scrivens Hearing Care and grandson of Sol Scriven, who founded the company in 1938.
Georgevic, also chairman of the National Community Hearing Association (NCHA), tells Optician Scrivens is the second largest provider of NHS hearing instruments in England. It now has 177 branches nationwide and works in 150 medical centres to provide hearing care.
However, Georgevic stresses that setting up hearing care services on the high street is far from straightforward, although the development and evolution of Any Qualified Provider (AQP) has had a positive impact on the company’s audiology business since new Department of Health requirements came in three years ago.
Scrivens has gone from doing no work for CCGs in 2012 to providing for 100 CCGs at present.
He says: ‘AQP has had its issues and a couple of community providers have actually pulled out. The model really suited Scrivens though. It suits our patient base and our ethos as a patient-centred organisation, with a slightly more ageing base of patients who have been with us for a long, long time and it suits our business model. We have embraced it wholeheartedly.’
The framework found the AQP approach for hearing services had been shown to have many potential benefits since being rolled out, but some potential for misunderstandings between commissioners and providers as a consequence of the three-year pathway tariff approach.
Indeed, Boots Hearingcare has made the decision to exit AQP audiology contracts by April 2017, saying they are ’no longer viable’.
NHS England framework
Georgevic welcomes the new NHS framework, saying hearing care services currently dominated by hospital visits ‘need to be de-medicalised’.
He adds: ‘Being able to provide hearing aids closer to home in a community setting that’s convenient and accessible for our patients has always been the right thing for our patients.’
Meanwhile, it is estimated four million people would benefit from a hearing aid but do not have one – not least due to the inaccessibility of hospital services.
Georgevic adds: ‘It’s been so medicalised and there’s a stigma attached to hearing aids we’ve all had to do something about.
‘The technology that’s available, both in the high street and hospital environment, has changed dramatically. We fundamentally believe our patients should have access to an NHS service on the high street.
‘It’s in line with the five-year forward view – treating patients at the right place and the right time – is something that we wholly subscribe to.’
While providers do not have to reside in an AQP area to move into hearing care services, it clearly does help.
He adds: ‘As a company we now provide a service for over 100 CCGs. The vast majority have gone down an AQP route. The framework will encourage CCGs in other areas that they should do something about the unmet needs of patients within their community.
‘This does make it easier. There are a number of CCGs that have been waiting for this document to be published as it had been reasonably well signposted it was going to happen. We are hoping more CCGs will take advantage of this and therefore community providers will be able to provide a choice for the patient.
‘AQP was meant to be competition on quality and not price. One of the things this framework is trying to sustain is transparency, accountability and a level playing field.
‘It says in the framework if there is an AQP contract then the services that are provided to that cohort of patients under that AQP contract should be the only type of contract. There needs to be a level playing field. There is absolutely no doubt from our experience that until now there has not been.’
Qualified providers in hearing services must achieve the Improving Quality in Physiological Services programme (IQIPS) during the contract period, something Scrivens is geared up to provide.
Georgevic says: ‘We were the first UK trader to embrace IQIPS. We did this about four years ago now because we had anticipated that this quality assurance badge would be something we would need. It isn’t straightforward achieving IQIPS accreditation.
‘It’s interesting that you’ve got other opticians who have contacted me and us as a company saying they want to do this but aren’t IQIPS accredited, and asking if we would be prepared to do a service within their outlet.’
As a result, Scrivens also outsources its hearing staff to other independent practices and medical centres keen to develop NHS adult hearing services.
Georgevic says: ‘We have worked very hard for all our staff to be very involved with both services [vision and hearing]. We provide a significant amount of training to our staff to enable them to embrace both sight and sound, optics and hearing.
‘I think we may be quite unique in that. I know other retailers say they do both and they do, but I think they do treat them as separate businesses. We don’t.’
It means a typical Scrivens practice provides services ranging from vision and hearing services, mending spectacle frames, and changing the wax traps or batteries of a hearing aid.
‘There’s no doubt that as we have evolved as a profession our hearing aid dispensers are well-equipped to be able to provide that service,’ he adds.
Learning from optics
Despite the new framework, Georgevic believes NHS community hearing care services are playing catch up with the optical profession. With hearing, at the moment there is no NHS national community provision, with variations across the country. It is hoped that as a result of the new framework and specification, there will be less variation in evidence.
He says: ‘Hearing care is much more immature in so far as this. With GOS you’ve got a well-recognised and mature national service – everybody knows what that service looks like. I would say that hearing is perhaps learning from some of the previous experience of optics.
‘There is variance across the country that does need to be ironed out. If there was a national solution for all the CCGs, then so much the better. However, for the moment the framework has done a pretty good job and as long as CCGs utilise it then we really have a patient-centred solution that could work and has worked in numerous areas since 2012.’
Looking forward, NHS Improvement has said there might be the opportunity for 20% to 25% savings by moving more hearing care services into the community.
Georgevic says: ‘As you can see from the NHS report they are saying CCGs can make significant savings. I don’t think adult hearing services have ever been looked at as forensically as they are now.’
Indeed, the more mature CCGs are looking closely at what they are spending. He says: ‘Now they have an opportunity of using framework specification and the KPIs to make it work not only better for them and the CCGs but for the patient’s benefit.’
In terms of its own KPIs, Scrivens boasts 90% of its patients still wear hearing aids after a year. Georgevic also says Scrivens’ referral to treatment times are the best in the country.
He says: ‘If patients are all saying they are gaining significant benefit from their hearing aids, better quality of life and all the good things that are part of an outcomes-based provision that can only be exciting for CCGs because in the past this was always very much a hidden service.
‘If we try to de-medicalise hearing and it moves out of a hospital environment, where generally you are treating people who are sick and have illnesses, we firmly believe that we can provide a better service for those patients. If you can get your glasses on the high street there is no reason at all you can’t get your hearing aids too.’
Among the potential improvements would be a move away from checking hearing patients back in with their GP every three years, which has ‘irritated the doctors and inconvenienced both patients and GPs’.
Georgevic says: ‘Actually, if you’re very happy with the service they are provided with and they have a hearing aid that is absolutely fine for their needs it does seem a bit anachro-nistic that you have to discharge them back to the GP when actually they are quite happy with the service. There are some contracts that have responded to that concern of patients.’
Meanwhile, traditionally many CCG areas ask the hospitals to simply provide new hearing aids after three years. ‘I’m not sure that’s necessarily the most efficient way of dealing with a hearing aid,’ he adds.
Setting up a hearing service
Despite the expansion of Scrivens and growth into hearing care, Georgevic is cautious about the potential for new starters in the marketplace – owing to the administrative burden involved in securing new contracts.
He says: ‘I’m not sure how easy it is for a sole practitioner or a practitioner with two or three branches to become involved on their own. There’s a lot of KPIs, financial, administration, IQIPS accreditation. So far you haven’t seen many independent audiologists embrace this – so I think it’s going to be challenging for an independent optician.’
In addition, Georgevic says the current tariffs for hearing care, and the fact that providers have pulled out of hearing services, shows the margins involved are ‘very tight’.
‘There’s a lot of system investment that needs to be developed to ensure you can meet the specifications that are in here. There’s quite a lot the CCGs are demanding to ensure you are providing the service they contracted you to provide. There are various thresholds that you have to meet. So it’s not simply an investment in the equipment side, the admin, the systems, the policies and procedures, and IQIPS accreditation is challenging. It’s difficult but I am not saying it can’t be done.’
He adds: ‘On the high street in the past you have been treated as the poor relation if you have a hearing service. It’s more of an equal service now than it’s ever been.’
Therefore, while those already established in hearing care, such as Scrivens, stand to benefit from the new framework, newcomers may struggle to make their mark immediately.
Scrivens has been providing hearing care for the past 60 years and looks certain to continue adding to this heritage.
‘My grandfather and father realised sight and sound were linked very closely. We’ve always been at the forefront of hearing care, it is something we think our patients have benefitted from and will enjoy. We want more people to be benefitting from a hearing solution,’ Georgevic says.
Potentially, Scrivens will look to move into areas where AQP schemes are set up for hearing services.
Georgevic adds: ‘It has evolved over the past three or four years so we are going into areas that have just commissioned adult hearing services. In this time there have always been new contracts that we have applied for and succeeded in meeting the criteria.
‘It’s been an exciting journey to see where it has gone but it’s still a very immature service at the moment. We’re always sharing and always learning and it’s been a very interesting pathway to be on.
‘It’s something my grandfather and my father have always thought is something that should be part of a high street environment.’