Pushing the Boundaries.qxd:Audiology - NHS England · NHS Improvement team supported the testing of...

NHSNHS Improvement

Audiology Improvement Programme

Pushing the boundaries:

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

AUDIOLOGY

Evidence to support the delivery of good practice in audiology

Pushing the boundaries: Evidence to support the development and implementation of good practice in audiology | 3

www.improvement.nhs.uk/audiology

Contents

Introduction

Age related hearing loss projects

Direct access tinnitus patient pathway

Balance

Collaboratively working with ENT to redesign pathways

Adults with complex hearing needs

Audiology transition projects

Children’s balance

Children’s hearing services

Central auditory processing disorder

Acknowledgement

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4 | Pushing the boundaries: Evidence to support the development and implementation of good practice in audiology


Introduction

During 2009/10 NHS Improvementworked wih 18 pilot sites acrossEngland as part of the Department ofHealth (DH) National AudiologyProgramme (led by the DH ChiefScientific Officer, Profressor Sue Hill),to identify and share innovative waysto improve the quality of patientexperience, increase productivity andsustain improvements over the longterm. The pilots covered a diverserange of clinical pathways whichincluded tinnitus, balance andchildren’s hearing, as well as agerelated hearing loss and those withmore complex needs

This publication has been written toshare the learning from this pilotphase of the NHS ImprovementAudiology Programme. Through aseries of case studies and examples, it aims to highlight areas ofinnovative and emerging goodpractice that can be used locally todeliver improvements for audiologypatients and their carers. One ofthese successes includes workingwith young people and the voluntarysector to construct an effective multi-agency approach to meeting theirneeds by providing timely access torelevant services.

This report contains information forthose professionals working in,commissioning or interfacing with,audiology services. This will includethose who are: • involved in the care of patients

who require audiology services• responsible for commissioning

audiology services • managing audiology services • involved in the education and

training of staff who will be working with patients who require audiology services.

The pilot sites were encouraged toemploy a range of serviceimprovement techniques asappropriate to their needs. Theseincluded process mapping, capacityand demand analysis, application ofLean methodology, process redesignand workforce/skill mix review. TheNHS Improvement team supportedthe testing of new ideas andpathways through site visits and byhosting a number of learningworkshops.

There are lots of practical exampleswithin this report to support clinicalteams in delivering quality andproductivity benefits for our patientsand a wider range of stakeholders.

Over the next 12 months, the NHSImprovement Audiology Programmewill be testing the key principles forchange in a small number of NHSsites, in a similar process to thatwhich has established winningprinciples in transforming cardiac andcancer care. As this informationemerges it will be shared withaudiology services and the widerNHS.

Dr Janet WilliamsonNational Director, NHS Improvement

Professor Sue HillChief Scientific Officer, Departmentof Health

SummaryEach of the age related hearing losspilot sites sought to move someelement of care into the community,reduce the number of steps in thepatient pathway and provide a moreeffective and efficient service forpatients. They sought to improve thequality of the service provided, whilstmaintaining or enhancing the patientexperience.

Moving care into the community andcloser to patients’ homes can throwup unusual and unexpectedchallenges, especially for hearingservices, for example, in providingsuitable accommodation and meetingthe required noise specifications, at abusy health centre.

The sites chosen were:• University Hospitals of

Leicester NHS Trust (Leicester Royal Infirmary)

• Nottingham University Hospitals NHS Trust

• Trafford Healthcare NHS Trust.

Age related hearing loss projects

IntroductionGradual deterioration of the earmeans that for most people, deafnessis an unwelcome feature of later life.Although the degree of disabilityvaries greatly, and some people adjustquite well to the slow decline in theirhearing, for many this form ofhearing loss causes frustration,loneliness and depression. It is estimated that the prevalence ofhearing loss amongst adults inEngland is 20% and the vision foraudiology and adult hearing servicesis to provide high quality, efficientservices, delivered closer to home,where long waits are a thing of thepast and where patients are treatedas individuals with personal needs(Transforming Adult Hearing servicesfor Patients with Hearing Difficulties2007).

With the publication of the WhitePaper ‘Our Health, Our Care, Our Say‘(Department of Health 2006) thevision for people to have greaterchoice, independence, control andempowerment was clearlyarticulated. This intentionallychallenged existing practice.

Clinical leaders now need to focus onhow to deliver effective care outsidean acute setting and in, or near to,patient’s homes.

This has focused audiologydepartments’ attention on improvingcurrent service provision toencompass these aspirations throughgetting the systems and processesright, using the best technologyavailable and planning an effectiveworkforce to deliver these improvedservices.

With increasing competition fromalternative providers, audiologydepartments need to be continuallylooking for ways to improve on theservices provided by reducing waitingtimes, enhancing both the patient’sexperience and the quality of careand providing efficient pathways ofcare.

The aim of this work is to identify thefactors that help or hinder progress inmoving care into community locationsand to share the lessons learnt with thewider NHS.




Initial findings from the pilot projectshave started to indicate that locallyled work, which forms part of thenational priorities, can be achieved byworking in partnership with allstakeholders. The key to their successstems from clear local clinical andmanagerial leadership and theapplication of robust projectmanagement.

By involving the whole team withinthe department and getting theiragreement to the proposed change,ownership was gained and the teamsactively worked together to achievethe best outcomes for their patients.The projects demonstrate acommitment to improving quality, theuse of new technology and increasingproductivity.

By streamlining the pathway andreducing the number of steps, timeand resources have been released,without compromising on quality.Patient satisfaction with the revisedpathways is high, along with stafffulfilment with the change in workingpractice. Extended roles have beendeveloped and a clear commitmenthas been demonstrated to continueon this improvement journey.



Triage in Primary Care: a new pathwayfor hearing aid candidates

Presenting Issues The traditional way to managepatients who may need a hearing aidis to assess at one appointment andfit at another. Recent advances intechnology mean that, for certainpatients, the two appointments canbe combined.

In order to know who would besuitable and who would need toattend both appointments, a simpletriage is carried out in primary care,prior to referral. This enables patientsto go into the correct appointmenttype for their needs.

The aim of this project was to pilotthe triage in primary care practicesusing a small screening device(Siemens Hear Check Screeners) and a short questionnaire.

The triage is done by either the GP or the practice nurse/health careassistant, and includes wax removal,where necessary.

Pilot work has shown that locally,approximately 40% of patients aresuitable for ‘assess and fit’ model.

What they did• Used new technological advances

to enhance the patient’s pathway • Redesigned the care pathway to

improve the patient’s experience • Developed clear and consistent

referral criteria for primary care practitioners

• Developed a direct referral form forprimary care to record screener outcomes and highlight any concerns regarding dexterity, poor vision etc

Benefits

QualityBy using two patient related outcomemeasures they have demonstratedthat the quality of service has notbeen compromised by the assess andfit appointment. For the patients whoonly needed to attend once, thisrepresents a real increase in quality.

InnovationThe utilisation of the screener and theuse of instant fitting technologies hasbeen an excellent example of thepotential role of innovation in patientmanagement.

• Initially trained four GPs to use screeners and the new referral form

• Offered 90 minute appointments tothose who were appropriate for assess and fit at the same time and60 minute assess appointments for those who did not meet the criteria, following on with a further 60 minute appointment for the fitting

• Promoted their early work/findings and recruited a further seven GPs to work with the pilot

• Recorded all the outcomes from thepilot to enable a full analysis to include a patient satisfaction questionnaire.

Numbers of patients on each pathway

Leicester Royal Infirmary




ProductivityThe number of patients who havecompleted the pathway through outthe duration of the pilot is 47. Ofthose 47, 23 were suitable for theassess and fit appointment, two outof the 23 chose not to have the 90minute appointment.

So 45% of referrals had a 90 minuteappointment, of these 67% had aidsfitted on the day. In terms of net timesaved, based on these relatively smallnumbers, 30 minutes time can besaved in 15% of referrals.

During the last 12 months, 2,420patients have been directly referred,even a 30 minute time saving on15% results in 180 hours of clinicaltime being saved.

Identifying the appropriate referralroute may save on the overall numberof referrals and cut costs.

PreventionBy educating GPs patients are morelikely to be referred to hearingservices at their first visit. Alsopatients who are being triaged intothe assess and fit pathway are havinga reduced delay in their treatment.

ContactPauline SmithClinical Scientist - [email protected]


Developing new pathways for patients requiringreassessment of hearing needs in Nottingham

Presenting Issues Being able to manage the everincreasing demand on local audiologyservices, while maintaining shortwaits and high quality services isbecoming more difficult. It isessential that departments look atdifferent ways of working to meetdemand within the resourcesavailable.

This pilot involved redesigning thecare pathways for patients whoroutinely require hearing aidreassessment, by developing newprotocols and pathways and movingthe service into a community locationwithin a local health centre, reducingthe appointment time in the clinic forthe majority of patients. This wasachieved with the introduction of a‘triaging’ type appointment. This enabled patients to be assessedand those who had experienced nochange in hearing, or only a milddeterioration requiring limited finetuning, to be treated separately fromthose requiring a full audiologicalreassessment.

Those patients assessed as requiringthe full reassessment would then beoffered a further appointment, moreappropriate to their need. This shouldimprove the department’s ability tomanage waits by improving capacityand increasing efficiency within theservice.

• Achieved a 46% reduction in number of attendances each patient has to make in the new pathway and a 43% reduction in the time spent in clinic

• Managed a greater number of patients within existing resources

• Maintained clinical quality within a shortened appointment

• Conducted a comprehensive patient satisfaction survey to assess opinion on the new pathway.

What they did • Improved accessibility for patients

who require reassessment of their hearing aid provision

• Provided a service that is delivered safely and effectively at a location that is closer to the patient’s home

• Developed clear and consistent referral criteria

• Reduced the number of steps in thepatient pathway

• Reduced the overall time spent in the clinic environment

Nottingham University Hospitals NHS Trust


Numbers of appointments in each pathway

Numbers of appointments in each pathway



Benefits

Quality• Clinical quality is maintained.• Patient satisfaction is increased.• Patients satisfaction results show

that 97% of patients from the pilotgroup would prefer a service local to them.

Innovation• The pathway has been refined,

minimising inefficiencies and creating a new model of care.

• A benefit to patients is identified bya 46% reduction in number of attendances each patient has to make in the new pathway.

Productivity• Increased efficiency by reducing the

time spent in clinic by 43% and thenumber of appointments required by 46%.

• A greater number of patients can be managed within existing resources which will allow recall forfurther reassessment in a more timely way, working towards the RNID gold standard of every three years.

• Patients are managed with the same clinical quality in a reduced overall appointment length.

Prevention• Additional capacity has been

identified to enable patients to be recalled for reassessment every three years.

ContactWilliam BrassingtonConsultant Audiologist / Head [email protected]


Care in the community for those needingdiagnostic assessment

Presenting Issues To improve access to hearingassessments clinics by providingadditional community based servicesThe audiology team developedimproved, streamlined pathways foradults with hearing loss andconducted a thorough review of theexisting skill mix and roles within thedepartment. The revised pathwaywas delivered from two communitybased sites.

Trafford Healthcare NHS Trust plansto become an integrated careorganisation. Part of this project wasto build upon this intention and tofurther enhance the workingrelationships between social care andthe local primary care trust providingseamless community based care, forthose in the community who havelong term conditions or a long termneed.

What they did• Agreed a reduction in the age of

patients who were able to be seen by the audiologist for a diagnostic assessment from 60 to 16 years of age

• Worked in partnership with ENT colleagues to enable audiologists to refer for MRI scans as part of thediagnostic assessment

• Achieved a reduction in the numberof steps in the patient pathway

• Moved care closer to home and into two community clinics using test booth facilities.

• Introduced extended roles for assistant practitioners

InnovationBy moving care into the communityand closer to the patient’s home, theTrust has responded to the wishes ofpatients. Trafford has the smallestaudiology department in the NorthWest and is one of the first trustsplanning to become an integratedcare organisation.

This means the trust will work inpartnership with social care toprovide seamless care in thecommunity for a range of long-termconditions. This pilot model of carefits perfectly with this vision.

ProductivityWith the additional clinics in place inthe community, patients can now beseen within two weeks of a referral

ContactMike PhilbinSpecialist Audiologist and Acting Head of [email protected]

• 120 patients have been assessed across the two new sites during thepilot phase

• Conducted a patient survey to canvas opinion on new pathway.

Former Manchester City and Unitedlegend Denis Law has recentlytravelled the new clinical pathway.

‘I am more than happy toendorse the new piloted wayof working. I couldn’t havewished for a smootherjourney.’

Benefits

QualityThis pilot project has reduced theneed for lengthy journeys for patientsto travel into the acute trust .Apatient satisfaction survey wasconducted with very positiveoutcomes and the number of steps inthe pathway have now been reduced. Staff satisfaction with their role hasincreased significantly.

Trafford Healthcare NHS Trust




Direct access tinnitus patient pathway

Baseline information from surveysand focus groups illustrated thatpatients often received limited adviceon management of tinnitus inprimary care. Lack of awareness oftinnitus management strategies andknowledge of services available inprimary and secondary care was alsorecognised. In addition, patientsexperienced delays of up to 20 weeksbefore attending tinnitusmanagement clinics when referredfrom ENT outpatients.

Early findings from pilot sites suggestthat between 60 to 85% of tinnitusreferrals could be managed by adirect access audiology service,provided that staff have theappropriate knowledge and skills, aredeemed as competent, and workwithin clinical guidelines andprotocols to enable access to ENTconsultants, if required. A reductionin referral to treatment times from 14weeks to less than four weeks hasbeen achieved. This efficiency hasreleased up to 85% of tinnitusoutpatient capacity, started to reducefollow ups required, and enhancedpatient satisfaction. Whilst thenumbers of patients accessing thedirect access service are small, due to

IntroductionThe publication of the DH GoodPractice Tinnitus Guide, Provision ofServices for Adults with Tinnitus, setsout the vision for services andcommissioning pathways. It suggeststhat for many patients, the pathwaysfor effective care are not alwaysstreamlined or as efficient as theycould be. Tinnitus or perception ofsound in either one or both ears maybe reported as the only complaint orit may be a symptom of one or moreunderlying pathologies. In the UK, alongitudinal study, published by Davisand El Rafaie1 suggests 10.1% ofadults had experienced episodes oftinnitus lasting more than fiveminutes and in 5% the tinnitus wasmoderately or severely annoying.0.5% of the study population wereaffected severely enough for it tohave a serious impact on their abilityto lead a normal life.

The experience of tinnitus can lead tomany complex sets of complaints.Patients may experience distress,helplessness or frustration, depressiveepisodes, sleep disturbances, lack ofconcentration and, in a smallerproportion of patients, may bechronically disabling. In some

patients, tinnitus may be associatedwith medical or otological conditionsthat need investigation and surgicalmanagement. Consequently, triageand differential diagnosis at an earlystage of presenting symptoms istherefore critical, to not only identifyappropriate management but reducethe impact for both the patientsquality of life and use of healthcareresources. Any delay in access toservices can potentially impede theprocess of tinnitus management andlead to a greater number of followups by professionals.

SummaryThree pilot sites aimed to implementa direct access audiologist/hearingtherapist-led clinic to enhance patientsatisfaction, improve tinnitusmanagement outcomes and reducereferral to treatment times.

The sites chosen were:• University Hospitals

Birmingham NHS Foundation Trust – Selly Oak Hospital

• Sherwood Forest Hospitals NHS Foundation Trust – Kings Mill Hospital

• Newcastle Upon Tyne Hospitals NHS Trust – Freeman Hospital

the project timescales, furthermonitoring will provide better insightinto clinical advantages, improvedpatient experience and value formoney.

Presenting issues Traditionally within all sites themajority of referrals into tinnitusmanagement clinics were from ENTconsultant clinics with a largeproportion of patients suffering frombilateral tinnitus with no underlyingmedical condition. Sites wereconvinced that many of the adultsbeing referred to ENT consultantswith tinnitus could have beenmanaged by audiologists, healthcarescientists or hearing therapists withthe appropriate level of training. Thiswas illustrated by a retrospectivepatient record audit, carried out byNewcastle Upon Tyne Hospitals NHSTrust, who found that 60% ofpatients referred to ENT couldpotentially be seen in a direct accessclinic. This compares with SherwoodForest Hospitals NHS Foundation Trustwho found that 73% of referralsfrom ENT were for bilateral tinnitus inan audit carried out in 2007. All threepilot sites were therefore interested indeveloping a direct access referralcriteria and management pathway.The aims of the projects were toimplement a direct access audiologist/hearing therapist-led clinic, toenhance patient satisfaction improvetinnitus management outcomes andreduce referral to treatment times.

Baseline information from pilot sitesidentified the following key issues:• Delay in patient access to

tinnitus management clinic of between 12 and 28 weeks in the pilot sites.

• Increased emotional impact of tinnitus, reported by patients who had a delay in access to service.

• Variation in patient satisfaction levels with speed of access to ENT outpatient clinic, explanation of tinnitus, ability to discuss condition, opportunity to ask questions and helpfulness of appointment.

• Inconvenience for patients attending multiple hospital visits prior to being seen by tinnitus management clinic – a potential of five visits to hospital, with contact with a variety of professionals.

• Inconsistent information given to patients by different professional groups can lead to patients requiring more frequent follow up visits due to delay in acceptance of condition and ability to adopt self management strategies due to anxiety and distress.


The patients’ story:

‘To try and speed the process of hospital referral up, thatcertainly would have helped me, I felt I was on my ownand not able to cope.’

‘The emotional impact of Tinnitus can be extremelydestructive, I lost my job, lost a relationship, it wastough.’

Focus Group North Tyneside Disability Forum Tinnitus Group

University Hospitals Birmingham NHS Foundation TrustPatient satisfaction levels with traditional Tinnitus pathwayThe trust conducted a postal satisfaction survey and 39 responses were analysed.

*qualitative data from patient survey



What they didAll sites set out to pilot a 'one stop'direct access tinnitus service using astrict referral criteria.

Direct access tinnitus referralcriteriaAdults, over the age of 16,complaining of persistent,troublesome tinnitus should bereferred directly to audiology.

Exclusion criteria• Unilateral or asymmetrical

hearing loss.• Pulsatile tinnitus or tinnitus

described as a cracking,popping or clicking noise

• Persistent otalgia or auraldischarge affecting either ear

• Vertigo

A range of different approaches tosetting up the service were used;

Newcastle Upon Tyne NHSHospitals set out to provide theevidence to support the need forchange in pathway by a retrospectivepatient record audit and workingcollaboratively with the NewcastleUpon Tyne Disability Forum TinnitusSupport Group. They set up a focusgroup to identify the issues with thecurrent pathway and consulted withpatients regarding their views on thedirect access service. They workedcollaboratively with fifteen ENTconsultants, to agree pathway,develop criteria for referral andprotocol for care.

ContactTom DavisonSenior Chief Audiologist,[email protected]

University Hospitals BirminghamNHS Foundation Trust set outinitially to triage ENT referrals, priorto publishing direct access service viaChoose and Book appointmentsystem. An additional 'one stop' clinic per week was set up toaccommodate direct access referrals.The clinic was managed jointly byaudiologists and hearing therapists,and in collaboration with twelve ENTconsultants.

ContactHuw CooperConsultant Clinical Scientist,[email protected]

Sherwood Forest Hospitals NHSFoundation Trust set out toimplement one direct access clinic per week via Choose and Book.Commissioners and users of servicecontributed to the steering group.Following agreement of the newpathway, public, primary andsecondary care communicationstrategies were used to raiseawareness. The clinic was managedby one audiologist, in collaborationwith three ENT consultants.

ContactMichelle BoothAudiologist, Chief Audiologist,[email protected]

How they did itPilot sites used a range ofapproaches to achieve goals:-• Set up steering groups and

engaged/ influenced stakeholdersincluding ENT consultants and trustmanagement. Patientrepresentatives attended steeringgroup meetings.

• Consulted with patients toprovide information about the pilotsite project and obtain first handfeedback about the historicalpathway.

• Process mapped historicalpatient pathways and agreednew pathway, in collaboration withall stakeholders

• Worked collaboratively, withENT colleagues to agree directaccess referral criteria and safeprotocol for 'red flagging' thosepatients requiring to be seen byENT consultant.

• Agreed protocols for audiologyled request for MRI with ENTconsultants and processing via trustclinical governance processes.

• Reviewed methods of follow upfor patients by telephone, email orclinic attendance.

• Calculated future demand andcapacity for service. Clinicappointments were increased from45 to 60 minutes to allow moretime.

• Raised awareness of newpathway by effectively engagingwith the public, primary andsecondary care via local communitymedia and communication teamstrategies.

• Piloted a 'one stop' clinic forpatients with tinnitus.


• Implemented method for usingindividual management plans(IMP). This defined each patient'sagreed needs and records anyagreed actions as they arecompleted. Patients are issued witha written copy of their IMP as wellas information about tinnitus andlocal support groups.

• Evaluated impact of serviceusing patient satisfaction,improvements in tinnitus handicapinventory, improvement in referralto treatment times, number offollow ups and requests for MRIscans.

Benefits

QualityImproved patient experience -Both pilot sites have demonstratedthat the direct access serviceimproved the patients experience andsatisfaction levels of the service.University Hospital Birmingham NHSFoundation Trust found that greaterthan 90% of patients felt that theappointment was helpful and theyhad to wait less time than expected.

Improved access and treatmenttimes - Pilot sites have demonstratedsignificant improvements in accessand treatment times for patientssuffering from bilateral tinnitus. Bothsites reduced their wait times to lessthan four weeks.

More optimum use of staff skillsin the pathway has led to ENTconsultants seeing the right patient at the right time. Andrew Reid, ENTConsultant, University HospitalsBirmingham NHS Foundation Trustreports.


Improved patient experience; What patients said:

'I understand this is a pilot scheme, it seems really good andhelpful. If at all possible, it should be continued, there ismore tinnitus out there than maybe is known'.

Sherwood Forest Hospitals NHS Foundation Trust, Patient satisfaction postal survey

'At the clinic they helped me; reassured me and helped meget all the information I needed. I wish I could have gotthere sooner. I now have hearing aids and live quite happilywith my tinnitus.'

University Hospitals Birmingham NHS Foundation Trust, Patient satisfaction survey

Example of Direct Access Tinnitus pathway at University HospitalsBirmingham NHS Foundation Trust

University Hospitals Birmingham NHS Foundation Trust• 15% (two out of the 13 patients seen) were 'red flagged' as requiring

referral to ENT (due to unilateral nature of their tinnitus). One patientrequested to see an ENT consultant for reassurance.

• Potential for 187 ENT outpatient slots released (based on annualreferral demand of 220).

Sherwood Forest Hospitals NHS Foundation Trust• 20% (Five out of the 25 patients seen) were 'red flagged' as requiring

referral to ENT with one patient requesting to see the consultant. 48%were seen as one stop service

• Potential for 80 ENT outpatient slots released per annum (based onannual referral demand of 120).



'This new pathway enablesmore effective access forother patients that requirean ENT opinion. Only a smallvolume of patients withtinnitus need a medicalopinion eg. Objectivetinnitus - these are pulsatiletinnitus or complex patients,of which tinnitus is asymptom with multiplemedical issues.'

Improved GP and publicawareness to enable moreappropriate referrals - Earlyfindings from Sherwood ForestHospitals NHS Foundation Trustsuggest that their communicationstrategies raised both awareness withboth GPs and the general public.

InnovationDirect access services are commonplace for hearing loss, however, directaccess services for tinnitus is evolving.The pilot sites demonstrate that themodel of service provision should bebased around matching the skills ofthe professionals to the patientneeds.

ProductivityRelease of ENT outpatientappointments - This pathway hasthe potential to release betweenapproximately 60 - 85% of ENTtinnitus outpatient appointments. Reduction in audiology/hearingtherapy follow up appointments -Early findings at Sherwood ForestHospitals NHS Foundation Trustillustrate potential reduction in newto follow up appointments.

PreventionImproving access and managementof tinnitus has the potential toimprove the quality of life as patientsmay become less prone to sleepdisturbance, anxiety, depression andmay enable more effective use oftherapeutic drugs or psychologicalsupport for patients. Robust clinicaloutcome data will need to becollected in order to validate theseassumptions.

Commissioner Impact - NHS Nottinghamshire County supportsextension of pilot to gain a better insight into improved patientexperience and value for money of service:

'The team have been very enthusiastic and driven in makingimprovements to access and outcomes for adults withtinnitus. Early patient feedback is positive particularly aboutearly access to the service and the excellent quality of careand advice given to them. As numbers of adults accessingthe service has been understandably small due to theproject timescales, I would be supportive of the pilot tocontinue a little longer to gain a better insight into theclinical advantages, improved patients experience and valuefor money of this service.'

Ellie Bevan-Davies, Head of Procurement and Market Management at NHS Nottinghamshire County


Reference1. Davis A and El Rafaie. Epidemiology of tinnitus, In Tinnitus Handbook(ed RS Tyler). Singular. Thomsom Learing. San Diego, 1-23. 2000.

IntroductionCommunity based studies in Englandand Scotland have suggested that 20-25% of the population experiencesymptoms of dizziness/vertigo, withone quarter losing time from work.

Referral pathways can be lengthy andcomplex. At Heart of England NHSFoundation Trust in Birmingham,patients were taking on average justunder five years to receive a diagnosisand subsequent management of theirbalance problem (HEFT BalanceService Audit 2007). This is typical tothat found by other specialist balanceservices in the UK, with patientsseeing on average 4.5 specialistsbefore receiving a diagnosis.

Balance projects were undertaken bythree very different services;• The National Hospital for Neurology

and Neurosurgery, Queen Square,London - a tertiary service led byaudio-vestibular medicine based atthe National Hospital for Neurology

• Cambridge University HospitalsNHS Foundation Trust (CUH) - awell established audio-vestibulardiagnostic and rehabilitation serviceworking in partnership withotology/neurotology in a largeteaching hospital. The localcatchment area is both rural andsuburban


• Heart of England NHS FoundationTrust, Birmingham - A multi-disciplinary team, based in anurban area, working togetherproviding a joint consultation.

SummaryIn the balance projects,multidisciplinary teams worked withpatients to agree protocols andclinical pathways, that improvedaccess to the appropriateprofessionals and investigations andtherefore led to earlier diagnosis andtreatment. Each of the three balancesites developed a more coherentapproach, providing consistentinformation to meet the needs of theindividual. Patients with a betterunderstanding of their condition aremore likely to adopt recommendedchanges and agreed managementplans. Early management may preventfalls and development of associatedconditions, such as depression.

The projects highlighted thefollowing emerging themes;• Good clearly-communicated referral

protocols and pathways.• Opportunities for inter-professional

learning and extended roles.• Patient engagement events

highlighted the importance of earlydiagnosis and intervention.

• Benefits of supporting informationto meet the individual patient'sneeds.

Presenting issuesAll three sites highlighted the need tounderstand the patient journey andthe flow of information. Each hadevidence that a large number ofpatients had seen severalprofessionals before being referred tothe balance clinic.

The teams wanted to develop andvalidate clear pathways, ensuring thepatient is seen by the mostappropriate professional in a timelyway, removing steps that did not addvalue. They were keen to involve allthe stakeholders and to develop amultidisciplinary service model.

All of the sites struggled to obtainrobust data, as very little usefulvestibular specific data had beencollected by the trusts. The use ofoutcome measures to monitor anindividual's progress was inconsistentand the aggregated departmentaldata was not collected. This madecollection of baseline data andprojection of potential benefitsdifficult.

Balance



What they didQueens Square• Introduced a one-stop balance

clinic with same day testing,diagnosis, physiotherapy andcognitive behavioural therapy (CBT)

• Implemented new patient triageinto uncomplicated and complexbalance patients, with experiencedaudiologists assessing theuncomplicated balance patientsusing a red flag system

• Extended the use of outcomemeasures and patient evaluationforms and collated the results ofthese to drive service improvement

• Production of patient informationsheets on inner ear balanceproblems, benign paraxysmalpositional vertigo (BPPV) andmigraine associated dizziness

• Streamlining administrativeprocesses, as a result of the process mapping session, theadministration procedures wereadjusted.

ContactDr Rosalyn DaviesConsultant in [email protected]

Cambridge University Hospitals• Built upon existing clinical

partnerships (otology/neurotology)and consolidated a thrivingmultidisciplinary team

• Created a service topography data-set to be collected monthly andreported back to the team

• Produced a written patient pathwayand information leaflets for theservice

• Introduced written individualmanagement plans (IMP) forpatients and made them availableelectronically to other professionals

• Implemented a patient outcomemeasures protocol and establisheda database to collate results

• Enabled patient involvement in theservice and better communicationbetween local professionalsmanaging balance patients.

ContactKaty ButlerClinical Scientist (Audiology),[email protected]

Heart of England• Developed an improved network of

stakeholders by reviewing pathwaysand developing relationships withthose who contributed to it

• Used a range of innovative ways toconsult patients and involve themin service developments

• Worked in partnership with localcommissioners and gained a betterunderstanding of costing the multi-disciplinary joint consultationservice model

• Changed the pathway to enablepatients to access other specialistservices without having to return totheir GP for a new referral

• Agreed referral criteria for access toservices and for onward referralsinto acute or specialist balanceservice.

ContactAmanda CaseyHearing Therapist,[email protected]


Laminated test information sheet developed at Queens Square

How they did itKey stakeholders were identified andproject teams established at each site,all included a physiotherapist. Each ofthe sites looked at demand and heldprocess mapping sessions withstakeholders, then identified thesteps in the process that wereunnecessary and did not add value(value stream analysis). Heart ofEngland included a patientrepresentative and her husband inthe session. She was able to articulateher experiences and feelings as shetravelled along the pathway in apositive and constructive fashion. Allthe stakeholders were then able tocollectively address any issuesidentified and develop improvedprocesses and pathways. At QueensSquare the secretarial staffhighlighted duplication of work andseveral systems being used to bookfollow-up appointments, leading toadditional checking.

Each of the teams developed newmultidisciplinary pathways, to get thepatients to see the most appropriateprofessionals at the right time,reducing the number of visits. Thisinvolved reviewing the skill set of theteam; at Queens Square theexperienced band 7/8 audiologistsreceived additional training so theywere able to see some


straightforward GP referrals in placeof audio-vestibular medicine (AVM).Taking detailed medical histories,examining patients, undertaking orarranging appropriate investigations,making a diagnosis and agreeingappropriate management. This wasdone in parallel with AVM clinics,

thus the consultant was available toprovide guidance and see patients. Toensure safe clinical practice, theconsultant audited the 16 patientsseen on this new pathway against ared flag questionnaire developed bythe team.


Validation of triage of new patient referrals for balance assessment and management


Patient and Public InvolvementEach site wanted to improve thequality of information provided topatients and their families. Thisinvolved consulting with patients andGPs, developing individualmanagement plans, new patientinformation leaflets and diagnostictest information cards.

The sites worked with reader panelsand produced a range of balancerelated information leaflets. The title‘Migraine Associated Dizziness’ forone leaflet was a suggestion from amember of the reader panel.

All of the teams used patientquestionnaires, at Queens Square thishighlighted issues with the waitingarea, the audiologists are nowfeeding this back and working withthe architects designing the newdepartment.

Cambridge University Hospitals NHSTrust held a facilitated patient forumto probe the issues important to theirusers and changes made as a resultof their comments will be fed back.

Heart of England had an experiencedinterviewer record a DiscoveryInterview; they were able to share thelearning from this with the team andother stakeholders. The team foundthis very powerful, it highlighted theimportance of planning and trainingin this technique, as the emotionalimpact on the patients can beprofound.

Benefits

QualityThe enhanced quality is reflected inthe quality enhancement tools (QET)scores, Cambridge UniversityHospitals NHS Trust used the relevantQET sections to assess the quality ofthe balance service alone, in just ninemonths they managed to increase thenumber of sections achieving level Aby 19%.

MDT brings together specialists inmanaging balance focusing on thepatients needs, providing evidencebased care that delivers the desiredoutcomes.

Sites are now using outcomemeasures, although only smallnumbers were available at the time ofwriting, they are able to demonstrateimprovements.

At Cambridge University HospitalsNHS Trust 80% of patients haveindividual management plans (IMPs)completed within 48 hours of theirappointment. These are stored on thetrust patient management systemalong with vestibular assessmentreports, allowing the relevantprofessionals trust wide access.


‘The exercises I was given helped greatlyto give me confidence.’

Focus Group Patient


An increased range of informativeand up to date patient informationleaflets are now available.

InnovationImplemented joint patientconsultations with MDT.• Development of new pathways and

extended roles, ensuring a clinicallyeffective and safe pathway.

• Consulted with and involvedpatients in service review anddevelopment.

ProductivityThe improved understanding anddata collection at the sites is to bemaintained and used to:

• understand and monitor demandand activity

• facilitate service developments• collate patient outcome measures• communicate progress effectively• support audit and research • develop robust business cases• determine cost of service.

• Clear protocols and use of red flagsresulted in more appropriate andbetter quality referrals to thecorrect professionals.

• Reduced costs as patients seen sooner by the correct professionalsleads to less duplication of workand unnecessary investigations.

• Reduced number of appointmentsin the new pathways.

All sites anticipate a reduction in didnot attend (DNA) rates, Heart ofEngland has been able todemonstrate a drop in DNA rate forvestibular function testing from 50%to 5%.

Prevention• Patients able to return to work

sooner and may be less prone tofalls and chronic depression, moreevidence is needed to verify this.




providers who may have concernsregarding the expansion of directaccess audiology services.

Presenting issuesTraditionally, the majority of patientssuffering from otological conditionsare referred to ENT and are seen inany of the 14 consultant clinics.Patients return for a further visit forany tests and may either be followedup by ENT or referred toaudiovestibular medicine (AVM).AVM is not accessible via Choose andBook.

Key issues identified with ENTaudiology pathways were:-• Delays in access to ENT and

threshold for referral on to AVM

Collaboratively working with ENT toredesign pathways

IntroductionThe Royal National Throat, Nose andEar Hospital (RNTNE), at Royal FreeHampstead NHS Trust, set out to pilotan audiologist-led triage assessmentclinic for new outpatient ENTreferrals. Whilst RNTNE is a tertiarycentre, a large proportion of work isalso for the local population. TheTrust also has a well-establishedAudiovestibular Medical Department.

Patients referred to RNTNE may havemultiple appointments from ENT,audiology, ENT follow upappointments to referral to theaudiovestibular team to enablemanagement of condition. This delayin access can lead to considerabledistress for patients and impact ontheir of quality of life.

SummaryInitial findings suggest that 75% ofENT otological referrals did not meet'red flag criteria' and couldpotentially be managed by thediagnostic audiology department in adirect access service, by staff with theappropriate skills and the ability torequest MRI scans. This efficiencycould result in shorter waiting timesfor ENT. In 95% of cases, audiologistsand ENT were in agreement as to thereferral pathway to audiovestibularmedicine or ENT.

This project demonstrates howaudiologists and ENT consultantsworked collaboratively to develop arobust method to validate theknowledge and skills of audiologystaff. This approach may be useful for

Traditional pathway for ENT otological referrals

• Inconvenience for patients asmultiple steps in pathway eg testsoften carried out after ENTappointment

• Perception that audiologists skillsnot utilised to full potential.

What they didThe overall aim of the project was tostreamline hearing, balance andtinnitus pathways using effectivetriage of ENT referrals by audiologists.The team determined the number ofsuitable referrals (i.e. did not meetany red flag criteria indicating referralto ENT), and to validate skills ofsenior audiologists to assess andmake decisions regarding appropriatemanagement.

How they did it• Process mapped patient

pathways and agreed a newpathway, in collaboration with allstakeholders

• Conducted a prospective patientrecord audit to determine whichotological referrals met 'red flag'criteria for referral to ENT

• Set up an audiologist-led triageassessment clinic

• Developed a clinical assessmentproforma

• Developed a system forrecording outcome andevaluating the assessmentprocess

• Developed questionnaires toevaluate patient and staffsatisfaction with service.

Benefits

QualityThis pilot provides evidence foroptimum use of staff skills to enablepatients to be seen by the rightperson at the right time, enhancingthe patient experience.

InnovationThe approach to this pilot provides arobust method to validate theknowledge and skills of audiologystaff, where providers may becautious.

ProductivityThe new model would potentiallyrelease approximately 45 RNTNEoutpatient appointments with ENTper week.


Findings from patients seen in the triage assessment clinic

22 patients seen in clinic - 20 % could potentially be seen and managed by audiologist. An additional 55% could be seen if staff had the ability to request MRIs.




IntroductionReferral of adults, with complexhearing needs, from secondary careproviders to specialist tertiary centresis often dependent on knowledgeand skills of referring providers andresources available for testing andmanagement. Adults with complexhearing needs may have undergoneseveral hospital visits prior to referralto a specialist centre for acomprehensive assessment. Whilstthere are many providers withdesignated clinics for patients withlearning disabilities there is a need toensure that other patients withcomplex needs receive adequateappointment time and expertise tomeet their needs, in a timely manner.

It is vital that referrers are aware ofspecialist services to ensure patientsreceive prompt appropriate treatmentand to minimise any delays in theirpathway. Central ManchesterUniversity Hospital NHS FoundationTrust found evidence to support thatthere was variation in thresholds fromreferring providers to specialistservices. For example, an audit ofreferrals to the Manchester cochlearimplant programme indicated thatpatients with a severe to profoundhearing loss had lived with their

Adults with complex hearing needs

symptoms for, on average, 12 yearsbefore being referred for the mostappropriate treatment.

SummaryCentral Manchester UniversityHospital NHS Foundation Trust, aimedto develop a service for adults withcomplex hearing needs which hasflexible yet clearly defined, pathwaysof assessment and rehabilitation forpatients referred from providersthroughout the northwest region.

Initial findings from the pilot sitesuggests delays in referral for optimalmanagement of patients withcomplex hearing needs. A key issuewas the difficulty assessing demandfor the service, due to varyingmanagement of patients by referringproviders.

The project highlights the importanceof referring providers being aware ofspecialist services to ensure patientsreceive prompt appropriate treatmentand to minimise any delays in theirpathway. The development of aregional complex hearing needsnetwork enables providers to achievethis by working collaboratively toenable patients to receive the mostappropriate care.

Presenting issuesCentral Manchester UniversityHospitals NHS Foundation Trust,audiology department at ManchesterRoyal Infirmary, providescomprehensive secondary and tertiaryservices to patients. Much of thetertiary work arises from specialistreferrals to the ENT department, andmany of these referrals are patientswith complex hearing needs.

The audiology team were interestedin developing a service for adults withcomplex hearing needs, which hasflexible, yet clearly defined, pathwaysof assessment and rehabilitation forpatients referred from the north westregion. Designated clinics for patientswith auditory processing disorders(APD) and learning disabilities werewell established within thedepartment.


There are some important issues thatneed to be addressed when dealingwith this patient group and staff willneed advanced diagnostic andhearing technology skills andequipment.

The team identified a need for adesignated regional clinic for complexhearing needs patients and a regionalnetwork to agree referral criteria andshare learning from clinic.

What they did• Defined complex hearing needs• Piloted a Specialist Hearing and

Rehabilitation Clinic (SHARC)initially with internal hospitalreferrals

• Conducted a survey of localproviders to determine serviceprovision for this patient group

• Developed a complex hearing neednetwork group for professionals

How they did it• Set up steering group• Agreed criteria for referral to

clinic • Process mapped historical

patient pathways and agreednew pathway, in collaboration withall stakeholders

• Estimated demand for pathway • Piloted clinic 'Specialist Hearing

and Rehabilitation Clinic (SHARC)' for three months

Assessment procedures set up in clinic room• Pure Tone Audiometry (PTA)• Aided and unaided CUNY

sentences (speechdiscrimination with lipreading)

• Aided and unaided BKBsentences (speechdiscrimination in quiet andnoise)

• Threshold Equalising Noise(TEN) test (for dead regions)

• Evoked potentials• Otoacoustic Emissions (OAEs)• Tympanometry and acoustic

reflexes.

Definition of Complex Hearing Need

Fluctuating hearing loss (e.g. Meniere's Disease)

Acoustic Neuroma (diagnosed)

NF2 (diagnosed)

Auditory neuropathy spectrum disorder (ANSD)

Ski-slope audiogram≥50 dB octave difference between 0.5 and 4 kHz

Severe-profound hearing loss ≥80 dB HL at 2 and 4 kHzNot CI candidates

Conductive hearing lossBC ≤20 dB HL with air-bone gap of ≥50 dBNot BAHA/VSB candidates

Mixed hearing lossAC ≥60 dB HL with air-bone gap of ≥30 dBNot BAHA/VSB candidatesFrequent (≥3) follow up/fine tune attendees

Suspected non-organic hearing loss • Evaluated impact of service bypatient satisfaction level, clinicaloutcome measures and case studies

• Conducted an online survey oflocal provider departments

• Set up a complex hearing needsnetwork.

BenefitsThe development of this clinicprovides many benefits in terms ofclinical effectiveness and theopportunity for professionals to learnfrom peer review case studies.

Quality• More clearly defined pathway and

continuity of care for patients. • 66% of patients reported improved

level of satisfaction compared withprevious experience.




‘Being able to have a designated clinic for patients whorequire more complex testing has allowed me as a clinicianto ensure I am giving my patient the best possible care inthe best environment. As we progress with our experienceof non-routine testing we will be able to offer patients alevel of specialism and care more appropriate to theirneeds. I envisage development of 'gold' standard testingand care pathways for these patients. I look forward todeveloping my clinical skills and shared learning with mycolleagues’

‘SHARC gives the audiologist the time and resources tohelp patients with non-routine hearing problems. Theclose links it has with other specialist services, such asimplants, means that patients can receive the mosteffective treatment for them sooner and, thereforeenhance the quality of their lives’

Experience of staff working in SHARC - Staff responses:

InnovationIntroduction of a designated clinic forpatients with complex hearing needs.The establishment of a regionalcomplex needs hearing network is anexample of how both secondary andtertiary providers can workcollaboratively.

ProductivityThe development and agreement ofreferral guidelines for local providers,via the regional network, willpotentially lead to adults withcomplex needs being referred moreappropriately, at the right time, to theright service to receive earlyassessment and hearing intervention.It is anticipated that this will lead to areduction in the number ofappointments offered either in localprovider or tertiary centre, with aconsequential positive impact on costefficiency and waiting times.However, more robust data wouldneed to be collected to validate thisassumption.

ContactMartin O'DriscollHead of Audiology,martin.o'[email protected]

Shahad SaeedPre-registration Clinical Scientist,[email protected]


Audiology transition projects

IntroductionThe National Service Framework forChildren, Young People & MaternityServices DH (2004) sets a standardthat young people should besupported to make the Transition toadulthood so that their maximumpotential in terms of education,health, development and well-beingcan be achieved. Furthermore, itmakes clear that services and staffshould respond to young people in asensitive way to encourageengagement whilst providing highquality support to enable theTransition from dependence toindependence.

Standard 4: All young peoplehave access to age-appropriateservices which are responsiveto their specific needs as theygrow into adulthood.

The National Service Framework forChildren, Young People & MaternityServices DH (2004), p.119

For young people with additionallong-term conditions or disabilitiessuch as deafness, the move to adultservices often involves a significantcultural change in experience whichneeds careful thought and handlingto have a successful outcome foreach young person.

The National Deaf Children's Society(NDCS) has provided guidelines forprofessionals working with deafyoung people to help them to modelservices, Transition from paediatric toadult audiology services in England,Quality Standards, NDCS (2005).

You're Welcome, DH (2007) says thatall young people are entitled toreceive appropriate health carewherever they access it. You'rewelcome Quality Criteria, DH (2009)lays out the principles, including selfassessment criteria, to supportservices in delivering a seamlessquality service. You're Welcome wasincluded in the 2010-11 NHS Operating Framework andhighlighted in the government childhealth strategy Healthy Lives, Brighterfutures, DH (2009)

SummaryPatient consultation and involvementenabled three audiology pilot sites toinvestigate their local service gaps inorder to develop new or improvedmodels of transition from children'sto adult hearing services.

Common themes around theengagement of young people haveemerged from the pilot project workresulting in some key hypotheses.Once tested these hypotheses couldlead to some potentially transferablelearning.

• Audiology transition for youngpeople needs to integrate withother partners (such as Connexionsand education) into the widertransition process where the centralfocus is the individual. This will helpto ensure that the educational,social, psychological and physicalhealth needs of the individual arebest met

• Raising the awareness of theimportance of getting transitionservices right will encourageservices to change to give improvedaccess to young people, deliveringbetter long-term outcomes foraudiological health into adulthood

‘Transition for young people is much more than thetransference of audiology care from paediatric to adultservices, it is about moving from childhood intoadulthood alongside all the confusion and uncertaintiesof their rapidly changing world.’




• Incorporating flexibility byintroducing the transition processat a much earlier age, recognizingthat young people will go throughthe process at their own speed,according to need and individualcircumstance, and allowing theyoung person to transition at theright time for them

• Access is likely to improve byconsulting and involving youngpeople in designing the pathwayand continuing to involve them inany changes.

• Improving information accessibilitythrough the use of multimedia suchas written leaflets, visualinformation and the use oftechnology for example, a websitesuch as NDCSs 'The Buzz' andsocial networking websites.Providing the option to viewinformation in British sign languageor subtitles will appeal to youngeraudiences allowing them to accessinformation at their own pace, intheir chosen language.

• Raising deaf awareness throughtraining of audiologists and othertransition professionals will improvethe patient experience andengagement of young people.

The pilot sites• NHS Devon in partnership with the

National Deaf Children's Society• NHS Tower Hamlets (leading) with

NHS City and Hackney• East Lancashire NHS Trust.

Presenting issuesCommon issues between the sitesincluded:• High DNA rates at the first adult

appointment • Many young people being 'lost to

follow up' in the transition process • Lack of support and training for

hearing service professionalsconcerning effects of hearing losson young adults

• Lack of training in the use andrepair of hearing aid devices usedby paediatic services, oftenresulting in the young personhaving their hearing aid changed attheir first adult appointment,despite being happy with theirprevious device.

NHS Devon found that although theirtransition model met with the NDCSquality standards, the uptake of theirservice was poor.

NHS Tower Hamlets and NHS Cityand Hackney had additional issueswhen young people beingtransitioned had to leave the speciallyconstructed children's unit to attendappointments in older style unfamiliarbuildings, with professionals who didnot know them, to access disparateadult audiology services.

East Lancashire felt that their servicedid not meet the NDCS qualitystandards and that the adult onlyaudiologists were poorly prepared toreceive newly transitioned teenagers,despite services being housed withinthe same building.


NHS Devon and NDCS used amultidisciplinary collaborativeapproach, led by a steering group ofa wide range of stakeholders. Theteam sought the views of youngpeople through five different focusgroups and opportunistic meetings ofyouth groups.

What they didThe views of young people hasshaped thinking in the modeling of anew integrated service whereaudiology services will be flagged byother professionals who are alsoworking with young people intransition. Learning within this projectincludes an awareness of thedifficulties associated withengagement of young people, therecognition that transition must beintroduced at an earlier age tofacilitate expectation and involvementand that the date of transition shouldvary according to individual need. Thework identifies, in addition to youngpeople with a severe to profoundhearing loss, that those with a mild tomoderate hearing loss can alsobenefit from inclusion to supporttheir longer-term engagement withaudiology services. The model,developed but as yet not tested, willcommence in September 2010 and ishoped that this model - once tested -

will provide a quality service that canbe commissioned and rolled outacross the South West.

ContactLouise ColeNDCS Regional Director South West [email protected] ParsonsClinical Director of Audiology, NHSDevon, Royal Devon & Exeter NHSTrust [email protected]

’I need help finding work as well as with my hearingaids, no one is helping me with that.’

’One had a beard so lip reading was impossible.’

Patient quotes - Focus Group

NHS Devon in partnership with the NDCS

NHSDevon

The new model pathway for NHS Devon developed by the multi-agencycollaborative group in consultation with young people


Photo Courtesy of NDCS



The team sought the views ofindividuals experiencing the existingpathway and newly developedpathway using an electronic webbased questionnaire.

What they didDeveloped an improved pathwaywhich decreases the length of timebetween the last children's serviceappointment and the first adultappointment, promoting thelikelihood of attendance. The trainingof audiologists working in adultservices on deaf awareness issues ishelping to support young peoplethrough more appropriatecommunication. Technical training foraudiologists in the use of anincreased range of hearing aiddevices. The team have produced animproved information pack in theform of two 'All you need to know'leaflets for young people, whichincludes contact details. Patient viewswill be monitored.

Key learning includes increasedawareness that the transition processshould begin at an earlier age andcontinue until the young person isready to transfer to the adult service.This will be an individually negotiated

choice, with some patients choosingto transfer at an earlier age thanothers. Young people are much morelikely to engage if there is a choiceand a variety of media through whichto do so. The increasing use oftechnology through use of websitesand computers appeals to manyyoung people so using an on-line toolto establish patient views may yieldmore returns.

ContactKaren GaudoinLead Clinical Scientist, NHS TowerHamlets & NHS City & [email protected]

Naomi AustinTeam Leader, Paediatric Audiology,NHS Tower Hamlets & NHS City &Hackney [email protected]

NHS Tower Hamlets and NHS City & Hackney

NHS

’I had less confidence in the adult service because it wasmy first time using this service and I didn’t know howtheir service work because it looked so different to mecompared to the children audiology department that Iused before.’

Quote (unedited) patient questionnaire

NHSCity and Hackney

Community Health ServicesTower Hamlets

Community Health Services

Transition flow chart - NHS Tower Hamlets & NHS City & Hackney


The team planned a patient forum toelicit patient views of the currentservice, and to shape a new improvedpathway. However after efforts torecruit patients, they found there waslittle appetite from young people toattend a forum. Instead, the teamdesigned and used a web based on-line survey similar to the one used byNHS Tower Hamlets and NHS City &Hackney. The questionnaire was sentto parents and carers as well asyoung people, as it was felt thatsome adolescents did not transitiondue to parental preference.

Responses to questions aboutchildren and adults hearing services:

What they didOn-line questionnaire results helpedthe team to shape a new pathwayand to improve the quality ofinformation leaflets, including a'frequently asked questions' sectionfor young people. Four audiologistsare being trained in new roles as'transition audiologists' to improvethe patient experience through theservice. It is expected that dedicatedtransition audiologists will encouragelonger-term attendance in clinic. Newsoftware has been introducedproviding dual access for both adultand paediatric audiologists.

Communication betweendepartments is thus improved,benefiting ongoing care andtreatment of young people throughthe delivery of a more seamlessservice.

Key learning includes theidentification of a need for earliertransition information for patientsand that transition is a 'stage' ratherthan an 'age' - different for everyindividual. Database interrogationrevealed that a number of youngpeople had never attended the adultdepartment or were no longerwearing their hearing aids.

‘At the moment, I feel that everything is already coveredand continue doing as you are. The quality of theservices are great.’

Patient quote

East Lancashire Hospitals

NHSEast Lancashire HospitalsNHS Trust




Therefore many young people maybe living at a sub-optimal audiologicallevel, possibly having an impact ontheir abilities within education or theworkplace, or indeed at apsychological or social level. Thesepotential difficulties may go on wellinto adulthood.

ContactDr Annabel DoddsConsultant in Paediatric Audiology,East [email protected] WhistonHead of East Lancashire Hearing andBalance [email protected]

Benefits

QualityQET scores improved from 59% to82% in 'quality of patient experience'(NHS Tower Hamlets and NHS City &Hackney).

Better preparation of patients to theconcept of transition aiding themanagement of expectation andInformation developed or improved -providing better support for youngpeople.

Audiology teams have expanded theirknowledge and skills and the changesmade have led to more young peoplecontinuing with amplification in EastLancashire.

InnovationWider access to services by beginningtransition at a younger (individuallyappropriate) age and the inclusion ofyoung people with a lower level ofhearing loss, improving the long-termoutcomes.

Increased range of professionals(outside audiology) who will supportthe audiology transition service andwidening of the transition contextthrough integration and jointworking with other transition services(NHS Devon).

Patient and public engagementthrough involving young people inthe design, monitoring andimprovement of audiology transitionservices, using a range of formatsincluding technology such aswebsites commonly accessed byyoung people and on-linequestionnaires.

The new role of transition audiologistwill increase the delivery of a morefocused service for young people,which will adapt through evaluation,to patient need (East Lancashire).Improved communication betweenadult and paediatric service throughuse of new software technology (EastLancashire).

Productivity• DNA rates reduced from 33%

(2008) to 14% (2010) during theproject (NHS Tower Hamlets andNHS City & Hackney).

• Improved quality of transitionservices largely made within currentresources.

Pathway for Transition from Children’s Hearing to Adult Hearing Services


Children’s balance

IntroductionThere is little epidemiological data onchildhood balance disorders, but ithas been suggested that 8% of 1-15year-olds in the general populationhad suffered vertigo and dizziness,with over a quarter of those affectedhaving symptoms severe enough todisrupt normal activity (Niemensivu etal, 2006).Children may present notonly with symptoms of dizziness, butalso with chronic instability labelledas clumsiness, or motordevelopmental delay.

The identification of the vestibulardysfunction, establishing the causesof dizziness, delayed motor functionor balance problems allows for theappropriate medical and rehabilitativemanagement to be applied. Balancetesting and the interpretation ofinvestigations, in young children,often involves a number ofprofessionals, with skills and expertisein this area.

Referral to specialist tertiary children'sbalance clinics, overseen by specialistaudio-vestibular physicians, is at best‘patchy’ and dependent ongeographical access to a specialistservice. Children are often referredvia paediatric/paediatric

audiology/neurology clinics, GPs orENT services and may haveundergone several hospital visits priorto referral for a comprehensivebalance assessment.

SummaryPilot sites sought to develop aconsistent referral, triage, assessmentand management pathway ensuringthat the staff skills were matched tothe needs of the paediatric balancepatient. The aim of both projects wasa more streamlined pathway leadingto a speedier diagnosis, fewer patientvisits and more rapid access toeffective rehabilitation.

Following consultation, a DVD andinformation leaflet were developed toexplain what to expect and alleviateboth parent and child anxiety.

Presenting issues• St. George's Hospital, London -

had a tertiary referral process, butthe growing referral stream overtime, and lack of proper selectionof referrals have been leading todecreasing service capacity, longerwaiting times and in-efficient use ofresources. It was felt that theintroduction of the II tier levelvestibular screening service by a

paediatrician skilled indevelopmental assessment as wellas in audiology, and who is trainedin the vestibular screening andassessment, should allow moreappropriate referrals to be seen inAVP clinics. This will lead to a betteruse of the III tier resources(experienced staff and expensiveequipment). There was additionalcomplexity, in that the secondarycare level service was managed in acommunity setting across a diverserange of providers. The level oftraining, and therefore competenceto manage paediatric balancedisorders, was considered to bevariable.

• Sheffield Children's Hospital -had their previous children'sbalance service withdrawn by theneighbouring acute trust, due to alack of paediatric facilities on site.They had acquired new specialisedtesting equipment for theChildren's Hospital, via charityfunding and wanted to develop anew comprehensive paediatricbalance service, with a clearly-defined clinical pathway. Thepathway would determine whichpatients required the input of anAV physician and which could bemanaged appropriately by a




specially trained healthcare scientist(HCS). This paediatric balanceservice was wholly based in apaediatric acute trust.

What the sites didSt George's Hospital• Developed a clear triage system for

referral at tier II and III. • Developed clear screening tools to

facilitate the triage and set up thetier II vestibular screening service inthe community.

• Identified educational needs toimprove the quality of appropriatereferrals.

• Retrospective audit to identifysource and appropriateness ofreferrals for 70 patients (see graph),to inform pathway redesign.

• Identified an internal tier IIIstreamlined pathways for childrenwith vestibular disorders. Thesimple triage of the referral lettersfor children below and above ageseven allowed redirection ofchildren to correct pathway.

• New pathways allowed increasednumbers of patients to be seen inthe consultant clinic from three tofive per session. The clinic now runsmore efficiently, with youngerpatients being assessed forvestibular tests at the time of theclinic and older children having hadtheir vestibular tests done prior toclinic.

• Less complex follow-upappointments seen in a tier IIvestibular clinic by the communitypaediatrician, with special interestin balance disorders, working inparallel with the AVP. This increasedclinic capacity and enhanced thediagnostic skills of thepaediatrician.

• Confirmation of clinic slots by theclinic co-ordinator, via a reminderservice, to reduce clinic DNA rates.

• Adoption of the experience baseddesign (EBD) tool to capture thepatient experience and informongoing service improvement.

• Implementation of a special interestgroup across Wandsworth (with theaim of future wider roll out toKingston, Richmond and Suttonand Merton).

ContactEwa RaglanConsultant Audio Vestibular Physician(Clinical Project Lead)[email protected]: 020 8725 1152

Sheffield Children's Hospital• Developed guidelines for

appropriate referral to the service.• Developed care pathways for the

assessment and management ofbalance disorders and symptomaticdizziness in children.

• Established guidelines and testedprotocols for appropriate use of theextended balance testing facilities.

• Defined the roles of individual staffwithin the multidisciplinary team todetermine which patients weresuitable to be managed by the leadHCS and which required input fromthe AV physician.

• Explored further options forrehabilitation, including linking withother teams such as physiotherapy,occupational therapy andpsychology.

• Developed a system for recordingoutcomes and evaluating theclinical effectiveness of the service,as an ongoing database, which willbuild an evidence base forvestibular testing in children.

• Developed a comments card andquestionnaire to evaluate theparent's/child's experience of theservice.

• Made a DVD to be used to explainthe procedures to the parents/child,to aid compliance during the testand reduce anxiety prior to testing.

• Developed a funding mechanism totake 'out of area' referrals, whichwould fund further development ofthe new service locally.

• Raised awareness of the paediatricbalance service to potential ' out ofarea' referrers within the Northernlocation (cochlear implant serviceswho previously would refer toLondon based providers) -developing a service in a localitycloser to the patient.

ContactDr Glynnis Parker FRCP DCH MSc,Consultant Audiovestibular [email protected]

How they did itBoth sites established a core projectteam and tried to engage with awider group of stakeholders e.g.physiotherapy, occupational therapy,paediatric neurology, GPs, ENT andcommunity paediatricians. StGeorge's were supported by theTrust's internal service improvementteam, which provided essentialdedicated project management timeand service improvement skills. Usingexisting meetings and establishednetworks helped with engagement,but both teams found that widerengagement was difficult, aschildren's balance services are a lowvolume specialty. Understanding thereferral sources for an establishedservice allowed the targeting of thehighest volume referrers.


Both of the sites reviewed theexisting triage criteria and agreednew criteria, which optimised theskills of key professionals.

St. George's Hospital felt that theirnew pathway, which triaged undersevens and over sevens to differentpathways, has the following benefits:• Greater opportunities for

professional development andsharing of knowledge across theteam

• Clearer triage criteria to allowbetter, more appropriate flow ofpatients through the clinics

• Increased capacity for new patientappointments in the consultantclinics.

More Consultant AV physician timewould be created by the communitypediatrician, with special interest inaudiology/vestibulometry, seeing lesscomplex patients for follow-up in aparallel run clinic (enhancingprofessional developmentopportunities). Testing of the newtemplate allowed the AV physician tosee five patients instead of threepatients per session, though clinictemplates could not be redesigned inthe timescales of the project.

Components of the proposed network

Sources of referrals, St George's Hospital (based on a retrospectiveaudit of 70 referrals)


Paediatric balance network care tiers I. II. III St. George'sHospital and Wandsworth PCT



23 patients were seen for vestibular testing by end of February 2010. Of the last 12 of these patients, halfwere triaged into either the consultant branch or the scientist-led branch of the service. Early resultsdemonstrate that the new pathway is effective. A database of clinical outcomes is being collated to evaluatethe continued effectiveness of the pathway as the service develops.

Care pathway and triage for redesigned balance pathway at Sheffield Children’s Hospital


Patient and Public Involvement The team at Sheffield Children'sHospital was keen to design theirnew balance service around theneeds of patients and carers. Theyused comments cards with targetedquestions, which were given to bothparents and children following theirbalance testing. Patient feedbackrevealed that patients didn't knowwhat they were coming for and 50%were worried about testing prior tothe appointment.

To address this the team designed apatient information leaflet, to be sentout before the appointment andmade a DVD of the test explainingwhat to expect and reduce bothparent and child anxiety.

Before:

After:

DVD cover of parent / patient information DVD


Triage protocol at St George’s Hospital



St. George's Hospital wanted tomake sure that their redesigned clinictemplate, where patients had morethan one visit for their tests and clinicappointment, was not seen as aretrograde step by patients. To assesstheir acceptance of the pathway andshorter clinic appointment, they usedthe Experience Based Design (EBD)tool to capture the patient experienceand inform ongoing serviceimprovement.

They also redesigned their children'sinformation leaflet, to describe thetest in terms of ‘a journey into space’to make the experience seem morefun and less daunting to a youngchild.

Benefits

QualityAt both hospitals there has been amore clearly defined care pathway,which aligns staff skills moreappropriately to meet patient needsand provides better consistency ofcare. Further opportunities have beenidentified through the establishmentof a 'Special Interest Group'. Moreoptimum use of staff skills has led toa more robust pathway, less relianton one individual.

The new service, with a streamlinedpathway, should lead to a moreaccurate diagnosis and better patientexperience in the clinic resulting inincreased compliance with theoffered treatment and a morefocused intervention with improvedoutcomes. This will be monitored, viaa patient database, over time.

There is already evidence that thenew patient information leaflet hasimproved the parent/child experienceand it is hoped that the DVD willenhance this further.

InnovationThere are only a few centres in thecountry that offer specialist balancetesting for children. The developmentof triage tools, care pathways forassessment (optimizing MDT skills)and treatment options offers twomodels that could be adapted locally.Providers, wishing to develop such aservice, would need to give carefulconsideration to the training anddevelopment of identified staff.

The Sheffield model would beappropriate for testing in an acutesetting, whereas the St. George'sapproach offers a networked modelwhere II tier screening and follow upvestibular services are delivered inthe community, with the III tierservice being delivered at the hospitalsetting.

ProductivityThe development of referralguidelines from primary andsecondary care will potentially guidethose children presenting withbalance concerns to the mostappropriate service and target thosemost likely to benefit from vestibularassessment.

The triaging of children into physicianor scientist led pathways willstreamline the care pathway, whichwill lead to an increase in the numberof patients seen in the consultantclinic. Where AV consultant physiciantime was the constraint, redesigningthe clinic, so that the patients wereseen with test results, allowed morepatients to be seen in each clinic bythe consultant.

Vestibular testing at Sheffield Children’s Hospital


PreventionImproving diagnosis and focusingmanagement will reduce themorbidity associated with balancedisorders in children, for examplepreventative treatment for vestibularmigraine or rehabilitation exercises.This can potentially reduce time offschool, leading to improvededucational progress, and/or increasephysical activity and improvement offitness. Data would need to becollected across health, educationand social care in order to validatethese assumptions or a literaturereview undertaken.

ReferenceNiemensivu R, Pykkoo I, Wiener-Vacher SR,Kentala.E. Vertigo and balance problems inchildren- an epidemiological study in Finland.Int J Pediatr Otorhinolaryngol 2006;70:259-65




IntroductionThe vision for children's hearingservices is for them to be identified,assessed and to receive the mostappropriate care for them close tohome, as quickly as possible. Thechildren and their families need goodquality support from a range ofprofessional groups and agencies thatcan meet their ever changing needs,whilst recognising the potentialimpact on their learning anddevelopment.

Information about communication,educational placement options andthe role of health, education andsocial care, needs to be given, alongwith rapid assessment of their needs.

In England, approximately 1,000babies are born each year withpermanent childhood hearingimpairment (PCHI), two thirds ofwhom will be affected bilaterally. In40% of those children, the hearingloss will be severe or profound.Bilateral PCHI has a major impact onthese children and their families andis often associated with a life ofconsistent underachievement(Transforming services for childrenwith hearing difficulty and theirfamilies - A good practice guide2008)

There have been significanttechnological developments whichcan improve the outcome for childrenwith hearing impairment. Thesebenefits will not be realised, unless anintegrated approach is adopted totransform hearing services forchildren and their families. Thisapproach tackles the various inter-related components, which includesinvolving children, young people andparents, improved cross sectorworking, systems and processes,technology and the workforce.

SummaryThe aim of this work was to identifythe good practice that exists and thatcan be developed when differentorganisations work together andshare the learning in order to improvethe current provision.

The sites chosen were:

South Tees Hospitals NHSFoundation Trust

ContactHelen Martin MSc Consultant Clinical Scientist(Audiology)[email protected]

Georgie HillClinical Scientist (Audiology)[email protected]

Warwickshire Local Authority

ContactJane CarterService Development Manager -Integrated Disability [email protected]

Both pilot sites sought to developpathways for children's hearingservices to ensure consistency ofavailable care irrespective of wherethe child lives. One site particularlyfocused on children with apermanent hearing loss. The key tothe projects success was in jointworking across health, social care andeducation. Engaging stakeholderswith different geographicalboundaries and diverse organisationalstructures was a key challenge inorder to gain agreement and advanceproposed changes and developmentsforward. Strategic level support and amechanism for agreeing to theoutcomes and actions provedessential. There were some earlybenefits gained by a betterunderstanding between the differentagencies of what each other couldpotentially offer the children.

Children’s hearing services


South Tees Hospitals NHSFoundation Trust

Presenting issuesThe audiology service at South Teescovers five main PCT areas and fourlocal authority areas. Professionalsinvolved in delivering these serviceswere aware of differences inprovision and testing facilities,resulting in different standards,dependent on where a child lived.Professionals were also aware ofdifferences in provision of associatedservices across the region, such asspeech and language therapy andsocial care. This has resulted in a‘postcode lottery’ for children with apermanent hearing loss and theirfamilies.

What they did• Set up a multi stakeholder steering

group, under the direction of thechildren’s hearing services workinggroup (CHSWG), to include health,education, social care and voluntaryorganisations such as the NationalDeaf Children's Society (NDCS) todirect the project.

• Held a 'stakeholder involvementday' to map and understandcurrent service provision andidentify where there were gaps inservices.

• Designed the 'ideal pathway',based on best practice from withinand outside the locality, gainingstakeholder views (includingparents of deaf children andprofessionals from across health,education, social care and voluntaryorganisations).

• Developed the concept of a ‘linkworker’ role to act as a single pointof contact to sign post parents toappropriate local services.

• Designed and undertook a postalquestionnaire to over 200 parentsof hearing aid wearers across awide geographical area andrepresenting a wide age range ofchildren and adolescents. Collatedand analysed the responses to testideas formulated at the'stakeholder day'.

• Undertook an audit of existingaudiology services against nationalquality standards for site & testingfacilities, as well as a skills audit ofstaff.

• Developed a new local guidelineand checklist to ensurestandardised testing for aetiologicalinvestigations and designed anaudit.

• Presented findings of the project tothe CHSWG via a written reportand hosted a feedback day forcommissioners, professionals andparents, to formulate an 'actionplan' around the results andproposed ideas.

How they did itUnder the direction of the CHSWG aproject steering group was set upincluding stakeholders from acrosshealth, education, social care, thevoluntary sector and parents.The day was designed to understandwhere gaps in current serviceprovision occurred and share pocketsof 'good practice'. Using thisinformation and the views of parents,who were present, the team createdthe ‘ideal pathway’ and formulatedthe concept of ‘link worker’ role tonavigate parents around local serviceswhen and where they wished toaccess them.

The ideas generated on the day werethen tested via a postal questionnaireand responses were received fromacross the area and from parentscovering a wide age range ofchildren. The responses to theconcept of a ‘single point of contact’were well received.

Parents were also questioned aboutwhere they would like to receiveservices and information, as well asby whom. This allowed differentoptions to be explored.

In parallel, the provision of audiologyservices were reviewed across thelocality and audited against existingquality standard for testing facilities,range of tests available, skills ortraining of staff performing the tests,as well as how 'child friendly' thefacilities were in terms of meeting thechildren's needs prior to testing.There was also an audit of theprovision of other services across thearea, such as social work and speechand language therapy and some ofthe services which had beensuggested from the involvement dayand postal questionnaire.

Results were generally good, but didprovide an action plan for upgradingsome facilities in terms of estate,testing equipment and staff training.This will be progressed through theCHSWG with the relevantcommissioners.

‘It would be good to have a named person to talk towho could point us in the right direction for whateverwe needed at the time’



The results audits, patient feedbackand the plans from the stakeholderinvolvement day were fed back toprofessionals, commissioners andparents at a 'feedback day' wherefurther action plans were developed.

Benefits

QualityProposal of a new pathway, followingdiagnosis, to include a single point ofcontact to access education, speechand language therapy, family andsocial support and the voluntarysector, developed through patientinvolvement. The proposed modelshould ensure equity of service acrossall areas, which should in turnimprove quality and efficiency.

A clear action plan for commissionersand service heads has beendeveloped to improve the level ofaudiology equipment and staff skills.

InnovationThe questionnaire identified parentswho are keen to be involved in servicedesign and development, which will beuseful in this and future projects.

Professionals from across health,education, social care and voluntaryorganisations, involved in childrenwith a hearing impairment, have abetter understanding of the range ofservices that can be provided and ofeach others roles.

A new ‘key worker’ role concept,who could provide this single point ofcontact would better meet the needsof carers wishing to access a complexrange of services, improving access.

Quality standards used and adapted for audit.

% of clinics meeting the standards for test room acoustics

ProductivityImproved testing facilities andtraining standards should improvestandards, resulting in fewer testshaving to be repeated in a secondaryor tertiary care setting to confirmdiagnosis.

A streamlined pathway and clarity ofrole should lead to less duplication bydifferent professionals, with an MDTapproach supporting this further. Proposals developed will be takenforward through the CHSWGthrough a written report, which willbe developed into a strategic plan.The CHSWG will engage with therelevant commissioners across theorganisations to progress issuesrequiring joint commissioningarrangements.


3zPushing the boundaries: Evidence to support the development and implementation of good practice in audiology | 43


Children’s permanent hearing pathway (Ideal redesigned)



Warwickshire Local AuthorityWarwickshire's AudiologyImprovement Programme

Presenting issuesThe provision of communityaudiology services acrossWarwickshire is very fragmented. Areview of services concluded that thethree localities ran very differentlywith duplication of roles and apathway that was inconsistentlyimplemented across the three acutetrusts, community services and theLocal Authority. The aim of theproject was to achieve consistency,streamline services, reduceduplication and identify any gaps inservices, while evaluating the staffskill mix.

What they did• Process mapped the patient

pathway across Warwickshire • Reviewed skill mix at various points• Identified existing data and

highlighted gaps in current datacollection

• Agreed a detailed action plan to betaken forward to include:• A multi-disciplinary team

approach to disclosure• A different approach to gaining

consent from parents• Agreement to reduce DNA rates • Rolling programme of joint

training for health visitors • Changes in the level of support

given by teachers of the deaf to children in schools

• A hearing interest space on the local authority's virtual learning platform that will offer support, advice and information to children with hearing impairment.

Benefits

QualityRelationships/change management;there has been an impact in terms ofbuilding relationships across the fiveorganisations, developing trust and ashared ownership of the audiologyservices' issues and challenges.Plans are in place to canvass parentsopinion of the services provided usingthe ‘little ears’ parents group to trialthe survey, acting on the feedbackwill enhance the quality of theirexperience.

Innovation• The virtual learning platform allows

children speedy access to help,information and support.

Productivity• The revision of the educational

audiologists role will reduce thenumber of hours spent travellingand allow more time to supportthose children who requirespecialist intervention.

• An agreed action plan to drivedown the high DNA rates willensure that the available capacitywithin clinics is used productively.

• A reduction in inappropriatereferrals will allow speedy access tohearing assessments, resulting inmore timely intervention.



Central Auditory Processing Disorder (CAPD)

IntroductionAuditory processing occurs in thebrain which recognizes and interpretssurrounding sounds. Central AuditoryProcessing Disorder (CAPD) occurswhen there is a disruption to theinterpretation process, despite thesounds being heard normally. Thecauses of CAPD are still unclear,however it is a disorder that iscommonly assessed and managedworld-wide.

To a skilled professional, CAPD can berecognised during childhood,sometimes as early as four years old.If, however, the auditory deficits arenot identified and managed early,many of these children will havespeech and language delays andacademic problems. This in turn canlead to comprehension problems andpoor academic performance whichcan continue on into adolescence andearly adulthood.

Due to the effects of auditorymaturation and languagedevelopment, CAPD can only reliablybe formally assessed at around sixyears of age. However, an informalassessment can be made from theage of four when certain pre requisiteskills are found to be under-developed to an age appropriate levele.g. phonological awareness.

Assessment and diagnosis of CAPDwould involve a child undergoing abattery of tests, undertaken by avariety of professionals,predominantly including anaudiologist and speech-languagetherapist. Treatment of CAPD isindividually prescribed, depending ontest findings and involves a variety oftherapies, such as language building,auditory integration training andmemory enhancement.

CAPD – Summary

The assessment and/or treatment of CAPD is a new andemerging field in the UK and there is a lack ofdocumented information from this country with regardto successful management. This team set out toexamine the local need for a CAPD assessment andtreatment service with a view to presenting a case forservice development.



NHS Tower Hamlets and NHS City & Hackney

Presenting issuesCurrently there is no service forchildren in the Tower Hamlets andCity & Hackney boroughs for theassessment or treatment of childrenwith suspected or diagnosed CAPD.In addition, there is no provision forstaff to develop such a service withregard to time, training orequipment.

What they did and how they did it• An audit was completed in July and

August 2009 by second and thirdtier audiology services in TowerHamlets and City & Hackneyboroughs in order to determine thenumber of patients who mightbenefit from a CAPD service

• 11 patients were found to besuitable for further diagnosticassessment

• A literature review was carried outto provide evidence to support thecase for a pilot study

• A multidisciplinary meeting washeld in order to get 'buy-in' fromother professionals, includingspeech and language therapists, ateacher of the deaf, occupationaltherapists, audiologists and aneducational psychologist

• A case study comparing the patientexperience of two sisters, one withearly and the other with a lateassessment, diagnosis andtreatment of CAPD was presented

• Senior management supportresulted in £3,000 being allocatedfor the team to purchaseequipment to provide a CAPDassessment service.

Next steps• Referrals will be made by the

audio-vestibular physician to theaudiology team

• CAPD assessments will be carriedout by the senior paediatricaudiologist

• Pilot to be audited and theevidence used to develop a CAPDbusiness case for submission to therelevant trusts for consideration.

Benefits

Quality and innovation• Provision of a new service to assess

and treat CAPD in children.

Prevention• Prevention of ongoing speech and

language difficulties and learningdelays in children through earlyassessment, diagnosis andappropriate treatment of CAPD.

ContactGovender NelaeniSenior Paediatric Audiologist,Hackney [email protected]

NHSNHSCity and Hackney

Community Health ServicesTower Hamlets

Community Health Services



Acknowledgement

The Department of Health AudiologyManagement Group and NHSImprovement would like to thank allthe pilot sites for their continuingsupport and commitment totransforming audiology services. Thelearning that has emerged from thiswork will prove to be exceptionallyvaluable to all audiology departmentsas they strive to improve the servicesthey deliver. The sites havedemonstrated benefits to the quality,innovation, productivity andprevention agenda with significantenhancements made to the patientand public experience. This is a creditto the sites involved and theirongoing commitment to improveservices and share their learning withthe wider NHS.



Glossary

ADP Auditory Processing Disorders

AVM Audio Vestibular Medicine

AVP Audio Vestibular Physician

BPPV Benign Paraxysmal Positional Vertigo

CAPD Central Auditory Processing Disorder

CHSWG Children’s Hearing Services Working Group

DNA Did Not Attend

EBD Experience Based Design

ENT Ear Nose and Throat

HCS Health Care Scientist

IMP Individual Management Plan

QET Quality Enhancement Tool

MDT Multi Disciplinary Team

NDCS National Deaf Children’s Society

SHARC Specialist Hearing and Rehabilitation Clinic





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Telephone: 0116 222 5184 | Fax: 0116 222 5101

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NHS Improvement

With over ten years practical service improvement experience in cancer,diagnostics and heart, NHS Improvement aims to achieve sustainableeffective pathways and systems, share improvement resources andlearning, increase impact and ensure value for money to improve theefficiency and quality of NHS services.

Working with clinical networks and NHS organisations across England,NHS Improvement helps to transform, deliver and build sustainableimprovements across the entire pathway of care in audiology, cancer,diagnostics, heart, lung and stroke services.

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