University Hospital Birmingham last week became the fourth NHS trust in England to launch a new-style audiology service, complete with state-of-the-art digital hearing aids, as part of a £10m project to bring services into the 21st century. The Royal National Institute for Deaf People (RNID) is at the forefront of this programme which warrants the label "groundbreaking" as much for its implementation, as its likely impact. For it is one of the first examples of a charity co-managing a Department of Health project.
The relationship between the RNID, the department and fellow partners - the NHS's purchasing and supplies agency and the Medical Research Council's institute of hearing research - has been testing. Initial discussions constantly verged on breakdown.
In one corner, the RNID was arguing for digital hearing aids to be universally available, insisting that the NHS's purchasing power - by far the largest in the world, with 600,000 aids bought each year - could reduce the £2,000 retail price to £75. In the other corner, NHS purchasing and supplies was challenging this premise and denying the figures. The charity also had to fight against the project becoming totally research-focused, instead of being the first wave of a national implementation stategy.
Five million people could benefit from wearing a hearing aid. This number includes more than half of all people over 60. Yet only 2m have one, and of these, a third hardly use them. Technology some 30 years out of date - which accounts for hearing aids that whistle and amplify background noise as much as speech - plus waiting lists of up to 18 months for a hearing aid test are just two of the reasons for the low take-up.
"Audiology is a derelict service," said John Lowe, director of technology at the RNID. "It's often out the back of a hospital, has no soundproof rooms to conduct hearing tests, is underfunded and staff morale is low. It's not a priority. After all, people don't die of hearing loss."
The first-wave project intends to evaluate the costs and benefits of digital hearing aids and to examine the most effective ways to provide them through the NHS. But it is not just about 20 NHS trusts buying the latest technology and making it widely available. It is about modernising the whole service. This involves recruiting extra staff, working with IT departments, buying computer equipment, developing new service protocols and training staff in those protocols, and in fitting digital hearing aids.
Having embarrassed the government, by highlighting the gulf between NHS hearing aids and their hi-tech counterparts available privately for £2,000, the RNID was asked by the health department in January to co-manage the project. Mr Lowe admits this came as a shock and was not easy for a campaigning organisation to accept.
"We had to think carefully if our involvement would be good or bad," he said. "We were flattered and we didn't want to respond to that. In the end, we thought the project would be more effective if we became part of the team." Having made clear that involvement would not silence its campaign to get the project rolled out across all audiology clinics, the charity took up the challenge.
The department says partnership-working is a key government objective. "We are using the RNID because of its expertise," said a spokesman, adding that views of the National Deaf Children's Society and British Deaf Association were also taken on board through a project reference group.
The RNID's project management role entailed recruiting a first-wave team, comprising a full-time member of staff responsible for the day-to-day running of the project, an assistant and a project audiologist - seconded on a part-time basis from the Royal Berkshire hospital in Reading - to advise on equipment, training and service delivery. In addition, much of Mr Lowe's time and that of James Strachan, RNID chief executive, is going into the project - not to mention the work of the charity's communications team in producing newsletters for audiology departments.
According to the charity, all this is paid for out of the £4m allocated by government for the project's first year. Some £2m is paying for digital hearing aids, £1.4m for computer equipment and the rest for extra staffing and training across the 15 trusts involved since April. Another five go live next April.
Approaching half of the 240 audiology departments in England applied to become a first-wave project. The 20 selected represent a cross-section - from large, well-equipped city clinics to small, rural outfits. The Royal United hospital in Bath has been fitting the Starkey Gemini behind-the-ear digital hearing aid since the end of September. Andrew Reid, the hospital's head of audiology, said: "It is a lot of stuff for the 10 staff to learn. There is ongoing training in using new audiology equipment and specialised computer software to programme the aids."
Independent researchers are based at each of the 20 trusts. Their job is to examine the cost benefits of digital hearing aids, compared to the analogue variety, using quality of life measures. They will also test whether two digital aids are better than one and the effectiveness of four different aids.
The audiology service currently costs the NHS £57m a year or £95 a person (£45 for the analogue hearing aid and £50 for the service). The RNID expects this to increase to a maximum of £138m a year or £230 a person (£150 for a digital aid and £80 for an improved service), although it firmly believes the cost of digital aids can be brought down with economies of scale once the project is rolled out to all audiology departments by 2004. The government has committed an initial £25m for this.
With partnership a much maligned term, Mr Strachan likens the charity's role vis-a-vis the government, to a joint business venture. "This is not contracting out," he said. "It is closer to seconding our expertise and knowledge to the Department of Health with both sides having contractual obligations."
Despite having started work in February, the contract was only signed last month after RNID lawyers advised that it could not be held to the delivery of a government project. Contract wording was changed to "best endeavours to coordinate".
For other charities thinking of taking a similar route, Mr Strachan said the key was to identify a problem and provide a solution by putting yourself in the shoes of government. "We came in as a catalyst, telling government that we could affect the lives of millions for relatively little money. Now that must be music to most ministers' ears."
Joy of hearing classical music
Kathleen Brown, 85, has had a hearing aid for 10 years. Last week she was fitted with a digital model at Bath's Royal United hospital. "Now I can hear what my two sons and their families are saying," she said. "I used to wear my old hearing aid all the time, but it was inadequate. I used to see they were talking, but because I couldn't hear the words, I'd ask a question and find out that was what they'd been talking about. It made me feel really stupid, especially when I was in a shop or having my eyes tested and my daughter-in-law had to act as an interpreter.
"When I was at prayer meetings I couldn't hear a word, so I'd turn up my hearing aid and there'd be a hissing noise. It was very embarrassing. People would turn round and look. Still I couldn't hear a word. I had to be in direct line with someone to hear what they were saying."
Mrs Brown said her lack of hearing stopped her going out and meeting new people. Now she is looking forward to getting back to her prayer meetings and listening to her collection of classical CDs and the radio without annoying the neighbours. "I love my music" she said. "It will be lovely to hear it without having to make it so loud."
Who it affects
• About 8.7m people in the UK (one in seven) have a hearing loss; three-quarters are over 60.
• Thirteen children in every 10,000 are born deaf or become deaf while very young - four of the 13 being profoundly deaf.
• Analogue hearing aids amplify sound, including background noise, which can drown out speech.
• Digital hearing aids can process sounds more precisely and can be finely adjusted to suit individuals and different sound environments.
