Providing integrated ear care and audiology as a community service

Introduction

We all take our senses for granted until we start to lose them. Reduced hearing – whether from excess ear wax, infection or natural decline with age, or a mix thereof – impairs the ability to communicate. This may lead to loss of independence, conflict with loved ones and reduced enjoyment of life. In Rotherham, since 2011, patients aged 55 and over who experience hearing problems have had access to a service combining safe ear care and specialist audiology, enabling their hearing problems to be addressed quickly and efficiently.

Integration

In 2011, the ear care and audiology departments at Rotherham Hospital were amalgamated. They had always had good informal relationships and an obvious synergy. It was hoped that having both disciplines in one place would improve services for people with hearing problems, particularly those aged 65 and over, who form the majority of patients. The goals were to improve the patient pathway, experience and quality of life by providing accessible, timely, efficient and friendly services, as well as to expand capacity to respond to increasing demand.

The amalgamation – which we believe is unique in the NHS – occurred in June 2011, when Rotherham community services were integrated with Rotherham Foundation Trust. Community services had a purpose-built health centre in central Rotherham with good transport links, parking and lifts – the new integrated ear care and audiology service moved into a suite in the building.

The integrated service provides:

• Ear care clinics and audiology clinics at the community health centre, hospital and various other venues;
• Home visits by nurses and audiologists;
• A newborn hearing screening service at the hospital and health centre;
• Patient advice, support, education and health promotion;
• Hearing aid repair sessions in local venues (run by volunteers from the charity Action on Hearing Loss);
• Sale of hearing aids, hearing aid accessories and ear care accessories such as swim plugs and noise plugs.

Patient education – on a one-to-one basis, through leaflets and the website – is an integral part of the service. Patients may, for example, be taught how to instil ear drops, while those with hearing aids are encouraged to attend training sessions to learn how to replace the batteries and tubing. The service also participates in research and trains nurses, audiologists and support workers in topics such as ear irrigation, instrumentation, infection treatment, microsuction and mould impressions.

‘One-stop shop’ service

In 2014 we created a ‘one-stop shop’ service for patients aged 55 and over. The previous year, a self-referral pathway had been agreed with trust committees and general practices. The one-stop shop was publicised via notices and leaflets in GP surgeries.

Patients aged 55 and over can self-refer and expect to see, on the same day, a specialist ear nurse and an audiologist. The nurse examines them, removes any ear wax (via instruments, irrigation or microsuction) and treats any infection. The audiologist then carries out a hearing test to determine whether a hearing aid is needed. In most cases, patients who need a hearing aid are issued with one on the same day.

Many hearing aids have a dome – a small tip that goes into the outer ear; if a dome is appropriate, the audiologist decides which size to use and the hearing aid can be issued. Some patients will need a hearing aid with a bespoke mould fitting – they will need to have made an impression of their outer ear, and wait for the mould to be created before receiving their hearing aid; this can take several weeks.

The most obvious benefit of the service is that it reduces the number of appointments for an individual patient, freeing up time so staff can see other patients. In 2015, a further step was taken when the service started selling hearing aids unavailable through the NHS. Patients who can afford them appreciate being able to buy them from us, rather than privately, and the sales provide a source of income for the service.

Most people experience natural hearing loss as they age. Hearing loss before the age of 55 needs to be investigated either at a specialist audiology clinic or an ear, nose and throat (ENT) department, both of which require referral from a GP.

Changing working practices

Pre-integration, meetings were held to tell staff of the proposed changes and let them talk to members of the other team. The leadership team met to discuss rota changes and see how more clinics could be held.

Nurses and audiologists had to learn to work together and some working practices had to be changed. New ideas were implemented and patient groups initiated. GPs and practice nurses were told of the changes and involved in promoting the service. Nurses trained audiologists to remove ear wax, while audiologists taught nurses how to carry out simple hearing aid repairs.

A new telephone appointment system was introduced and reception staff trained in its use. Communication, data collection and reporting were improved, partly by extending the electronic patient record system from the old ear care department to the new service. A more-efficient stocktaking system was also introduced.

Changing working practices is not always easy but most staff members supported the changes and all were eventually won over through open team discussions, training, encouragement, support, and being shown how the changes would improve the service.

Outcomes

The outcomes have been overwhelmingly positive. Appointments are in an accessible, user-friendly location, rather than at the hospital (which is outside of Rotherham and has poor parking). The number of appointments needed by individual patients has dropped (in most cases, second appointments are no longer needed), thereby expanding the team’s capacity to see other patients. The service is naturally expanding as our patient population ages; in the last five years, our audiology caseload has increased by 7,000 to 18,000 patients.

“We were impressed by the creation of a successful model at a difficult time when faced with funding pressures” (Judges’ feedback)

Waiting times have reduced: previously patients could wait up to three months to see an audiologist but now the target six-week wait is routinely achieved. Nurses were already achieving that target; now they achieve waiting times of one to three weeks.

Staff have embraced integration and become one efficient, close-knit team. Skills have been extended, communication has improved, and staff work more flexibly for the benefit of patients – from whom we receive much praise (Box 1) and many recommend us to friends and families.

Clinical and financial sense

When the two departments were amalgamated, so were their budgets. Over the years, fewer appointments, more-efficient staff rotas and improved working practices allowed us to make cost savings. The sale of training courses, specialist ear care instruments, ear care equipment and hearing aids provides us with an income.

In 2016, cost savings and income allowed us to recruit additional staff, further increasing capacity and reducing waiting times. The team currently comprises 30 staff: a head and deputy head of service, a clinical lead, five specialist nurses, two healthcare assistants, nine audiologists, two associate audiologists, one technician, three newborn hearing screeners, two administrators and three admin support roles.

Many general practices provide only basic ear care in the form of wax removal – and some do not even offer that – while many trusts rely on their ENT department to pick up all but the simplest ear problems. Many audiology departments send patients back to their GP because they are not supposed to deal with wax blockages.

These ways of responding to the inevitable hearing problems of an ageing population are expensive for the NHS and bad for patients, who have to attend endless appointments with the associated delays, expenses, discomfort and distress. A combined, community-based service makes clinical and financial sense. Close working relationships with the hospital ENT department and local general practices are essential to provide a complete patient pathway and the best possible outcomes from the combined expertise.