Proportion of Digital Aids of the total of all Private Hearing Aids – 1996-2000
Prepared for:
THE DEPARTMENT OF TRADE & INDUSTRY
By:
MAKROTEST LIMITED
29 Culverden Park
Tunbridge Wells
Kent TN4 9QT
Tel: 01892 510 711
Fax: 01892 511 930
E-mail: makrotest@msn.com
21/102
27th June, 2001
1.1 This is a report on the study to review the Hearing Aid Act 1968 and Amendment 1989.
1.2 The objectives of the study were:-
1.3 The research at Stage 1 consisted of desk research and a number of interviews with key organisations including the DTI, HAC itself, NHS and RNID. As a result of this first stage an initial report was presented to the DTI including a detailed programme and topic list for the interviews at Stages 2 & 3 of the research. Stage 2 involved talking to hearing aid manufacturers and Stage 3 to dispensers and a number of other organisations. A summary of all the interviews is shown in the table below.
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Manufacturers Dispensers:
HAC Council members:
Other Organisations:
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10
3
2
3 |
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* Dispensers interviewed as council members also being included in the
dispenser numbers given above.
** The Big Three dispensers are: Amplivox & Ultratone, Hidden Hearing and
Scrivens. |
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A full list of all organisations and individuals interviewed is given in the Appendix to this report. All the interviews were carried out by 5 consultants – Nick Rubashow, Graham Barley, Marta Victor, Catherine Williams and Robin Huckle.
1.4 After Stage 3 detailed analysis took place at Stage 4. This was carried out in two ways:-
1.5 A draft report was produced at the end of Stage 4. Further discussions then took place with the DTI, the HAC, BSHAA, the Chief Scientist at the Department of Health and the NHS Policy Unit.
1.6 In addition to the interviewing work a number of other documents were consulted. A full list of these is given in the Appendix to this report.
1.7 Throughout the report we use a number of initials – they are listed below:-
2.1 The Market for Hearing Aids
2.2 Market Trends
2.3 Distribution of Private Hearing Aids
2.4 Consumer
2.5 Other Issues
2.6 The HAC
2.7 No Change to the HAC
2.8 Recommended Changes to HAC Operation
We recommend that a new complaints procedure including some power of summary jurisdiction be introduced on similar lines to that of the Optical Consumer Complaints Service and the General Medical Council. The new complaints procedure would:-
| COMPLAINTS PROCEDURE |
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By using this procedure:-
2.9 Other Recommendations
2.10 Changes to the Composition of the HAC
We recommend a change to the composition of the HAC to ensure greater representation of dispensers in order to:-
However, we believe it is important to have strong independent voices on the committee. This would include direct representation by consumer organisations such as Hearing Concern, RNID etc. and to have two medical representatives on the Council – one involved in qualifications/training and the other sitting on the investigative committee.
2.11 Who the HAC Report To
We believe consideration in the long run should be given to move the HAC to the Department of Health.
2.12 Timing
The changes to the HAC fall into two categories:-
2.13 Other Issue – The Move Towards One Market
Nearly all European countries have close integration between the public and private sector, with clients being entitled to a minimum level voucher and then being able to choose a dispenser and which type of aid to buy. Dispensers believe there are considerable benefits to this system as:-
3.1 In this section we examine the current market for hearing aids in detail and examine a number of factors affecting the operation of the Hearing Aid Council. We then examine the views about the Hearing Aid Council, its effectiveness and operation from the viewpoints of manufacturers, dispensers and council members.
3.2 In the table below we show our estimates for the market for hearing aids in 2000, both in volume and value terms.
| VOLUME 000 |
APPROXIMATE VALUE £000 * |
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DIGITAL
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25 |
84,000 |
ANALOGUE
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20 |
45,000 |
| TOTAL | 150 | 129,000 |
| * To calculate the value at
consumers’ prices we have taken the following average figures – Analogue £500, Digital £1,400. |
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| VOLUME 000 |
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| Central Contracts (primarily Analogue & BTE) Additional Purchases by NHS Trusts Scotland |
500,000 40,000 50,000 |
| TOTAL | 640,000 |
| * Issued 230,000 new, 320,000 re-used. | |
Source: British Hearing Aid Manufacturers’ Association (BHAMA) and trade statistics
| % | |
| Private dispensers excluding Big 3
By the Big 3 NHS central contact NHS off list Education / universities |
33 25 29 11 2 |
| TOTAL | 100 |
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BASE: £53 million |
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Source: Institute of Hearing Research
3.3 Within the Private Sector
Proportion of Digital Aids of the total of all Private Hearing Aids – 1996-2000
3.3 Market Growth Within the Private Sector
3.4 Within the Public Sector
Source: BHAMA and trade estimates
3.6 Market Structure
There are approximately 120 organisations registered with HAC and dispensing hearing aids. There are around 1,100 individuals registered with HAC. The market structure itself is very concentrated as the Big 3 dispensers employ around 600 dispensers i.e. over 50% of the market. Nearly all the other dispensers are employed in/by smaller companies, with a great majority employing less than 5 dispensers each.
3.7 Amongst private dispensers there are 21 NHS Trusts currently registered with the HAC. We talked to over half these Trusts and believe that the total number of private aids sold by these Trusts is relatively small. However, there is other evidence/viewpoint that private sales by NHS dispensers is much higher. There are estimated to be in the order of 150-170 dispensers who have qualified with the HAC through the fast track process, initially having qualified under BAAT. We discovered that there was a wide variety of viewpoints about how many hearing aids these dispensers were selling. It has been difficult for us to get firm evidence about this.
3.8 There are two organisations representing dispensers:-
3.9 The current market structure gives rise to a number of issues:-
3.10 Method of Distribution
Traditionally private hearing aids have been dispensed by home visits. Initially the Hearing Aid Council Act was set up in order to control and regulate home visits. Currently the industry estimates that the market is divided up broadly:-
It is difficult to be precise about this figure. Two of the Big 3 have almost 80% home visits. Some of the smaller independents have retail establishments/use of retail establishments, sometimes within NHS Trusts.
3.11 Unlike the optical industry, currently the number and size of retail outlets used for the dispensing of private hearing aids is low. A more significant retail presence would increase the standing of the hearing aid profession and from the consumers’ viewpoint. The current high proportion of home sales and consequent advertising does little for the image of the industry, while a high quality retail presence as in the optical supply chain would improve the professional standing of the industry (see Appendix 4 on the optical supply chain).
A greater retail presence would also enable HAC to be more visible to consumers.
3.12 There is now a clear trend towards retail. There are a number of reasons for this:-
3.13 NHS Trust Sales of Hearing Aids
This is a controversial topic as some dispensers, primarily the Big 3, are very worried about the increasing involvement of NHS Trusts in selling hearing aids. They see this as unfair competition, particularly if it is carried out by NHS audiologists who may be moonlighting. Other dispensers, particularly the smaller independent ones, are less worried about this and often have closer relationships with NHS Trusts and gain referrals from them. Some dispensers may also have a contract to supply and dispense hearing aids on behalf of the NHS Trusts. As we discussed earlier in paragraph 3.7, the exact amount and volume of aids sold privately through NHS Trusts and audiologists is difficult to estimate.
3.14 We discuss the future market trends in the paragraphs below.
aids than previously. For a digital product sometimes a higher quality
product and an easier to control product can be produced in a ‘behind the ear’
version. Thus, the proportion of ITE sold privately has diminished marginally.
(d) Disposable Aids – As Songbird has just been introduced it is not clear what trends are in relation to disposables. Boots, who are introducing the Songbird disposable product, see this as an "low threshold product" sold through retail outlets. If this is successful it will have a major impact on the market, particularly in relation to establishing a strong retail presence.
The issue of how disposables relate to the HAC Act is important and is discussed in paragraph 4.7.
3.15 Mail Order Sales
Mail order sales of hearing aids are a concern as they currently by-pass HAC regulations. Manufacturers believe that the number of aids sold in this way is extremely small. However, there is a related issue – advertising of free hearing aids, followed by an audiological test, and used as a way of building databases or, in certain cases, switch selling. We discuss in paragraph 4.7 whether the Act should be amended to include other forms of contract including mail order.
There is, however, a related issue – advertising of free hearing aids, followed by an audiological test, used as a way of building databases or, in certain cases, ‘switch selling’. By switch selling we mean approaching the consumer to sell them i.e. a full hearing aid after having given them a free hearing aid or cheap hearing device. Whilst this practice is not obviously against consumer interest it is of considerable concern to many dispensers and organisations representing the consumer, as it is often seen as poor practice and gives a poor impression/image of the dispensing industry. The major dispensers who do advertise in this way say that they have to do this to increase sales to an economically viable level. They add that they would not continue with this practice if the market was bigger – i.e. operated as one market on the lines of many European countries.
3.16 Sales Through the Internet
We believe that currently there are very few sales of hearing aids through the Internet. The Internet is primarily used for information. However, there are one or two European dispensers who advertise cheaper hearing aids on the Internet and one Danish dispenser who is prepared to come to England and fit a hearing aid, although he is not registered with the HAC. This has caused concern both amongst manufacturers and dispensers who would like this type of activity to cease. These purchases do not appear to be in the consumers’ interest as both fitting and service/repair of aids is not readily available or cheap.
3.17 The Consumer
The prime consumer for private hearing dispensers is in the 60-80 age range. Relatively few private aid purchasers are under 60, with the majority of younger hard of hearing in children being dealt with primarily by the NHS.
3.18 There are a very large numbers of potential consumers. MRC estimates that around 7.8 million people have a hearing impairment and could benefit from a hearing aid but only 1.7 million people actually currently have a hearing aid. It is thought that most people wait for a few years after they have a hearing problem before they actually do something about it. There is still a considerable stigma attached to having a hearing aid. There are also perceived to be specific problems related to hearing aids:-
3.19 In terms of consumer satisfaction it is difficult to be precise about the degree of satisfaction with private dispensers. There is evidence that for both the National Health and private hearing aids there are a number of people who feel their hearing aid has given them no benefit and a significant number (in the order of 20%) of people do not use their hearing aids at all.
3.20 The Audit Commission Report was clear that the current dispensing of hearing aids by the NHS was of a poor standard, both in terms of type of aid dispensed and the standard of service and aftercare offered.
3.21 In the 1996 study by Hearing Concern criticised the standard of aftercare and service offered by some dispensers, showing that some 12% of purchasers were dissatisfied. A more recent survey by Hearing Concern conducted in 2001 showed the type of advice given by dispensers was more likely to be satisfactory in the private sector than the NHS. It also showed that private aids were judged to be considerably more effective – over half were thought good compared with one-third of NHS sales. However, the criticism of private dispensers that occurred was that only 39% of purchasers considered the aids to be good value for money.
3.22 The other issues mentioned by the consumer organisations in relation to private dispensing of aids were:-
3.23 The number of consumer complaints received by the HAC has increased over the last few years. In 1998 it was around 160. By 2000 it had reached 217 and in 2001 is currently running at around 260 per annum. The type of complaints are listed below.
TYPES OF COMPLAINTS RECEIVED BY THE HAC
September 2000 - May 2001
| Unsuitable hearing aid | 64 |
| Faulty hearing aids | 60 |
| Lack of care by hearing aid dispenser | 32 |
| No refund given although aids returned within trial period | 26 |
| Method of selling | 23 |
| Bad fit of hearing aid including causing pain | 21 |
| Unclear paperwork given to client including problems re lost deposits | 19 |
| Problems re insurance of hearing aids | 6 |
| Problems regarding payments for hearing aids | 5 |
| Hearing aids sent to dispenser and not returned to client | 3 |
| Potential breach of Clause 7 of the Code of Practice | 3 |
| Potential breaches of Code of Practice re incomplete paperwork received from hearing aid dispenser | 3 |
| Unsupervised trainee | 3 |
| Potential breach re registration of hearing aid dispensers | 2 |
| Potential breach Clause 16 of the Code of Practice | 1 |
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* Note complainants often have more than one reason for contacting the Hearing Aid Council | |
A significant number of these complaints relate to fitting of an unsuitable hearing aid or faulty hearing aid, or hearing aid not fitting properly. It is probable that the number of complaints could be reduced if Continuous Professional Development was compulsory. For example, the number of complaints about unsuitable hearing aids and the bad fitting of hearing aids would probably be reduced if all dispensers had compulsory competence based Continuous Professional Development on both technical issues and good practice.
A further comment we should make at this point is that in the context of 150,000 private aids sold per annum 260 complaints is not a large number.
3.24 Because of the above issues and perceptions about the private dispensing of hearing aids the industry has a mixed reputation amongst some consumer organisations who are concerned about the extent of regulation. There is also relatively little contact between consumer organisations and the HAC.
The main methods of marketing private hearing aids are discussed below.
3.25 Advertising
Some of the major dispensers, primarily two of the Big 3, indulge in extremely forceful advertising. Claims made about the performance of hearing aids can be sustained and do not breach ASA standards. However, there are some individual and independent dispensers, NHS audiologists and others representing consumer interests who believe the advertisements are too aggressive, are misleading and are often followed up in an aggressive way, though generally complying with HAC regulations. The advertisers counter these with the following arguments:-
3.26 In addition to advertising in the national press there is a considerable amount of advertising in the local press, Yellow Pages and specialist magazines. This is often done by the smaller independent dispensers.
3.27 Recommendation
Many dispensers exist primarily by recommendation from previous clients, but also recommendation from NHS.
3.28 Referral
The issue of NHS referrals / recommendations and of some dispensers operating on NHS Trust premises is another controversial issue. Some of the major dispensers believe that this is unfair competition. However, some of the smaller dispensers have either set up links or have contracts with NHS Trusts. These links should be seen in a positive light as they are likely to help break down the current distrust between the NHS and the private dispensing profession.
3.29 The Use of Web Sites / Internet
As discussed earlier, Internet sales are small and only carried out by dispensers not operating within the UK. The UK dispensers have developed their own web sites, primarily for information.
3.30 The HAC is responsible for the HAC Examination Qualifications for Dispensers. The HAC has an examination committee with three members, all of whom are council members. There is currently a proposal to include a member from the main professional body BSHAA to sit on the examination committee. The HAC qualifications thought by the dispensing industry to currently produce a high standard of dispensers. A training programme prior to taking the exam is around 6 months. Currently, around 40% of candidates taking the exam actually pass. The candidates then have to serve another 800 hours under supervision before they become fully qualified dispensers. After this there is currently no requirement for continuous professional qualifications.
Training is carried out by the major dispensers, with only limited independent training facilities.
3.31 Within the NHS the nearest equivalent qualification is BAAT. This audiologist qualification is broadly similar to that of HAC but with a number of important differences:-
Currently, it is possible for BAAT qualified audiologists to fast track the HAC and become qualified HAC dispensers. Around 170 NHS audiologists have done this within the last few years. There is no corresponding reciprocal arrangement, although this is being examined currently. The slowness of reciprocity has caused some concern amongst dispensers, although there is little evidence that many of them wish to practice within the NHS. This is, however, an important issue as it illustrates the different requirements of NHS audiologists & private dispensers. This and a number of other factors contribute to the distrust that exists between the private sector and the NHS audiologists. The factors are:-
3.32 In the long run there is also the issue of unitary qualifications, which is being examined separately within the NHS. There are a number of issues of concern here to dispensers. They are:-
3.33 Continuous Professional Development
Currently neither HAC nor BAAT have any compulsory continuous professional qualifications to ensure that dispensers are up-to-date in terms of their knowledge and technological developments of hearing aids and of all issues relating to meeting consumer needs. In the NHS for audiologists there is no system that exists at present. Within the private sector AIHAP have started its own continuous learning qualifications and BSHAA has adapted these with its CUES system, which is a points system for ensuring that dispensers are kept up-to-date. In order to qualify dispensers have to achieve a certain amount of points each year. There are mixed views about the standard of CUES but it is recognised as a good idea and in the longer run many dispensers believe that HAC should adopt this system and insist that all dispensers update their skills in this way. The NHS will be recommending Continuous Professional Development for all healthcare professionals who want this type of training and development to be competence based and assessed.
3.34 There has been considerable discussion of the costs of hearing aids, but a recent Office of Fair Trading investigation in 1998 cleared the dispensing industry of over charging.
3.35 It is difficult to put the precise breakdown of costs but we believe the following is broadly typical:-
Marketing costs are currently very high. This is particularly so amongst some larger dispensers who have high advertising and database marketing costs. Dispensers who operate primarily through recommendation or referral from the NHS have the lowest marketing costs.
If the private market was able to help with the NHS provision overall costs could be reduced.
3.36 The NHS has now recognised that its current provision has been patchy and that the standard of hearing aid dispensed by the NHS has been poor. The advent of digital hearing aids provides a unique opportunity for the NHS to radically upgrade both its technology and service in relation to hearing aids. Part of this process has been to examine the issues related to dispensing digital hearing aids in 20 centres. Currently four centres are fully operating and up to March 2001 a total of just over a thousand digital aids have been dispensed. The idea is to develop clear standards and practice in dispensing hearing aids and then to roll out this programme throughout the NHS.
3.37 The dispensing of digital hearing aids requires:-
It was the view of many of our respondents including manufacturers, NHS audiologists and private hearing aid dispensers that the NHS would have considerable difficulty in recruiting and training staff to be able to deliver digital aids throughout the NHS. They thought that waiting lists are likely to lengthen considerably. This view was reinforced by the RNID survey ‘Audiology in Crisis’ published in March 2001.
3.38 The impact the roll out of digital hearing aids would have on the private sector is unclear.
3.39 The great majority of respondents we talked to, both private dispensers, NHS audiologists and manufacturers, agreed that digital hearing aids generally offered a better product to a great majority of consumers than the analogue hearing aid. There was, however, great emphasis on the need for the digital aid to be correctly fitted. Within the private sector there was a view that at least two or three return visits were required to make sure the hearing aid was properly adjusted and fitted. The NHS is attempting to manage the fitting and adjustment with just one return visit. This was thought to be inadequate by many private dispensers and by Hearing Concern.
3.40 The advent of the digital hearing aid currently means that there is a need for greater consumer focus than previously. The benefits of the aid need to be explained carefully, what it can and cannot do, and the need for the hearing aid to be properly fitted and adjusted. The dispensers believe that this signals the beginning of a more consumer-focused era for hearing aids. It is clearly important that when consumers visit the dispenser they are made aware of all the other equipment (loops, inductions etc.) that can help them overcome their hearing loss or minimise its effects.
3.41 In this section we discuss the role of the HAC, its effectiveness and attitudes to the way it currently operates. We then discuss the possible changes to the HAC.
The Role of the HAC
3.42 The role of the HAC is seen as consumer protection. Generally dispensers and manufacturers see that there is a need to ensure that hearing aids are dispensed in a thoroughly professional way and that consumers are fully protected from unscrupulous or unqualified dispensers. We recognise that the HAC came into existence in 1968 because there were a number of unscrupulous dispensers selling hearing aids on a doorstep basis. There was a general agreement that HAC regulated the function well in its early days and it was set up to meet a very specific need. Many dispensers thought that this role would be continued in the future and no major changes to its objectives were needed. There is, however, another view that the role of the HAC should be seen in a wider context – not only protecting the consumer but generally ensuring and promoting very high standards in the dispensing of hearing aids.
3.43 Views on the effectiveness of the HAC varied to quite an extent.
3.44 We mention above that council members believe that the HAC does not have enough contact with the private dispensing profession. The HAC is somewhat isolated and has few contacts with key stakeholders, both within private dispensing and amongst other organisations including consumer interest organisations and the Department of Health and NHS. We believe that this isolation is a weakness which prevents the HAC from keeping fully up-to-date in a changing environment. We discuss how this issue should be addressed in paragraph 4.25
3.45 The number of complaints to the HAC has risen over the last few years, but not very dramatically. In 1996 there were around 150 complaints. This has now reached a total of 216 in 2000 and is running at the order of 260-300 for the year 2001. The increase in complaints was thought to be due to:-
3.46 Also, the issue about the variety of complaints came from complaints where there was considerable evidence of serious malpractice and fraud to complaints about misleading descriptions of audiologists. The way these complaints have been interpreted has clearly varied considerably over the last few years. Some previous investigative committees have dealt with a number of these complaints informally, talking to dispensers and relatively quickly resolving the issue. This informal approach has been criticised by some committee members. Currently the approach is more rigid, taking more complaints forward to the investigative committee, which can slow down the speed at which these can be resolved and which, if taken further, can result in large legal costs. We believe a clearer set of rules and procedures is needed to eliminate different individual interpretations of the Code of Practice.
3.47 There were a number of people who thought that the HAC should be more visible. This view was reflected via a number of smaller dispensers. Others felt that it would be risky if the HAC became very visible, as the number of complaints would increase, and under the current structure the HAC would not be able to deal with it.
3.48 Currently complaints are handled by the HAC by:-
Currently, a higher proportion of cases are moving from the Investigative Committee to the Disciplinary Committee, which is resulting in a larger number of legal cases and far higher legal fees. This leads to a number of problems:-
For a list of complaints going forward for disciplinary action see Appendix 3.
3.49 There was a view that unless the current system changes it will break down, as far too many cases are going to legal proceedings, accordingly the costs are rising substantially and timescales for resolution extending. It was also felt that the current Investigative Committee does not distinguish clearly enough between trivial and serious breaches of the Code of Practice. This was because they had no mechanism for doing so.
3.50 Composition of the HAC is an important issue as the precise competition and balance between those within the dispensing profession and those outside it influence attitudes to the operation and effectiveness of the council itself.
3.51 Currently the HAC consists of:-
This structure was imposed in 1989. Previously there had been a higher proportion of dispensing representatives.
3.52 Within the dispensing profession there was a view that the current structure is wrong because:-
The consumer element is thought by some to lack authority. There was a suggestion that possibly representatives of consumer bodies should be included – like Hearing Concern, Age Concern, etc. This would give the representatives more authority than individual consumers.
3.53 The changes we discussed with our respondents were:-
We discuss these in turn and develop the context that identifies and develops the significance of each issue:
Summary Jurisdiction
3.54 Summary jurisdiction allows the imposition of fines without court action. This is a device used by GMC, the optical industry and other professional bodies to enable them to act quickly on complaints and to avoid expensive legal fees.
3.55 There were very positive attitudes to summary jurisdiction amongst all our respondents. It was felt that summary jurisdiction would considerably reduce costs and increase the efficiency of the HAC. Care would be needed in terms of the level of fines and of setting up an appeals procedure and of the composition of the Investigative Committee. There was also concern that possibly a number of complaints should never even reach the Investigative Committee. We discuss this more fully in Section 4. The introduction of summary jurisdiction would be welcomed by dispensers and dispensing organisations as well as council members.
Auditing / Best Practice
3.56 The ability to check that professionals are conforming to the required regulation and Best Practice by some form of auditing is practiced by GMC and other professional organisations.
3.57 We discussed with our respondents whether some form of auditing, either on a regular or occasional basis, could be part of the HAC function. This would be to ensure that dispensers are keeping up proper professional standards and are obeying the full rules of the Code of Practice. This idea was welcomed by some dispensers but cost implications were worrying to some. It was felt that this could probably require a specialist professional team and these costs might be significant.
3.58 It would be welcomed by a number of independent dispensers who felt that it would be important to do this to monitor the practices of some dispensers who they felt were not keeping to the proper professional standards. [We discuss this issue more in Section 4] Another suggestion was that this auditing should be carried out by one of the professional bodies – possibly BSHAA. The idea was welcomed by some but it was pointed out that BSHAA did not represent the dispensing professional fully.
3.59 The Code of Practice is clearly important. It is the chief way in which the Act itself is applied to the profession.
3.60 It was felt that a major review of the Code of Practice was probably required. Again, viewpoints were rather different on this.
3.61 There was a strong feeling amongst manufacturers and dispensers that dispensers should be more fully involved in the HAC. Dispensers would prefer a council which consisted of 6 or 8 dispensers, a minority of 3-5 consumers and possibly medical professions. It was felt that a larger number of dispensers would deliver an improved balance of representation for the industry and would improve the current situation, which many independent dispensers felt was dominated by representatives of the Big 3.
It was also felt that a larger number of dispensers would give greater ownership of the HAC amongst the dispensing profession.
The counter argument to this was that the dispensing industry was felt by some not to be mature enough to have a high degree of self-regulation. This view was strongly held by some NHS audiologists and appears to be reinforced by some of the very aggressive national advertising by some private dispensers. A further argument was that the dispensing industry, because of its structure, was currently dominated by large dispensers and that this again was against the best interests of consumers.
3.62 Closer Links with Dispensing Profession and Other Organisations
It was felt that HAC would be more effective if it developed closer links with the dispensing profession rather than the current arms length policy. This would mean more discussions with BSHAA and AIHAP and more informal discussions with dispensers generally.
In addition, we believe the HAC should develop closer links with the Department of Health, in particular the new shadow Health Professional Council. It will also be beneficial to establish closer contact with consumer organisations such as RNID and Hearing Concern.
3.63 We believe that it is important for the HAC to develop closer links with the above organisations and for this reason we are recommending the formation of a new advisory body (see paragraph 4.25)
3.64 Attitudes to HAC Fees
Currently there are negative attitudes to the HAC fees, particularly the recent rises caused by rising legal fees. These are of most concern to the Big 3 and larger dispensers. Independent dispensers were less worried by the level of fees but would like to have more say in the way fees are spent.
3.65 It was strongly felt that, as dispensers paid for the HAC, they should have a reasonably strong say in the council and in how their own profession was disciplined. Having said this, most dispensers recognised that there needed to be a strong independent voice on the committee but did not want this voice to be in the majority.
3.66 Many dispensers felt angry that there was a clear viewpoint of some council members that private dispensers were unfit to have a high say in their own regulation and they had relatively low professional standards. In terms of the qualifications and the HAC exams it is clear that standards are now thought to be relatively high. We found little evidence in our study that standards were low, although there obviously were a number of cases where certain members of the profession behaved in an unprofessional manner.
3.67 Consumer Representation
There was a view expressed by some dispensers that individual consumer representation was not thought to be very effective. Consideration should be given to having formal consumer organisation representation on the council from organisations such as Hearing Concern, RNID, Age Concern, Help the Aged etc.
4.1 In this section we examine a number of possible actions / changes to the HAC that could be taken in order to best protect consumer interests. These include:-
We discuss each of these in turn.
4.2 This is not a practical option as:-
4.3 There was a strong view expressed by manufacturers, dispensers and consumer organisations that there was a need for regulation in order to ensure against malpractice by actions by dispensers that were not in the consumer interest.
4.4 In other European countries regulation exists through professional bodies which do not distinguish between private & public practice. They have a unitary qualification, which often has separate dispensing and medical audiological qualifications.
4.5 We believe that there is a clear need for regulation on a number of issues relating to regulation that need to be examined.
4.6 The issue of coverage of low power devices and any device put in the ear. Many of our respondents thought the regulations should be extended to ensure coverage of all devices put in the ear. This was despite the recognition that low powered devices cannot damage the ear. The argument for regulation of these devices was:-
The counter to the above arguments given by some respondents was:-
Although we recognise that both arguments are valid, we do not believe that it would be a necessary or practical for regulation to be extended and to include these devices.
4.7 The disposable product Songbird, now being marketed by Boots, needs to be taken into consideration. Although it is a disposable product it should come under the jurisdiction of the HAC.
Complaints Procedures
4.8 The current procedures within the HAC are resulting in:-
Also, the current procedures are framed in such a way that interpretation of the procedures can be different. Currently a higher proportion of complaints go through to disciplinary procedures than previously, primarily because the current investigative committee interprets complaints in a different way than the previous committee.
We recommend that the process that considers and administers the response to complaints should be governed by a transparent set of rules which are significantly less likely to be influenced by perspective, background, motivation of staff and relevant committees.
We further recommend that the process should include the effective screening of complaints and that an arbitration pathway is established for those complaints that, whilst warranting attention and discipline, do not necessarily have to pass to the investigative committee to be resolved.
4.9 From our examination of other regulatory procedures other health professions (in particular the Optical Consumer Complaints Service and the General Medical Council), we believe that a more effective approach to dealing with complaints would be as follows:-
Initial Screening of Complaints against a clearly defined set of rules to identify:-
1. Those cases within the terms of reference of the HAC
2. Those cases that could be initially the subject of arbitration (to A)
3. Those cases to be considered by the investigative committee (to B)
| COMPLAINTS PROCEDURE |
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By using this procedure:-
4.10 In order to implement this approach it will, however, be necessary to have one full-time professional employee at the HAC able to undertake the screening and conduct the arbitration with dispensers. We believe this probably could be funded by:-
Reactions to the proposed changes in complaints procedure have been extremely positive.
Inspection / Audit
4.11 We have considered the issue of inspection/auditing. There is little doubt that this approach can be effective, however we consider that the costs of implementation would be unrealistic for the HAC to bear. To fund an Inspectorate and operate in the field would require fees from dispensers that are an order of magnitude beyond those currently levied.
We also believe that:
then professional standards will become higher and the necessity for audit/inspection will diminish.
Note that we are recommending that Continuous Professional Development should become compulsory under the revised Code of Practice. This is discussed in paragraph 4.18
4.12 We believe there should be a number of changes to the Code of Practice. It should now include:-
4.13 We have already stated that we believe that in order to practice dispensers will need to show that they undertake Continuous Professional Development. This should be competence based and under the administration of the HAC. The dispensing industry through BSHAA could bid for the supply of these services.
4.14 The whole issue of qualifications is a complicated one. We believe in the long run the separate qualifications for private dispensing in the NHS is not beneficial to the consumer.
4.15 Reciprocity is now being discussed and we understand this is a difficult issue as private dispensers’ training and qualification focuses more on the dispensing of aids, while that of BAAT focuses more on the diagnostic and medical conditions, as well as dispensing. BAAT also requires supervision in clinical practice.
4.16 In the longer run the move towards a unitary qualification, which is an NHS objective, seems a very sensible one. We believe, however, that care needs to be taken when this is set up and that there are separate qualifications for:-
We believe it would be wrong to have a degree level entry for audiologists and dispensers if the current Code of Practice and referral system dispensers do not need to have full medical qualifications. In other European countries, and in the optical supply chain, there is a distinction between those who are medically qualified to analyse problems/disease/illness and those who can dispense aids.
4.17 This move towards unitary qualification is clearly not going to happen quickly, but we believe it is important that the above issues are taken into consideration when unitary qualifications are finalised. We strongly recommend that the HAC gets in touch with, and keeps in touch with, the Shadow Health Professions Council (and the full Council when it comes into existence next year) to ensure that the above issues are recognised. With the unitary qualification the regulation of hearing aids could well be organised in a similar way to that of the optical supply chain and to the European audiological model.
4.18 When the unitary qualification exists some of the functions of the HAC will clearly be devolved into the new professional organisation. This leads us to the long-term role of the HAC and where it should be placed.
4.19 We are recommending that there should be a new advisory body which should meet with the HAC twice a year. The advisory body should consist of a number of key stakeholders and should have an input into the HAC and keep the HAC up to date of all relevant developments of the hearing aid dispensing and the consumer interest. These stakeholders should consist of representatives of the hearing aid profession including BSHAA, AIHAP and possibly BHAMA. Organisations representing the consumer including RNID, Hearing Concern, Age Concern & others and representatives from the Department of Health & NHS and from professional organisations such as BAAT. The key function of this advisory body is to ensure that the HAC is well informed of developments and concern consumers’ best interest in the dispensing of hearing aids.
Council
4.20 We believe that there is a need to change the composition of the HAC to ensure greater representation of dispensers. We believe this would:-
However, we also believe it is extremely important to:
4.21 In terms of the medical profession, the current position where they have the same number of representatives as dispensers can, because of the process issues described, lead to unproductive conflict. We believe that medical representation should be reduced to two members. When appropriate, further expert advice can be co-opted to the disciplinary committee.
4.22 Thus, we would like to see a committee with 8 dispenser members with quotas to ensure that half the members are drawn from independent dispensers. We would then like 2 appropriate consumer organisations to be represented – this would be a formal representation by the organisation rather than an individual. There would then be 2 places on the Council for the medical profession. The Council Members should be chosen, as currently, by adherence to the guidelines published by the Office of the Commission for Public Appointments.
We would stress that the above changes would bring the HAC into line with other health professions, all of which have a majority of practising members on their regulatory bodies (see National Consumer Council Report – Regulation of Health Professions 2000).
4.24 We are aware that changes to the HAC composition will require legislation and we discuss the issue of timing of all changes we have recommended in paragraph 4.34. Another aspect of changing HAC composition is that by giving dispensers a majority with the Council this could be seen as returning to the pre-1989 situation. We should stress that we believe this is not a retrogressive step as:-
Chairperson
4.25 We believe, as currently is the case, that the chairperson:
4.26 Currently, the HAC reports to the DTI. This is probably because when it was set up it was primarily concerned with the commercial malpractice of dispensers. Although this is obviously still a major concern we believe in the longer run consideration should be given to the move to the Department of Health.
4.27 The reasons for believing a move to the Department of Health would be useful are:-
4.28 The changes we are recommending fall into two categories:-
4.29 Another issue which was brought to our attention by many dispensers and organisations representing the dispensers is the difference between the UK market, the Rest of Europe and indeed the Rest of the World. All other countries do not have a totally free NHS type operation. Nearly all European countries have close integration between the public and private sector, with clients being entitled to a minimum level voucher and then being able to choose the dispenser and which type of aid to buy. The benefits of this system are:-
4.30 The above developments would make the industry operation similar to that of the optical industry (see Appendix 4).
| INDEPENDENT DISPENSERS | ||
| Mr W M Walker & Mr P Ince | Mr Crate | |
| Hearcare (Worcester) Limited | Hearing Direct Limited | |
| Unit 6 | 1100 Parkway | |
| Reindeer Court Shopping Centre | Solent Business Centre | |
| Worcester WR1 2DS | Fareham PO15 7AB | |
| Tel: 01905 724 866 | Tel: 0800 389 7029 | |
| Mr P Syner & Mr Syner (Jnr) | Mr Ball | |
| Solihull Hearing Centre | South West Hearing Services | |
| 29 High Street | 50 St James's Street | |
| Solihull B91 3SJ | Taunton, Somerset TA1 1JR | |
| Tel: 0121 705 7177 | Tel: 01823 257 529 | |
| Mrs S Wroe & Mr S Wroe | Mr Richard Moss | |
| Professional Hearing Aid Services | Oxford Hearing Centre | |
| 46 Church Croft | 157 Eynsham Road | |
| Madley | Oxford OX2 9NE | |
| Hereford HR2 9LC | ||
| Tel: 01981 250 750 | Tel: 01865 861 861 | |
| Mr P J Ormerod & Ms J Booth | J B Goodwin | |
| David Ormerod Hearing Centre | Streatham Hearing Aid Centre | |
| 18 Trinity Square | 324 Streatham High Road | |
| Llandudno | London SW16 6HH | |
| N Wales | ||
| Tel: 01492 877 989 | Tel: 0208 677 4992 | |
| Mr Warner | Mr Adam Shulberg | |
| Wallis G Carter | Cubex | |
| (Bateman's Hearing Aid Centre) | 25 New Cavendish Street | |
| 6 Abbey Churchyard | London W1G 8LP | |
| Bath BA1 1LY | ||
| Tel: 01225 464 363 | Tel: 0207 935 5511 | |
| Mr Robert Beiny | Mr Robert Mills | |
| The Hearing Healthcare Practice | PPP/Columbia Healthcare Limited | |
| 129 Southdown Road | Audiology Dept., Portland Hospital | |
| Harpenden | 234 Great Portland Street | |
| Herts AL5 1PU | London W1N 5PH | |
| Tel: 01582 767 218 | Tel: 0207 580 4400 | |
| Mr Ian Peter Croft | Mr David Bagley (Head of Audiology) | |
| Hearing Help | Addenbrooke's Hospital | |
| 22 High Street | Cambridge | |
| Pinner, Middlesex HA5 5PW | ||
| Tel: 0208 869 9999 | Tel: 01223 217 797 | |
| Mr Ormerod | ||
| Ormerod Hearing | ||
| 5a Blackhorse Way | ||
| Horsham | ||
| Tel: 01403 218 700 | ||
|
|
||
|
BIG THREE |
||
| Mr C P Cartwright - Chairman | Mr Alan Rudge | |
| Amplivox & Ultratone Limited | Hidden Hearing | |
| Stanneylands Road | Maidstone | |
| Wilmslow | ||
| Cheshire SK4 4HH | Tel: 01527 515 604 | |
| Tel: 01625 417 025 | ||
| Mr Mark Georgevie & Mr Day | ||
| Scrivens | ||
| Monaco House | ||
| Bristol Street | ||
| Birmingham B5 7AR | ||
| Tel: 0121 622 2674 | ||
|
NHS DISPENSERS |
||
| Mr Andrew Reid Royal United Hospital Audiology Department Coombe Park Bath BA13 96 Tel: 01225 824 035 / 428 331 |
Helen Martin Chief Audiologist Winchester Hospital - part of digital trial Winchester Tel: 01962 824 437 |
|
| Ms Tracey Glover Stepping Hill Hospital Audiology Department Stockport Lancs Tel: 0161 419 4184 |
Karen Dewhurst Chief Audiologist Salisbury Healthcare NHS Trust Salisbury District Hospital Salisbury Tel: 01722 336 262 |
|
| James Battersby / Ashok Waghe The Royal National Throat, Nose & Ear Hospital Grays Inn Road London WC1X 8DA Tel: 0207 837 8855 |
||
|
NEW DISPENSER |
||
| Adrian Evans Boots St Mary’s Court Nottingham NG1 1LE Tel: 01159 493 784 |
||
|
MANUFACTURERS |
||
| Mr David Charmer - Managing Director & Mr Roger Lewin Phonak UK Limited Cygnet Court Lakeside Drive Warrington Cheshire WA1 1PP Tel: 01925 623 600 |
Mr Don Thistleton Lavis Medical Aaron House 2-6 Bardolph Road Richmond Surrey TW9 2LS Tel: 0208 332 7829 |
|
| Dr Nolan Starkey Laboratories Stockport |
Mr Stuart Canterbury GN ReSound Limited 1 Landsdowne Close Weston on the Green Oxfordshire OX25 3SX |
|
| Mr Lawrence M Werth PC Werth Limited Audiology House 45 Nightingale Lane London SW12 8SP Tel: 0208 772 2700 |
Bev Allen / H Franklin Audimed 511 Upper Elms End Road Beckenham Kent BR3 3DB Tel: 0208 663 0760 |
|
| Ms Alison Miller Otikon Quadrant House 33-45 Croydon Road Caterham, Surrey CR3 6PG Tel: 01883 331 720 |
Desmond Greener Audiophon Horley Tel: 01293 823 040 |
|
| Delorian Wright A & M Hearing Crawley |
J Chowdrey Puretone Rochester Tel: 01634 719 427 |
|
|
HAC COUNCIL MEMBERS |
||
| Mr H Vaughan Thomas Ruthin Council Wynnstay Road Ruthin Tel: 01824 706 152 / 234 / 006 |
||
| Mr Tony Corcoran Chief Audiologist Wessex NHS Trust Bournemouth Tel: 01202 301 255 |
||
| Gillian Booth Dundee Hospital Audiology Tel: 01382 633 867 |
||
| Dr L Yeoh St Hellier Audiology Tel: 0208 295 2565 |
||
| Denise Yates 32 Southcott Village Leighton Buzzard Beds LU7 7PS Tel: 01525 850 335 |
||
|
OTHER ORGANISATIONS |
||
| Mark Lutman Chief of Sound & Balance Southampton University Tel: 02380 592 287 |
||
| Mr Weatherall Institute of Chartered Accountancy 412/6 Silbury Boulevard Milton Keynes Tel: 01908 248 100 |
||
| Mr Gordon Lindsay GMC 178 Gt Portland Street London W1W 5JC Tel: 0207 915 3637 |
||
| Ms Judith Christie GOC 41 Harley Street London W1G 8DJ Tel: 0207 580 3898 |
||
| Adrian Davis Institute of Hearing Research Science Road Dunkirk Nottingham Tel: 0115 951 5151 |
||
| BSHAA • Alan Rudge • Mark Georgovic • David Ormerod • Martin Scott • Desmond Greener |
||
| BAAT • Jackie Johnson – Worthing Hospital, Audiology |
||
| Hearing Concern F de Bere 7-11 Armstrong Road Acton W3 |
||
| RNID Angela King & Dr John Low 19-23 Featherstone Street London EC1Y 8SL |
||
| Department of Health • Heather Simpson – NHS Audiology Services • Judy Sanderson – NHS Policy • Peter Greenaway – Chief Scientist |
||
Hearing Concern
NHS
General Medical Council
IC AEW
Optical Consumer Complaints Service
Audit Commission
National Consumer Council
Better Regulation Task Force
MRC Institute of Hearing Research
Hearing Aid Council
RNID
| TYPE OF COMPLAINT | BREACH OF CODE OF PRACTICE |
| Allegation of unsupervised training | Clause 12 and 27 |
| Poor audiometry | Clause 9 |
| Referable condition | Clause 5 |
| Perforation of ear drum by dispenser | |
| Failure of high standard of ethical conduct, Possible negligence | Clause 2 |
| Failure of high standard of ethical conduct | Clause 2 |
| Referable condition | Clause 5 |
| Poor audiometry | Clause 9 |
| Lack of response to HAC letters and no records | Clause 21 |
| Rudeness and failure to remedy | Clause 2 |
| Lack of response to HAC letters | Clause 21 |
| Failure to return deposit and discourtesy | Clause 2 |
| Complaint, asked patient to take off her top and personal | |
| matters. Public interest issues, serious misconduct | Clause 2 |
| Failure of high standard of ethical conduct | Clause 2 |
| 2 sensos November 1999 do not work. | |
| Is the hearing aid suitable? | Clause 3 |
| Misled patient regarding a break clause and the contract | Clause 11? |
| Poor audiometry | Clause 9 |
| Unsupervised training | Clauses 12 and 27 |
| Lack of records, tried to get records from dispenser | Clause 21 |
| Invoices not compliant may be breach of | Clause 11 |
| Aids under 2-year guarantee not given to the patient by the | |
| dispenser | Clause 2 |
| Lack of ethical conduct insurance issue | Clause 2 |
| No audiometer mentioned | Clause 9(b) |
| No indication of make and model of hearing aid | Clause 11 |
| Possible non-supervision of trainee | Clauses 12 and 27 |
| Was trainee registered? | |
| Poor audiometry | Clause 9 |
| Referable conditions not referred | Clause 5 |
| Paperwork | Clause 11 |
| Insurance claim | Clause 2 |
| Suitability of hearing aid | Clause 3 |
| Suitability of hearing aid | Clause 3 |
| Poor audiometry | Clause 9 |
| Patients rights not documented | Clause 11 |
| Failed to provide information | Clause 11 |
| No provision for servicing | Clause 18 |
| No response, no records | Clause 21 |
| Application inappropriate | Clause 10(b) |
| Registration rules, change of address not notified | Clause 8 |
| Wrong battery size/failing to fit moulds | Clause 3 |
| Conduct | Clause 2 |
| Referable ? | Clause 5 |
| Incorrect paperwork | Clause 11 |
| Unsupervised trainee | Clauses 12, 23 and 30 |
| Unsupervised trainee | Clause 12 |
| Lack of supervision | Clause 24 |
| Incorrect description of dispenser | Clause 7 |
| Breach on Stationery | Clause 7 |
| Breach on Website | Clause 7 |
| Breach on Website | Clause 7 |
The General Optical Council (GOC) was established in 1959 as a result of the 1958 Opticians Act. The 1958 Act was updated and amended in 1989.
The Council itself comprises 28 people of whom 9 are lay members, 4 are clinical opthalmologist's. The balance of members come from within the profession and are either elected by the profession or nominated by the trade, professional and teaching/training bodies.
The GOC now has a full time staff of 14 that includes a Director of Conduct who is a solicitor. The GOC deals with all cases considering professional conduct.
Note: A separate body, the Optical Consumer Complaint Service (OCCS) deals with all consumer complaints. The OCCS board has a majority of lay members and a lay chair - the core approach of the OCCS is arbitration to resolve consumer complaints quickly.
The process at the GOC is that complaints are dealt with initially by the Director of Conduct. A majority of cases are dealt with at this stage, for example, consumer complaints are passed to OCCS. The next stage in the process is referral to the chair of the Investigation Committee (a practicing optician) again many complaints are dealt with this second stage, for example through referral to the appropriate professional body. The remaining cases are then considered by the Investigations Committee (8 members: 3 lay, 3 opthalmic opticians, 1 dispensing opticians and 1 clinical opthal