Independent Review of Audiology Services in Scotland

Establish a time-limited National Implementation Group with a Project Lead to provide the necessary project management leadership to produce and monitor a plan to implement the Review’s recommendations. It is advised that Group membership is multidisciplinary, including patients and third-sector representatives, reporting directly to the Scottish Government. While it will be for the Scottish Government to set the Group’s terms of reference, appoint its members and determine specifically how the recommendations should be taken forward, it is advised that this Group should play a vital role in: • defining national audit and peer review processes; • supporting the establishment of local working groups; • ensuring all relevant stakeholders are represented in the national and local groups’ structures and activities; • coordinating any actions nationally, regionally and locally; • ensuring the recommendations are applied consistently across Scotland in line with the “Once for Scotland” approach (14), but also supporting adaptation of the recommendations as necessary to reflect local needs. It would be prudent to ensure that opportunities are taken during the implementation phase to share learning through collaborative effort at Governmental and professional levels.

Establish an Audiology Specialist Advisory Group, a single body with oversight of paediatric and adult audiology services which reports to the Scottish Government. An indicative description of responsibilities for this Group is below; • To provide scientific and technological advice on NHS audiology matters to the Scottish Government. • To advise on policy matters relating to the provision of safe, cost-effective, high-quality NHS audiology services. • To ensure national oversight of quality assurance and review audit and performance data across the clinical pathway. • To advise on matters relating to workforce planning, education and training of those involved in the provision of NHS audiology services. • To enhance the reputation and profile of NHS audiology. • To enhance the identity, culture and morale of NHS audiology services. • To advise on strategic planning and development of NHS audiology services. • To encourage a collaborative approach, with representation from NHS audiology services, medical audiology, specialist services, higher education institutions and the Scottish Government.

Establish a single policy home for audiology within the Scottish Government.

Appoint a Healthcare Science (HCS) Lead in each Health Board. While we are specifically interested in Board-level oversight of audiology, director-level leadership, as currently applies to other major clinical groupings, would also benefit audiology and the wider HCS community. The absence of such HCS leadership has been a major feature of the Review’s varied deliberations; left unresolved it is a potential future failure point in the governance of the wider HCS workforce. The following remit for an HCS leader would benefit audiology, helping to assure safe care and outcomes for the population served by this and other specialist HCS disciplines; • Support and monitor education, training and registration of clinical staff, including oversight of core training registers. • Responsibility and accountability for clinical governance issues – alerting the Health Board Chief Executive to service issues that may impact on safety and the reputation or performance of the organisation. • Ensure quality assurance programmes are in place and that the organisation complies with specific quality requirements and accreditation schemes. • Receive external audit reports/reviews on behalf of the organisation, providing challenge and support for the delivery of quality assured HCS services. • Encourage organisational support for service improvement informed by patient feedback, outcomes of audit/review and technological innovation. • Ensure organisational support for implementation of national strategies and policies. • Promote and provide high-level support for the needs of the service within the organisation, as a healthcare discipline. • Encourage an identity and a culture of collaboration across HCS services in the organisation. • Support HCS leadership development. • Participate in national strategic and collaborative efforts, with counterparts in other Health Boards. Ideally, to have authority to achieve the above, a Healthcare Science Lead should hold an executive level position and responsibility at each Health Board. This may be more viable in association with a wider professional partnership grouping, but always with a post-holder who has clear responsibility for and knowledge of HCS.

Conduct a comprehensive workforce review with a particular focus on skill mix with reference to professional best practice guidance and linking in with professional bodies.

Develop a robust workforce plan to ensure appropriate safe-staffing levels and equitable patient-staff ratios.

Develop a suite of national job descriptions to improve consistency across all job descriptions particularly of those at band 7–8, Head of Service and Deputy Head of Service level. This work should link with professional best practice guidance and be informed by the Academy for Healthcare Science (AHCS) Good Scientific Practice document (26) and for Heads of Service posts to the AHCS Standards of Proficiency for Higher Specialist Scientists document (27).

Review and formalise collaborative arrangements with neighbouring Health Boards to ensure sustainable service delivery for specialist audiology services.

Use the most updated version of the Audiology Patient Management System to enable consistent data recording and reporting and ensure delivery of effective, high-quality patient care across all Boards.

Define and ensure adoption of a consistent patient pathway for adult and paediatric audiology, with reference to best practice guidance and national service quality standards, which is responsive to innovations over time. This will enable consistency of care, comparative audit and reporting of performance between Health Boards.

Design services based on demographics, geography and local needs ensuring that stakeholders are a key contributor to the process as per the Scottish Government’s Scottish Approach to Service Design (28).

Undertake a review of NHS Board internal governance arrangements to ensure strong accountability links for audiology reporting within NHS corporate and clinical and care governance structures.

Review the Audiology Heads of Service Group’s terms of reference to ensure alignment with local and national guidance around NHS Scotland good governance (29).

Review and define professional accountability for the audiology service within Scottish Government and NHS Board governance structures.

Clearly specify the need for healthcare science leadership skills development in job descriptions for all posts, proportional to the level of seniority. If candidates are less developed formally on appointment, then an unequivocal commitment must be given to engage with a programme suitable for the role. Health Boards may offer such support through organisational development and learning.

Ensure recruitment panels for NHS leadership posts for audiology, as a healthcare science service, include external senior audiology and local healthcare science professionals.

Ensure that advanced and ongoing leadership development of those in senior positions (healthcare science band 7 and above) is understood to be the norm and recorded as part of an individual’s ongoing personal development utilising national programmes such as Leading to Change with the option to develop bespoke leadership development programmes if required.

In line with the Health and Care (Staffing) (Scotland) Act 2019, ensure all individuals with lead clinical professional responsibility for a team of staff receive sufficient time and resources to discharge that responsibility, along with their other professional duties. They should have opportunity to engage and contribute with healthcare scientists in other disciplines to foster mutual support on matters related to the delivery of healthcare science services.

Posts requiring specialist skills must only be open to candidates formally qualified to the agreed national standard. Examples of such include existing specific UK-level healthcare science routes available such as the Scientist Training Programme and Higher Scientist Training Scheme. The BAA’s Higher Training Scheme (HTS) modules are an industry-standard that could be adopted in Scotland with eligible staff registering to do HTS within 18 months and complete three years thereafter.

Staff in post should gain a qualification or equivalent recognition to demonstrate clinical competence in a specialty area. For example, the BAA’s HTS modules currently provide a scheme to develop competency and allow for competency assessment. It is recommended that the Scottish Government works with that professional body on capacity to throughput candidates and to develop local examiners in Scotland to assess competency.

In readiness for promotion opportunities and to build workforce capability, the Scottish Government should encourage Health Boards to pursue equivalency to secure Clinical Scientist Registration and Higher Specialist Scientific Registration for consultant level leadership.

Define minimum education and training needs and minimum ongoing continued professional development and reaccreditation arrangements to maintain competencies for those: • performing auditory brainstem response assessment of children, including peer review; • leading two-person assessment of pre-school-age children; • fitting hearing aids to children; • performing tinnitus assessment of adults; • leading vestibular assessment of adults; • undertaking adult assessment and rehabilitation.

Establish a Core Training Register for safety-critical diagnostic testing performed by the team.

Establish a Continuing Professional Development Champion or Training Officer in every department offering audiology services. The individual must practise evidence-based training and include external training as well as internal. It is advised that this is reflected in the relevant job description.

Ensure annual appraisals include regular review of an individual’s competency and training record.

Ensure all services are connected to a network of trainers and verifiers to ensure uniformity of high standards of specialist skills and to provide evidence of training assurance to external auditors, thereby cementing a quality culture.

Current undergraduate BSc programmes should run annually, and previously run courses should be restarted. They should prioritise school-leaver/non-degree-holding entrants.

Urgent consideration should be given to the sustainable funding of programmes.

Consideration should be given as to how programmes could be formalised, if desired by service, into degree apprenticeships, and how Boards could be assisted to embrace the model.

There should be direct sponsorship of selected students to undertake the pre-registration MSc as it stands. NHS Scotland placements should be prioritised for students who are directly sponsored.

Consideration should be given as to how to recruit and retain such sponsored trainees.

The existing programme should run an intake as planned in 2023.

Promote and support access to the Dip HE in Hearing Aid Audiology as an element within the NHS career pathway, also ensuring that the course offered reflects the evolving needs of the NHS.

Consideration should be given as to how NHS departments can be incentivised to place staff on the Dip HE in Hearing Aid Audiology course and retain them.

Articulation is required between the DipHE and BSc top-up modules to allow Boards to accelerate workforce supply, both in Scotland and beyond.

All NHS trainees regardless of programme pathway should be mandated to acquire a National Training Number from NHS Education for Scotland which would ensure monitoring of training progress.

All trainees entering NHS Scotland employment must, on completion of their training, be eligible for registration either with Health and Care Professions Council or Registration Council for Clinical Physiologists – Academy for Healthcare Science (AHCS) registers.

All NHS training departments should be registered as a training centre with NHS Education for Scotland.

Boards should ensure that all audiology staff eligible for registration are professionally registered either with the Health and Care Professions Council or Registration Council for Clinical Physiologists – Academy for Healthcare Science to demonstrate professionalism and public protection.

All audiology staff involved in delivery of training must be trained by the university provider, professional bodies and encouraged to engage with the wider healthcare science training community via NHS Education for Scotland trainer courses.

Trainers should be formally trained and recognised to deliver and verify training across all levels. This should be harmonised across Scotland with training formally incorporated into job descriptions. Consideration should also be given to developing a cadre of key trainer-verifiers for specialist skills in Scotland who can cover multiple Health Boards. A collaborative approach to training should be encouraged to share training capacity across Health Boards through a training consortium approach.

Develop, implement and report on a mandatory basis against an agreed set of robust national key performance indicators (KPIs) for annual audit, with suitable governance arrangements. These should be informed by the outcomes of the KPIs survey conducted as a part of this Review. It is advised that the Audiology Specialist Advisory Group (see earlier) should oversee the review and development of this list of KPIs to reflect changes to practice and any national shortfalls or elements of service quality in need of improvement. Wherever possible, there should be collaboration with professional counterparts across the four nations to support country comparison of common KPIs. The following KPIs are suggested as priority for regular benchmarking: • patient reported experience measures (PREMs); • patient reported outcome measures (PROMs); • bone anchored hearing aid (BAHA) provision/head population/year; • continuing professional development/head population/year; • paediatric pathway indicators (for significant milestones in the diagnosis and management pathway); • positive predictive value (PPV) measurement; • multidisciplinary team working; • aetiological investigation of children with permanent hearing loss.

Establish KPIs for routine monthly, discrete (non-aggregated) referral to treatment waiting times performance reporting through Health Boards. This should include: • waiting times for all adult audiology procedures (aggregated); • waiting times for first assessment of hearing for children (other than those referred from the Universal Newborn Hearing Screening Programme).

Develop evidence-based national service quality standards for NHS audiology services in partnership with third-sector organisations, service users, professional counterparts in the other UK countries, professional bodies and Healthcare Improvement Scotland. Review and update them on a regular basis. Development should reflect the multidisciplinary nature of services, include views of those with lived experience identified through the work of the Reference Group and any further lived experience engagement, with appropriate governance arrangements in place.

Establish a local service-level quality assurance and improvement plan which describes roles and responsibilities, resourcing and reporting outputs. The plan should be updated regularly, reflecting outcomes of audit and performance against KPIs.

Introduce an accountable post-holder in the audiology service to oversee and drive local quality improvement initiatives and ensure senior staff develop quality systems thinking awareness for themselves and their teams.

Define and adopt a robust external audit process for the service quality standards, in partnership with professional bodies, third sector partners, service users and professional counterparts in other UK countries. This should feature site visits and observation of clinical practice. Explore partnership working opportunities with other UK countries to establish a reciprocal audit process for scrutiny external to Scotland. The Scottish Government should mandate Health Board participation in the audit process, ensuring the release of clinical staff to participate as assessors. Outputs should include audit reports to be sent to Health Board Chief Executives and a collective national audit report to be provided to the Advisory Group (see earlier).

Explore opportunities and identify the best approach to achieve external accreditation of NHS audiology services with external agencies such as the United Kingdom Accreditation Service and counterparts in other UK countries. Thereafter, Health Boards should pursue external national accreditation of audiology services as indicated and collectively agreed.

Develop and deliver an annual reporting and escalation process for audit against service quality standards, with agreed governance arrangements in place. Outcomes should be presented in the public domain. Annual publication should develop a better public understanding of local and national outcomes to encourage contribution to any national solutions where required. To deliver on this work, it is crucial all Boards have robust data and digital infrastructure.

Ensure recommendations from the most recent review report around the Universal Newborn Hearing Screening Programme in Scotland are addressed at pace.

As commissioners of the SCIP, National Services Scotland National Services Division and Health Boards should establish a collaborative working group, working to defined terms of reference and with appropriate governance arrangements. This group should be tasked with conducting an annual joint audit/benchmarking coordination event to review audit outcomes across all partners. This should routinely explore whether cases meeting criteria are referred in a timely way and the appropriateness of referrals. The group should consider variations in implantation (by Health Board area) as a high-level indicator of combined (Health Board and SCIP) performance. It is advised this group should explore introduction of measures to reduce variation and optimise onward referral, such as Cochlear Implant Champions.

Commission national-level training for ABR assessment of infants. This training should be mandated for all audiologists performing such work. The format should include one-to-one assessed sessions and face-to-face training sessions. Content for this training should be guided by the learning from the case sampling audit exercise.

Support the establishment of a national external peer review scheme for ABR assessments with mandated participation across NHS Scotland for all audiologists performing ABR assessments. It is recommended this could be taken forward as a mini project with consideration of best practice across the UK.

Conduct a wider audit of ABR cases referred from the Universal Newborn Hearing Screening Programme, with defined scope: i) review of cases to identify where management can and does need to be revised; ii) further identification of training needs at individual audiologist level; and iii) obtain information to guide changes to service delivery model for the ABR assessment. It is advised that the Implementation Group should determine the scope of the audit and if there is a period of time before this is established, the Heads of Service Group for Audiology should be tasked with this.

Ensure implementation of local action plans to mitigate and minimise risk to patients against the KPIs surveyed as a part of the work of the Review. This will support readiness for formal external audit.