1. The next steps in Building the System
National System of Care for Children and Young people with Hearing Impairment The next steps in Building the System for NE London
Barts Health PAWG
Eddie Herter
Waheeda Pagarkar
Ratna Shah
Jo Page
Margaret Baldwin
Watkin PM
September 2014
National System of Care for Children and Young people with Hearing Impairment
The next steps in Building the System
NE London
By Barts Health PAWG
A 15 minute presentation on

2. … joining up all audiology services for 5 districts
Waltham Forest
Redbridge
City and Hackney
No notes
Newham
Tower Hamlets

3. … joining up all audiology services for 5 districts – 400,273 0-19 yr olds
Waltham Forest
76,261
Redbridge
68,981
City and Hackney
79,682
No notes
Newham
100,864
Tower Hamlets
74,485

4. Barking, Dagenham and Havering
… joining up all audiology services for 7 districts – 499, yr olds
Waltham Forest
76,261
Redbridge
68,981
City and Hackney
79,682
Barking, Dagenham and Havering
99,079
The National System is currently being actively built for 5 boroughs in NE London with a population from 0-19 yrs old of 400,000. There is also positive engagement with Barking, Dagenham and Havering where many of the services are run by NE London FT and it would be rational for their inclusion. This would increase the population to 500,000 with a birth rate >30,000 / year – the sort of population size for an Audiology Network recommended by the RCPCH.
Newham
100,864
Tower Hamlets
74,485

5. … joining up all audiology services
Waltham Forest.
WXH sites- 3rd Tier
2nd Tier – None
School Nurse Screen by NEL Foundation Trust
Redbridge
WXH sites- 3rd Tier
2nd Tier – None
School Nurse Screen by NEL Foundation Trust
ENT Acute Surgical
Whipps Cross University Hospital
ENT Acute Surgical
Homerton University Hospital
City and Hackney
Hackney Ark-3rd Tier
Hackney Ark + John Scott HC – 2nd Tier
School Nurse Screen by Homerton UH Trust
+ Education
Waltham Forest
Redbridge
Newham
Hackney
Tower Hamlets
Barking and Dagenham
Havering
Networking the various services to be inclusive of all audiology activity however presents significant challenges.
Although there are inevitable discussions about joining services into a single system, there is clear 3rd Tier engagement in the process
2nd tier services also make a significant contribution to diagnostic audiology activity in Newham, Hackney and Tower Hamlets and the 2nd Tier services are run by three different Trusts (ELFT; NELFT; Barts Health).
All the districts also implement School Hearing Screens. There is no national protocol for the screens and screening coverage, results and outcomes are variably reported with some screens not being required by the commissioners to collect or report any screen data.
Audiology services also interface with ENT services. Within the context of the local implementation of the National System for Audiology there are 5 different acute ENT services – all working with Paediatric Audiology Services to provide conservative management of “glue ear”. However there is no acceptance by the largest ENT provider that additional performance measures to evaluate NICE compliance is required. Is the rate of use of surgery <10 years the only statistic of value?
Joining with Education is also central to building an inclusive and integrated system, but only the strategic importance of joint working is only “virtually” recognised by some of the Children’s Services. Although all services work jointly with education across the Network with some examples of good practice, a local offer of services for Hearing Impaired children and their Families has not been co-produced with clinical services in a majority of NE London districts.
Tower Hamlets
Hackney Ark- 3rd Tier
Royal London + Steels Lane HC-2nd Tier
School Nurse Screen by Barts Health
Newham
West Ham Lane-3rd Tier
West Ham Lane-2nd Tier
School Nurse Screen by EL Foundation Trust
ENT Acute Surgical
Royal London Teaching Hospital
ENT Acute Surgical
Newham General University Hospital

6. … joining up all audiology services through commissioning
Local CCGs Waltham Forest, Tower Hamlets , Newham , Barking and
Dagenham , and Redbridge , NHS England, Barts Health and other local
providers have established a clinical transformation programme called Transforming Services, Changing Lives.
A key element of the programme
will be to consider how best to ensure safe, effective and sustainable hospital services at Bart's Health and Homerton hospitals, set in the context of local plans to further develop
and improve primary, community and integrated care services.
With such disparate views and disparate services is it probably not practicable, feasible or possible for a clinician build of a unified Audiology System.
The engagement of those commissioning the services is critical.
We aim to engage a commissioner and provider programme (Transforming Services Changing Lives) which itself aims at driving forward The Case for Change in primary, community and integrated care services in all the NE London districts. We believe that we can use this as the vehicle for building the Audiology Network.

7. … joining up all audiology services through commissioning
What does good look like
What is working well
What is not working well
What are the constraints
commissioner support
to implement the National System for an integrated NELondon Audiology System
The Transforming Services Changing Lives programme required that we submitted our Case for Change in terms of :-
What does good look like
What is working well
What is not working well
What are the constraints
The plan for the integration of local audiology services into a single system driving continuous “across the board” quality improvements through an annual report of performance was presented within the Case for Change structure set out by the NE London Commissioning Support Unit.

8. … the plan to join up all audiology services
i. Council
ii. Health watch
iii. CCG
iv. Children Services
v. Public Health
vi. Social Services
CHSWG
Parents
NDCS
The National System of Care
for
Children and Young People
with Hearing Impairment
North East London
Health + Wellbeing Boards
The plan is to submit the required annual report using the standards outlined in the National System template. Because this has a wide service and agency remit it will be presented to the local CHSWG for consideration, change and ratification. This will enable the NDCS and parent representatives to be actively engaged in the process. The way of achieving appropriate parent consultation is currently the subject of focus group discussions held by our Parent Support Co-ordinator.
Following CHSWG ratification the Annual System Report will be presented to the Health and Wellbeing Boards by the local Public Health Service. The presentation to the Health and Wellbeing Board allows engagement across the local council and agencies.

9. … the plan to join up all audiology services
i. Council
ii. Health watch
iii. CCG
iv. Children Services
v. Public Health
vi. Social Services
Health + Wellbeing Boards
There was agreement that this reporting process to the local Health and Wellbeing Board would be trialled in Waltham Forest by Waltham Forest Public Health – following a presentation to them of material about the National System on the Healthcare Public Health website.

10. … the plan to join up all audiology services
i. Council
ii. Health watch
iii. CCG
iv. Children Services
v. Public Health
vi. Social Services
The National System of Care
for
Children and Young People
with Hearing Impairment
North East London
DRAFT REPORT
SEPTEMBER 2014
Health + Wellbeing Boards
It was requested that the initial draft pilot report for Redbridge and Waltham Forest be submitted to the local Public Health Dept. by October 2014 – requiring submission to the CHSWG in September The challenge of transforming the table of levels of quality standards into a readable and appropriate document is important and the example of the Diabetes Network Report previously commended by the project manager and recommendations from the current National Network meeting will be used. Because of the time frame an interim draft report has been produced.

11. … the report to the H+W Board
NHS CCG
Paediatric Audiology Provider
Borough
BY?
Identification of Deafness
Access to accurate diagnosis
The provision of clinical care
The provision of integrated support
WHAT?
eSP and SMaRT
Clinical Reporting System
Shared register updated
from eSP and SMaRT
BY?
The interim draft report for Redbridge and Waltham Forest has been functionally subdivided the system components into
Identification of Deafness
Access to accurate diagnosis
The provision of clinical care
The provision of integrated support
Each functional component of the system reports performance for a slightly different local population defined by the CCG of residence, their attendance with the provider Paediatric Audiology Department, or their residence within the borough.
Each functional component of the system also aims at measuring performance by different reporting systems, the eSP and SMaRT systems for the screens, the Clinical Reporting System for the Provider and an integrated register of Permanent and Persistent Hearing Impairment for assessing the performance of the integrated support. This will require further local developments of the reporting systems.

12. … the report to the H+W Board
Accessible, Readable and Interesting and Contains………
i. Scored Performance Statements ii. Tabulated Performance measures
iii. Epidemiology report
iv. Action plan
The National System of Care
for
Children and Young People
with Hearing Impairment
North East London
DRAFT REPORT
SEPTEMBER 2014
The interim draft report for Redbridge and Waltham Forest contains scored performance statements, tabulated performance measures, and an action plan. It is also intended that it includes an epidemiologically based report on PCHI updated for the previous year. The latter is particularly relevant to Children’s Services in forward planning.

13. … action plan to the H+W Board
The NHS in East London has to meet the needs of some of the most deprived areas in the UK and providing care for children and young people with hearing impairment today whilst planning for tomorrow requires the availability of robust local evidence on the epidemiology of hearing loss. To achieve the best outcome for every hearing impaired child they must receive the best clinical care delivered by high quality medical and surgical services. The most beneficial amplification must be available to them – including when required early access to implantable devices.
The provision of clinical care  
… action plan to the H+W Board
For children with persistent or permanent childhood hearing impairment (PCHI) by Provider Paediatric Audiology Clinic(s)
WXH Paediatric Sites
All parents of babies and children with a confirmed PCHI are offered referral to appropriate medical consultants for aetiological investigation and assessment in a timely fashion – evidence based or informed by professional guidance
All appropriate cases are offered hearing aid fitting within 4 weeks of confirmation of hearing loss unless delayed for management reasons - measured by the NAS12 Performance Indicator
Appropriate hearing aids are fitted according to MCHAS or other accepted professional guidelines and programmed with appropriate features using real ear measures and prescriptive fitting rules.
Robust on-going audiological care is proactively provided throughout childhood including regular checking and replacement of hearing aids, hearing aid settings, and use in the home is carried out. This information is shared with colleagues to form part of the child’s integrated support and audiology care plan.
*A hearing aid repair, ear-mould replacement and battery issuing service is available and accessible to parents and other professionals each working day throughout the year
Hearing aids, listening systems and other devices have been purchased through a regularly audited joint procurement system
90% of profoundly deaf children identified by the NHSP whose parents wish for implantation are implanted before 12 month - measured by the NAS13 Performance Indicator
Promote awareness of and raise awareness among healthcare professionals of the preventable causes of hearing impairment with information available in all healthcare settings
Provide robust evidence to support the epidemiology of hearing loss with the aim of reducing the number of children with preventable hearing impairment per births
The National System of Care
for
Children and Young People
with Hearing Impairment
North East London
DRAFT REPORT
SEPTEMBER 2014
An example of the page from the Interim Draft Report for Redbridge and Waltham Forest is shown.

14. … action plan to the H+W Board
Improving Identification
Whilst the Neonatal screen is undertaken to an approved national standard and routinely reports validity data – this is not the case for the School Entry Screen. The possible movement of school nursing services to Public Health and the availability of a designed screen reporting programme (SMaRT) provides an opportunity for Audiology to work with the school nursing services and Public Health to reverse this situation.
The National System of Care
for
Children and Young People
with Hearing Impairment
North East London
DRAFT REPORT
SEPTEMBER 2014
The Action Plan has functionally subdivided the criteria into system components to be actioned. Because of the significant changes that are required only those criteria where the quality standard is not achieved or is not obtainable have been reported for action.
Improving Identification
Whilst the Neonatal screen is undertaken to an approved national standard and routinely reports validity data – this is not the case for the School Entry Screen. The possible movement of school nursing services to Public Health and the availability of a designed screen reporting programme (SMaRT) provides an opportunity for Audiology to work with the school nursing services and Public Health to reverse this situation.

15. … action plan to the H+W Board
Improving Diagnostic Services
The IT systems are not yet in place to report all the measures required to assess the level of performance of this System component. Performance reporting can be built into the Clinical Reporting System.
Not all the standards have yet been agreed eg the performance measure to evaluate the implementation of an appropriate system of “Watchful Waiting” and national rather than local measures should preferably be employed.
The National System of Care
for
Children and Young People
with Hearing Impairment
North East London
DRAFT REPORT
SEPTEMBER 2014
Improving Diagnostic Services
The IT systems are not yet in place to report all the measures required to assess the level of performance of this System component. Performance reporting can be built into the Clinical Reporting System.
Not all the standards have yet been agreed eg the performance measure to evaluate the implementation of an appropriate system of “Watchful Waiting” and national rather than local measures should preferably be employed.

16. … action plan to the H+W Board
Improving Clinical Care
Measuring the performance of our Clinical Care requires the further development of the integrated register of PCHI with data imported from eSP and SMaRT. This should also be the basis of the annual epidemiological report made to Public Health. In addition it is clear that we are not achieving the target for Cochlear Implantation in infancy. Evidence should be made available from the register with improvement targets set. The integrated register should also enable co-ordination of clinical activities with the educational service.
The National System of Care
for
Children and Young People
with Hearing Impairment
North East London
DRAFT REPORT
SEPTEMBER 2014
Improving Clinical Care
Measuring the performance of our Clinical Care requires the further development of the integrated register of PCHI with data imported from eSP and SMaRT. This should also be the basis of the annual epidemiological report made to Public Health. In addition it is clear that we are not achieving the target for Cochlear Implantation in infancy. Evidence should be made available from the register with improvement targets set. The integrated register should also enable co-ordination of clinical activities with the educational service.

17. … action plan to the H+W Board
Improving Integrated Support
Although the Local Offer has been co-produced in some of the NE London boroughs, an agreement (with terms of reference) has not been co-produced between local Education Services and the Audiology Service detailing how service providers will give integrated support to deaf children and their families is required. There is now an agreement with local Audiology Services that there will be an integrated agreement produced and available for Children’s Services in both boroughs.
The National System of Care
for
Children and Young People
with Hearing Impairment
North East London
DRAFT REPORT
SEPTEMBER 2014
Improving Integrated Support
Although the Local Offer has been co-produced in some of the NE London boroughs, an agreement (with terms of reference) has not been co-produced between local Education Services and the Audiology Service detailing how service providers will give integrated support to deaf children and their families is required. There is now an agreement with local Audiology Services that there will be an integrated agreement produced and available for Children’s Services in both boroughs.

18. and to follow………………….
This method of building the System will allow it to be refined and then spread across the pilot Network by the end of the year.
To be inclusive this cannot be simply clinician led and will require the positive local engagement of parents, NDCS, commissioners, education and project management – reaching the parts others can’t.