I am grateful for the opportunity to raise the question of the funding and assessment of cochlear implantation, and I do so as chair of the all-party group on deafness. I am pleased to see the Health Minister in his place; I know he has this issue on his radar.
The starting point is a petition calling for a review of the tests for implants approved by the National Institute for Health and Care Excellence. I have been contacted by my right hon. Friend the Member for Wolverhampton South East (Mr McFadden) and my hon. Friend the Member for Rotherham (Sarah Champion) on behalf of their constituents Lamina Lloyd and Diane Matthews respectively.
Both constituents fall foul of the Bamford-Kowal-Bench test—the BKB test. It is this aspect that concerns them and their MPs, and they want it reviewed and changed. I will come back to that later, as well as to the case of Robert Gee, a constituent of the hon. Member for Daventry (Chris Heaton-Harris), who I am pleased to see in his place on the Treasury Bench. I want to register my appreciation for Action on Hearing Loss, the Action Group for Adult Cochlear Implantation, Professor Chris Raine and the Ear Foundation for their assistance with briefings for this debate.
I shall start with papers sent to me by the Ear Foundation. Sue Archbold writes:
“I was at the World Health Organisation in Geneva for the meeting on World Hearing Day, 3rd March...with WHO for the first time confirming that cochlear implants and hearing aids are cost-effective and should be made more widely available globally”.
The WHO has produced two documents: “Global costs of unaddressed hearing loss and cost-effectiveness of interventions” and “Action for hearing loss”. I am sure the officials at the Department will have brought them to the Minister’s attention.
Professor Chris Raine, who I believe is one of the UK’s leading clinicians in this field, emailed me and wrote:
“are funded for health and NICE only look at this aspect. What needs to be addressed is, value for the taxpayer. For example, in education: children with CIs are now going into the mainstream sector which results in a significant saving of education funding of special classes. We have a generation now going through higher education, and this means better employment prospects and more people paying more tax. Adults who go deaf can expect better health outcomes with CIs. Deafness is associated with illness and unemployment. Also, studies in the USA and France have shown improvement and reduction in dementia in the elderly. We are spending £13 billion on dementia.”
Professor Raine concludes with the recommendation that
“we need adult hearing screening”.
The Ear Foundation has produced a document, “Improving access to cochlear implantation: Change lives and save society money”, written by Brian Lamb OBE, Sue Archbold, PhD, and Ciaran O’Neill, PhD. It recommends, for instance,
“That NICE urgently conducts a formal review of its current guidance on cochlear implants”,
and that the review
“considers lowering the current audiological threshold for candidacy…That any cost benefit analysis done…ensures…real world benefits are taken into account”,
including those relating to social care. It also states:
“A screen for candidacy for cochlear implants should be built into routine audiological appointments.”
Action on Hearing Loss writes:
“More adults could benefit from cochlear implantation than are currently doing so. NICE…should review and update its current guidance on cochlear implantation”.
It also writes:
“74% of children who could benefit from cochlear implantation aged 0-3 have received them, increasing to 94%, by the time they reach 17 years of age. The comparable figure for adults who have severe or profound hearing loss is only around 5%.”
I am sure that the Minister is aware of that.
“Research is also currently underway to see whether the BKB…sentence test… could be excluding adults who could benefit.”
The document recommends a review of guidelines, as well as the raising of awareness of cochlear implantation among the public and NHS organisations and professionals.
Brian Lamb also writes, this time on behalf of the Adult Cochlear Implant Action Group:
“Hearing loss is one of the most challenging health and social issues facing the UK...Those with hearing loss have higher rates of unemployment and underemployment.”
Hearing loss is associated with the risk of developing dementia:
“Those with severe hearing loss are at five times the risk of developing dementia as those with normal hearing”.
I remind the Minister again of the billions that we are spending on dementia.
“In older age people with hearing loss are at greater risk of social isolation and reduced mental well-being”.
Yet we have never had better solutions to address hearing loss.
The ACIAG states:
“Hearing aids can make a huge difference to the majority of people, but for those who are severely or profoundly deaf cochlear implantation offers the main way of hearing spoken language again. We now have world-leading technology in cochlear implants to address hearing loss, but many more people could benefit from this transformative technology than currently do.”
It also states:
“There are an estimated 100,000 people with a profound hearing loss and 360,000 with a severe hearing loss who might benefit from implantation at any one time. Yet”
—as I said earlier—
“only 5% receive CIs.
The UK currently has one of the most restrictive tests across the whole of Europe...In this country it is not until the hearing loss is over 90 dB that people qualify, while in Europe the majority of clinics use a measure between 75-80 dB.
We also use a word test, the BKB test, which is no longer fit for purpose according to a recent review by experts in the field who concluded, ‘use of this measure... alone to assess hearing function has become inappropriate as the assessment is not suitable for use with the diverse range of implant candidates today’.
The guidelines have been in place since 2009 and not reviewed since 2011.
The Action Plan on Hearing Loss, published by DoH”
—the Department of Health—
“and NHS England in 2015, made clear that there should be ‘timely access to specialist services when required, including assessment for cochlear implants’.”
That action plan was widely welcomed when it was published, and I, along with others, commended the Department, officials and Ministers at the time, but much of it seems to be being ignored by a number of clinical commissioning groups. Indeed, some are following policies that contradict the plan. The ACIAG requests more research on the links between hearing loss and dementia, and mental health issues. In conclusion, it writes:
“The NHS has been a leader on cochlear implant technology and helped transform many people’s lives. The NICE guidance was welcome when originally produced in 2009, but we are now falling behind the access available in many developed countries. It is our health and social care services which will pay the cost of not intervening early for those who could benefit.”
I wear two hearing aids, primarily because of damage to my ears sustained while I was in the fire service, although I am sure that age has now added to the problem. I am one of the 11 million people in the UK—one in six of the population—who suffer from hearing loss. Despite the annoyance I cause friends and family by asking them to repeat things, the use I make of the House of Commons loop system, and the assistance I seek here from the sound engineers and technicians, who are always very helpful, I still rely on my hearing aids because they work for me, despite sometimes having limitations. However, I have listed the problems for people suffering profound hearing loss, which are much more serious. We can do something about this; we have the technology, and it is not a matter of costs, because it should save money. It should save the NHS and the taxpayer money, as well as allowing profound hearing loss sufferers to live more complete and productive lives.
In conclusion, I return to the emails from the constituents of my colleagues. One of them writes:
“Lamina passes the pure tone threshold for a cochlear implant, but had to take a speech recognition test in what she regarded as a ridiculously false atmosphere of a soundproof booth with very simplistic sentences in an environment totally different from real conversation or the normal outside world. She is, in her own words, too deaf to hear, but not deaf enough for an implant.”
Robert Gee, the constituent of the hon. Member for Daventry, writes similarly, but gives more details of what 70 dB actually is. He says:
“Now just to give you some benchmarks: 60 dB equates to the volume of conversation in a restaurant. 70 dB is twice that volume (busy traffic). 80 dB is 4 times that volume (an alarm). And 90 dB is 8 times (factory machinery etc).”
He then refers to the sentence comprehension test:
“A candidate qualifies if they can only hear (with hearing aid fitted) and repeat less than 50% of the sentences which are played over speakers. The problem with this test is that it is conducted in a soundproof booth with the sentences played at 70 dB...double the volume level of standard conversation. This test does not represent reality at all.”
I give the last word to Mrs Diane Matthews, who started the petition to ask NICE for a review. She writes:
“I started a petition for NICE to revise their cochlear implant tests after refusal again for a CI in January this year...The tests are in a soundproof room at a sound intensity of 70 dB. Whilst I understand there has to be set parameters, this does not mirror the real world. There should be a test with background noise and the sentences should be comparable with adult conversation...A CI is life-changing and whilst it’s not a cure, it’s the best option. To know there is something to help and be denied is heart-breaking when you want to work and contribute to society.”
I hope that NICE will accept the requests from individual patients, professional clinicians and campaign organisations, and I hope that the Minister in his response can articulate something in the way of support, or at least acceptance and understanding that there is a major issue out there, and obviously write to NICE directly as well.
We have a solution. It is at worst cost-neutral, and in reality offers huge cost benefits both in productivity and economically, and in human wellbeing. I am looking forward to hearing the Minister’s response.
I congratulate the hon. Member for Poplar and Limehouse (Jim Fitzpatrick) on securing this debate on such an important subject. Profound hearing loss is a major issue; the points he raised are substantial and I will address them. I also congratulate him on his work on the all-party group on deafness, and on raising awareness. I also want to offer congratulations in respect of the emailed stories that the hon. Gentleman used in his speech, and, in particular, I want to congratulate Diane Matthews on the petition, which also raises awareness of this important matter.
The hon. Gentleman has raised two substantive issues. One relates to NICE and the question of whether the BKB test and the threshold of 90 dB are appropriate, compared with what is used in other parts of the world. It is not for me to instruct NICE on what to do, but I will come back to the question of NICE guidance later. This is a particularly important piece of guidance because it is technical, which means that it is compulsory, unlike some NICE guidance, which is just for consideration. Therefore, it is important that we get this right.
The hon. Gentleman also talked about awareness among commissioners. He mentioned the action plan not being implemented as effectively as perhaps it should be, and I will say more about that as well. In doing so, I have been informed by, among other things, the extremely good paper that the Ear Foundation put out last October on improving access and by a paper written by Brian Lamb of the University of Derby about better assessments for cochlear implants. Both pieces of work were very good, and I would not have read them had I not needed to prepare for this debate. So we have achieved that, at least.
We know that around 700,000 adults in this country have severe or profound deafness, and that 80% are over retirement age. That demographic is increasing, so this issue is increasing, and, as I have said, it is important to get this right. We also know that between 370 and 400 children are born each year with profound deafness. This excellent technology can be a life-changer for children and for adults. The hon. Gentleman told us that, unless we get this right, employability can be affected. He mentioned the tax base, but this is important for all sorts of reasons. People’s mental health can be affected, and those with hearing loss are something like five times more likely to contract dementia than the rest of us. That is a sobering statistic. There is also an increased risk of isolation. As he said, all those factors lead to a greater reliance on our NHS and social care systems. That is set out in a number of papers. Indeed, a World Health Organisation paper went into great detail about it.
Let me describe our response to these points and our view on how the system ought to be working. Cochlear implants are commissioned by the specialised commissioning part of the NHS through 17 specialist centres across the country. There is effectively a two-tier approach involved. The clinical commissioning group should do a general assessment to identify the issue, then send the individual for further assessment involving the tests that the hon. Gentleman has described. If appropriate, they go on to get an implant, followed by the necessary rehabilitation and maintenance work.
Roughly speaking, we do between 1,100 and 1,200 of these implants every year in this country. That is split approximately 60:40 between adults and children. Those figures have been fairly static over the past five or six years. The NICE guidance that drives those figures was last done in 2009 and updated in 2011. As the hon. Gentleman said, however, the technology is moving quickly and we need to address the question of whether that guidance is still appropriate. He mentioned the action plan on hearing loss, which we introduced in 2015. It set out in some detail what best practice was and what action the CCGs should be following. They are the first point of contact for prevention, early diagnosis and patient-centred management. There is also a commissioning framework, which came out after the action plan. It set out a requirement for consistency and the removal of the inequalities of access that we have heard about today. It requires “clearly defined referral arrangements” that will provide
“timely access to cochlear devices when required”.
Of course, the devil is in the detail, and the words “when required” have led to some of the issues that we are discussing. Following on from that, we are currently working on a joint needs assessment toolkit and a “what works” guidance, with case studies that should help to increase awareness and knowledge of all this among commissioners at CCG level and more generally.
The problem that still exists, and the one we are really debating today, is that, in spite of all that, there is evidence of the technology being under-utilised despite its life-changing characteristics, particularly among the adult population. The hon. Gentleman talked about 5% of adults being able to benefit from the technology. My figure is 7%, but that is not something that we will quibble about. The uptake is much higher among children with profound hearing loss, with 74% of such children under the age of three and 94% of under-17s having an implant. That could lead us to think that commissioners do not always consider the technology as an appropriate solution when a retired or older person has profound hearing loss. In a sense, I suppose that is age discrimination.
As for international comparators, the Ear Foundation paper talked about the US, Germany and Australia as being stronger users of the technology than we are, which is true, but it is not clear that we are behind the field as badly as the paper may imply. I looked at some detailed numbers from across Europe, and we are stronger than Luxembourg, Belgium and others, but it is fair to say that we are probably in the third quartile, at best, so there is room for improvement.
The NICE guidance is the crux of the hon. Gentleman’s point and also what the Ear Foundation talked about. The first thing to say is that I do not tell NICE what to do. Politicians do not influence what is a technical, scientific evaluation. However, we understand that the guidance has not been updated since 2011. There have been a series of quite rapid changes to the technology, surgical procedures have improved, and there is more evidence of the technology’s cost-effectiveness.
I am pleased to say—the hon. Gentleman did not mention this, but it is a fact and nothing to do with anything that I have done—that NICE is currently reviewing the guidance, and that review is due to be completed in the summer of 2017. NICE will be considering all the new evidence, including the work of the Ear Foundation, the World Health Organisation and, indeed, Brian Lamb’s paper. I will also see to it that the issues raised in this debate, in both the hon. Gentleman’s remarks and my remarks, go to NICE as part of the process, so that it is under no illusion as to whether Parliament has considered the matter, and so that it knows that we are extremely keen that it comes to the right answer. It is for NICE to decide whether the BKB test is right and whether 75 kHz is the right measure. The good news for this debate is that that process is happening and is due to be completed in the summer.
On GP awareness, the hon. Gentleman mentioned the action plan, and there probably is an issue there. If we look at the figures for children and the figures for adults, we see that there may be a reluctance to commission the technology for older people just because it is not seen as one of the natural things to do if someone has lost their hearing in their 70s or 80s. There is no pressure from the Government for that to happen, and it should not happen. We work with Health Education England and others on GP training and similar matters. We will make sure that the fact that cochlear implants can make such a radical difference to people’s lives is emphasised with GPs as part of the process. In any event, when new NICE guidance comes out, particularly the technological guidance, which is compulsory, that is likely to create quite a lot of impetus for getting the knowledge out to the CCGs and specialist centres, and therefore to the people who have to make the decisions.
I finish by thanking the hon. Gentleman again for securing this important debate. I have not discussed deafness in this Chamber since I have been a Minister, so it is good that we have had the opportunity to do so. I hope that he finds my remarks encouraging.
Question put and agreed to.
Motion made, and Question proposed, That this House do now adjourn.—(Chris Heaton-Harris.)