Cochlear Implantation

David Mowat Excerpts

Friday 24th March 2017 Commons Chamber

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

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.