PUBLICLY FUNDED AUDIOLOGY SERVICES
IN NEW ZEALAND
A National Benchmarking Exercise
Benchmarking information on a range of issues identified by MidCentral Health was obtained from nine publicly funded audiology services serving populations not dissimilar from MidCentral Health. Services from the three main population centres were not included in the wider aspects of the exercise, although specific information was sought from some of them regarding best practice.
Thanks are due to the audiologists and managers of the services involved for their willingness to participate in this exercise, and for the time they made available to make the project successful and, hopefully, useful to all concerned.
CLINICAL PRIORITY AND KEY REVENUE GENERATORS
Average, maximum and minimum waiting times for the six main categories of audiological clients are shown in Figure 1. Adult hearing aid clients show the highest average waiting time (8.7 months), and the largest variation between services (a range of 1 - 24 months). Details of the waiting times for the various services demonstrating the wide range are shown in Figure 2. The maximum waiting time for all other client groups was 4 months.
The much greater waiting time for adult hearing aid clients than for other client categories demonstrates graphically the lower clinical priority that these clients typically receive. The reason for this disparity is presumably the availability of private services focussed primarily on this client group. Young children at risk of hearing loss needing assessment, and those found to have hearing loss and needing hearing aids were given priority by all services.
Total outputs budgeted ranged from 1,292 to 3,100.
Because of the different formats for presenting outputs, insufficient numbers of services were available for more detailed comparison.
Populations living near the various services varied from just under 55,000 to over 300,000 (based on 1996 census data provided by NZ Health Information Service). The average was 125,900.
Outputs related to population
The funded visits per head of population ranged from a high of 1:34 to a low of 1:107, with a mean of 1:51.
In no hospital did ORL pay for audiometric support services supplied by audiology. In one case, the ORL department paid for additional time above budget for which an audiometrist was employed. In another service, work was being carried out on developing an inter-service agreement.
The price paid by the Health Funding Authority per visit generally varied from $25 to $100 with an average of $48. In two areas, a higher price had been negotiated for hearing aid fittings. These prices again varied – in one area the fee was $120, in another, it was $150 for the initial hearing aid assessment, and $100 for follow-up visits.
Total contract prices varied from $48,000 to $312,000.
Revenue generated did not necessarily correlate with population served. The average funding per head of population was 77c. The range extended from 23c to $2.08. There was no obvious population-based explanation for the differences in funding levels.
Take-up of newer audiological tests
Otoacoustic emissions (OAE) were available in four services. A fifth service had approval to purchase equipment for OAE. In two services OAE was being used to test high-risk neonates. All those with OAE used it as a crosscheck with adults and children needing hearing assessment.
Testing for central auditory processing was available to some extent in all services. Two provided screening only, and most others commented that although available, demand was not very high.
All hospitals used computerised systems to make appointments. Five services admitted to also using manual diaries because they were easier to visualise. In a few cases these were stand-alone systems, but by far the majority were connected to the hospital’s main appointments system.
Coordination of HA appointments
Five services purchased hearing aids and earmoulds directly (ie without the involvement of their purchasing departments). In some places, the practice was to schedule a series of appointments for hearing aid fitting and follow-ups once the assessment was completed. In others, where deliveries were not so reliable, no appointments were made until the devices ordered had arrived at the clinic. Sometimes, appointments were made sequentially. In these cases, the services tended not to book far in advance, so they were assured of having clinic time available when required.
Computerised billing system
Most services used manual dockets for billing clients for hearing aid purchases. In four cases, computerised billing followed completion of manual dockets.
Clinical data were generally not stored on computer, apart from hearing aid information stored through the Noah system. One city hospital not part of the main survey had networked their laptops so that hearing aid client information was available at all of their clinical delivery sites. This has proved a useful innovation, and is well supported by the hospital’s IT and data management services.
Output information was available at all services through the appointment systems. This administrative requirement often seemed to prove a limiting factor, because the services were required to use an appointments system which was less than optimal for their needs.
Four services stored all their files within their own space. Others were divided between divisional and main hospital filing departments. In these cases, files for hearing aid clients, and often also summary cards for other high priority clients such as infants were kept in the clinic.
Where the clinic had its own filing system, simple manila folders were the norm.
Stock management systems
Only one of the services used a computerised stock control system. This consisted of an Access database. One of the city audiologists consulted commented that the Noah hearing aid performance system which she used was about to introduce a stock control package, and this could well be a valuable innovation, given the usefulness thus far of the Noah system in storing client data.
In a few cases, audiologists expressed satisfaction with the way their satellite clinics worked. Mostly, however, they were a cause of concern to them. Concerns included time spent travelling to and providing the clinics, transportation of equipment, and the fact that some groups of clients (eg child hearing aid clients) were hardly more likely to attend these clinics than the hospital-based clinics.
Only one of the hospitals surveyed does not have any rural clinics in its area of influence. In another case, there is a rural clinic, but provision is subcontracted to a private provider.
Rural clinics range from 1-3 hours from the base hospital. In the case of the 3-hour clinic, staff make a habit of flying to attend clinics.
In all but one case, the primary aim of the clinic is to provide ORL support. In one case, this support is provided by an audiometrist. In two cases, follow-up for paediatric hearing aid clients is also provided. In one area only, follow-up of adult hearing aid clients is the only service provided.
Position in hospital organisational structure
In one case, where the organisation is obviously fairly flat, the audiology service is located in the hospital service. In three cases it is located within Surgical or Surgical/Medical groupings. In all other cases it is within Clinical Support, Disability Support Services, Allied Health, or a combination of these groups.
In all but two cases, the senior audiologist was responsible to a General Manager of the hospital service. The two exceptions were responsible to Unit Managers of their particular sub-service. In one area currently responsible to a General Manager, a proposal is under consideration to transfer responsibility to the Outpatients Manager. In the one city hospital service (not part of the main survey) where this is the case, this has not proved efficient – with up to three levels of management attending most meetings because of poorly delegated authorities.
The average number of budgeted FTEs for qualified audiologists over the services was 2.0, with a range of 0.8 – 3.2. However, the average of currently filled positions was only 1.1, with a range of 0.1 – 2.2. These data indicate a severe national shortage of audiologists employed in the public sector.
In addition, all but one service employed audiometric technician/s. The average was 0.8 FTE, with a maximum of 2.0.
Data comparing the FTEs budgeted and actually filled (and also including non-qualified audiometric staff – the Total Audiology figures) as a function of population served are given in the following Table. These highlight the effects on services available of the shortage of audiology staff.
In addition, an average 0.8 FTE support staff (range 0.3 – 1.2 FTE) were employed.
Roles & responsibilities of Audiology staff
Titles and job descriptions for the head audiology positions varied from area to area. In almost all cases, however, management of the audiology department was included, and in many cases, a specified amount of the person’s FTE was set aside for carrying out administrative duties. Two areas did not have a designated head audiologist – these were both areas with a single audiologist employed part-time. In both of these places, dissatisfaction with the status quo was expressed.
Technicians when employed, were supervised by the head audiologist in all but the two above-mentioned situations. Duties varied according to the needs of the service, and the capabilities of the individual, but essentially were restricted to routine tasks, or involvement in more complex tasks with the active role being taken by the audiologist.
Current issues and impact on current and future services
There was little awareness among audiologists interviewed of changes in the national context.
A range of
issues were brought up when this topic was introduced – two audiologists
expected further privatisation or subcontracting of services to occur in their
areas. Another referred to increased funding their service had received related
to child health and Maori health priorities. One area was perceived to have
sub-standard services which needed drastic improvements.
Links to ORL services
Relationships between audiology and ORL services varied from provision of regular ORL support by audiology to very independently run services with a large number of reciprocal referrals. In a few cases, the services were physically close. In all cases, audiologists expressed satisfaction with the relationship. In a few instances audiologists wished that they had even closer communication with ORL specialists, and in one case, the audiologist was aware that there was a similar wish from ORL practitioners.
Links to disability services
In four cases, audiology was organisationally linked to DSS. In another case, they shared space. In one case, there was no contact, and in a second, very little.
Links to key community providers
By far the most important community resource as far as audiologists are concerned are hearing therapists. Relationships based on 2-way referrals are the norm. One audiologist who also practises privately commented that her relationship was stronger through her private practice, because of a policy of purchasing therapy sessions for hearing aid clients. In one area, the therapist sometimes attends appointments with clients. In one area, the hearing therapist was the first port of call for clients with malfunctioning hearing aids. Some audiologists expressed interest in improving even further the relationship between themselves and hearing therapists.
Relationships between audiologists and the Deaf Association were very limited, primarily because they have few clients in common.
Vision hearing technicians generally had good relationships with audiologists. In one case, a VHT was employed on a part-time basis by the audiology service to assist with paediatric assessments.
Advisers on Deaf Children are generally seen as close colleagues by audiologists. In one case, the relationship is seen as needing improvement, and the audiologist is motivated to work on this. Links with itinerant teachers of the deaf are sometimes strong and sometimes nonexistent.
Other links seen as important to varying degrees by audiologists are Speech Language Therapists, Public Health Nurses, and Community Health Workers. General Practitioners were occasionally mentioned. In several cases, audiologists commented that they received direct referrals from GPs.