Joint Committee on Health díospóireacht -
Wednesday, 28 Feb 2024

Development of a National Hearing Care Plan: Chime

An Cathaoirleach

We will commence the committee's consideration of issues relating to the development of a national hearing plan. From Chime, I am pleased to welcome Mr. Mark Byrne, chief executive officer; and Mr. Brendan Lennon, director of advocacy.

I will read a note on privilege. Witnesses are reminded of the long-standing parliamentary practice to the effect that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks and it is imperative that they comply with any such direction.

Members are also reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against any person outside the Houses or an official, either by name or in such a way as to make him or her identifiable. I also remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit a member to participate where he or she is not adhering to this constitutional requirement.

Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any member participating via Microsoft Teams that, prior to making their contribution to the meeting, they confirm that they are on the grounds of the Leinster House campus.

We will commence our consideration on the developments of a national hearing care plan. I now invite Mr. Mark Byrne to make his opening statement on behalf of Chime.

Mr. Mark Byrne

Good morning. I thank the members of the committee for organising this session on the need for a national hearing care plan and for extending an invitation to Chime to present to the committee on this important subject.

Ireland needs a national hearing care plan. According to the national audiology review of 2011, there are 300,000 adults with significant hearing loss. However, according to The Irish Longitudinal Study on Ageing, TILDA, in 2017, only one in five older people with hearing loss had hearing aids, and they only got them as a last resort. In 2019, our own analysis showed that as a country we prescribe hearing aids at less than half the rate of the UK, and while this has improved slightly in the meantime, we are still more than a third behind. The body of research that demonstrates the considerable increased health risks associated with unaddressed hearing loss is growing, with dementia, depression and social isolation some of the most significant issues. On the other hand, recent research also shows that hearing aids largely eliminate the increased health risks associated with hearing loss. The health burden associated with unaddressed hearing loss is significant. In 2021, the WHO recommended that governments invest in national hearing care plans. It said that for every €1 invested, governments could expect a return of almost €16 over the following ten years. This return on investment is approximately one third of direct health cost savings for the State, and two thirds in improved quality of life for individuals and their families, such as improved productivity and independence.

Why does Ireland need a national hearing care plan? As I have already stated, Ireland prescribes hearing aids at a rate well below that of the UK and consequently, has a high rate of unaddressed hearing loss. In turn this has a negative impact on the quality of life and health status of those with unaddressed hearing loss. However, there are other reasons Ireland needs a national hearing care plan. We have persistently long HSE audiology waiting lists. Over 20,000 people are currently on these waiting lists, and half of them are children. In some areas of the country the wait is up to three years. We are aware that for the past two years the HSE has been developing a framework that would address waiting lists in a substantive way. The framework involves two phases. Phase 1 is a procurement process to develop a panel of approved providers and phase 2 would follow whereby local HSE management could tender for services to address waiting lists locally, using that approved provider list. We understand that this process, which has been delayed many times, has hit another roadblock as the HSE procurement division will not progress the framework model until funding is made available. Meanwhile, we are aware that some people on HSE audiology waiting lists are presenting to private providers and availing of the treatment benefit hearing aid grant while awaiting their HSE audiology appointments. This is leading to a level of duplication that is inefficient and wasteful.

Approximately 70% of provision of hearing aids is through private providers. The sector has little independent oversight or governance in customer care or quality standards, despite the State investing €26 million in 2023 through the provision of hearing aid grants. While we welcome this investment, we believe a national hearing care plan would go some way to providing a level of oversight that would ensure better standards of hearing aid prescription and patient care. Another compelling reason for a national hearing care plan is the improved quality of life that adults experience when they have their hearing loss addressed, be it through hearing aids, cochlear implants or assisted listening devices. More than 80% of hearing aid users report that the aids improve their quality of life and social relationships. As one client of Chime who was fitted with hearing aids stated, “life is so much easier when you can hear”.

Chime has campaigned for a national hearing care plan for a number of years and members of this committee have been helpful in raising the issue with the Department and the Minister, Deputy Stephen Donnelly, on many occasions. Chime met with the Minister in May 2023 and he was positively disposed to the development of a national hearing care plan. In January 2024, Department officials committed to set up a working group in the coming weeks to develop the plan. They said that the working group would be tasked initially with making recommendations to reduce the level of unaddressed hearing loss among the adult population, and we understand that these will go forward for consideration in the Estimates process for Budget 2025.

There is a major health opportunity for the State and the Irish population to reduce the health burden and improve the quality of life of many people through reducing the level of unaddressed hearing loss in the population. A national hearing care plan is required to deliver this. We now need all stakeholders to focus on delivering this in a timely fashion as promised. It is vital that the Minister, Deputy Donnelly, and the Department of Health lead the process with vigour and address some of the current pinch points, such as the availability of funding to address waiting lists, as a matter of urgency. We look forward to working with members in the coming months to ensure that a national hearing care plan is developed and commenced later in 2024. I thank the committee.

An Cathaoirleach

I thank Mr. Byrne. I invite members of the committee to discuss this matter with the witnesses. Senator Seán Kyne will begin.

Senator Seán Kyne

I thank the Chair. I wish to welcome the advocates from Chime. I thank them for their advocacy on this important issue. As everybody gets older, health deteriorates. Hearing is one of those issues. Are the witnesses talking about the natural ageing process or about younger adults that may, for whatever reason, suffer hearing loss? Is this a natural ageing issue?

Mr. Mark Byrne

It is both, Senator. We are talking about the natural ageing process, primarily. That is the larger number. However, there are people within that figure of 300,000 who have acquired hearing loss through work accidents, loud music or through other conditions and diseases, but the big number is most definitely people who have been affected by ageing, yes.

Deputy Seán Kyne

Okay. Are the health risks taken seriously enough by health practitioners? Are they on the lower end of what people might deem urgent?

Mr. Brendan Lennon

In 2021, Chime did its own survey of almost 600 people between the ages of 50 and 80 who had a level of hearing loss. They told it that they were aware of the link between hearing loss and depression, but not necessarily aware of other links such as cognitive decline. According to international experts, and as set out in Dementia Prevention, Intervention and Care: 2020 Report of the Lancet Commission, 8% of dementia is preventable through early management of hearing loss. Indeed, other modifiable factors such as social isolation and depression add to that 8% figure because they are associated with someone living without amplification. The wider public understands, and more than 40% of people in the survey understood, the link between depression and hearing loss. However, they did not understand the link between that and other issues, not just cognitive decline; there is a wide range of issues associated with hearing loss, from functional independence to increased hospitalisation as they are more prone to have accidents because they are less in tune with their environment. Therefore, the health burden is considerable but the wider public is not aware of it.

It is not that people are unaware that their hearing is deteriorating. In the survey that I mentioned, 43% of people noted a deterioration in their hearing, including 37% of people in their 50s. Quite a lot of people notice a deterioration but it tends to be gradual and something they adjust to and live with. Initially, they turn the television up a bit. They listen harder, which they are not aware they do. This undoubtedly has some connection with cognitive decline as we know from MRI scans in recent years that when people are listening harder, they employ other parts of their brain to concentrate on listening.

They do that to the detriment of things like short-term memory, for example. That is one of the primary indicators of cognitive decline, ultimately, possibly leading to dementia.

The wider public are not aware of those issues but we are. Given that we have such a high level of unmanaged hearing loss, this is a significant health opportunity for the State to reduce the health burden, actually save money and improve quality of life.

Senator Seán Kyne

I was not aware of the link between hearing loss and dementia but I am certainly aware of it now. One always worries about these things for oneself and one's family so I will take cognisance of that link.

Mr. Byrne said that Chime representatives have met the Minister for Health and there is a working group. Is he confident that things are moving as regards the creation of a national hearing loss plan?

Mr. Mark Byrne

It is hard to say if we are that confident. The plan has been delayed a number of times and the procurement piece has been especially challenging. There is a bit of momentum at the moment but one of the challenges for Chime is competing priorities and the need for the political will to make something happen. Progress is slower than we would like. We get that there are a lot of priorities in health but if the plan continues to be put at the bottom of the list of priorities, we will continue to have high waiting lists and a high level of unaddressed hearing loss.

We have momentum at the moment. One of the reasons for attending today is to ensure there is awareness of the issue and cross-party political will and support for a plan. As we have outlined, this would be financially beneficial for the State and improve quality of life. There has to be an urgency behind it to get people moving in the right direction. There are practical issues involved. For example, the grant comes from the Department of Social Protection, yet leadership comes from the Department of Health. Political will is required to bring about the momentum that we feel is needed. It is not complicated.

Senator Seán Kyne

On technological advances, some people do not want to show signs of age or whatever else but I note that hearing aids are becoming more compact, smaller and less obvious. I presume the quality of hearing has improved with technological advances.

Mr. Brendan Lennon

Yes, there is no doubt that modern digital hearing aids are much better than the analogue hearing aids available 15 or 20 years ago. The price of hearing aids also varies because some have features like noise cancelling or noise reduction that work very well in different environments. The more basic hearing aids do not have such programmes. Overall, 85% of the people who are fitted with hearing aids say that their quality of life has improved and the hearing aids meet their expectations, while two thirds say they wish they had got them earlier.

We mentioned the TILDA study from 2017, which was published in 2018. It found that only one in five people in Ireland who had significant hearing loss had hearing aids. When we looked at the wider numbers we were able to see that at that time we were prescribing at below half the rate at which the UK was prescribing. TILDA also noted in the responses given by participants that people tended only to get hearing aids as a last resort.

We agree that there are two key pieces here. The first is that the wider public have timely access to hearing aids and other supports in respect of their hearing loss. The second is for the Department to consider an education, as opposed to commercial, piece as part of its national hearing care plan. That would include making information available to the public and encouraging people to consider whether their hearing has deteriorated and to take action. Key key health professionals along that pathway have a role to play, in particular GPs. In the past, we have found that GPs are often reluctant to encourage their patients to consider hearing aids. Some 70% of the people who need to get hearing aids have to find the money to buy them, while the remaining 30% have medical cards. GPs are, therefore, often reluctant to tell people to go out and buy something that might cost them €3,000 or €4,000. That is why we need more affordable and accessible pathways for people to access hearing aids and similar supports to be provided in a timely fashion at an earlier point in the pathway. That is the key.

If people wait to take action, two challenges arise. First, they may already be in a position where they are experiencing depression and a level of cognitive decline that they should not be experiencing. Second, when they get hearing aids, having waited anything from five to ten years, it is much more difficult to adjust to and habituate to the hearing aids because, in many cases, people's brains have forgotten sounds and no longer recognises them. When hearing aids are fitted and they may find themselves all of a sudden asking what a certain noise is or saying they cannot stand a door creaking or the noise of a fridge. All that is because they have not heard these noises for many years, so it will take a lot more persistence and effort to adjust to wearing a hearing aid. The earlier a plan is rolled out, the better it will be for everybody.

Deputy Pauline Tully

Reference has been made to the national audiology review of 2011. I presume the purpose of the review was to assess the number of people with hearing loss who require help. Has another review been done since? How often should reviews be carried out? Why have none been carried out since 2011? Should they not be done more frequently to inform the State what services are required?

Mr. Brendan Lennon

The report was carried out by the HSE. It was quite focused on HSE services and provision at the time. One of the key pieces of information in the review was that 8% of adults in the Irish population have significant hearing loss and should receive audiological support and intervention. That is where the figure of 300,000 people with hearing loss came from. The figure is slightly higher now with censuses showing increases in the population. The recommendations of the report were very much focused on the provision of services by the HSE. Some of the recommendations have been implemented. Obviously the HSE only provides services to people who have medical cards and children under the age of 18 who have hearing loss.

Traditionally, parliamentary questions have focused on the HSE's audiology waiting list and a many of the replies are confined to issues around the HSE's provision of audiology services, which are problematic in the main. The problem is the persistent waiting list, which we mentioned. What is not so well known is that 70% of audiology services are provided by the private sector which is subject to very little regulation or oversight. In fact, anybody can set up an audiology service and prescribe hearing aids. There is nothing in place to say a person needs a certain level of qualifications or facilities must reach a certain standard. The only kind of oversight is in the hearing aid grant scheme under the Department of Social Protection, which features a list of approved providers who must be members of the professional association, the Irish Society of Hearing Aid Audiologists, ISHAA, but that is all. Last year, in our opening statement, we provided a figure showing that almost 28,000 people made a hearing aid claim.

That equated to between €26 million and €27 million in value. As it is demand led and PRSI related and is, therefore, a social insurance scheme, the State is probably investing more - I do not have the exact figure for the HSE - in audiology support via the Department of Social Protection than the HSE. I do not think that is well-known. It is important because that pathway is the one where people will often want to get support, but they simply cannot afford it as they do not have the money in their pocket.

Deputy Pauline Tully

It was said that many people only get hearing aids as a last resort, which is maybe because they do not want to be seen as getting older or whatever it is, but if people need corrective eyewear, they get glasses. Is the cost more of a deterrent, however? It may be both, which I presume will be addressed in the national hearing plan. The fact, for example, that dementia can be caused by hearing loss is not well-known. It was raised by the Alzheimer Society of Ireland at the committee a few weeks ago, but if information like that were public, more people might be inclined to have their hearing checked and addressed. At the same time, will the cost still be a huge deterrent for many? How much does the grant or PRSI payment cover?

Mr. Brendan Lennon

The Deputy touched on an important point. It is a little complicated but I am happy to go into it. We have been campaigning for a number of years, prior to 2020, for an improvement in the terms and conditions of the hearing aid grant. At that point in time, the hearing aid grant was a maximum of €500 for one hearing aid, or a maximum of €1,000 for two hearing aids. It also had the proviso that the maximum grant payable was 50% of the value of the hearing aid. At that time, for example, some what we call basic or level 1-type hearing aids might have been in the range of €1,400 to €1,600. Somebody would then get a grant of €700 to €800 and have to pay the balance of €200 or €300. We were very much aware that cost was a major barrier for people. At that point, 3.5% of hearing aid claims were for those level 1, basic hearing aids. That 3.5% is an important figure. I will also mention that prior to the financial crash, believe it or not, the hearing aid grant was a maximum of €760 per hearing aid. It is now significantly lower than it was in 2006 or 2007.

In 2020, due to our efforts with the Department of Social Protection, it had to bring forward a report, under the Social Welfare Bill, on the affordability of hearing aids. That report was published in August 2020. The Department's report, in its wisdom, assessed that cost was not a significant factor. It did not want to increase the grant, but it removed the 50% tariff. In other words, everybody could claim €500 for a hearing aid, irrespective of whether it cost below €1,000. What subsequently happened was the hearing aid manufacturers all introduced new level-1 hearing aids at a cost of €1,000. Effectively, somebody who had eligibility for the PRSI hearing aid grant could pop along to get hearing aids "free with PRSI" - that was the catchphrase in some of the advertisements. As a result, when that change came into effect in May 2022, every month since then, an additional 1,000 people, and it has been extremely consistent, have claimed that grant. In addition, of the 28,000 claims last year, since the change, instead of 3.5% of people getting the level-1 basic hearing aid, it is now almost 29%. That is an issue for us as regards the appropriate and quality provision of hearing aids, or the right hearing aid for the person.

We think this has happened for two reasons. A considerable number of people have come forward because they have no spare money in their pockets, if we think about what has been happening with inflation and so on in the past couple of years. People are going in and saying to their provider that they are there to get the free €1,000 hearing aids because they have no money. We also believe a considerable number of people - we do not know how many but, anecdotally, it is significant - who are in their 70s and 80s and on HSE audiology waiting lists, are being told they will wait up to three years for a first appointment, but they also have PRSI eligibility. We think a considerable number of those people are electing to go along to get the free hearing aid until their HSE audiology appointment comes up. This is where we are talking about duplication and inefficiency in the system and the fact we think people are not getting the right hearing aids that are fit for purpose. A national hearing care plan would include recommendations around, perhaps, instead of having just one, single level grant, having a two-tiered grant system so people would get the appropriate hearing aids they need.

Deputy Róisín Shortall

I thank the witnesses for the work they do in Chime. Mr. Lennon provided very interesting detail in the past few minutes on the dynamics within the hearing loss world, if you like, and how the support system is determining practice, which it seems may not be good practice. He made a very good case. The point made by the WHO is that for every €1 invested the State gets a return of €16. On that basis, this seems a complete no-brainer, but that point does not seem to have been taken on board at all by the Department. I received a reply to a parliamentary question last year about a hearing aid plan, and there is no indication the Department is serious about it at all. That is something the committee should take up because, as has been made very clear, this whole area is very much overlooked. The point was made that nobody thinks twice about getting glasses to correct his or her vision at any age, whereas the attitudes to hearing aids are very different. That is part and parcel of the education programme that is needed.

Mr. Lennon talked about nearly a third of people opting for the level-1 hearing aid because of the fact it is free and the cost is fully covered by the State. How many levels of hearing aid are there?

Mr. Mark Byrne

Generally, we work off a range of five. Trying to find the best use and primary need patients have is driven by lifestyle. We look at things such as whether they are working or are in a noisy environment, and the type of activities they do outside of work. As we touched on earlier-----

Deputy Róisín Shortall

Presumably, effectiveness is-----

Mr. Mark Byrne

Exactly. As we touched on earlier, some of the modern hearing aids are great at blocking out background noise and maybe making it more focused on the immediate conversation, which is very helpful. Again, however, as Mr. Lennon touched on, the challenge we are seeing is that people are just opting for the free version.

Deputy Róisín Shortall

The lowest, yes. We have a situation where large numbers of people who should have hearing aids do not for various reasons. There is no understanding of the link between hearing loss and dementia, in addition to having a much lower quality of life, difficulties in relationships and all of that, and the isolation that comes with hearing loss. For a large number of people who get hearing aids, those hearing aids are probably not good enough for their needs.

It is a seriously problematic area that we need to pursue.

The figures for the waiting list are absolutely shocking. The last figures I have are 22,000, of whom 5,000, adults and children, are waiting more than a year and up to three years. Over 6,0000 are waiting between six and 12 months. That is an absolute disgrace. Then people are being forced into the private system. What would be the optimum model of care in relation to hearing loss? Should much more of the work be done at State level rather than outsourced to the private sector? Is that Chime's view or does he think a mixed model can meet the needs of people, providing it is adequately funded?

Mr. Brendan Lennon

In the short to medium term, we think a mixed model would be the most effective in reducing the waiting lists and supporting more people to get hearing aids in a timely fashion because we will not be able to gear up the public service in a matter of a year to 18 months to do that. In the UK, where virtually everybody has an entitlement to public health and audiology services through the NHS, 30% of the provision for NHS patients is delivered by private providers but it is done according to standards set by the NHS and according to protocols and procedures there. The individual has a choice of whether to go to a private provider or to the NHS itself. If I was living in Clifden, for example, and needed to see an audiologist and had a medical card, I would need to travel to Galway. If I had the choice to go to the HSE or a local provider, I would only have to go down the road. Many of these people are in their 70s and 80s, do not have public transport and so on. We believe that it should be mixed in the short to medium term and we are agnostic about the whole thing in the main. What we are interested in is that this health opportunity is grasped and that there is a clear plan and policy in place, which there is not, for the full population and not just for the 30% in the HSE. Probably the best way to do that in the short and medium term is a mix.

May we say a little about the procurement roadblock we have spoken about? Last year, the Minister told us there was money there to address waiting lists. We knew the HSE was setting up a framework to address waiting lists in audiology. This framework would include a two-stage process. In phase 1, a panel of approved providers with appropriate qualifications, facilities, etc. would be created and in phase 2, local managers in regional health organisations could tender for services to address their waiting lists locally. We think that is a good plan. We thought it would have begun to roll out in 2023. We expected phase 1, to set up the panel, would roll out in the first quarter of 2024. Now we understand that because no funding is earmarked for addressing waiting lists in 2024, that the procurement division in the HSE has stalled and it will not move forward until there is funding in place. We believe that is something that the Minister and his Department need to resolve sooner rather than later. Otherwise the issue of the waiting lists, which has been interminable, will continue.

Deputy Róisín Shortall

I have one more question on the HSE waiting lists, if I may. It is all ages from nought up. We have talked a lot about older people and the reduction in quality of life. The situation has to be even more pressing for children because you are talking about loss of childhood, language acquisition, education and all of that. Are those two services run together or is there a separate children’s service within the HSE?

Mr. Brendan Lennon

There is a separate service in the sense that paediatric audiologists in the HSE have higher levels of qualifications and they see the children. Since the 2011 report, one of the good things that happened, mainly through our efforts at the time, is that newborn hearing screening has been introduced. That means all newborn children are screened for hearing loss at birth and are identified quite early, within the first couple of weeks in life, and fitted with appropriate hearing aids, if that is appropriate, in a very timely fashion. That works really well and is an advance since 2011. As for the 10,000 adults on the waiting list, virtually all have a hearing loss. Of the 10,000 children, the vast majority do not but they may have been referred because they have temporary hearing loss or they have concentration issues in school, etc. Around 5% of those children do have a persistent and problematic hearing loss. The Deputy is right; they are going about their business as best they can day to day but they are missing out on communication, language learning and all of that, at home, in school and so on. It is very frustrating from our perspective. I looked it up and in 2022, I could find three High Court cases where awards were made for delayed or missed diagnosis of audiology issues and hearing loss. Those three cases alone cost €1.3 million. This is why we need to deal with the waiting lists. It is, to use the Deputy’s phrase, a no-brainer: sort out the procurement pathway and reduce the waiting lists. The HSE has the capacity to address the day-to-day need if it could only catch up.

Deputy Neasa Hourigan

I welcome the witnesses this morning. Chime’s opening statement outlined that rate of prescription of hearing aids is much lower here than in the UK. That is always a useful comparison for us. Does Mr. Lennon know offhand what the difference is between the two?

Mr. Brendan Lennon

We do. Going back five years, we were well below 50% and we are now somewhat above 50%. We will be just over half of that five-year window. If we compared that as numbers of people, it would be 81,000.

Deputy Neasa Hourigan

And that is compared to the UK.

Mr. Brendan Lennon

It is per head of population. I am looking at the number of hearing aids that are prescribed annually in the two jurisdictions. Those figures are available per head.

Deputy Neasa Hourigan

So the shortfall is significant. Returning to the waiting list issue, the approved providers process and procurement, will Mr. Lennon outline what we are talking about in relation to approved providers? It is private providers; that is, those who are already on the high street, effectively?

Mr. Brendan Lennon

Yes, that is my understanding. If we want to dig deeper, I understand that the insourcing element of the procurement process, which might look at public employees also working extra to address the waiting list, is not being considered at the moment. We want all our professionals who are capable of providing these services to be as active and involved in doing so as possible, because that is the quickest way to address the shortfall, both for children and adults.

Deputy Neasa Hourigan

So it would be the types of providers that we see now when we walk around our cities and towns.

Mr. Brendan Lennon

Yes.

Deputy Neasa Hourigan

And that the HSE would create a contract with them and that you could go straight to this private provider for your full referral and appointment.

Mr. Brendan Lennon

Yes.

Deputy Neasa Hourigan

One of the items Mr. Lennon outlines, though, is that there is a lack of governance and oversight of the private sector. Does he imagine that reform of that would go hand in hand with sending more public clients to private providers?

Mr. Brendan Lennon

Yes. With regard to the procurement system proposed, the framework, and the provision of services, one of the biggest obstacles to getting to the point of being ready to rock ‘n’ roll was the issue concerning interventions, the recording of interventions and making them accessible via the HSE’s own IT system. That has been overcome. An important part of the process is oversight of the interventions, the protocols, the programming of hearing aids and so on.

Deputy Neasa Hourigan

So, there will be information sharing between the private group and the public group?

Mr. Brendan Lennon

Private providers under the proposed framework would have to report via an IT protocol available to the HSE to audit and oversee according to protocols and standards.

Deputy Neasa Hourigan

To be clear, is it envisaged that the HSE will, at the end of the year, carry out an audit on how many cases have been seen?

Mr. Brendan Lennon

Absolutely. That has to be reported to it.

Mr. Mark Byrne

I would like to think any procurement process would insist on certain standards, certain audiology qualifications and some of the things that have been missing in the private sector.

Deputy Neasa Hourigan

It seems like a good way of pushing waiting lists down; however, when a private provider is introduced you also have to be very careful that you create good frameworks for good auditing and the good use of public money. Also, the principle of good fences making good neighbours should be in place.

Who is on the working group and how much progress has it made? Budget 2025 was mentioned. From having been at meetings in this room for a while, I believe that if we are working towards budget 2025, we are largely talking about a hearing plan in 2026, which is far away for many people. Do we know who is on the working group and the progress it is making?

Mr. Mark Byrne

We have had an indication of who will be on it. There has been a little movement on it. It will be most valuable if all the parties, including the private providers, have an input. Also, the Department of Social Protection needs to be involved. To be honest, we have had different conversations with the Department of Health about who will be on the committee.

Deputy Neasa Hourigan

Has the committee not been formed?

Mr. Brendan Lennon

No. Our last meeting with the Department officials was at the end of January and we were told then that the working group would be established in the following weeks and that membership-----

Deputy Neasa Hourigan

So there are no terms of reference in the general-----

Mr. Brendan Lennon

No, we do not have that data yet.

Deputy Neasa Hourigan

When a working group is about to be formed, as in the following couple of weeks, the terms of reference will usually have been in the ether for people such as the delegates for several weeks. Are there no terms of reference right now? Have the delegates no information on whether private providers will be included or whether groups such as the Department of Social Protection will be included? Is there no information currently available?

Mr. Brendan Lennon

We were told at our meeting with Department officials at the end of January that the working group would be established in the following weeks and that terms of reference were being finalised. We have not seen the finalised terms of reference. The membership being considered at the time was to include staff from the Department and the HSE. We also were told it would include someone from the Department of Social Protection and a GP, which we believed was good. However, that was the last we heard.

Deputy Neasa Hourigan

Therefore, there is no point in my asking about a timeline as we are far from that.

Mr. Brendan Lennon

What I should say is that we were told the intention was to have the working group set up in the following weeks and that it would concentrate initially on unmanaged hearing loss in adults, which is what results in delays on the private side, and be tasked with making recommendations that the Minister could consider for the Estimates process for budget 2025. That was categorically stated to us at the meeting.

Deputy Neasa Hourigan

However, if the working group is not yet set up, it would really have its work cut out for it if it were to get something together for budget 2025.

Mr. Brendan Lennon

The working group will have to work pretty fast.

Deputy Neasa Hourigan

I have a final question. While I am aware that Chime is not the HSE, knowing what the delegates know about the sector, are they aware of whether audiology departments in primary care are fully staffed or what staffing levels are like? If they are not fully staffed, is it contributing to waiting lists?

Mr. Mark Byrne

For sure. Anecdotally, we hear of vacancy levels of between 20% and 30% across several disciplines within the HSE. I am sure audiology fits into that. I do not know whether Mr. Lennon has any more detail.

Mr. Brendan Lennon

I do not. I do know audiology got additional posts in recent years. It was one of the better disciplines in terms of vacancy rates in the HSE. There is no doubt but that the development of the audiology degree course in UCC has been very important in that regard.

An Cathaoirleach

Following today’s meeting, the first thing the committee will try to follow up on is the working group.

Senator Martin Conway

I thank the delegates for attending. I have a straightforward, simple question for them: have they met the Minister, Deputy Donnelly, recently?

Mr. Brendan Lennon

As recently as May 2023. That would have been the last meeting.

Senator Martin Conway

At that meeting, was there a commitment to set up the working group? Were the delegates given timelines at that stage?

Mr. Mark Byrne

Not specifically at that stage. It is fair to say the Minister was positively disposed to the idea but there was much conversation about competing priorities.

Senator Martin Conway

I agree with Deputy Hourigan that the timeframe is very tight to feed into the Estimates process for budget 2025. My understanding is that the officials start preparing the Estimates in July. Really and truly, the working group would need to be set up immediately and work through quarter 2 of this year to have the recommendations signed off on. If at this stage the terms of reference are not even available and we do not know what they will be, it is an issue. I agree with Mr. Lennon on including a GP and private providers but unfortunately I am not very confident that we will see anything substantial for budget 2025. I do not like to be pessimistic.

In answering Deputy Shortall, reference was made to doing hearing tests on newborn babies. Could Mr. Lennon elaborate on that? Are all newborn babies tested? If hearing issues are identified, are they dealt with immediately? Could Mr. Lennon talk us through the process?

Mr. Brendan Lennon

It is something that happens in maternity hospitals. The job title is “newborn hearing screener”. The screeners are employed to screen all babies in maternity hospitals at the point of birth. This entails a simple probe in the ear. Around 3% to 4% of babies are subject to a referral after the screening, are screened further and, if necessary, sent for a full audiological assessment, all within a matter of weeks. That works really well.

Senator Martin Conway

So they get their full audiological assessment and are then referred on if interventions are needed. Could this result in a scenario in which, in five or ten years, no schoolchild will have hearing loss that has not been identified?

Mr. Brendan Lennon

Would life be so simple?

Senator Martin Conway

Sometimes life would be simple, only humans complicate it.

Mr. Brendan Lennon

The thing is that a certain number of children, or around three per thousand, are born with some hearing loss or hearing issue, but the prevalence of hearing loss doubles across childhood.

Senator Martin Conway

So the proportion of children who develop hearing loss going through primary and post-primary school could rise from 4% to 8% or 10%?

Mr. Brendan Lennon

Yes. It is about 0.6%, or six in every 1,000 children. Just over 5,000 children in our primary and secondary schools, according to the NCSE, have significant hearing loss.

Senator Martin Conway

One would wonder why this screening of babies did not begin happening a long time ago. It seems very simple. As our guests probably know, I do a great deal of advocacy work for eye care and sight loss, and there is a need for a national strategy for the prevention of preventable sight loss as well. A lot of national strategies are needed. From our perspective, and I think I speak for everybody at the committee, we support that call.

How is Chime funded?

Mr. Mark Byrne

We are funded about two thirds directly from the HSE and about one third of our income comes through fundraising or product sales.

Senator Martin Conway

The bulk of the latter third come from product sales. There is a commercial wing to the organisation.

Mr. Mark Byrne

We call it social enterprise. Everything that is generated from that goes back into the service.

Senator Martin Conway

I am not suggesting it does not. That is fine.

Deputy Colm Burke

I thank the witnesses for their presentation. To return to the issue of hearing loss among young people, especially young people with disabilities, is Chime satisfied there are enough checks in that area? Sometimes when a physical or intellectual disability is identified, the fact there may be other disabilities, such as relating to hearing, can very easily be ignored. Is Chime satisfied there is sufficient monitoring in that area or could more be done on it?

Mr. Brendan Lennon

To be fair, our understanding and experience in that area is that in the case of people under the age of 18, the HSE is providing those services. Young people with additional needs are well assessed for issues such as hearing loss over the period. In the main, that is our experience. It could be that some people may have a profound intellectual disability and audiological assessment might be very difficult, but we are not aware that that is common, by any means. Our sense is that is well taken care of and provided for by the HSE.

Deputy Colm Burke

In respect of young people generally, the witnesses talked about the monitoring of babies after they are born. To help parents understand that issues might arise at a later stage, however, are they being given enough information in order that they can identify at an early stage where a child at the age of, say, three or four might have a hearing difficulty that might not have been obvious on day one but which might at that point begin to be noticeable? Are there certain signs parents should watch out for in that scenario?

Mr. Brendan Lennon

That is why 10,000 children are on the waiting list, even though about 95% of them do not have a hearing loss. It is because parents are vigilant as to how their children are functioning generally, and if they notice a deterioration, their child not being as attentive as they think they should be or their language not developing as they think it should, one issue that often comes to mind for them is that there may be an issue with the child's hearing. We are referred a lot of children who may be showing some challenge or delay in their development that is not caused by hearing loss. That is why, as I said, we have 10,000 on the waiting list, even though more than 90% of them do not have hearing loss. We need to identify those children earlier. We are not doing that, and that is a problem.

Deputy Colm Burke

Is there a way that waiting list of 10,000 could be dealt with? Obviously, the challenge is having an adequate number of people to carry out the assessment but at CUH, for example, where there was a huge waiting list for gynaecological services, the consultants went away and got space at the Mater. They were able to do very significant work in a short timeframe and reduced the waiting list to 4,500. We are not talking about 10,000 waiting in one place but throughout the country. Could a targeted mechanism be put in place to deal with that waiting list?

Mr. Brendan Lennon

Absolutely. That is the procurement process we are talking about. We just need it to kick off as soon as possible. There is capacity in the system, in regard to people who are employed both on the public side and on the private side-----

Deputy Colm Burke

It would need to be co-ordinated, however-----

Mr. Brendan Lennon

Yes.

Deputy Colm Burke

-----and Mr. Lennon is saying it would have to be a co-ordinated effort by both the public and private sectors working together to see whether we could reduce the waiting list.

Mr. Brendan Lennon

Yes, and that needs to be led by the Department and the HSE to establish the procurement framework-----

Deputy Colm Burke

When the witnesses met the Minister, was the possibility of setting up a mechanism for dealing with that waiting list raised with him?

Mr. Brendan Lennon

Yes, that was mentioned and the Minister said there was no issue on his end. This was in May 2023 and he mentioned a figure. Approximately €350 million is available to the HSE to address waiting lists and that was not the issue at the time. The outstanding challenge, as we understood it, was that the HSE did not want to proceed until it could be sure it would have good oversight of any waiting list initiative. When I say "oversight", I mean that any interventions, protocols and all the work done would be recorded-----

Deputy Colm Burke

I fully accept the point about oversight, but how long will it take to set that up? Could it be done in three months if people put their minds to it?

Mr. Mark Byrne

Again, that is probably a question for the HSE, but I would have thought three months, with goodwill, would absolutely be possible. The HSE has been working on this initiative for three or four years, maybe longer. The thought process has been put into it and the frameworks have been worked on. If the desire is there, it could be rolled out in a matter of months.

Deputy Colm Burke

Turning to a different issue, I have come across a few cases of people in nursing homes who have hearing aids without a follow-through system to assist them. I do not know whether the witnesses have come across this. Could a better system be provided for elderly people in nursing homes who are using hearing aids but are not necessarily getting the necessary support within the system? Has Chime dealt with issues like that? I have certainly come across a number of cases of it.

Mr. Brendan Lennon

Yes, we have. In fact, only last week, I attended a session where we were presented with the beginning of a research project we are involved in to provide sight and hearing care to residents in a number of nursing homes as part of a preliminary research project. The figures presented by the lead researcher at that information workshop were pretty shocking. It was UK research rather than Irish research. It showed that 13% of residents of nursing homes had a hearing aid and were probably using it, 7% had normal hearing and 80% had hearing loss with no support. That is indicative of what the Deputy is talking about. One thing that might come out of a national hearing care plan, and has certainly come out of Covid and work we did, is that not all residents of nursing homes who have hearing loss are best provided for with hearing aids. Other, simpler devices could be used and we would like that to happen.

Deputy Colm Burke

Are we putting in enough effort to make staff in nursing homes more aware of and involved in assisting those residents who have hearing loss? Could we be doing much more in this area? We focus very much on the nursing care aspect of nursing homes, but I am not sure if we focus as much on sight and hearing issues in this context.

Mr. Brendan Lennon

I must agree with the Deputy on this point. I am not sure organisations like HIQA, for example, look closely enough at this aspect. I think it is part of what a national hearing care plan would look at in terms of education. I agree with the Deputy that people working in areas like nursing homes need to be more aware and to have more education and information concerning the importance of hearing loss being managed for their residents.

Deputy Colm Burke

I thank Mr. Lennon.

Deputy Bernard J. Durkan

I apologise for arriving late. I thank our witnesses for coming in, giving us the benefit of their advice and outlining their concerns. Turning to the number of people currently waiting for assessment, diagnosis and treatment, how is this waiting list progressing? Is it going up or down? I presume it is not going in the right direction in any event.

Mr. Mark Byrne

Mr. Lennon probably has a greater history with this aspect than I do, but certainly more than 20,000 people are on the waiting list now. Broadly, half these people are adults and the other half are children. The figure was as high as almost 23,000 about 15 to 18 months ago. In the time we have been campaigning, the number has generally been consistently in and around the 20,000 mark for several years now.

Deputy Bernard J. Durkan

What is the rate of ascent or descent, as the case may be?

Mr. Mark Byrne

I would say it is holding very steady at approximately 20,000, certainly going back over the past five years-----

Deputy Bernard J. Durkan

How long would people be on this list?

Mr. Brendan Lennon

These are the people on the HSE's waiting lists accounting for the figure of 20,000. Regarding the length of time people can be told they might be waiting, we dealt with a lady about 18 months to two years ago who was told she would be waiting three years for an appointment, and she was in her 80s. This is ridiculous. Equally, though, there is an unknown waiting list of people out there too. The HSE is only catering for 30% of hearing aid provision. The other 70% is concerned with the wider public. We know a significant number of people have hearing loss and have done nothing about it yet. One of the primary reasons for this is that they do not have any money in their pockets. This is one of the issues.

Some 20% of people do not have PRSI eligibility, so they must pay the full cost. These might be people who were getting hearing aids from the HSE when they were children. They then left school and got a job. Three or four years later they might have needed to replace their hearing aids and, for the first time in their lives, found they had to pay for the cost themselves. I have a colleague in work who had to take out a credit union loan 20 years ago to buy her first set of hearing aids. She had been a hearing aid user. All of a sudden, then, her hearing aids stopped working and she was then faced with paying for her hearing aids.

We mentioned the HSE audiology review in 2011. One of the recommendations in that report was that young people who had hearing loss as children would have a lifelong entitlement to avail of audiology services from the HSE, but that has never been enacted. It is to be hoped Sláintecare will deliver this in time. Young people in their 20s and 30s, however, are faced with buying and paying for hearing aids for the rest of their lives. In terms of the cost we are talking about in this regard, it is like running a second car.

Deputy Bernard J. Durkan

In the matter of children having suffered from hearing loss, which can, of course, have a very serious impact on their education, awareness of the environment, as well as impacting health and safety issues, etc., how do the witnesses see this issue being brought into focus and under the microscope, for want of a better description, to ensure the setting out of precise deadlines for these children to be dealt with? To a large extent, they cannot speak for themselves. What can we and the witnesses do about this situation in the short term?

Mr. Mark Byrne

This again goes back to the procurement framework we are campaigning for and chasing the Department of Health to roll out. It would probably argue there are capacity issues in the system, but we are not so sure about this. Certainly, however, if the public-private partnership model were to be used, where some of the capacity in the private sector could be availed of, this would, in turn, free up some of the paediatric audiologists in the HSE, many of whom also see adults. I refer to focusing on the targeted work for the children.

One of the points we were making earlier was that we are caught in the mud on this issue without the political will and we will continue to be in this situation if a bit of leadership and direction is not shown in respect of really managing waiting lists. I suppose this is the case across the board in many areas, but without this proactive leadership to manage the waiting lists, we will be talking about this problem this time next year, the year after that and so on. We have a little bit of momentum now with the talk of a working group being set up. The first urgent job must be to get this procurement framework up and running. It is very similar to the UK model that Mr. Lennon spoke about earlier, where people can go to their local private audiologist. This might involve a voucher system where there would be reimbursement from the HSE. It would, though, have to be in line with proper standards and protocols to ensure people are getting the right hearing aids. If we were to adopt this public-private partnership model, there is no reason, certainly in the short term, these waiting lists cannot be targeted and brought in a positive direction very quickly.

Mr. Brendan Lennon

In fact, the procurement framework is not really an issue for the working group, as such. It is there in place. It just has not been activated. This is a matter for the Department and the HSE to work out. We did not put a precise number on this, but we did say that around 5% of those 10,000 children do have hearing loss and need some sort of audiological intervention. This is 500 children around the country who are impacted. We do not know who they are, but we must find out as soon as possible to ensure they can get the right support and their learning and development do not continue to be compromised. I have already alluded to how expensive it can be to deal with such situations and to people being so frustrated they have taken the State to the High Court for failures in audiology service provision.

Deputy Bernard J. Durkan

I am coming to my last question. What efforts are being made in various occupations to bring about the elimination of hearing risks? For instance, there was an emphasis in this regard some years ago in relation to deafness as an issue in the Army. I think, generally, this was handled and resolved to the greatest extent possible. Many people, however, are still working in workplaces where the noise is unbelievable. Let us take power stations as the classic example of where the engines in use have a really rasping impact on the hearing system. These are high-powered two- or four-stroke diesel engines. Some of us have worked in close proximity with them in the past.

I remember when you got off a vehicle in that environment and then sat down to look at television at night, it was necessary to switch the sound down to the lowest possible setting to prevent an impact on the hearing system. I never understood why that should have been the case. I would have presumed that one's hearing would be less sensitive after exposure to that type of noise, but, in fact, it was actually more sensitive. It was possible to hear at a greater distance, with sounds being sharper and more distinct, etc. I refer to dealing with these kinds of situations in respect of a means of preventing hearing loss insofar as is possible. To what extent is this happening now in all cases? I know there is a greater tendency to use headphones and so on and so forth, but some of the noise coming through them from time to time can be excessive as well.

Mr. Mark Byrne

A lot of this activity falls on us now. We have quite limited resources, but some of our awareness campaigns and information sessions do have some success in respect of professionals, including health professionals, like GPs.

Some of it is donated by advertising by some of the commercial operators. It builds a bit of awareness. One of the cornerstones of any national plan concerns education and awareness. It is an issue that is not talked about. It is typically dismissed - "Grandad's sitting in the corner with the television blaring". This is often the attitude we see. It involves education and building awareness around the issues across society in order that people with hearing loss take action and take action earlier. Mr. Lennon spoke earlier about how the lack of knowledge around hearing loss among GPs is a bit worrying. There is a hesitancy about talking to people about spending €3,000 or €4,000 on a hearing aid. We spoke about the education system earlier in terms of a lack of awareness and knowledge and the journey parents have to go on. There is, therefore, a key piece relating to this issue, which is building awareness and breaking down stigma and barriers to allow people to take action. We often compare it to eyeglasses. Thirty or 40 years ago, there was a social stigma about wearing glasses when you were in school. As a society, we have been able to overcome that. We now have a similar urgent task to do in breaking down barriers and resistance to hearing aids, which people associate with getting old. We want to change that conversation but it will need will, a budget and some resources to launch that awareness and education campaign that is a cornerstone of any national care plan. It is across society. It includes health professionals and members of the public. It is across the board. We need to get that conversation started and bring it to a high level because we are talking about 300,000 people in the country who are affected by hearing loss. It is a large number, one in seven of us, nobody is talking about it and we need to start that national conversation.

Mr. Brendan Lennon

I will add to the piece around prevention and occupational noise. This is much better managed and there is greater awareness in the workplace around that. I am not saying it is perfect because people sometimes do not follow the advice or use the equipment their employer might be providing. Young people listening to music is probably the greater issue in terms of prevention. This is another area where awareness needs to be created. We are not saying people should not listen to music. They should. It is good for your cognitive and mental health. It is about listening to it within reasonable and safe volume levels. That is the big education piece. Again, we think a national hearing care plan would be an element of it.

An Cathaoirleach

We have only touched on many of the issues this morning such as how people lose their hearing. In their opening statement, the witnesses talk about the 300,000 adults. This was from a survey carried out in 2011. Thirteen years later, with the growth in the older population, the figure is probably far higher.

The witnesses spoke about how one in five older people have hearing aids. Alternatively, you could say that four out of five do not have them whichever way you want to look at it. I want to touch on the point that many of them only got them as a last resort. Could the witnesses touch on that?

Although the evidence is only anecdotal, many older people I know who have hearing aids leave them in a drawer. Do the witnesses have any figures relating to that? Hearing aids are quite expensive. Many people I talk to who leave them in the drawer said they found it very difficult to get used to them. At level one in the public system, a hearing aid has a hard piece of plastic that someone puts around his or her ear. People can pay huge prices if they buy hearing aids from a private provider. The person goes in on the basis of the provider giving him or her the best advice about which particular hearing aid is best for him or her. If a working group looks at this issue, it needs to look at making it far simpler to put a hearing aid on. You can get devices for listening to music so why can you not get something similar for a hearing aid? They are probably available if someone wants to listen to television. Some older people will only put one device in their ear. People say that is not good.

We did not touch on dementia and the importance of hearing with regard to that today. The fact that the brain fills in spaces in silence - it is amazing what the brain can do in this regard. Where would testing of children's hearing normally be carried out? Would it have been in schools years ago? We know that testing for other issues is not happening any more because nurses and others are not going into schools. Could the witnesses expand on that? The witnesses said there is a challenge regarding 10,000 children. What do the witnesses hope comes out of that working group?

What will the framework for the working group involve? What do the witnesses hope that will achieve? When the witnesses met the Minister eight months ago, he was agreeable to establishing it. It highlights how slow the system is when it comes to getting anything done. All of us in the Houses want to see movement in this issue so there is no political pushback and I do not think there is any pushback within the HSE but the system seems so grindingly slow when it comes to trying to get anything done. I wish the working group well. This committee will follow that up but I would be interested in hearing the witnesses' thoughts on how this could move on.

Mr. Mark Byrne

I will take those questions in reverse order. If there was drive and energy in the Department, the working group would already have been established. We are often told about competing priorities but a lot of resources are available. Our main reason for asking to appear before the committee today is that while these topics do come up for conversation, there is the political will to know that we are stuck in a broken system. There should not be any barriers to setting up a working group that is cross-departmental, engages with stakeholders and gets things moving. That should not be beyond us. For us, the follow-up with the Minister will be key to keeping that on the agenda.

Regarding children, Mr. Lennon will be closer to this. If 95% of those children do not have hearing loss, we are really talking about a robust screening process. Again, this should not be beyond the capacity of the HSE to set up a robust process whereby we can work through that waiting list quickly. If we ring-fence a small team of people, we would work through a list like that very quickly and really free up resources to go to the 5% of children who actually have a hearing loss. It needs to be very targeted. Public hospitals do not necessarily always work so I see something like a dedicated screening team focused on working through the waiting list. I think we would see good results from that.

Mr. Brendan Lennon

I will address the Chair's question about people putting their hearing aids, on which they may have spent a lot of money, in the drawer.

We mentioned that satisfaction with hearing aids is 80%-plus among users. However, that means 15% to 20% of people maybe do not have great satisfaction and are probably putting them in the drawer or have set them aside. As I mentioned earlier, sometimes that might be because the longer a person delays, the longer it is to habituate to them. I would also say, however, that this is part of a national hearing care plan with appropriate standards and protocols. Prescribing somebody the correct hearing aids and fitting them correctly is important, but it is not the end of the story. As part of the pathway, there need to be at least one or two follow-up checks with people when they get hearing aids, and further checks should be offered for those who struggle. That is a key part of supporting people.

Sometimes people have a complex hearing loss as well. There might be other issues like that. Personality comes into it because perseverance can sometimes be important. People need someone who is, if you like, holding their hand and encouraging and advising them along the way. For example, a simple piece of advice we think many people do not get is that when they are habituating to hearing aids, they should build it up a couple of hours per day, but they should not go to the supermarket or restaurant in the first couple of days because those are the more challenging environments. People will get discouraged and find it difficult. Therefore, we believe that kind of counselling, if you like, and support is often missing for some people, particularly those who are struggling. That is one of the important elements of an appropriate care package, which would mean fewer people will put their hearing aids in the drawer.

An Cathaoirleach

Unfortunately, we have run out of time. I really appreciate the witnesses coming in this morning. We have touched on many issues. We did not get into everything. We could have talked about challenges around emergency eye and ear care and how people get into that, but there was not enough time. We will certainly follow up as a committee on some of the issues the witnesses raised this morning. Again, if they feel they want to expand on some areas or there is an area on which the committee has not focused but needs to be followed up, they should please contact the secretariat. I thank the representatives from Chime for their engagement with the committee on the important matter of the development of a national hearing care plan.

The meeting is now suspended and will resume shortly with the group from Debra.

Sitting suspended at 11.02 a.m. and resumed at 11.10 a.m.