Overview
This commissioning guidance is intended to support integrated care boards (ICBs) in their consideration and planning for the commissioning and delivery of ear checks for children and young people with special educational needs and disabilities in residential schools and colleges.
Eligible population
This service is aimed towards supporting the provision of ear checks for autistic children and young people (CYP) and those who have a learning disability, or both who attend a residential special school or college in England either as a residential or as a day pupil. A ‘whole school’ community approach should be adopted as part of the eligibility criteria to ensure equity for all children and young people within these educational settings. The age range for these services is 4 – 25yrs (24yrs and 364 days). CYP who attend special residential schools and colleges have a range of impairments or conditions, that will require individual consideration of their needs and any reasonable adjustments that may be needed.
Exclusion criteria: Individuals already diagnosed with a hearing loss who are already under the care of paediatric audiology or ear, nose and throat (ENT), or where ear checks are contraindicated.
See Ear checks in residential special schools and colleges service – practising standards and clinical guidance and draft service specification (a log in is required for the FutureNHS platform) for additional information.
Target audience
There are approximately 274 residential special schools and colleges located across England, with approximately 18,000 CYP with special educational needs and disabilities (SEND) attending these settings
Ear checks service offer
All eligible children and young people should be offered a maximum of 3 in-school ear checks, in line with recommended guidance. These should include.
- an ear check when first entering the special residential school/college system.
- an additional check when transitioning between stages within the special residential education system (i.e., primary school to secondary school or, from secondary school to college, or leaving secondary school at 18 years of age).
- to reduce the risk of excessive testing, where there is no known concern around a child’s ear health, we would recommend a minimum of two years between checks.
- receive a maximum of 3 checks within the residential special school/college career.
Indicative quality requirements (KPI’s)
- number/percentage of eligible population offered an ear check.
- number/percentage of eligible population who consented to receiving an ear check.
- number/percentage of ear checks successfully completed.
- number/percentage of ear checks requiring onward referral for follow up or additional treatment.
- number/percentage referred to primary care.
- number/percentage referred to community audiology services.
It is recommended that frequency of reporting should be annually as a minimum but should be determined by the local commissioner in discussion and agreement with the contracted provider.
Ear checks pathway
It is recommended that as part of the planning for commissioning ear checks in special residential schools and colleges, integrated care boards (ICBs) also consider and discuss locally agreed referral routes with primary care, community audiology services and ENT departments to ensure a robust referral arrangements. This should also plan for the additional call on services and increased demand for diagnostic services, as well as onward management.
There may be additional complexity that may also need to be taken account of where there are several community audiology services across a large ICB geography.
Ear checks pathway flow diagram
Perform the ear check in both ears, following the clinical standards and local standard operating procedures
A. Pass (clear response)
1. If there is a clear response in both ears, retest the student’s ear health at a transition point or exit, as specified in the service specification.
B. Fail (no clear response)- referral require
There are three possible outcomes related to no clear response in one or both ears:
1. Wax or Ear Infection suspected – refer to primary care
2. Suspected permanent hearing loss or glue ear, and further diagnostic testing is required – refer to audiology
3. On advice of audiology, If there is concern about the ear health of the child that requires medical attention, such as a perforated ear drum or other abnormality such as a cholesteatoma – refer to ENT
Governance arrangements and clinical peer review for non-audiology practitioners
Where ear checks are delivered using a school led or community nurse led model, the ICB would need to ensure appropriate clinical governance and oversight of the service, training and reviewing of tests from an audiology service. See commissioning considerations and assumptions below for further advice.
Local standard operating procedures (SOP) should be developed between the contracted service provider and the local audiology and ENT services. Where delivery of the ear checks is undertaken by non-audiology staff, this should include clear guidance on arrangements and responsibilities associated for clinical peer review, by both non-audiology staff and clinical reviewers. It should make clear local referral pathways for each potential outcome.
Clear guidance should be developed locally for clinical peer review for those that fail the ear checks (see ear checks pathway diagram). Local referral routes would need to be identified for the three possible care pathways, subject to identified need of the child or young person.
- primary care
- paediatric audiology services
- ears, nose and throat (ENT) services
Clinical peer review process should be agreed locally, and standard operating procedures developed with a UK accredited Improving Quality in Physiological Services (IQIPS) Paediatric Audiology Department on a local or regional basis that have experience of working with this cohort of CYP.
Ear checks workforce models
As part of the ear check pilots undertaken in 2023, three different in-school delivery models were used and evaluated. The three delivery models used three different staff groups. These were utilizing a school-led model, an audiology led model and finally a community nurse led model.
- audiology led – service was delivered by specialist paediatric audiology clinicians who had been trained in supporting children and young people with SEND
- school led – service provided by on-site school trained clinical or non-clinical school staff employed by the school or college involved
- nurse led – service was provided by suitably trained nurses from local community nursing peripatetic services, such as Children’s Universal Services (where workforce includes school nurses and health visitors), or Community Learning Disability Nursing teams
Evaluation of each of the different delivery models, showed that there was a high rate of acceptance and achievement in the successful completion of ear checks within the pilot schools by all three models. Rates of acceptance were slightly higher amongst the audiology and nurse led models, than the school led model, though achievement was greater than 80% in all three.
In all models, obtaining a meaningful ear check reading was associated with the skill and confidence of the checkers, in addition to the training they received. All checkers, regardless of model of delivery, expressed an enthusiasm and wish to successfully complete ear checks. There were mixed reviews from checkers about how confident and prepared they felt to carry out the checks. It did appear that those who had completed more checks were more confident that they were doing them correctly and the school led checkers talked of having gained confidence over time.
| Workforce model | Strengths | Weaknesses |
|---|---|---|
| Audiology led | Specialist expertise in paediatric audiology and so will be audiology trained and therefore familiar with ear check processes already. Understanding of developmental milestones. Adaptable/tailored approach to individual needs. Access to multidisciplinary team and referrals for further diagnostic tests and follow up. Less requirement for peer review of ear checks results. Access to NHS clinical systems. More likely to already have access to suitable equipment and be familiar with calibration and maintenance requirements. | Limited capacity in paediatric audiology workforce. Requirement for travel and to be off site, making this a resource intensive service. Staff will require increased training on meeting CYP with SEND needs and reasonable adjustments. |
| Community nurse led | Potential to have expertise in paediatric nursing, learning disability nursing or both. May be familiar with the schools already if working with CUS. Established trust with students. Community experienced and so will be used to often being flexible in approach. Experience of working with families/carers and other stakeholders in meeting the needs of people with complex needs. Access to NHS clinical systems. | Potential existing staffing pressures may prove a challenge to source appropriate nursing capacity and suitably experienced staff. Will need to undertake associated ear check audiology training. Will need training on maintenance and calibration of equipment. |
| School led | Utilises familiar staff that know the CYP. Experienced in supporting CYP with SEND needs, including accommodating communication and sensory issues. Established trust with individual CYP. Potential to support familiarisation of ear checks into the curriculum. Utilises existing school resources and familiar with the working of the school or college. | Potential school staffing pressures may challenge appropriate capacity to support delivery of service. Will need to undertake associated ear check audiology training. Will need training on maintenance and calibration of equipment. Complex administration without access to NHS clinical systems. More complex commissioning and clinical governance arrangements required. |
Key stakeholders that may be able to provide specialist advice and assistance to support the commissioning of ear checks
Integrated care board’s (ICB’s)
- ICB exec lead – children and young people with special educational needs and disabilities (SEND)
- ICB exec lead – children and young people
- ICB exec lead – learning disability and autism
- ICB exec lead – Down syndrome
- ICB transformation leads – covering primary care, children and young people, planned care
- senior responsible officer for SEND
- chief nurse’s
NHS England – regional teams
- regional lead – audiological scientists
- regional SEND lead
- regional learning disability and autism leads
Schools and parent/carer engagement
- headteachers
- residential special school/college governing boards, via the chair of governors.
- parent/carer groups and networks
Local authority’s
- directors of public health – key links to children’s universal services (health visitors/school nurses)
- directors of children’s services – key links for educational settings, children’s social care and broader links for services and advice to families/carers of disabled children and young people
Community health trusts
- paediatric audiology and ENT services
Commissioning responsibility and contractual arrangements
Recurrent revenue funding from NHS England for delivery of hearing checks in special schools has been provided to ICBs through core ICB programme allocations, using the target distribution for 2024/25 ICB core services.
Each ICB must ensure that an ear check service is commissioned for those children for whom it has responsibility under the Who Pays? rules.
The ICB which hosts a special residential school should take the lead in putting in place the necessary arrangements through which ear checks can be delivered for all eligible pupils attending that school. Other ICBs will have responsibility for some children in that school (for example, where they have been placed out of area) and should work together with the host ICB to put in place pragmatic and proportionate arrangements which ensure that all children in each school are provided with the required checks.
In awarding contracts to providers of ear checks, ICBs must ensure that they comply with the requirements of the NHS Provider Selection Regime, as applicable.
Due to the complexity around guaranteeing appropriate clinical governance of non-clinical and non-NHS delivery teams (i.e. school-led model), it is recommended that if services are delivered by such arrangements, that ICBs commission the ear check service from a local audiology service to lead on the overarching management, training, review and clinical oversight of the service and that agreed sub-contracting arrangements are put in place for individual school-led ear check delivery. See NHS Standard Contract -General Conditions (GC12 -Assignment and Sub-Contracting) and Technical Guidance – Para 38 (Assignment, novation and sub-contracting). NHS England » 2024/25 NHS Standard Contract
Financial assumptions
Systems are subsequently funded on the assumption that each hearing check will take resources equivalent to 1-hour A4C B7 audiologist, 1-hour A4C B5 audiology support and 30 minutes A4C B7 audiologist for clinical peer review of ear check results when delivered by non-audiology services. Funding includes provider overheads.
The ear checks pilot services indicated that on average each hearing check would utilise 1-hour of contact time which would include person-centred familiarisation and administration of the ear check. Up to an hour would be needed for all associated administration activities and any referrals needed associated with the ear check. An additional 30 minutes would also be needed for clinical review of test results by a qualified audiologist where services are delivered by non-audiologists.
Training standards
These standards are set out in more detail in the Practicing standards and clinical guidance, and the requirement included in the Ear checks service specification.
Further information
Paediatric audiology services are encouraged to apply for UK Improving Quality in Physiological Services (IQIPS) accreditation. IQIPS, managed by UKAS, aims to enhance patient care and safety for physiological tests through accreditation. It covers eight disciplines, including Audiology, crucial for diagnosis and treatment. Accreditation offers benefits such as sharing best practices, enhancing efficiency, and national recognition. NHS England, the Care Quality Commission, and professional bodies endorse IQIPS for improving patient outcomes, making it integral to healthcare provision.
Use this UCAS website to search the current list of accredited paediatric audiology services in England.
An interactive map shows the location of the paediatric audiology services that supported the ear checks pilot, which are listed below:
- University Hospital and Western NHS Trust, St Michael’s Hospital
- St George’s University Hospitals NHS Foundation Trust
- Torbay and South Devon NHS Foundation Trust, Torbay Hospital
- University Hospitals Plymouth NHS Trust
- Norfolk and Norwich University Hospitals NHS Foundation Trust
- Cambridge University Hospitals, Addenbrooke’s
- Nottingham University Hospitals NHS Foundation Trust
- Sheffield Children’s Hospital
- Leeds Teaching Hospital NHS Foundation Trust, St James’s University Hospital
- Calderdale and Huddersfield NHS Trust, Calderdale Royal Hospital
- Alder Hey Children’s Hospital
- Berkshire Healthcare NHS Foundation Trust
- Guys and St Thomas NHS Foundation Trust
- Oxford University Hospitals NHS Trust
Publication reference: PRN01338_i