Background

Hearing loss in childhood can have a significantly negative effect on the development of language and communication and on educational and socio-emotional development.[1] Undiagnosed or late diagnosed hearing loss can increase these effects as the opportunity for appropriate early treatment and interventions are missed[2]. For children with a learning disability or complex needs, an undiagnosed hearing loss can exacerbate existing challenges to development. The prevalence of hearing loss is believed to be greater (up to ten times higher) in autistic children than in typically developing children. Evidence suggests that hearing loss in those with a learning disability could be as high as 40% in the adult population, suggesting increased likelihood in the younger population. It appears that children with a learning disability are less likely to access hearing testing than typically developing children, especially those who are in residential education[3]. Furthermore, some autistic children and young people (CYP) and children and young people with a learning disability may not be able to articulate changes in their hearing or experience of pain in the ear. Therefore, transient or permanent otological issues may not be identified and remain untreated.

As part of the commitment in the 2019 Long-Term Plan[4], NHS England undertook a pilot to deliver ear checks in residential special schools using a number of different workforce models and asked the Health Innovation Network (HIN), South London’s Academic Health Science Network (AHSN), to evaluate.

Traditional hearing testing in school aged children requires subjective responses from the child to identify when they hear a sound. For autistic children and young people and children and young people with a learning disability, existing testing strategies are often not suitable. Although newborn hearing screening is routinely offered soon after birth, children and young people may not receive a subsequent hearing check following this unless there is a concern around their hearing.  The aim of the pilot was to test a proof of concept to provide ear checks for children attending residential special schools. The rationale was to test the acceptability of the testing methods and assess the strengths and weaknesses in delivery using three different practitioner groups. Being able to provide a flexible and personalised approach was seen to be essential to supporting children and young people with complex needs to access ear checks.

The UCL Co-Production Collective worked with NHS England to provide co-production support in two stages. The first was with relevant stakeholders in the seven NHS England regional areas to gather views and generate ideas about how to develop more acceptable ear checks for autistic children and young people, and those with a learning disability, or both. This informed the co-production of an approach to make ear checks more accessible, to test and learn ‘what works.’

Overview of the Intervention

Types of ear checks

In addition to an external visual check of the ear and ear canal, up to three types of ear checks were performed on each child or young person, based on whether they received a clear response for the preceding check. The ear check protocol consists of transient evoked otoacoustic emission (TEOAE), video recorded ear examination (otoscopy), and a pressure test of the ear (tympanometry).

TEOAE: This check uses a click stimulus to briefly stimulate the cochlea across a wide frequency range and record the response from the outer hair cells in the external ear canal. A disposable tip is placed over the probe which delivers the stimulus. The probe is then placed at the entrance of the ear canal to record the TEOAE. This check is widely used as a tool during new-born hearing screening. For this pilot, it was agreed by clinical experts that should a TEOAE obtain a clear response, it was not necessary to continue with subsequent checks.

Ear Examination (Otoscopy): This check was only completed if the TEOAE did not provide a clear response in both ears (i.e., the TEOAE was not “passed”). Ear examination was performed using the Tympa Health smartphone-enabled video-otoscope so that the examination of the ear canal can be recorded and uploaded to cloud storage. This type of ear examination supports the referral decision, as well as indicating whether a pressure test (Tympanometry) can or should be performed.

Pressure Test (Tympanometry): This test assesses the volume of the ear canal, integrity of the ear drum, and the middle ear pressure. This can help identify issues such as middle ear effusion (glue ear), which may be more common in children with a learning disability diagnosis.

Training overview

Staff delivering checks attended a series of training sessions to ensure they were equipped to deliver ear checks within the school setting. Training consisted of three core components:

1. Initial in-person protocol run through, equipment familiarisation and programme orientation day with the project team
2. Asynchronous online and in-person British Society of Audiology (BSA) accredited ear examination (otoscopy) training signed off by an accredited faculty
3. Transient evoked otoacoustic emissions (TEOAE) and tympanometry theoretical and practical training

Alongside introduction to technical aspects of the pilot, sessions covered a range of learning points including familiarisation techniques, safety and hygiene, ear anatomy and physiology, and data collection and governance. Further support (e.g. visits to schools by NHS England) was offered on an ad hoc basis, when required.

Models of delivery

Three different models of delivery were predetermined by NHS England and presented to participating pilot schools: 1) school led, 2) audiology led, and 3) nurse led. The selection of model for each school was based on what was most appropriate for the children within each particular school and what was most appropriate for each setting considering resource and capabilities available. Existing health governance and communication processes were used.

Testing the use of three different staff-group models was intended to enable a more flexible, and sustainable service model to better support local commissioners and systems for future roll out of this service. The differences between each model were based on the type of professional that was assigned to carried out the checks. These people were referred to as ‘checkers’.

School led model: Any person already employed at the school, deemed most appropriate to carry out the checks was selected by the school to deliver this model. The rationale behind the school led model was to reduce anxiety associated with having an ear check carried out by someone who was unfamiliar to the child.

Having the check delivered at school by a familiar person should enable a more appropriate approach to support individual need and provide a more flexible approach, such as the time, day, or location in the school for the check to be delivered. However, the school would need to be able to allocate appropriate resource for carrying out the ear check programme.

Quality assurance, governance and support were provided by an assigned Audiology Department, performing peer review and offering guidance. This process ensured safety of this model, but also facilitated joined up care and services.

Audiology led model: This model involved an audiologist(s) delivering checks within the school. The rationale behind this model was that audiologists have the right specialist clinical expertise to deliver ear and hearing checks and can ensure the correct decision is made for onward referrals. In addition, some audiologists will have experience of working with children and young people who have complex and additional needs.

Nurse led model: This model included a nurse, external to the school, who delivers the checks as a peripatetic service. The rationale behind the nurse led model was that some nursing staff may already offer ear checks or have experience working with special schools (e.g., special school nurse, practice nurse, learning disability and autism specialist nurse). This outside support would be helpful for schools who do not have the capacity to deliver the checks themselves, but still wish to provide the service.

Fifteen residential special schools took part in the pilot across England and were offered three models of delivery, with ear checks carried out by either: (1) school staff, (2) an external audiologist/s, or (3) an external nurse.

Peer review process

The school led and nurse led models required ear check results to undergo a peer review process.

The purpose of peer review was to provide essential clinical governance, to ensure the quality and safety of results. Peer review was completed virtually by audiology staff based at an audiology department participating in the pilot. This process was used to support clinical decision making for onward referrals and involved:

• reviewing the ear check outcome. This included cross referencing the outcome form with:
  • TEOAE and Tympanometry results attached to the form
  • Otoscopic examination videos on the Tympa Health cloud
• providing a decision on the appropriate next steps and onward referral based on findings

Consent for an attempted ear check

Consent was required in advance of an ear check, either by a parent / carer or from the young person themselves (where they were over 16 with capacity to consent). NHS England provided draft consent forms to each participating pilot school.

Schools used existing methods to contact parents /carers to obtain consent. Methods of contact included email, parent/carer communication portals (including apps), and physical letters. In some instances, schools advertised the pilot via relevant social media, sent out articles in their newsletters, invited the NHS England project team to open days, hosted webinars, or directly called parents/carers and/or sent text messages.

Evaluation approach

The aim of the evaluation was to:

• assess the feasibility and acceptability of this intervention and any adjustment required
• inform associated clinical standards and guidelines
• support subsequent service planning and future commissioning
• and make recommendations for future exploration

The evaluation took a mixed methods approach using activity data associated with the ear checks (e.g., participation, familiarisation, acceptance, and outcomes), a survey with school staff and parents / carers, and interviews/focus groups with key stakeholders.

In addition, five schools were selected for qualitative case studies which included interviews / focus groups with checkers, other school staff, and parents / carers, in addition to observations and informal discussions with children and young people.

Findings

Participation in ear checks

The total school population eligible for the pilot was 1,392 children. There were 655 consent forms returned granting consent and 623 children had at least one attempted ear check.

Acceptance of ear checks

In total, 522 (83.8%) children fully accepted relevant checks. Having a check attempted in a familiar environment such as a school setting was well received, as it reduced disruption to routine. Impact of familiarity of checker on acceptance was mixed. However, evidence suggests checks delivered by or with the assistance of a familiar member of staff facilitates acceptance. Children and young people reported feeling more comfortable having a check attempted by someone known to them.  Where children expressed hesitancy around the checks, personalised familiarisation methods appeared successful in reassuring children and young people of the process. Familiarisation around use of equipment and what to expect in the ear check process e.g., expected sound, aided acceptance. All children in residential special schools have complex needs, but those with the highest level of need were least likely to accept the check.

Outcome of ear checks

Out of the 623 children receiving an attempted ear check, concern about hearing has been expressed for 19 (3.0%) of them. Four of these children did not fully accept a check. Eighty-one children (13.0%) were referred either to onward care or further testing. Of these 81 children, approximately half were referred for wax management and half for further audiological assessment.

Comparing the three models of delivery

The three models of delivery were school-led, audiologist-led, and nurse-led. The school led model was applied to 12 schools, with two schools adopting an audiology led model, and one a nurse led model. Any comparison of models should be interpreted with caution due to the much lower numbers of children receiving the audiology and nurse led model compared with the school led model.  All checkers, regardless of model of delivery, expressed an enthusiasm and wish to successfully complete ear checks. Checkers in the school led model were less likely to feel as confident in delivering checks compared to those in the audiology model. Checkers in the school led model were more likely to request additional training.

There was an acknowledgment that the merits of the school led model were staff members’ expertise in working with children and young people with additional support needs. The audiology led model provides specialist clinical input. The nurse led model offers a clinician who may already have knowledge in audiology and in working with children and young people with additional support needs. In response to the school survey, just under half of schools (7/15) reported that ear checks impacted on the delivery of other day-to-day activities in the school, such as a reduction in therapeutic sessions. This was true regardless of model of delivery as time was still required to complete administrative tasks and organise sessions.

Perceptions of implementing and delivering ear checks

Overall, there is enthusiasm for and commitment to the pilot by all stakeholders, which was seen as addressing an important unmet need. Stakeholders and school staff thought the impact of the ear checks was potentially life changing, with the ability to hear facilitating access to environmental sound. Schools saw the pilot as an opportunity to upskill staff, although some concerns were expressed around workforce capacity to deliver.

Some parental/carer perceptions of the information they received on the ear check process and outcome suggests the need for improvement in communication with them. Additionally, where not offered, some would have appreciated the option of attending a check with their child.

Training was an important component of preparing for delivery of ear checks, with the ability to practise contributing to increased confidence. Checkers found the equipment straightforward to use overall, but also found some features of the equipment could impede successful delivery of checks (such as technical issues, tip type, interoperability). There was occasional deviation from the ear check protocol where appropriate to support acceptance and capture a result that was clinically meaningful. 

Consideration of administrative systems and processes, staffing levels, training, referral management, and governance should be given when developing resources and guidance for scale up of the ear checks service in residential special school and college settings.

Future policy and commissioning decisions need to consider the entire ear health / hearing pathway (i.e. within schools, audiology services and primary care) and how to address issues of the complexity in and variation across local approaches to commissioning.

Conclusions

Eighty-one children (13.0%, n=81) were referred following an ear check, for wax management or further audiological assessment. Need for wax management was higher in this pilot than in the general population[5].  Findings indicate that this approach to conducting ear checks in residential special schools can address a previously unmet need. For those who consented to have a check, there is quantitative evidence of high levels of acceptance among children and young people, suggesting a feasible approach. Although consent for ear checks could be further increased, this intervention contributes to improving equity of access for children with supportive needs.

Overall, the intervention was well received by children and young people, parents / carers, school staff and audiologists. Having checks delivered or facilitated by a familiar staff member, within a school setting, were highlighted as positive factors. Checkers appeared to gain confidence in conducting the checks over time. Where children expressed hesitancy around the checks, personalised familiarisation methods appeared successful in reassuring children and young people of the process. Pupil familiarisation around use of equipment, for example what sound to expect during a TEOAE, also seemed to aid acceptance. For children with sensory needs, extra time spent on familiarising them with the process and what to expect was associated with increased acceptance. With regards to the three outlined models of care, there was a recognition of the strengths of each, for example knowing the child or young person, technical knowledge, and medical expertise.  

Despite schools being provided with adaptable consent forms, it is unknown to what extent they were utilised and understood. A greater focus on improving the consent process may help to increase uptake and access to checks. Other practical issues linked to calibration of equipment, availability of tips, and the battery life of key devices is key to supporting staff to deliver checks. There is no ‘one-size-fits-all’ approach to aid acceptance. Children have individual needs, and this evaluation has highlighted the importance of a tailored approach developed jointly between schools, parents / carers, and the individual concerned.  However, it must be noted that aspects of a child’s diagnoses and associated symptoms might affect acceptance of an ear check, potentially making it inappropriate for them. Next steps for these children and young people should be considered. 

Key areas for improvement identified include communicating more clearly to schools about what is required to implement and deliver the intervention and better communication from schools with parents / carers about ear check process and outcome. Staff working across the entire ear health pathway (e.g., within schools, primary care, and audiology services) will need to be supported via training and building-in workforce capacity to undertake checks and onward management. It will be important to consider capacity required to support this intervention as well as other aspects of the ear health pathway.  Both schools and audiology departments will likely require additional support and resource. This must be funded and therefore factored into future commissioning decisions. 

To achieve the best outcomes, the infrastructure must exist to facilitate ear checks and any required treatment. Attention should be paid to supporting use of equipment required for checks, considering the order in which ear checks are attempted to increase identification of issues such as wax, and management of referrals. To reduce the burden of data entry, single automated systems could be explored.

The complexity of and variation across existing commissioning structures means that the optimal approach to sustaining and scaling-up the programme remains unclear.  However, additional work is being undertaken within the wider NHSE programme to understand and address these challenges.

Key findings

• Based on the findings from the pilots undertaken, we believe there is unmet ear health and hearing need amongst children and young people in residential special schools.
• Individualised and flexible approaches to ear checks delivery supports acceptability.
• Interdisciplinary working supports achievement in obtaining a meaningful check, improves clinical governance and supports access to onward care.

Limitations

This evaluation collected quantitative data on 623 children and young people, and qualitative fieldwork with 75 individuals. The school survey received a 100% response rate, and 84 parents/ carers completed the parent/carer survey. However, there were limitations to the evaluation:

Quantitative data

• The demographic data on children who did not have a consent for an attempted ear check is unknown. Data was not collected on reasons why a parent/carer chose to not return or provide consent for their child to have an ear check.
• The assessment form did not capture the familiarity of the additional people present during an ear check.
• There was a disproportionate breakdown of models of delivery, with limited data on the audiology and nurse led model limiting any comparisons between models. 

Qualitative data

• A disproportionate number of parents/carers were engaged who provided consent for their child to have an attempted ear check compared to those who did not provide consent.
• A site visit was not completed at one of the case study schools, and therefore no observations of ear checks or pupil engagement were able to be carried out at this school.
• Pupil engagement was limited due to the challenge of adopting methods to engage with children and young people in an appropriate and meaningful way.

Surveys

School survey

• Schools completed the survey at different points in the implementation of the ear checks model (e.g., some during implementation and other weeks after implementation), which meant that perceptions were captured at different stages which may have influenced opinion provided at that timepoint.

Parent/carer survey

• There was no response from parents/carers from six schools, which means that perceptions from almost half of schools were not captured and are therefore not as reflective of the overall sample.
• A disproportionate number of responses were captured from parents/carers who provided consent for their child to have an attempted ear check compared to those who did not consent.

Additional limitations

• This was a pragmatic evaluation of a real-world pilot. Therefore, some findings such as reasons for referrals were unable to be validated within the timeframe.
• Although ear checks being delivered within the school setting appears to have been well received, there is no direct comparison for acceptance and acceptability in other settings such as healthcare.

Recommendations

Increasing access to ear checks

• Consent:
  • to increase informed consent rates, materials would benefit from further co-production with parents/carers and schools/colleges to tailor how information is provided, and the best method of contact is offered.
  • consent rates would benefit from proactively following up on non-responses. Finally, consents could be incorporated into requests for consents for other health related interventions e.g., flu vaccinations, dental or eye checks. 

Supporting staff to deliver ear checks

• Equipment: To ensure usability and suitability of equipment used for ear checks, features such as tips and battery life should be considered.
• Staffing: Staff capacity should be considered in all three models to allow for protected time to attempt ear checks, for additional support, and to manage referrals. This should additionally be factored into commissioning decisions. 
• Training: Time, resource, and funding should be allocated to provide initial and ongoing training to staff delivering checks, with systems in place to ensure competency.
• Capacity and resource: The successful delivery of hearing checks depends on the appropriate allocation of resources and capacity. The more complex the pupil profile, the more resource is required. Given limited resources in education and healthcare at present, appropriate funding and resourcing are key. Thinking about the national roll-out of the programme, project resourcing needs to be carefully considered across the entire pathway e.g., delivery of checks, peer review as required, and onward referral.

Supporting parents/carers through the process of ear checks

• Communication with parents/carers: Parent/carer communication could be improved by working closely with schools around the use of co-produced templates e.g., for consent, background, process, reporting outcomes and next steps. Schools should be provided with a choice of formats and content, personalised to suit the varying needs and preferences of parents / carers / guardians e.g., detail of information provided.

Clarifying Referrals for further assessment or treatment

• Wax management: For children receiving a referral for wax removal, clear pathways and plans need to be presented to parents/carers and schools to know where to go to get treatment. There are currently unclear guidelines around where ear wax removal is done due to the services being decommissioned alongside suggestions that build-up should be self-managed. However, GPs are most likely to offer this service. It is important to support parents / carers and schools across the entire pathway, and not just at the point of delivery of ear checks.

Supporting children and young people who do not accept an ear check

• Next steps for children and young people who do not accept their check: Data collected suggests that there may be instances whereby some children and young people may not be able to accept a check in any situation. Consideration should be given to appropriate course of action should this be an outcome, especially to children where a concern around their hearing exists. NHS England is currently working on a questionnaire to support parents / carers in optimising the circumstances in which a child or young person will accept a check, thereby increasing successful uptake.  This is being validated by London Health Innovation Network.

Supporting scalability and sustainability of the ear checks programme

• Buy-in from key stakeholders: To support successful delivery of ear checks going forward, increased awareness around the importance of ear health and not just hearing from all stakeholders involved is key. ‘Ear checks’ appears to now be the agreed upon term and encompasses all ear related health such as infection and wax management rather than solely focussing on hearing. This term should be used for roll-out. 
• Ear check protocol: In some cases, the order in which checks are carried out may need to be reconsidered to increase the chances of wax build up being identified, for example attempting an otoscopy first where this is a concern.
• Frequency of checks: The frequency of checks should be further explored, for example what is the optimum screening interval based on need, as this will inform resource allocation.
• Consider entire ear health pathways: It was acknowledged that the ear check programme will not stop at the point of the delivery of an ear check but will require attention in other areas such as monitoring and ongoing care. Therefore, the entire ear health pathway should be factored into future decisions. Support, resource and capacity required for ongoing care following a referral should be factored into commissioning plans to achieve best outcomes for children and young people.
• Flexibility in approach: If wax is a common issue, this could be checked during an already booked primary care medical appointment for another condition, in line with the NHS England aim of ‘Making Every Contact Count’.
• Better understanding where unmet need exists: This evaluation revealed that most referrals were for wax management and other issues such as infection or glue ear, rather than suspected hearing loss.  However, it is unknown whether those referred for wax management also had hearing loss. Further work should look to follow-up with children referred to understand the level of confirmed hearing loss.
• Data management: Findings indicate more staff were needed to support with the additional requirement (e.g., data recording for peer review). A single point of data entry would reduce administrative burden associated with implementing the ear checks programme. 
• Financial implications: To support scalability and sustainability, the use of health economics should be explored. This could include a cost-benefit analysis of delivering the programme, considering physical costs and savings, alongside quality of life and perceived staff, parent / carer, and pupil impact. This could be applied to compare models of delivery. 
• Further research: Findings suggest that younger children are less likely to accept an ear check. Findings also revealed that older children were more likely to be referred. This finding indicates the importance of earlier identification alongside training and resource allocated to staff delivering checks to increase acceptance rates in younger children.

References

[1] Yoshinaga-Itano C. From Screening to Early Identification and Intervention: Discovering Predictors to Successful Outcomes for Children With Significant Hearing Loss. J Deaf Stud Deaf Educ. 2003 Winter;8(1):11-30. doi: 10.1093/deafed/8.1.11. PMID: 15448044.

[2] Hall AJ, Maw AR, Steer CD. Developmental outcomes in early compared with delayed surgery for glue ear up to age 7 years: a randomised controlled trial. Clin Otolaryngol. 2009 Feb;34(1):12-20. doi: 10.1111/j.1749-4486.2008.01838.x. PMID: 19260880.

[3] https://www.nice.org.uk/about/what-we-do/into-practice/measuring-the-use-of-nice-guidance/impact-of-our-guidance/nice-impact-people-with-a-learning-disability

[4] NHS Long Term Plan

[5] Guest JF, Greener MJ, Robinson AC, Smith AF. Impacted cerumen: composition, production, epidemiology and management. QJM. 2004 Aug;97(8):477-88. doi: 10.1093/qjmed/hch082. PMID: 15256605.

Publication reference: PRN01338_v