The public health challenge of hearing impairment is growing, as age is the major determinant of hearing loss. Almost one in four (22.6%) over 75-year olds reports moderate or severe worry because of hearing problems. There is a 40% comorbidity of tinnitus and balance disorders. Good outcomes depend on early presentation and appropriate referral. This paper describes how the NHS Improvement Programme in England used service improvement methodologies to identify referral pathways and tools which were most likely to make significant improvements in diagnosing hearing loss, effective referrals and better patient outcomes. An audiometric screening device was used in GP surgeries to enable thresholds for effective referrals to be measured in the surgery. Revised referral criteria, the use of this device, new “assess and fit” technology in the audiology clinic, and direct access pathways can transform audiology service delivery so that patient outcomes are measurably better. This, in turn, changes the experience of GPs, so they are more likely to refer patients who can benefit from treatment. At the end of 2011, 51？GP practices in one of the audiology pilot areas had bought HearCheck screeners, a substantial development from the 4 practices who first engaged with the pilot. 1. Introduction In the UK, NHS Audiology services are complex health systems in complex environments. They provide “end-to-end” care with newborn screening, diagnostic assessment of patients, dispensing of hearing aids, and appropriate follow-up to ensure good outcomes are obtained. Historically, audiology services were commonly commissioned from the acute sector and have had a low priority because of the silent and insidious nature of the disability. In addition, the general public do not see hearing impairment as a dramatic health problem requiring urgent intervention. First presentation in the UK is usually to the General Practitioner (GP). Although the majority (80%) of UK patients access their hearing care through the NHS , there is also an option to use the independent sector without a GP referral. There are recent initiatives involving screening, for example, by telephone or internet , which may in future lead to self-referral without the need for GP involvement. The public health challenge of hearing impairment is growing due to the demographics of the population, as age is the major determinant of hearing loss. Hearing impairment in the UK affects one in ten adults aged 55–74 years. Over the next 15 years hearing impairment will be an increasing population problem, because
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