Independent report

Kingdon review of children's hearing services: final report

Updated 4 December 2025

Applies to England

Letter to the Secretary of State

Dear Secretary of State,

It is easier to build strong children than to repair broken men.

– Frederick Douglass

Thank you for asking me to undertake a review of children’s hearing services in England. As both a paediatrician and a parent I have found my investigations deeply concerning. I hope that my report tells the tale of a service that, despite warnings over many years, was assumed to be low risk and so sailed under the radar without external scrutiny and with a remarkable lack of investment in the workforce. In fact, we know that this is a high-risk service because the consequences of failing to identify deafness in a child are disastrous. Furthermore, with the advent of whole genome sequencing in newborns there are going to be significant opportunities to intervene with gene therapy. This will place new demands on this struggling service.

The users of children’s audiology services are babies and small children at a critical window of brain development who have every chance of developing normally and reaching their full social and economic potential. However, I have found evidence of systemic failings in children’s hearing services over many years. While I am in no doubt that huge efforts have been made at every level of NHS England in responding to these failures, I am unconvinced that we have understood the depth of the problem and have no reliable plan to move forwards currently.

I have undertaken this review at a time of great change in the National Health Service and in an environment of deep financial constraint. Nevertheless, the NHS Constitution is clear and the 7 key principles underpinning the constitution must remain the lodestar by which we work - no matter how young my patient, no matter how numerous the competing priorities, the care I give my patient will be safe, effective and of the highest standard. Furthermore, my duty of care extends to the colleagues I work with, who should expect to be supported, trained and developed. I have used these principles to frame my recommendations.

I am angry that so many people I interviewed referred to children’s hearing services as a ‘Cinderella’ service, in other words, a service that is often overlooked, undervalued and underfunded. Why should any of us accept that children are being offered critical treatment by an overlooked and undervalued service? I have been resolute in my ambition for this review and have made recommendations with the aim of transforming these services into a world class programme of care that we can all be proud of and the public can rely on.

My review was undertaken in just 3 months and so I have had to rely heavily on what I have been told. There will inevitably be topics I have not covered and facts I have not unearthed. There were many issues I would have liked to delve into more deeply, but the need for a speedy review precluded that. I am nonetheless confident in the recommendations I am making and have framed them around the ambitions laid out in the recently published 10 Year Health Plan for England as far as possible. I will rely on those officials who engage in implementing them to iron out the finer details. I am very grateful to the very many people who gave their time and expertise to support this work. I would like to make clear that it has not been the role of this review to make any judgement on the performance of individual services or individual officials.

I am sure you will find my report as concerning as I do. For every year we delay fixing this problem, more children will come to harm. This review has identified potential inconsistencies in the NHS England methodology used to calculate the numbers affected so we cannot be certain how many have been failed by services in England to date. We can be confident that the loss of human capital is significant. I fear that time is not on our side.

It is worth remembering that NHS Scotland undertook a very similar review of hearing services led by Professor Jackie Taylor. Her detailed report and recommendations were published in August 2023. My understanding is that very little action has taken place as a result of this. From conversations I have had during this review, it is my hope that children’s hearing services can act as a blueprint for effective quality oversight. If we can get this right for deaf children, we can get this right for everyone and for every service that attracts little scrutiny.

I commend my report and its recommendations for your consideration and urge you to take prompt action to see them implemented.

Dr Camilla Kingdon
7 August 2025

Acknowledgements

My original remit was to undertake this review in 12 weeks. With agreement from DHSC ministers, the review was extended by 2 weeks to allow sufficient time to analyse all the responses and data received, but this work took place at pace. I pay tribute to my wonderful review secretariat who immersed themselves in this topic and engaged thoughtfully and compassionately with our many stakeholders.

I have met a huge number of incredibly hardworking and committed audiologists and others working in this field. They have shared their passion for their work and at times it was difficult to hear their sadness, frustration and sense of moral injury from working in an NHS service that quite simply could and should be better. I sincerely hope this review helps make the NHS the inspiring place to practise audiology it should be.

The National Deaf Children’s Society has supported our work with great integrity and professionalism. Their simple request to me was that I promise to keep deaf children and their families front and centre of this review. I hope I have done this justice and I acknowledge their tireless work supporting deaf children.

I have conducted over 100 interviews for this review and I am truly grateful to everyone who agreed to participate. Some went the extra mile with second interviews and offering feedback on drafts of the report. I am so grateful to all these colleagues - those happy to be mentioned by name are listed in annex A.

Through our call for evidence and focus groups, I have heard from a wide range of professionals working with children’s hearing services, and parents and carers of children that have used these services. Insights from the call for evidence and focus groups have been invaluable in shaping my understanding of the sector and how it is experienced by people accessing care and support.

I met the chair of the All Party Political Group for Deafness and heard about the good work they are doing to understand the issues facing deaf people. I am grateful to the Royal National Institute for Deaf People for facilitating this.

Finally, a review like this is inevitably commissioned when there is evidence of patients coming to harm. There is no doubt that many babies and children have been failed by hearing services in England. I pay tribute to them and hope this review goes some way to giving voice to their experiences. My personal motivation for leading this review is to understand what went wrong and to make recommendations that mean this does not happen again. I sincerely hope my work achieves that.

Executive summary

Introduction

This review was commissioned by the Secretary of State for Health and Social Care and began in April 2025. It was tasked with considering the response of NHS England to the service failures in children’s hearing services. The review was also asked to make recommendations for action and identify lessons learned that are relevant to other health services.

In the 3 months dedicated to this review, I have had the privilege of speaking to over 100 audiologists, healthcare leaders, charities, educationalists, academics and officials from NHS England and the Department of Health and Social Care (DHSC). Our call for evidence had over 450 responses and I had the pleasure of taking part in 2 focus groups for parents and carers of deaf children, facilitated by the National Deaf Children’s Society.

However, in preparing the recommendations of this report, it has struck me again and again that these are not new recommendations, although they would certainly be transformational if implemented for children’s hearing services in England. So many concerns raised with officials, as well as formal reviews and inquiries cover the same topics and urge similar action (see reference 1).

Facts

Nearly 300 children have been harmed (and the review and recall of patients to identify harm is still ongoing in some areas)

Some affected children are yet to be identified due to variation in how the programme has been implemented in different areas of England and between providers. Therefore, this review believes the reported number is very likely to be an underestimate. See section 3 for further details.

NICE guidelines not met

The latest guidelines for glue ear in children under 12 recommend referral for formal assessment, usually by both ear, nose and throat (ENT) and audiology, and reassessment for deafness within 3 months. This review has heard that waiting lists for these services are too long to allow these timelines to be met.

Opportunities for treatment of congenital infection and new gene therapies are emerging

Congenital cytomegalovirus (congenital CMV) is one cause of deafness in babies and may be picked up following newborn hearing screening. New treatments may improve hearing outcomes if the infection can be treated within a month of birth (see reference 2). Although many NHS trusts conduct newborn hearing screening within days of birth, this review has heard of at least one NHS trust which now conducts newborn hearing screening 8 weeks after birth. For babies with congenital CMV related deafness, this is too late. A recent study in Nature demonstrated successful gene therapy for children with congenital deafness caused by the OTOF gene. As new treatments emerge for congenital infection and genetic disorders, it will be more important than ever that children’s hearing services in England are providing accurate and timely diagnosis and referral.

Key findings of this review

Finding 1: the failed or late identification of deafness has had a profound impact on many affected babies and children, and their families

The review heard over and over again about the real harm caused by missed and late identification of deafness in children. Parents and carers of affected children have described fighting to be taken seriously and access the care their child needed, being offered appointments on a waiting list over a year long and making significant personal and financial decisions to ensure their child gets the care they need. It is clear that the quality of children’s hearing services is variable and individuals have emphasised the lack of deaf awareness demonstrated in some services. These services should be setting the standard for deaf awareness in the NHS. Further findings are set out in section 2.

Finding 2: the NHS England Paediatric Hearing Services Improvement Programme that was established in 2023 has not met the target it set for recalling affected babies and children and has lost the confidence of external stakeholders

The programme has not been set up for success. It has not had the power to mandate regional structures or integrated care boards (ICBs) to initiate incident response processes and has operated with fewer staffing and budget resources than that requested by its senior responsible owner (SRO). It has therefore not been able to deliver improvements to children’s hearing services at the same time as co-ordinating a national review and recall programme, despite admirable efforts made by individual members of staff. External stakeholders have expressed a lack of confidence in the programme and this review believes that the programme needs urgent redesign. Further findings are set out in section 3.

Finding 3: communication between NHS England and DHSC about the service issues in children’s hearing services did not follow expected practice and there was no dedicated DHSC lead

Although DHSC ministers were sighted tangentially on the service issues in children’s hearing services and the Paediatric Hearing Services Improvement Programme (PHSIP) between December 2021 to September 2024, there was no formal submission outlining the issue and the proposed response for ministerial awareness or approval until September 2024. Several different policy teams within DHSC have responded to queries about children’s hearing services within this period, with no one team taking responsibility for the issue. Further findings are set out in section 4.

Finding 4: there has been no assurance of quality, as measured by safety, effectiveness and patient experience, in children’s hearing services in England, for some time. Service delivery is highly varied and so it follows that outcomes are unacceptably variable

This review has heard that there is little or no effective oversight of the performance of children’s hearing services by commissioners. Data collection, other than waiting time targets, is largely absent. There are examples of excellent practice in England, but many parents and carers have described fighting to get the care their child needs. In common with so many children’s care pathways, services are seeing children with increasingly complex and multiple needs, which has placed significant pressure on services. This review recommends a network delivery model, underpinned by clinical supervision and peer review. Further findings are set out in section 5.

Finding 5: children’s hearing services are rarely on anyone’s radar - regionally, at ICB and at provider level - nor among regulators, for example the Care Quality Commission

In common with many other ‘Cinderella’ services (in other words, services that are often overlooked, undervalued and underfunded), children’s hearing services typically have unclear escalation pathways. This review has found little evidence of any board reporting opportunity or review by regulators. Some audiologists, organisations representing audiologists, the National Deaf Children’s Society and others raised the alarm about deteriorating quality in children’s hearing services before the issues at NHS Lothian came to light. However, this should also have been evident to providers and commissioners. Only 27 out of 139 children’s hearing services are fully Improving Quality in Physiological Services (IQIPS) accredited. Further findings are set out in section 5.

Finding 6: the audiology workforce has been neglected for years, their status and profile is low. There is little professional governance and fragmented professional representation. There is a lack of coherent workforce planning and little investment in research

The audiology workforce lacks professional governance and suffers from an absence of a single professional register. There is no consistent process for assessing a practitioner’s fitness to practice and continuous professional development (CPD) is seen as a luxury that few services can justify. There are multiple organisations that represent professionals working in audiology. Many senior audiologists shared concerns about the quality of professional training in audiology. It is not surprising that I found morale among paediatric audiologists to be very low, and I heard examples of poor workplace culture, bullying and fear of speaking up. The lack of strategic data collection and workforce modelling in children’s hearing services means there is little future planning. There is a notable lack of investment in audiology research. One stakeholder said that “without investment in the workforce and intelligent use of data, we’ll be back in this position in 10 years’ time”. Further findings are set out in section 5.

Finding 7: the findings of this review are highly relevant to any service which attracts little attention, investment or scrutiny, but has the potential to cause lifelong harm when quality standards are not upheld

This review has heard concerns from stakeholders that the issues highlighted in this review are common to:

• other children’s health services
• other audiology services
• other community health services
• services which include other healthcare scientists

There are over 50 healthcare sciences. The review did not have the resources or remit for a detailed investigation of these, but to give one example, the Institute of Physics and Engineering in Medicine reported in 2021 that “clinical technologists (engineering) is becoming an ageing workforce with almost half (48%) over the age of 50” (see reference 3). Clinical technologists are responsible for maintaining, monitoring and operating sophisticated medical equipment used in diagnosis and treatment. Further findings are set out in section 6.

Summary of recommendations

The way forward: 3 themes with 12 recommendations

I am optimistic that the problems I have described can be solved. The solutions are neither overly complex nor expensive - but this will require a focused piece of work that must be co-produced with frontline audiologists and with parents and carers of affected babies and children.

Theme 1

Understanding the scale of the current problem.

Recommendation 1: the role and remit of the current Paediatric Hearing Services Improvement Programme needs urgent review to focus on completing review and recall

Following the transition of DHSC and NHS England to one organisation (hereafter called ‘the new organisation (DHSC and NHS England)’), the new organisation (DHSC and NHS England) should consider how to best continue the Paediatric Hearing Services Improvement Programme (PHSIP). Based on the findings of this review, the most effective responses have been by strong regional teams. Regional teams must be enabled to use local incident response processes with very clear timelines for completing all follow-up assessments and discharge and or placement on a treatment pathway where required. The central programme team should be suitably funded and resourced and fulfil the role of supporting regional teams. The name and terms of reference of the programme should be revised to more accurately reflect its focus on review and recall of children affected by service issues.

Theme 2

Placing these services on a secure footing for the future.

Recommendation 2: children’s hearing services should be commissioned using a modern service framework and model commissioning contract

The new organisation (DHSC and NHS England) should use the new service frameworks proposed in the 10 Year Health Plan to drive improvement and innovation by defining the goals for the care pathway in children’s hearing services, setting standards and supporting the workforce to deliver these goals.

The new organisation (DHSC and NHS England) should develop a model commissioning contract for ICBs to use for children’s hearing services. This should include key performance indicators (KPIs) relating to safety, effectiveness and patient experience. This contract should ensure services can protect ringfenced time for clinical audit, quality assurance and CPD activities. This approach has the potential to act as a template for other similar services.

All ICBs should support their children’s hearing services to become IQIPS accredited and identify capital funding to improve audiology testing equipment where needed in order to facilitate that process.

Recommendation 3: professional registration of audiologists must be a requirement in the NHS and relationships between national organisations and organisations representing audiologists should be reset and formalised

The new organisation (DHSC and NHS England) should work with the organisations which represent audiologists and with NHS trusts to require all audiologists to be registered on a single professional register, which is operated by an appropriate body on a non-statutory basis.

The numerous organisations representing professionals in audiology should merge to create a single body responsible for engagement with national institutions and development of appropriate guidance, training and curricula for audiologists. This body should play a role in developing and maintaining a single professional register of audiologists.

The new organisation (DHSC and NHS England) should establish clear policy responsibility for healthcare sciences, including audiology, and publish a charter setting out expectations on both sides for engagement between the relevant organisations representing professionals in audiology and the new organisation (DHSC and NHS England).

Recommendation 4: children’s hearing services should be delivered by a network model, rather than a ‘hub and spoke’ model

The new organisation (DHSC and NHS England) should work with ICBs to redesign the delivery model for children’s hearing services, creating networks which facilitate robust clinical supervision and peer review. The example of child safeguarding networks should be considered during the design process.

The new organisation (DHSC and NHS England) should work with ICBs to ensure services are of sufficient size that staff members can rotate and observe others in their clinical practice on a regular basis. Any unsafe services should be closed and service provision reallocated.

Recommendation 5: NHS trusts and ICBs should implement improved governance arrangements for audiology and apply these to other healthcare sciences

Every NHS trust should appoint a lead healthcare scientist who is responsible for reviewing KPIs across healthcare science professions, including audiology. This individual should be responsible for managing risks and issues in the relevant services and be required to report to the Trust Board at least twice a year.

Every ICB should have access to healthcare science expertise to support effective service commissioning.

Every NHS regional team should retain a regional healthcare scientist and ensure they have adequate training and support to manage risks and issues across all healthcare sciences, including managing incident response processes when needed.

Recommendation 6: improved data on individual children’s hearing services should be used by NHS trusts and ICBs to monitor service quality and outcomes

The new organisation (DHSC and NHS England) should act to implement the recommendations of the recent Review of patient safety across the health and care landscape immediately and reform the role of the National Quality Board.

The new organisation (DHSC and NHS England) should identify a number of KPIs to measure the performance of children’s hearing services and require ICBs and/or NHS trusts to report against these and publish them annually.

NHS trusts and ICBs should put in place robust data analysis and governance arrangements to review these KPIs and address any issues arising on a regular basis as part of their quality management systems.

The new organisation (DHSC and NHS England) should issue and publish the results of a benchmarking survey into the provision of different treatment options (in particular different types of hearing aids and eligibility criteria for cochlear implants) for deaf children across England and work with the National Institute for Health and Care Excellence (NICE) to issue updated relevant guidance to help standardise care.

Recommendation 7: undergraduate and postgraduate training pathways for audiologists working in children’s hearing services need wholescale review and redesign, as does the approach to CPD

The organisation responsible for maintaining the single professional register for audiologists should require all its members to undertake regular CPD, funded by their NHS trust.

The new organisation (DHSC and NHS England) should commission the National School of Healthcare Science to redesign the undergraduate and postgraduate training pathways and funding arrangements for audiology to ensure sufficient training in paediatric speciality for paediatric audiologists, develop standards for the curriculum and independent assessment of diagnostic testing ability.

The new organisation (DHSC and NHS England) should commission work to develop appropriate CPD training modules for audiologists, including on quality assurance and safety standards in children’s hearing services. This should include the involvement the National School of Healthcare Science and the organisations representing professionals in audiology.

The new organisation (DHSC and NHS England) should consider possible ways in which audiologists could demonstrate competence to train in advanced practice.

The new organisation (DHSC and NHS England) should consider asking the proposed College of Executive and Clinical Leadership (see reference 4) to design a systematic approach to leadership and management training in NHS service delivery, including the professional development of healthcare scientists.

Recommendation 8: national research funding bodies should invest in research activity and capacity in audiology

National research funding bodies should encourage research to realise the potential offered by machine learning, data analysis and other technologies in children’s hearing services.

Recommendation 9: children’s hearing services should be setting the standard for deaf awareness and improve processes for seeking feedback from patients and their families

All children’s hearing services and all audiologists should be setting the standard for deaf awareness and should have access to regular training on how to ensure they can meet the communication needs of their patients.

All children’s hearing services should seek feedback from service users, and ensure systems are in place for patients, parents and carers to provide feedback in a timely manner, with reassurance that the feedback is welcome and will help to improve care provided. These processes must be accessible to all users.

Theme 3

Applying the lessons learned to similar services.

Recommendation 10: the next NHS Workforce Plan should include workforce modelling and recommendations specific to the healthcare science workforce, including audiology, and action should be taken to improve workforce culture and morale in children’s hearing services

The new organisation (DHSC and NHS England) should change the way workforce data is collected and coded to enable posts in all healthcare sciences, including audiology, to be identified by seniority, speciality and setting and enable effective workforce planning.

The new organisation (DHSC and NHS England) should adapt the NHS Staff Survey workforce codes so that responses from healthcare scientists can be identified by speciality (for example, audiology) for separate analysis, ensuring this would not compromise the anonymity of individual staff members in small services.

The successor or successors to the National Guardian’s Office should complete and publish a review into workplace culture in children’s hearing services and provide recommendations for measures to support the workforce. This should include consideration of whistleblowing, bullying, stress-related illness and stress-related early retirement in children’s hearing services.

Recommendation 11: a regional incident response process should be formalised to enable a more structured response to service issues which do not meet NHS emergency preparedness, resilience and response (EPRR) criteria, including clear guidance around public communications and action should be taken to improve early identification of emerging issues

The new organisation (DHSC and NHS England) must establish arrangements and responsibilities for a regional incident response process. This process would set out the approach for managing widespread patient safety and quality incidents that are serious but do not meet the threshold of a national incident, in order to provide standardised responses, including leadership, risk management, escalation routes, staffing resourcing and funding.

The new organisation (DHSC and NHS England) must ensure proactive communication to the public and to affected patients is planned at an early stage when widespread patient safety or quality concerns are established, in line with the approach taken in policy areas such as screening.

The new organisation (DHSC and NHS England) should create a ‘special projects team’ to investigate quality and safety concerns in specific areas of the health system and make recommendations for improvement before handing over to ‘business as usual’ (BAU) policy teams or incident response processes.

The new organisation should consider creating a horizon-scanning function which leverages the potential of artificial intelligence (AI) and machine-learning to analyse sources of information coming into the department, improves the data collected across different health services and looks proactively for emerging risks before they become issues.

Recommendation 12: written guidance should be provided for all officials regarding how and when to raise service issues with ministers and horizon-scanning processes should be subject to review

As part of the transformation programme which will create a new organisation out of DHSC and NHS England, specific training and guidance should be provided for all those transitioning to a civil servant role regarding when and how ministers should be sighted on safety or quality issues and regarding expectations for working with ministers.

1. Setting the scene

What are our obligations as a society to children with disability?

The United Nations Convention on the Rights of the Child (UNCRC) grants all babies, children and young people a comprehensive set of rights. The UK signed the convention, and it came into force as law on 15 January 1990. For example, article 23 of the UNCRC lays out the rights of children with disability and this is pertinent to this review:

A child with a disability has the right to live a full and decent life with dignity and, as far as possible, independence and to play an active part in the community. Governments must do all they can to support disabled children and their families.

How common is deafness in children?

Deafness is one of the most common congenital anomalies worldwide. The World Health Organization (WHO) estimates that 34 million children worldwide live with disabling deafness and approximately 1 in 1,000 babies born will have moderate to severe deafness. The impact of deafness on language acquisition is dependent on the age of onset and the severity. A lack of appropriate intervention can lead to serious negative implications for the child’s development, education and social skills.

Research demonstrates that children who are born deaf or acquire deafness within the first months of life, who are successfully identified and receive appropriate interventions within 6 months of age, are on a par with their hearing peers in terms of spoken language development by the time they are 5 years of age (see reference 5).

Children who have a delayed identification of deafness are expected to require more expensive care to support their learning and development outcomes. In severe cases, they may also require additional care later in life. Effective children’s hearing services and timely intervention for affected children is not only a moral imperative, but a financial one for an NHS in straitened financial circumstances. WHO cost-effectiveness studies have demonstrated financial benefits of universal newborn hearing screening that link into diagnostic and treatment pathways in all economies globally.

Why is hearing screening so important?

The rationale for newborn hearing screening followed by prompt diagnosis and treatment is centred on the huge benefits for the baby in terms of language and cognitive development. The infant brain is primed to develop complex neural pathways when stimulated. Sound is a powerful stimulus and so, if the baby and young child is deaf, the opportunity to learn to interpret sound and so develop spoken language is diminished with potentially devastating consequences. There is also evidence that these complex pathways can be stimulated by sign language (see references 6 and 7).

There is a critical period of time, or ‘window of opportunity’ in childhood development for learning to interpret sound and thus to learn to speak or sign. As time ticks by, that ‘window’ slowly closes. Children’s hearing services therefore provide time critical diagnosis and treatment.

Children with autism and other complex needs also use children’s hearing services to exclude deafness before a diagnosis of a neurodevelopmental disorder can be confirmed.

What is an audiologist?

In the United Kingdom, ‘audiologist’ is not a protected title and the audiology profession can include a number of titles and job roles, such as hearing aid dispenser, healthcare science practitioner and clinical scientist. For the purpose of this review, audiologists are considered to be any healthcare professional who assesses or treats deafness and balance disorders.

What is a healthcare scientist?

Healthcare scientists work across a range of healthcare professions and play a vital role in the diagnosis, prevention and treatment of disease. Healthcare scientists work in more than 50 specialisms which can be categorised into 4 groupings:

• laboratory (pathology) sciences
• physiological sciences - including audiology
• medical physics and clinical engineering
• bioinformatics

How are children’s hearing services commissioned?

As of April 2025, the majority of children’s hearing services are commissioned by ICBs with a few notable exceptions.

The Newborn Hearing Screening Programme (NHSP) is currently commissioned by NHS England, although plans have been announced to delegate commissioning of this programme to ICBs from 1 April 2026 (see reference 8).

The following services related to children’s hearing are commissioned by or with input from the specialised commissioning team in NHS England:

• auditory brainstem implants - this is a highly specialised service which is commissioned by the national team at NHS England
• cochlear implantation services (adults and children) and bone conduction hearing implant and middle ear implant services (all ages) - these are specialised services for which NHS England provides a national service specification that is then used by ICBs to commission the services locally

What does the care pathway for children’s hearing services include?

Newborn hearing screening is offered shortly after birth and is ideally done within the first 3 weeks but can be offered up to 3 months after birth. If results from the newborn hearing screening do not show a clear response, the baby will be referred into audiology services.

Once referred, audiologists will confirm diagnosis for example, using auditory brainstem response (ABR) testing. If deafness is present, further tests will be undertaken to understand the cause of deafness, for example, testing for cytomegalovirus (CMV). Depending on how the audiology service is set up, this may require referral into a different service, which could be ENT, community paediatrics or audiovestibular medicine.

If hearing aids are required, the audiologist will fit appropriate hearing aids and set up regular follow ups. If appropriate, it is possible to be referred for an implant service where assessment by a multidisciplinary team will consider suitability for implant.

Alongside diagnostics and treatment, audiologists may make referrals into other support services, for example, for speech and language therapy and support from a Teacher of the Deaf.

This pathway is also described in annex B.

What events led to this independent review being commissioned?

May 2021     

Scottish Public Services Ombudsman upholds a complaint by the parents of a child about the standard of care and treatment provided by Lothian NHS Board to their child in relation to their hearing.

December 2021     

British Academy of Audiology (BAA) governance review of NHS Lothian paediatric audiology services is published.

December 2021     

NHSP for England begins analysis of diagnosis of permanent childhood hearing impairment (PCHI) for babies referred from the screen, leading to identification of initial 5 sites that were identifying significantly fewer deaf children than would be expected based on national averages in February 2022.

March to December 2022        

NHSP team continues analysis and undertake reviews of relevant sites.

March 2023     

‘NHS England investigation into low yield sites from the Newborn Hearing Screening Programme: Interim Report’ is produced. The report concludes “…this audit has identified major problems within the paediatric audiology services at all 5 sites” and “There are themes common with the NHS Lothian report, including the lack of late diagnostic concerns not being flagged and limited oversight, suggesting that there is no assurance that these issues are not widespread.”

April 2023     

NHS England’s PHSIP is established.

14 September 2023

NHS England publishes ‘Paediatric Hearing Services Improvement Programme: system recommendations for immediate action’ on its website for action by regional and ICB clinical and quality leads.

20 September 2024

NHS England provides a submission to DHSC ministers, setting out a high-level update on the PHSIP. NHS England also advises DHSC that the Health Service Journal is expected to publish a story on the matter.

24 September 2024

Article titled ‘Revealed: Dozens more children harmed after care failures’ is published in the Health Service Journal.

24 September 2024

NHS England publishes ‘Paediatric Hearing Services Improvement Programme - operational guidance’.

28 September 2024

Article titled ‘NHS hearing units misdiagnosed thousands of children and did nothing’ by Shaun Lintern, Health Editor, is published in The Sunday Times.

What elements of hearing services have not been considered in this review?

It has been beyond the scope of this review to consider hearing services for adults, any hearing services offered by independent healthcare providers and any hearing services which fall within the remit of primary care.

What terms does this review use to refer to children who are deaf?

The review refers to ‘deaf children’ to describe children who are profoundly Deaf and children who have hearing loss but are not profoundly Deaf.

What terms does this review use to refer to the new organisation which will replace DHSC and NHS England?

On 13 March 2025, the Secretary of State for Health and Social Care announced that NHS England would be brought into DHSC over the course of the next 2 years. This review understands that the transformation programme is already underway and that although the 2 organisations will continue to exist until March 2027, that ways of working between the 2 organisations are expected to change from now. This review therefore describes recommendations which would be the responsibility either of DHSC or of NHS England in the past as the responsibility of the new organisation (DHSC and NHS England).

2. Impact on affected children, their families and the professionals who support them

Introduction

This report is about how services failed to deliver safe care which resulted in children coming to harm. This review believes that NHS England’s report that nearly 300 children (as of May 2025) have come to harm as a result of failed or delayed diagnosis or treatment is an underestimation. The review heard about the impact delays in identifying deafness can have on a child and their ability to learn to communicate, whether that is spoken or signed.

In conducting formal interviews of external experts and officials, 2 overarching themes came through. Firstly, there was the concern that NHS England’s response to the failings in children’s hearing services did not place the child at the centre of their vision and focus. An NHS source told The Sunday Times in 2024 “we have forgotten the children in all of this”.

And secondly, the review heard concerns from a variety of sources about the lack of priority given to children’s health services overall, with concern about how children’s healthcare is not given the same level of attention as adults’ healthcare. 

A priority for the review was to ensure that babies and children remained front and centre and that their experiences, and that of their families, were used to influence recommendations to improve the care of deaf babies and children in the future.

Seeking feedback from parents, carers and professionals in children’s hearing services

The review engaged with a wide range of parents, carers and professionals through focus groups and the call for evidence and heard views about the service failures and the impact of NHS England’s response to these failures. The review heard evidence from:

• 2 focus groups with parents and carers facilitated by the National Deaf Children’s Society, including a British Sign Language (BSL) interpreter where needed
• a call for evidence that received over 450 responses: 53% of responses were from individuals sharing their personal views, 43% of responses were individuals providing their professional views and 4% of responses were from organisations. The vast majority of individuals sharing their personal views were parents or carers of children that had accessed audiology services and just over half (53%) were referred into audiology services from the newborn screening hearing service

The full response to the multiple-choice questions is set out at annex C. In the quotes below:

• ‘FG1’ and ‘FG2’ refer to the focus groups
• ‘CfE’ refers to the call for evidence
• ‘I’ is a quote from an individual
• ‘PR’ is a quote from a professional
• ‘ORG’ is a quote from an organisation

For quotes from the call for evidence, these are then followed by either a participant code or the response code.

Where information is included in square brackets ‘[]’, this has been added to the original quote to correct the grammar or allow for the quote to be shortened without losing its original meaning.

In some cases, square brackets have been used to anonymise personal details about the individuals described. An ellipsis ‘…’ indicates where words have been removed from the original transcript in order to shorten the quote, for example, to remove the word ‘um’.

The parents and carers who contributed to this review were clear about what it has meant to receive poor-quality care, providing numerous examples of delays and misdiagnosis and the impact this has had on children and their families.

Parents talked about fighting for good quality care and fighting for their concerns to be heard. The review heard a lot about the significant time and emotional resources invested in persuading healthcare professionals that a child is experiencing hearing difficulties. One focus group participant told the review about how repeated tests lasted nearly 4 years before their child was identified as deaf at nearly 5 years old.

FG2:

… when we went to audiology, they dumbed it down… [they said] ‘Mum, you’re just a first-time mum’. I was a single mum at the time… ‘Maybe you’re… worrying a bit too much’ … When we went for the first tests… my child passed everything… We kind of went on with this from 18 months, and like I said before, they were diagnosed at 4 years, 11 months [with hearing loss].

In the case of congenital cytomegalovirus (CMV), when a baby is born with a CMV infection, for a minority of cases if left untreated it can cause deafness. Treatment is time critical, and the antiviral treatment must be started within 4 weeks of birth. However, the review heard parents’ frustrations with delays to diagnosis and treatment.

FG2:

They… lost the swab in the post. Twice. And then, finally… the consultant for… Children’s Audiology basically said, … ‘Come to my office… and I will walk it into the lab myself’. And within two days, we had the diagnosis of CMV. But by then, it was too late… by the time [my child] was diagnosed, it was 12 weeks… which could possibly have had repercussions, because recently their deafness has been diagnosed as profound, whereas they started off with mild deafness. So we can’t know for sure, but it would have been good if we’d been prompt with the diagnosis.

The review also heard numerous examples of poor-quality care and the impact this has had on children and their families.

FG1:

They were testing, you know, banging things behind [my child], and [my child] was turning. Looking back now, [my child] was seeing reflections and shadows and things like that. They said, oh, we think [your child] has got congestion, go away for 3 months. So, okay, I did what I was told, but I was convinced there was something more and so then I was ringing during those 3 months, and they were saying, you have to wait. We go back 3 months later. They do, you know what I now think [were], like, genuine tests, ABR tests, and found [that my child] was profoundly deaf.

FG1:

When [my child] was diagnosed as having hearing loss in both ears, that did qualify them for [a] Teacher of the Deaf. [This person] came to the house, got the wrong child, wrong age, wrong sex, didn’t know who they were there for. [They] told us not to do BSL, why would they need that, etc. Then they left. We actually ended up having the Head of Children’s Services, in our local council come into our living room and tell us that there was no Teacher of the Deaf that could be provided for our child at that time.

The impact on the affected children

Long waiting times have led individuals to seek care in the independent sector

Long waits for care and concerns about the quality of care has meant that parents and carers felt the only option for their child was accessing care in the independent sector. The review heard from a number of individuals frustrated that they could not access timely and high-quality care in the NHS.

CfE I-187:

We went private through frustration and after being told the waiting list for [grommets] would be over 18 months and that it would seriously delay my 3 year old[‘]s speech to wait that long and that my best hope was for a cancellation.

CfE I-177:

Waiting list for referral is far too long. Had to go private for a hearing test for my [child] which revealed moderate/severe hearing loss - I have been battling this with [the NHS] for over a year, to be told I’ve still potentially got a year before I would even get a hearing test for my child, let alone treatment afterwards.

CfE I-163:

My 2 year old son has a speech delay which affects his daily life. We have been referred to speech and language therapy who haven’t been able to offer the correct support as this is a hearing problem that could be treated quickly before his development is affected further. Now we know he has glue ear, we are still having to wait too long to see a consultant to treat the problem, and are being directed through speech and language therapy. He needs hearing aids in the interim but [we are] still waiting to see a consultant so nothing can be done unless we pay the private clinic fees.

Babies and children are experiencing long waits for all parts of the care pathway from referral to identification of deafness to treatment or support and the regular follow up appointments required following identification of deafness. Long waits for services was a common theme across both the focus groups and call for evidence responses.

CfE I-195:

Following referral in [our local area] we were told that the target for an initial hearing test would be 18 weeks; as the parent of a two and a half year old with delayed speech this seemed too long to wait at a critical development stage, so we were forced to go to a private clinic for an initial assessment. This confirmed the need for grommets and adenoid surgery, given the horrendous waiting list times we were forced to pay £6,000 for private surgery which we could ill afford. Thank goodness we did, because the letter for the initial NHS audiology appointment came 13 months later - 42 weeks later than target.

CfE I-189:

The waiting list time for children who are suffering from hearing loss and the consequences of that is just too long however. Over a year wait between appointments is not acceptable.

CfE I-200:

Having to wait over 18 months for an appointment for a 2 year old is awful.

Waiting times are a clear cause for concern with approximately a quarter of parents responding to the call for evidence reporting high levels of dissatisfaction:

Figure 1a: percentage of responses to the question ‘How satisfied were you with how quickly you were referred to additional sources of support?’

Response	Very satisfied	Satisfied	Neutral	Dissatisfied	Very dissatisfied	Total
Percentage of responses	22	26	14	13	25	100

Figure 1b: percentage of responses to the question ‘How satisfied were you with how quickly you received follow-up treatment in children’s audiology services or ear, nose and throat (ENT) services?’

Response	Very satisfied	Satisfied	Neutral	Dissatisfied	Very dissatisfied	Total
Percentage of responses	23	23	14	12	27	100

Individuals also referred to frustrations with inconvenient appointment times, having to take children out of school and taking time off work for multiple appointments.

CfE PR-016:

Would be good if standard check ups could be outside of school hours, as [my child] will always need ongoing appointments [this] does mean [that they] miss school lessons to attend.

Testing processes lasted years and required repeat hospital visits

Parents and carers reported concerns about the testing processes lasting years and requiring repeated hospital visits before finally getting a diagnosis. The review heard about the impact this has had on the child and their families.

FG1:

We went to the hospital, I think it was every 6 months for about 3 years, didn’t get any answers. We did this for an hour at a time, and then they’d say, oh, well, [your child] is a bit young, we can’t really tell you anything, we can’t draw any conclusions, come back in 6 months. 

CfE I-158:

We’ve been told ranging from nothing wrong with [your child]’s hearing… to well it could be glue ear we’ll wait (2 years of glue ear and no assistance or other help/referrals), to well it could be genetic as 3 generations of deafness from moderate to profound deafness. And nothing no genetic testing, no advice just come back in 3 to 6 months time.

Parents described a lack of confidence in the hearing testing process and gave examples of failed identification of deafness

The review heard a number of examples from parents and carers about their lack of confidence in the hearing test process. Parents and carers described not getting a clear diagnosis and needing repeated hospital visits as adding to their lack of confidence in the tests. The review heard that parents and carers were not always provided with a clear explanation of why tests were being undertaken and what they would show. The review also heard examples of misdiagnosis that delayed treatment and caused significant delays at a time critical period of a child’s life.

FG1:

… to be honest, I didn’t really feel like they really cared, you know, I didn’t really feel that they were trying to get to the bottom of it. It was just… oh, you’re back again, let’s do some tests, and it’s the silly ones, when you have to turn to the left and see the jumping monkey, you know… I just thought the whole thing was ridiculous, to be honest.

CfE I-155:

The actual testing in our experience has been wrong. Our son has had huge delays as a result of misdiagnosis and continued misdiagnosis.

Parents described having to fight for high-quality care

Parents and carers regularly referred to “going into battle” and “fighting” to get the care and support their child needed. A common theme across the call for evidence and focus groups was the need to convince and persuade healthcare professionals that their child was experiencing hearing difficulties. Parents and carers expressed frustration that their concerns were not taken seriously and reflected on the significant time and emotional resource required to ensure their concerns were listened to.

FG2:

With my child, of course, we had to go through a battle just to get a referral for a cochlear implant. Which shouldn’t have been the case. I mean, … because we had to wait 3 years, 3 and a half years since [my child] had the surgery for cochlear implant, and that’s a very big delay, … which can affect the learning.

CfE I-142:

We’ve had to fight and advocate aggressively every step of the way and it’s been exhausting, upsetting, demoralising and deeply rattled our trust in the NHS.

CfE I-104:

If I hadn’t have pushed for my [child], (as a mother instinctively I knew something was wrong yet no one would listen to me or take me seriously,) [child] would still not have been diagnosed.

Approximately 1 in 3 parents and carers responding to the call for evidence (30%) did not feel that their views and concerns were considered and taken into account.

Poor communication between services and inconsistent quality of care added to the frustration that parents and carers felt while advocating for their child.

CfE I-142:

[Would like to see:] consistency of care with same consultants; better cooperation between audiology and ENT departments; complete overhaul in secretarial efficiency of typing up notes and booking appointments- we’ve been lost in the system for months at a time on at least 3 occasions and with young children you don’t have months to waste waiting for a secretary to get through their work load.

Focus group participants’ accounts of varying interactions with individual audiologists and health professionals demonstrated an absence of consistency in the approach of individual professionals towards communicating information to children and their families.

FG2:

The thing that I struggle with is we see two different audiologists… and… the way the message is delivered very differently, depending on who you get. We have one who’s very… ‘Oh, this is fine, there’s no change, everything’s good, don’t worry about it’ … We can have the same results with a different audiologist… and it’s a lot more… of a somber experience, and it’s like, have you looked at cochlear implants, start looking at this now? … So I think, really, it just would be nice to have some consistency in the messages that are delivered, but it’s very, very confusing to walk out with the same results, but a different feeling from the audiologist. Dependent on who you get.

FG1:

It was really weird, because [my child’s] very first speech therapist, when [my child] was a couple of months old, … used to come to the house. They [therapist] absolutely didn’t seem to have a clue what they were doing… But then we got this excellent person that literally went through and told you why we were doing what we were doing, and why things were happening the way they were. So it’s having someone come in and just want to do things to your child without really explaining. Was… was more the issue. 

Promoting greater consistency in professionals’ approach towards communicating with children with deafness and their families could help to alleviate the confusion and emotional exhaustion that many of the focus group participants described as part of their interactions with children’s hearing services. 

High levels of geographical variation are impacting on the care received

The review heard from focus group participants about the extent of geographical variation between services and the significant implications this can have for the support and care that a child and their family receives. Recounting their experience of moving from one hospital to another, one focus group participant described how:

FG1:

It didn’t go very well at our first hospital, and we’d actually moved house and… to be frank, I was getting fed up with having to drive an hour and not getting any answers. I didn’t feel supported, as I’ve mentioned. I had another baby at this point… [so] we decided to change hospitals, to the one near us, and it was like a switch was flicked, and the audiologist was amazing. First meeting, they said, yeah, well, [your child] needs hearing aids in both ears. And it was like… the train had started moving, you know, we were like, right, now we’re going to do something.

Geographical variation is not limited to audiology services. The review heard from professionals about the importance of school screening programmes in identifying mild or acquired deafness. It was another example of variation in services available. However, school screening is out of scope of this review.

CfE PR-189:

Some areas have stopped the school screening programme and this is concerning as the mild or acquired [hearing loss] may not be picked up until a lot later.

Parents felt audiology services showed a lack of deaf awareness

It came as a surprise to the review that many of the focus group participants and call for evidence respondents reported a lack of deaf awareness in hearing services and feeling dismissed by audiologists and other health and care professionals - even when they finally got beyond the stage of fighting for access to hearing services.

CfE I-072:

There should be better deaf awareness among all staff at audiology departments, including receptionists. Names need to appear on screens, patients should not be called in waiting rooms. Staff should know not to talk to patients when their hearing aids are not in, nor should they face away from patients who may be reliant on lip reading.

A frequent view was that awareness of the importance of deaf identity, and the use of BSL as an integral aspect of this for many deaf people, is lacking in some audiology settings. There was frustration from parents at the lack of availability of BSL in audiology departments and a call from individuals for the promotion of BSL by medical, support and educational staff. Many individuals responding to the call for evidence felt that BSL should be offered when their child first sees an audiologist. Respondents called for BSL classes to be provided for deaf children and their families.

CfE I-070:

It would be a great place for our children to see professionals use the sign that we practice at home… I feel that anyone working with deaf individuals should have basic sign skills to use within hearing appointments. Especially when children have to take their hearing aids off to be tested, it’s very important that they still have access to language during this time.

The review also heard about the important role Teachers of the Deaf can play, but many individuals referred to mixed experiences and to the need for more Teachers of the Deaf.

A significant number of parents and carers expressed frustration, noting that audiology departments should be setting standards for deaf awareness and ensuring that their patients’ communication needs are met. This extended to basic communication skills, including feeling enabled to use the word ‘deaf’ when talking to parents about their deaf child. 

FG2:

With audiology, which seems… totally ironic, considering they work with deaf people… There’s no BSL in our audiology department whatsoever. No use of the word deaf, which is… mind-blowing. We had to… literally give permission to the audiology department. We were saying, you can use the word deaf. There’s nothing wrong with it, it’s not a dirty word.

We had to also encourage them to use boards when calling names, like a little whiteboard, because they’d just come out still wearing masks. How are these children hearing their names in the waiting room? They’re not. So it’s just trying to get them… to use a little bit of gesture or BSL, learn some basics, use a whiteboard for the names. And use the correct terminology and empower these children to be deaf children. That was something that was really important to us.

Late identification of deafness impacts a child’s development, learning and confidence

Identification and treatment or support for children with deafness is time critical. In childhood development there is a critical ‘window of opportunity’ for learning to interpret sound and learning spoken communication. Through the call for evidence, interviews and focus groups the review heard difficult stories about the impact late diagnosis had on children and their families.

CfE I-040:

[My child’s] friends were learning to read and write he was learning to speak for the first time. As a result [my child] has suffered severe developmental delay to which [my child] is still trying to catch up now age 10.

CfE I-049:

We waited 18 months for a 9 month referral following the ABR [test] when [my child] was a month old, where we were advised it was probably conducting hearing loss only and we should come back in 9 months. At 20 months my [child] was finally seen again to find out [my child] did actually have underlying hearing loss as well… My [child] lost out on many months of support and understanding because we didn’t realise [my child] was deaf.

How NHS England responded to concerns raised by patients, families and clinical professionals

Feedback is not routinely sought by children’s hearing services and parents expressed concern about anonymity

Feedback from service users is important for improving services and enhancing patient care. While some parents and carers reported their child receiving care in responsive services that sought their views, the majority had issues with how feedback was gathered and used. Focus group participants were asked whether they were given opportunities to provide feedback, and if that feedback was acted on. Most were not asked to provide feedback and were not aware of the process to complain about services.

Focus group participants expressed doubts over the ability to remain anonymous and raised concerns about possible repercussions of providing negative feedback on the care their child received. 

FG1:

I found it quite difficult to… think about whether I should do that [provide feedback] or not. I felt, although it would have come across as anonymous, I felt worried that it might have had some kind of impact on… my child’s care going forwards. And I felt like, because there’s that… imbalance of power… I feel like it’s hard to criticise… so up to this point, I haven’t put in how I feel about… our journey… I think they’d work out who I was… I’d be worried about the backlash from that.

FG2:

Nothing comes back, or in my experience, then they can get quite defensive that you’re raising an issue. And you don’t feel like there’s any conclusion.

FG1:

They’re going to be able to know who we are, because the circumstances of every child in the service are going to be… quite unique, and you can’t anonymise fully. When you’re dealing with kids with very specific needs, they’re going to be identifiable to somebody. And that… that fear of there being some comeback.

A minority of focus group participants shared experiences of having raised complaints or concerns about the services they received and described the positive changes that came about as a result.

FG2:

My feedback was taken on board. I mean, they have given training to all staff, raised awareness that [condition], you know, everyone, or the whole team, audiology team is aware of [condition], and early referral is key, and early intervention is key for a good outcome.

A minority of focus group participants and parents and carers responding to the call for evidence were able to acquire initial access to children’s hearing services without facing significant challenges or barriers. One focus group participant described how ‘it’s never been a fight’ and, expressed feeling very lucky they could access the services and support their child received without long waits.

FG1:

[Child] was very lucky that [child] was born where [child] was. At the time [child] was. 

Where babies and children access services, the review heard some stories of excellent care, and how this had been valued by the parents and carers, as well as the babies and children. For example, individuals referred to the service as “fantastic”, with supportive staff and excellent support from the Teachers of the Deaf, as well as being impressed with the speed of their first referral and feeling like staff listened to their concerns. This included examples from professionals and individuals of professionals working together across disciplines to support the child.

CfE I-143:

The audiology teams we have seen have been great and clearly explain results.

CfE I-157:

After our first appointment at [hospital] everything changed - our consultant advocated for us, [my child] was fast tracked to hearing aids (which [my child] was very overdue for) and has now had cochlear implants. Once we were in the system, the support was exemplary.

CfE I-021:

Our audiology services have been fantastic. They always take the time to listen to our views. The experience of going in is very pleasant.

Recommendation 9: children’s hearing services should be setting the standard for deaf awareness and improve processes for seeking feedback from patients and their families

All children’s hearing services and all audiologists should be setting the standard for deaf awareness and should have access to regular training on how to ensure they can meet the communication needs of their patients.

All children’s hearing services should seek feedback from service users, and ensure systems are in place for patients, parents and carers to provide feedback in a timely manner, with reassurance that the feedback is welcome and will help to improve care provided. These processes must be accessible to all users. 

3. Response of NHS England to the service failures in children’s hearing services

Timeliness of NHS England’s response to emerging issues in children’s hearing services

Concerns have been raised about the quality of children’s hearing services since 2013

The time period covered by this review is from December 2021 to March 2025 inclusive. Therefore, this review has not had the scope to look in detail at actions taken prior to this period. However, the review has heard from numerous contributors that concerns about children’s hearing services were raised with NHS England and Public Health England (PHE) from 2013 onwards. This review has heard from various stakeholders that this included a letter sent to the office of the chief scientific officer in NHS England and officials in PHE in 2013, which stressed the importance of quality assurance across all elements of pathways for children’s hearing services when the NHSP moved to PHE. A background report attached to that letter set out:

The Newborn Hearing Screening Programme (NHSP) Quality Assurance (QA) programme, which ran for four cycles between 2008 and 2013, covered the diagnostic auditory brainstem response (ABR) testing (see footnote 1) (used on the majority of babies that refer from the newborn hearing screen) and other key aspects of the paediatric habilitation service.

During the first 2 cycles of NHSP Quality Assurance, 13 of the 113 NHSP NHS screening programmes were referring screen positive babies to paediatric audiology departments that were identified as providing unsafe diagnostic ABR testing. Services in these departments were suspended, look-back exercises undertaken and babies recalled for further testing… With the refocus of the NHSP’s quality agenda to the core business of screening following the transition to Public Health England (PHE) the NHSP Programme centre has been working to ensure that standards previously part of NHSP quality assurance are fully embedded within other structures. As such, the programme will no longer provide specific quality improvement support for paediatric audiology services which are beyond screening from 1 April 2014.

Footnote 1: Auditory Brainstem Response (ABR) testing is the main diagnostic test used by audiology services once a referral has been made following the NHS Newborn Hearing Screening Programme (NHSP). Historically, testing has been carried out in audiology departments with little or no external support or quality assurance.

Issues were also outlined in reports such as the National Deaf Children’s Society’s (NDCS) Listen Up reports, which provide an overview of children’s hearing services in England, Northern Ireland, Scotland and Wales based on surveys sent to children’s hearing services. In 2014, NDCS’ Listen Up report included a call for the continuation of the existing quality assurance programme for children’s hearing services and mandation of IQIPS accreditation.

In 2020, a number of organisations representing professionals in audiology came together to publish a Rapid Review into Paediatric Audiology. This report suggested that without national oversight and a form of quality assurance for children’s hearing services, it was very difficult to be assured that each child is achieving the best possible outcome and made recommendations to NHS England on how best to ensure services were meeting the needs of deaf children. Although these events took place outside of the scope of this review, it is clear that risks and concerns were raised repeatedly by audiology professionals and organisations in the years prior to the NHS Lothian review and that opportunities to intervene were missed.

The initial response to the report into failures at NHS Lothian was swift although it took approximately 15 months to establish the need for an England-wide response

The BAA’s independent Review into NHS Lothian Paediatric Audiology was published in December 2021. Even before the report was published, this review has heard that NHSP responded and worked throughout 2022 to establish whether the same issues were present in children’s hearing services in England. Through analysis of data from the NHSP national IT system, ‘Smart for Hearing’ (S4H), which is used to record screening, audiological and aetiological assessment outcomes for every baby born in England, 5 audiology service outliers that had identified significantly fewer babies than might be expected with a PCHI were identified and investigated. A sixth site was included in the investigation having discovered that a number of children referred by the newborn hearing screen for ABR testing which had been reported as normal were in fact deaf.

In March 2023, the interim report of the NHS England investigation into low yield sites from the NHSP concluded that “There are themes common with the NHS Lothian report, including the lack of late diagnostic concerns not being flagged and limited oversight, suggesting that there is no assurance that these issues are not widespread.” On the basis of England-wide performance concerns, NHS England took the decision to establish the National Steering Group for Quality Improvement in Hearing Services. As set out in the terms of reference, “The primary purpose of the steering group is to drive quality improvement across paediatric hearing services in England”. The Steering Group first met in April 2023 and continued to meet monthly (except in January 2024) until February 2024.

The Paediatric Hearing Services Improvement Programme was operating in a challenging environment with a lack of information about children’s hearing services in England

The establishment of the Steering Group and PHSIP coincided with an organisational restructure within NHS England and an extremely challenging fiscal and operational environment. Specifically, the PHSIP team has told this review that the programme was established without dedicated clinical, programme and project leads, in a team with an already broad and complex portfolio, with a more than 50% vacancy rate.

NHS England officials have explained that on initiation of the PHSIP, they did not have an accurate understanding of the provision of children’s hearing service providers nationally, and therefore were at a significant disadvantage establishing the full extent of issues within those services. This review has heard from interviews that the lack of understanding and expertise in audiology specifically was a barrier to the effective running of the programme in its initial months.

The national programme focused on a risk stratified approach due to existing pressures within children hearing services; this may have been unavoidable but did delay the recall of some children

In an attempt to avoid a blanket recall of all patients, which risked overwhelming children’s hearing services, NHS England’s focus in this period was on gathering data to risk stratify services - to inform the prioritisation of services for in-depth review - and to build capability within children’s hearing services to undertake recalls where necessary. While some stakeholders have indicated their support for NHS England’s approach to targeting services where there is lowest assurance first, others felt that the pace of change has been slow as a result, described by one contributor to the review as “glacial”. 

The national programme did not provide clear messaging about the urgency of the recall and review process

At no point during 2023 did any official NHS England communications refer specifically to the time critical nature and life-long impact of unidentified and not appropriately treated or supported deafness in children. It is the opinion of the review that this is likely to have contributed to the lack of urgency shown in some regional responses.

In September 2023, NHS England communications setting out recommended actions to be taken by ICBs described quality improvement, as well as ‘historical peer review’ and ‘patient safety and duty of candour’ (see reference 9) but does not explicitly recommend review and recall of affected children. The NHS England letter to ICBs that accompanied these recommendations made clear that they should be implemented “as a matter of urgency” but nonetheless was titled ‘Quality Improvement in Paediatric Hearing Services: recommended actions for immediate implementation’ (see reference 10). Neither the guidance nor its covering letter provided context of the lasting impact that delays to identifying and appropriately managing deafness have on children.

Although the PHSIP governance was redesigned in April 2024, national operational guidance for the review and recall of children was not published until September 2024

The governance of the PHSIP was reviewed in early 2024. NHS England has explained that this was to further drive change and clarify responsibilities in line with the NHS operating framework and the national framework for service review, reassessment and recall. A Programme Board was established from April 2024, with all regional medical directors included in the membership of the board. The updated governance set clear priorities for planning the review and recall of children and babies who may have been missed or whose deafness may not have been identified. However, national operational guidance, which included the national service assurance framework to support the national review and recall process, was not published until September 2024. NHS England has explained that draft guidance was available from late 2023 through its restricted access NHS Futures site and through regional Programme Board members. However, the delay in finalising and publishing the guidance means a clear call to action and unified approach to review and recall was missing for a large part of 2024 due to time taken to finalise and publish the guidance.

Organisations and professionals raised concerns in the call for evidence about a lack of communication, consistency and transparency through the review process.

CfE PR-117:

We still don’t know the scale of the problem, which is a barrier to being able to respond appropriately. This lack of transparency may have been on purpose, with NHS England not wanting the notoriety of ‘Lothian’ which has become a byword for paediatric audiology failings. But at least with Lothian we have a detailed report and know what happened and can learn from it.

CfE PR-147:

Poor communication and organisation throughout. Feels like decisions were made in real time. Lack of clarity around criteria for rating sites and what it will take to move out of this. Lack of support, and tokenistic offers of wellbeing.

CfE PR-050:

The process has been unclear from the start. This includes a lack of clarity about what problem we are trying to solve - I don’t feel this has been articulated effectively.

The speed of regional responses varied dramatically despite all regions receiving the same communications at the same time - this remains an issue now

It is worth pointing out that 2 NHS regions in particular recognised the urgency and severity of the issues, and using incident response structures, were able to identify and address service issues within their regions in a timely manner. For example, action taken by one of the original 5 sites identified by the NHSP analysis was described in a ministerial reply to MP correspondence in October 2023. This set out steps taken in early 2023 to:

• suspend ABR testing at the trust
• commission a BAA full review of its children’s hearing service
• implement BAA recommendations to investigate all the cases classed as serious incidents

In contrast, the review has been told that in some areas, local leaders understood they were being advised to or decided to await national guidance and/or funding to support the recall and review of affected children. This review has heard from stakeholder interviews that at least one of the original 5 sites identified in 2022 has only begun to recall affected children in 2025. This was not an acceptable delay. NHS England has told this review that they provided clear instruction to local leaders, for example, in the letter published in August 2023 which stated “All ICBs are now requested to work with their paediatric hearing service providers to implement the recommended actions in the document attached as a matter of urgency” (see reference 11).

Robustness of NHS England’s response and the Paediatric Hearing Services Improvement Programme

The service issues in children’s hearing services did not meet the written guidelines for declaring a national incident

Despite criticism in the media and elsewhere that this programme should have been declared as a national incident, this review agrees with NHS England officials that the criteria for a national incident were not met in this case. The published NHS emergency preparedness, resilience and response (EPRR) framework sets out that for the NHS, EPRR incidents are defined as one of the following:

• business continuity incident - an event or occurrence that disrupts, or might disrupt, an organisation’s normal service delivery, to below acceptable predefined levels
• critical incident - any localised incident where the level of disruption results in an organisation temporarily or permanently losing its ability to deliver critical services; or where patients and staff may be at risk of harm
• major incident - the Cabinet Office, and the Joint Emergency Services Interoperability Principles (JESIP), define a major incident as an event or situation with a range of serious consequences that require special arrangements to be implemented by one or more emergency responder agency

Although the nature of the issues in children’s hearing services do not meet the EPRR incident definitions, the lack of an incident response framework for issues of this kind has left the PHSIP without the ability to mandate regional or local action in response to the service issues in children’s hearing services. This has significantly undermined its effectiveness as a national response. As noted above, the review notes that the regions that utilised an incident response methodology appear to have implemented the most robust and timely responses to these issues.

This review has heard some challenge that it is the job of effective leadership teams to implement incident response processes even without statutory responsibilities in place, however, it is the opinion of this review that clear guidance would have been incredibly helpful in this case.

Requests made by the PHSIP for funding and resource were not wholly approved. This has undermined the effectiveness of NHS England’s response

The PHSIP’s ability to co-ordinate an effective national response and support regional responses has also been hindered by resourcing and funding being below what was requested by its SRO for successful delivery. Funding requested by the programme team during 2023 and 2024 to support their activities was not wholly approved by NHS England executive leaders. The programme team has provided the following timeline of requests made to NHS England’s chief financial officer and/or chief executive:

• March 2023 - initial funding request made for clinical, project and programme leads to deliver the programme. Funding for clinical specialists approved in June 2023. Additional funding and posts for programme and project leads not approved on basis that posts should be established from reprioritisation and/or reallocation of existing resource
• June 2024 - funding request submitted for 4 key areas of the programme: review and recall; workforce; quality; national review. Following discussions between the programme and NHS England finance team to review the funding request, national funding for subject matter experts (SMEs) to support review and recall was agreed in August 2024
• September 2024 - further funding request covering SME to support review, recall, reassessments, and external quality assurance development as well as a service model review to identify sustainable approaches. Funding for SMEs approved
• November 2024 - business cases submitted for patient lived experience, national service review and external quality assurance. All business cases rejected at this stage
• December 2024:
  • business case submitted and approved for national SME register to support review, recall and reassessment
  • funding allocation for 2025 to 2026 submitted. Funding for 2025 to 2026 confirmed in March 2025

The uncertainty around what funding the programme might receive and when contributed to a lack of robustness in planning.

The PHSIP has not inspired the confidence of external stakeholders

A number of external stakeholders have expressed a lack of confidence in the programme’s ability to grip the issues in children’s hearing services at a national level. For example, this review has heard that working groups on topics such as quality, data and workforce were stood up and down in 2023. The PHSIP team has told this review that some groups were stood down for a number of reasons:

• in response to completion of programme activity design
• leaks to the press of unvalidated data
• personal accusations against staff members placed on the internet
• suggestions from stakeholders for governance alterations to improve delivery and to broaden membership where needed

Stakeholders interviewed by the review reported feeling “threatened” by a requirement to sign confidentiality agreements. Although confidentiality agreements are not uncommon when working on sensitive topics, this suggests a lack of trust between the programme team and external stakeholders.

When risks and issues have been raised regarding the PHSIP, escalation appears to have had little impact

The review has also been told about the ongoing risks and issues associated with the PHSIP, for example:

• regarding national programme resourcing
• the funding and workforce needed to undertake the review and recall of babies and children
• funding and resources for ongoing quality improvement, such as IQIPS accreditation

While the PHSIP risk register that has been provided to this review records and provides mitigations for risks on programme funding, communications, data, workforce and capacity to deliver the review and recall, these are not reflected in the PHSIP’s contribution to the wider NHS England risk register and in several cases, no mitigations have been put in place due to a lack of resource.

The PHSIP has provided regular briefings to NHS England’s governance structures, including the Medical Directorate Senior Management Team, Quality and Performance Committee and the Executive Quality Group, in line with its agreed governance and routes for escalation. However, this review has seen little evidence of actions taken as a result of briefings to the Quality and Performance Committee and the Executive Quality Group which have contributed to the effective management and mitigation of risks to and issues in the programme.

The NHS England PHSIP team have shown admirable determination to continue their work despite governance, resourcing and funding obstacles

Despite these shortfalls of the programme, all members of the PHSIP team who were interviewed for the review have expressed dedication to the cause of reviewing and recalling children who have been harmed and an admirable determination to do the best they could in the circumstances. In some cases, individuals have taken proactive action outside the scope of their roles and at personal cost to themselves to progress the national programme. This review and many of those who have contributed to it have recognised the challenging circumstances in which the programme team has operated and paid tribute to its individual members.

Evaluation of NHS England’s plan for reviewing individual services and cases

Deadlines for recall and reassessment of children have not been met

The ambition to recall and reassess children identified as requiring a follow up assessment by 31 March 2025 was not achieved nationally. The further ambition to either discharge or place patients on an appropriate treatment pathway by 30 September 2025 is also unlikely to be achieved nationally. Both of these targets have been described to this review as deliberately ambitious targets intended to call the system to action.

Progress on recall and review has varied by region and by provider

The progress made by children’s hearing services on review, recall and reassessment has varied between regions and providers. This review has heard that a number of factors played a role in this variation.

Good progress has been made in regions where there has been alignment with incident management and where funding was identified within region to support the response. For example, the review has consistently been told of effective responses in regions where command and control structures were put in place, with overall leadership provided at the regional level and, where regional budgets were reprioritised to provide funding for review and recall activity. These regions did not wait for guidance or funding from the PHSIP team and in some cases the methodologies they developed have been adopted and promoted to other regions.

Capacity to undertake patient review and recall has been constrained due to the availability of suitable trained audiologists

The PHSIP established a national SME register to provide access to a pool of competency-checked professionals and a process for matching SMEs to support services in review, recall and reassessment. Before joining the register, every SME must be assessed for competence by expert audiologists. Final versions of the competency framework against which SMEs are assessed were published by the PHSIP in February 2025. However, due to delays, this review has heard some trusts have had site visits scheduled with SMEs whose competence has not yet been assessed. They have been informed that the SMEs’ competence may need to be assessed after the site visit has taken place. This undermined some trusts’ confidence in the findings of site visits. The PHSIP team has told this review that the process for assessing SMEs competence was developed but it was necessary to initiate site visits before formal assessment and sign-off. They agree that ideally, competency assessments would occur prior to commencement of visits but recognise that there is a national shortage of experienced clinicians with the expertise to assess competency.

Where competent SMEs have been identified to undertake review visits, the review has heard that much of the work has been done on top of SMEs’ existing workload - resulting in site visits taking place at weekends and during annual leave. Furthermore, these site visits have relied upon unpaid goodwill of individuals due to the delays in agreeing funding arrangements. The PHSIP team secured national funding for an SME register and management system in December 2024. However, issues have remained with SMEs being owed for historical hours worked prior to the funding being agreed and the payment system being established. This has contributed to SME capacity constraints and has affected the morale and the wellbeing of the profession.

The capacity of NHS trusts to offer mutual aid has been constrained due to waiting list pressures

The capacity to review and recall patients created a conflict with maintaining (and in some cases recovering or improving) waiting time performance (as reported through the nationally mandated diagnostic waiting times and activity collection known as DM01). The review has heard that this has been a barrier to organisations providing mutual aid to other services, due to concerns about the impact on their own DM01 performance. Although the September 2024 guidance provided information on managing waiting times and mutual aid, confirmation that DM01 could take second place to the review and recall programme was only provided in June 2025. The review has been told that this was despite earlier calls to relax or pause DM01 from regional leads who identified this as a barrier to mutual aid as early as June 2023. 

Some concerns have been raised about the methodology used for risk stratification of services and how consistently this has been applied, although it has not been possible to assess this in detail in this high-level review

This review has also considered evidence about whether the programme’s approach to review and risk stratification has delivered the correct outcome for all services. For example, the review has been told of concerns about services achieving a high assurance rating - and therefore no in-depth review to determine if patient review and recall is required - on the basis of IQIPS accreditation alone. Stage 2 of the National Service Assurance Framework set out in NHS England’s Paediatric Hearing Services Improvement Programme operational guidance states that “A service is defined as high assurance if it is UKAS accredited with no data concerns identified”. However, the review has heard concerns that IQIPS accreditation does not assess individual audiology professional performance, and therefore, alone is not an effective measure of assurance. Concerns about consistency of how the response was rolled out were also raised in responses to the call for evidence.

It is out of scope of this review to assess individual services and ratings given as a result of the assurance framework, and whether that framework has been applied consistently. The review team has at all stages recommended that concerns about patient safety should be appropriately escalated within the relevant organisation. Nonetheless, key lessons should be learnt from such concerns to ensure consistency and transparency is applied across all services reviews for the remainder of the review and recall programme.

The risk stratification process is one of the lynchpins of the entire review and recall programme. If services have not been consistently or accurately risk-rated, this calls into question the robustness of the review and recall programme as a whole and means the number of children potentially affected by these issues could be much higher than currently estimated. This review sincerely hopes that is not the case.

The review and recall programme has had a negative impact on some audiology professionals and their wellbeing

Responses to the call for evidence has provided insight into audiology professionals’ views and experiences of the programme’s approach to reviewing services. Some professionals felt that the review and recall are important to improving services and has given their patients a better quality of care already.

CfE PR-03:

My overall impression has been that people have been working very hard to establish a process for review of audiology services, but this was effectively starting from scratch and it therefore took time for us to get clarity on how the process was to work. The review itself was a positive process. It provided an opportunity to scrutinise our own processes and learn from feedback from the PASQAT [Paediatric Audiology Quality Assurance Tool] review team. It has also provided an opportunity to improve the way we work and communicate with our commissioners.

CfE PR-064:

Much needed review. Highlighting the potential lack of investment / training in children’s audiology services leading to some significant cases of lack of diagnosis / identification of deaf children which has led to significant harm to some children.

Nevertheless, professionals also outlined negative experiences relating to how they have been treated and the toll it has taken on their mental health and wellbeing. Some respondents reported that colleagues were leaving the department or profession which was exacerbating existing staffing issues.

CfE PR-028:

Unrealistic deadlines for both review and recall work have added significant pressure to an already fragile workforce.

CfE PR-132:

Sites were openly and publicly named and shamed and in some cases wrongly. The process was extremely demoralising.

CfE PR-024:

It is shockingly poor [the] way staff have been treated during this review. It has affected morale detrimentally.

Respondents expressed frustration at poor communication and lack of transparency about decisions made as part of the review and recall process. In addition, professionals raised concerns that plans were not put in place once a review of services had happened and service were paused which has had a detrimental impact on patients.

CfE PR-085:

There was a lack of transparency around decision-making by commissioners, funding and management of conflicts of interest. The local team and patient population were not consulted or canvassed regarding their views and ideas, it was not possible to talk with commissioners/those making the decision.

CfE PR-095:

Going through the review, it felt as though it was all being made up as we went along. A thorough and detailed process should have been set out at the start and service providers should have been made aware of standards that they were being assessed against before the review began. It felt ‘cloak and dagger’.

CfE PR-143:

… No consistency - some departments under significant scrutiny, others not… Harm ratings / levels not consistent - despite BSA recommended procedures being followed for children with mild hearing loss, they have been given moderate harm ratings.

Professionals often highlighted that short timeframes leading up to the service being reviewed with little or no notice of visits to services from SMEs and without regard for ongoing work commitments. The review heard about how the review and recall process have put additional pressure on staff.

CfE PR-192:

The time in between highlighting concerns and plan for action for the children involved is months and months. This is unacceptable for the patients involved but also the staff managing this at organisational level.

Transparency of NHS England’s response to issues in children’s hearing services

NHS England first published information addressed to parents and carers who might be worried that their child is affected by the issues in children’s hearing services in a blog published on its website on 4 October 2024. Prior to this, communication with the public was through responses to media reports or managed by ICBs and providers, guided by a communications toolkit produced by the PHSIP. NHS England has also informed this review that ICBs were advised to follow NHS policies and procedures such as the Duty of Candour process for all services undertaking recall to ensure families of patients received high-quality and timely information at all sites where needed.

While this review recognises the duties of ICBs and providers to communicate with affected families, there was a failure by NHS England to provide information to families who might be worried about their child when widespread issues in children’s hearing services were identified in 2023. This is considered further in section 4. 

NHS England’s communications have also failed to acknowledge that in some cases the damage done to affected children will no longer be reversible. For example, the wording in NHS England’s blog published on 4 October 2024 describes “what is being done to support local services to find and treat children with hearing impairment they might have missed” (see reference 12). Similarly, the Paediatric Hearing Services Improvement Programme operational guidance describes that review and recall will “mitigate harm caused by misdiagnosis or delayed diagnosis” and “address harm caused by misdiagnosis or delayed diagnosis” (see reference 13). Stakeholders interviewed by this review explained that this will not be the case for all affected children and felt that this should have been acknowledged publicly.

In summary

In making recommendations, the review is clear that the priority must be to complete the review, recall and where needed and possible, treatment of children affected by service failures. At this stage, wholescale changes to the programme risk destabilising the progress that is being made. Therefore, the national PHSIP should continue, subject to urgent review of its role and remit to allow the prioritisation of completing review and recall.

All recommendations for improving children’s hearing services for the medium to long term are included in section 5 and this review recommends that work on those recommendations is taken forward separately to avoid the issues encountered by the PHSIP in prioritising between these tasks previously.

Recommendation 1: the role and remit of the current PHSIP needs urgent review to focus on completing review and recall

The new organisation (DHSC and NHS England) should consider how best to continue the PHSIP. Based on the findings of this review, the most effective responses have been by strong regional teams. Regional teams must be enabled to use local incident response processes with very clear timelines for completing all follow-up assessments and discharge or placement on a treatment pathway where required. The central programme team should be suitably funded and resourced and fulfil the role of supporting regional teams. The name and terms of reference of the programme should be revised to more accurately reflect its focus on review and recall of children affected by service issues.

Recommendation 11: a regional incident response process should be formalised to enable a more structured response to service issues which do not meet EPRR criteria, including clear guidance around public communications and action should be taken to improve early identification of emerging issues

The new organisation (DHSC and NHS England) must establish arrangements and responsibilities for a regional incident response process. This process would set out the approach for managing widespread patient safety and quality incidents that are serious but do not meet the threshold of a national incident, in order to provide standardised responses, including leadership, risk management, escalation routes, staffing resourcing and funding

The new organisation (DHSC and NHS England) must ensure proactive communication to the public and to affected patients is planned at an early stage when widespread patient safety or quality concerns are established in line with the approach taken in policy areas such as screening

The new organisation (DHSC and NHS England) should create a ‘special projects team’ to investigate quality and safety concerns in specific areas of the health system and make recommendations for improvement before handing over to BAU policy teams or incident response processes

The new organisation should consider creating a horizon-scanning function which leverages the potential of AI and machine-learning to analyse sources of information coming into the department, improves the data collected across different health services and looks proactively for emerging risks before they become issues

4. Response of DHSC and governance arrangements between NHS England and DHSC

Robustness of NHS England’s identification and oversight processes

In May 2021, the Scottish Public Services Ombudsman upheld a complaint by the parents of a child about the standard of care and treatment provided by NHS Lothian Health Board to their child in relation to their hearing. In response to the recommendations of the Scottish Public Services Ombudsman, the British Academy of Audiology (BAA) was commissioned to undertake an independent clinical audit and governance review of the children’s hearing services at NHS Lothian Health Board. The review found systemic failings which led to some deaf babies and children not being identified or significantly delayed in identification and appropriate treatment or support (see reference 14).

When the report of the Lothian review was published in December 2021, the NHSP team in NHS England decided to conduct an analysis of the data collected by the programme and ultimately concluded that there were 5 sites that were on or under 2 standard deviations from the national rate of PCHI, that is these sites were identifying significantly fewer deaf children than would be expected based on national averages. During 2022, NHS England officials coordinated with NHS trusts to gather additional information, confirm their analysis and design an external peer review of the services which began in November 2022. The information and analysis were handed over to the PHSIP, which was set up in early 2023.

What were the origins of these service failings?

The review sought to understand whether there were any signals prior to 2021 that problems were developing. Although it is outside the time period covered by the terms of reference, this review has heard that a more robust system of national oversight existed across the care pathway of children’s hearing services prior to the Health and Social Care Act 2012 which led to the restructuring of national health bodies. The Newborn Hearing Screening Programme was introduced in 2001 and at that time, a series of national quality standards existed which related to screening, diagnostics and ongoing support for children. The review has been told that the NHSP team at that time were responsible for monitoring quality across the entire pathway.

When responsibility for the NHSP moved to PHE in 2013, the new NHSP team were only responsible for quality oversight of the screening programme. This was in line with the approach taken for other screening programmes, on the basis that quality assurance for referral and treatment required different expertise. This expertise had previously been contracted from outside the NHSP team. This review has been told that representatives of the profession wrote to both PHE and NHS England officials in 2013, referring to the importance of continued quality oversight of the entire pathway. The report attached to this letter is quoted in section 3.

This review has seen a copy of a letter which it has been told was sent in response from PHE officials later that year, which states “It is our intention to strengthen and build strategic and operational partnerships with key stakeholders in health and early support to enable an effective transition from the current situation to the ‘system-wide approach’” and referring to planned work with members of the audiology profession on “ABR quality assurance and peer review networks” (see reference 15).

PHE set up an NHSP Advisory Board which was attended by external advisors as well as PHE officials. The NHSP team subsequently developed, collected and published data on the time from screening outcome to attendance at an audiological assessment appointment (see reference 16). This review understands that the introduction of the UKAS IQIPS accreditation process for children’s hearing services was intended to introduce quality assurance of the referral and treatment elements of the care pathway. As described in section 5, only 27 out of 139 of children’s hearing services in England have IQIPS accreditation.

In 2015, NHS England published an Action Plan on Hearing Loss (PDF, 781 KB). This document stated that: “There is a fivefold geographical variation in the referral to assessment time for hearing tests in newborns and the UK has one of the lowest rates of cochlear implantation in Europe for young children with severe and profound deafness by age 2 years.”

In 2021, the NHSP team moved into NHS England and continued to hold responsibility for commissioning the NHSP and monitoring the quality of the screening section of the pathway. This review has been told that the number of full time equivalent (FTE) working on the NHSP has since decreased from 4 FTE in 2021 to approximately one FTE as of 2025. From 1 April 2026, the commissioning of the NHSP is intended to be delegated to ICBs as part of a wider initiative to devolve the commissioning of more screening services to local structures (see reference 8). At present, this review understands that discussions are ongoing regarding what arrangements will be made to oversee and quality assure the care pathway for the screening programme as well as the wider care pathway for children‘s hearing services.

In summary

This review considers the response during 2022 to have been proportionate, timely and effective. However, it is unclear why the data collected by the NHSP team was not being regularly scrutinised to identify trends in quality between 2013 and 2021. It is also unclear why no measures were taken to put in place national oversight of quality for the remainder of the pathway during the restructures in 2012. This review can only conclude that the identification and oversight processes in place are insufficient.

The devolution of commissioning to ICBs is a good opportunity to introduce effective quality assurance for those services, like children’s hearing services, which have historically received little attention or interest at provider, commissioner, or national level. The recent report by Dr Penny Dash into patient safety makes a similar recommendation to “revamp, revitalise and significantly enhance the role of the National Quality Board” (see reference 17).

Communication and collaboration with DHSC, especially regarding early intervention, transparency and governance

The chief scientific officer (CSO) in NHS England is responsible for providing overall leadership for over 50 healthcare science professions, of which audiology is one. The NHSP team in NHS England is responsible for commissioning the national NHSP, overseeing its delivery and providing assurance of the quality of the service delivered. The responsibility for overseeing the quality of services delivered in children’s hearing services sits with the individual ICBs who commission these services. There is no dedicated policy team for audiology or for the NHSP in DHSC.

This review has heard from DHSC stakeholders that for some similar services there is a dedicated policy team in both NHS England and DHSC. Cancer screening programmes were given as an example. This review has heard that any service or quality issues which arise in screening are notified by the NHS England team to the DHSC team who then inform ministers. It is usual to provide a timeline at this stage, recommending that the issue should be investigated first. The relevant NHS England team then ensures capacity, processes and guidance are in place to resolve the issue. The teams coordinate to produce communications. The minister will make an announcement to Parliament and awareness of the issue will be raised among members of the public through other channels. This review was told that ministers usually wish to announce the issue as soon as possible. The investigation and response plan are usually generated within a few weeks at most.

However, it is worth noting that there is no consistent expectation that such a process will take place for every policy area. There is also no written guidance for NHS England and DHSC officials about how they are expected to work together to respond to safety or quality issues or the circumstances in which issues of this kind ought to be escalated to DHSC ministers.

Communicating with DHSC ministers and/or officials

In the case of children’s hearing services, the analysis done by the NHSP from December 2021 was not communicated either to DHSC officials or to ministers and no immediate plan was made for informing Parliament or the general public. The subsequent launch of the PHSIP in early 2023 also did not result in any proactive communication to DHSC officials or to ministers. The communications provided to ICBs and NHS trusts are outlined in section 3. The first formal piece of advice to ministers which recommended actions to respond to the issues in children’s hearing services was not sent until 20 September 2024. This is a delay of over 18 months.

During the period from December 2021 to September 2024, there were at least 3 instances where ministers and/or officials in DHSC were sighted on references to the issues in children’s hearing services and to the PHSIP in NHS England:

1. In a submission sent to a junior DHSC minister in March 2023: the submission describes, among other topics, the outcome of the review into children’s hearing services in NHS Lothian and the expected timelines for NHS England’s response. No further information was requested on the basis of this submission, and no update was provided to DHSC ministers in April 2023. The policy team who had written and cleared this submission were largely redeployed in May 2023 to work on the response to industrial action in the NHS.
2. In a response to ministerial correspondence answered in October 2023: this referred to the experiences of a family whose child’s deafness was not identified and treated promptly. The response, provided by NHS England officials, refers to the work being done at one of the original 5 NHS trusts to improve their services and recall affected children. This letter was signed by a junior DHSC minister, but no policy official or private secretary requested any further information about the PHSIP at that time.
3. In a response to 2 Parliamentary questions (PQs) from the House of Lords in February and March 2024: these described the PHSIP’s focus on “delivering several strategic interventions over a short, medium and long-term period” and “supporting paediatric audiology services regarding review of patient records, including ensuring that children identified as requiring reassessment are prioritised” (see reference 18). The lack of clear policy ownership for audiology is demonstrated by the fact that these 2 PQs, from the same member of the House of Lords, on the same topic and within a month of each other were answered by 2 different policy teams in DHSC. The responses were delivered by the DHSC Lords minister.

It is worth noting that it was a different individual minister involved in each case.

In September 2024, the PHSIP sent advice to a director general in DHSC and advised them that they were planning to inform the current Secretary of State about the issues in children’s hearing services and the NHS England response. This coincided with the publication of an article in the Sunday Times about the deaf children who had not been identified and included quotes from NHS England officials who felt the national response (that is the PHSIP) was too slow, underfunded and insufficient. It was in response to this advice that the Secretary of State commissioned this independent review.

Since that point, the PHSIP have provided several pieces of advice to the Secretary of State to provide an update on the progress of the review and recall exercise to reassess children whose deafness may not have been identified and ensure they have access to appropriate treatment and support. In terms of governance, these pieces of advice have not followed the usual departmental process. Employees of NHS England are public servants, rather than civil servants, and so any advice they provide would usually be signed off or ‘cleared’ by a DHSC official. In this case, these pieces of advice have been sent up without DHSC ‘clearance’.

In summary

This review concludes that the governance processes between NHS England and DHSC have not operated effectively or consistently in the case of children’s hearing services. There was little opportunity for DHSC to intervene early on in the response, as communication between the organisations was haphazard and disjointed. The information provided on request was comprehensive but there was little proactive attempt by NHS England to inform the relevant senior officials in DHSC as they did in September 2024. It is the opinion of this review that this was only done in response to external media interest, which made open communication unavoidable. Since September 2024, the focus of DHSC’s response has been on the commissioning and delivery of this independent review.

Recommendation 12: written guidance should be provided for all officials regarding how and when to raise service issues with ministers and horizon-scanning processes should be subject to review

As part of the transformation programme which will create a new organisation out of DHSC and NHS England, specific training and guidance should be provided for all those transitioning to a civil servant role regarding when and how ministers should be sighted on safety or quality issues and regarding expectations for working with ministers.

5. State of play in children’s hearing services

Commissioning of services

With the exception of specialised implant services, children’s hearing services are now commissioned entirely by ICBs, taking into account the needs of their local populations. Commissioning is a powerful lever to drive up standards and hold providers to account for performance and quality. However, this review has heard that there is wide variation in commissioning of children’s hearing services by ICBs and that services are often bundled with other services such as ENT or diagnostic services or community services or included in block contracts. This review notes that this issue is not specific to children’s hearing services and the 10 Year Health Plan describes the need to deconstruct block contracts to align better with activity and quality.

Evidence provided to this review suggests that audiology contracts do not include the requirement for clinical audit, quality assurance, peer review or CPD for trained audiologists. They also do not include provision for research initiatives. As a result, these essential activities do not appear in job planning in the vast majority of children’s hearing services.

The review has also heard that commissioning contracts often do not contain KPIs for audiology. This means that there is little opportunity for commissioners to scrutinise service data to ensure services are delivering as expected and in line with best practice. The value of local commissioning is lost if no one has a handle on the outcomes for local patients.

NHS England officials have told this review that they last published national guidance for commissioners of children’s hearing services in 2019 (see reference 19). However, they explain that it is not possible to ensure this guidance is implemented by ICBs and that NHS England as an organisation lacks the levers to mandate elements of the guidance. The review is of the opinion that the failure of ICBs to implement national guidance has contributed significantly to the failings of this service. Experts in service commissioning were clear that commissioners can and must hold providers to account on performance and quality. The lack of consistent national guidelines was also raised in responses to the call for evidence issued by this review.

CfE PR-148:

The lack of clear national guidelines persists - there are lots of guidelines but they do not give black and white normal ranges or necessary settings for all tests.

Patient voice is integral to designing and commissioning services that meet the needs of the people using those services. In the call for evidence, many parents and carers described the complexity of the care pathway for children’s hearing services and said that they faced significant challenges navigating the health and care system on behalf of their child. Designing and commissioning services with input from service users will improve patient experience.

Demand for children’s hearing services is also in flux and has changed since most current commissioning arrangements were put in place. The increase in the number of children being assessed for autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) has dramatically increased the number of hearing tests needed. Deafness must be ruled out before a diagnosis of ASD or ADHD can be made.

This review has heard that audiology clinics are not resourced to accommodate the needs of children with ASD or ADHD, who generally need multiple appointments to identify deafness. For example, a 4 year old with autism, might need 4 to 5 audiology appointments and sedation for a hearing test.

The 10 Year Plan refers to a white paper on schools to be published in the autumn, which will detail the government’s approach to reforming services for children and young people with special educational needs and disabilities. This review welcomes this commitment from the government.

External inspection of service delivery

The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England. This includes children’s hearing services. According to their website “We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve. We monitor, inspect and regulate services and publish what we find. Where we find poor care, we will use our powers to take action.” A recent review into the operational effectiveness of CQC was published in October 2024 and has suggested a number of actions for improvement.

In terms of children’s hearing services, this review has heard that the Care Quality Commission rarely focus on audiology services within an NHS trust when conducting a review, and do not have specialist expertise in audiology which would allow them to look at the quality of diagnostic testing or audit processes. Of the 10 most recent NHS trust inspection reports published by CQC as of 10 July 2025, none mentioned audiology services and there has been no recent thematic review of audiology services in England.

The United Kingdom Accreditation Service (UKAS) offers IQIPS accreditation for audiology services. Although UKAS accreditation for audiology services has been championed by NHS England since the IQIPS launch in 2012 and recommended through the PHSIP, as of 11 July 2024, only 27 out of 139 services in England are fully accredited (with a further 2 accredited but currently suspended). More services have applied for accreditation since the beginning of the PHSIP and as of May 2025, 27 services are applying for accreditation. However, this only accounts for 54 out of 139 services in total. This review has been told that the failure to apply for accreditation is primarily due to a lack of funding, a lack of resource and a lack of perceived priority of audiology services when considered alongside other services within an NHS trust or ICB.

This review has heard from some audiologists, typically in larger teaching hospitals, who have replanned the work of their teams to accommodate the time and budget for a designated quality lead and have successfully achieved IQIPS accreditation as a result. These audiology teams have generally been better placed to bring issues to the attention of their trust and/or ICB leadership through concerted campaigns or receptive leadership.

This review has also heard that the IQIPS accreditation, although helpful in promoting good systems and practices around quality assurance, does not include an objective assessment of the quality of the services themselves. In other words, IQIPS cannot be the whole solution for robust external inspection of service quality in audiology. 

PR-067:

Accreditation is helpful as a quality indicator but unfortunately IQIPS is not a direct reflection on quality of service and therefore perhaps not a sufficient marker of clinical quality in view of the administrative and cost impact along with the lack of full assurance of clinical quality.

Although before the period being considered by this review, the potential limitations of IQIPs were raised in a report shared with Public Health England and NHS England in 2013 which stated that “The success of this type of accreditation - and the confidence of the profession - is crucially dependent on the knowledge and expertise of the reviewers and their ability to identify areas of poor or unsafe practice.” More information on this report and its covering letter that was sent to Public Health England and NHS England in 2013 is provided in section 3.

Some professionals responding to the call for evidence called for accreditation to be mandatory, provided that the resource was available to support the accreditation process. The limits of IQPIS accreditation were also raised through the call for evidence. For example -

PR-157:

I believe that there needs to be a good hard look at the national accreditation programme (IQIPS) as services that had this accreditation were still being found to be delivering substandard care.

Responses to the call for evidence from organisations included frequent references to the need for proper accreditation and quality assurance for audiology services.

ORG-016:

We recognise challenges around accreditation, we feel specific accreditation with regular updates, should be compulsory for all professionals providing children’s hearing services regardless of their professional backgrounds.

Capital funding for infrastructure and equipment

This review has heard from several sources through interviews and the call for evidence that some children’s hearing services are conducting hearing tests in rooms which are not sufficiently soundproofed and with equipment which is no longer fit for purpose. IQIPS accreditation includes ensuring that equipment is appropriate, well-maintained, and calibrated according to relevant standards. The review heard frustration expressed by service leads in accessing capital funding to maintain equipment and facilities. ICBs have a role to play in helping facilitate funding and making the process less convoluted and difficult.

The review heard concerns from professionals responding to the call for evidence about frustrations with having access to up to date fully functioning equipment.

CfE PR-004:

Department heads have been asking for equipment to be refreshed and for IT to prioritise fixing computers and update compatibility issues with their outdated equipment. In the last year, not one of the trusts I work with has been successful in improving the situation.

CfE PR-194:

Our audiology equipment is over 10 years old, more than 50% of the functionality does not work. With the trust having ‘no money’ to upgrade. 

Recommendation 2: children’s hearing services should be commissioned using a modern service framework and model commissioning contract

The new organisation (DHSC and NHS England) should use the new service frameworks proposed in the 10 Year Health Plan to drive improvement and innovation by defining the goals for the care pathway in children’s hearing services, setting standards and supporting the workforce to deliver these goals.

The new organisation (DHSC and NHS England) should develop a model commissioning contract for ICBs to use for children’s hearing services. This should include KPIs relating to safety, effectiveness and patient experience. This contract should ensure services can protect ringfenced time for clinical audit, quality assurance and CPD activities. This approach has the potential to act as a template for other similar services.

All ICBs should support their children’s hearing services to become IQIPS accredited and identify capital funding to improve audiology testing equipment where needed in order to facilitate that process.

Professional registration for audiologists

In the UK, ‘audiologist’ is not a protected title so any individual can call themselves an audiologist without relevant qualifications or experience. There is no single professional register for audiologists in England. Clinical scientists and hearing aid dispensers are required to register with the Health and Care Professions Council (HCPC) but other audiologists are eligible to join voluntary registers administered by the Academy of Healthcare Science (AHCS). For audiologists who are neither clinical scientists nor hearing aid dispensers, there is no explicit requirement to be registered in order to practise in the NHS. This review has heard that many audiology professionals working in the NHS are not registered at all.

This review has heard that the guidelines around where to register depending on your experience and qualifications can be confusing for audiologists and their employers, let alone the public they treat. The review has also heard that the equivalence process for joining the HCPC register for clinical scientists - without having completed the Scientist Training Programme (STP), a Masters level degree - is so lengthy and complicated as to be prohibitive, leaving some very highly experienced audiologists who trained outside the UK unable to apply for jobs at higher grades. This is equally true for audiologists who trained before the STP was introduced during the Modernising Scientific Careers initiative in 2012.

This review has not been able to identify any clear rationale for why some audiologists are registered and others are not and this does not appear to be linked to the level of clinical risk involved in the activities they might carry out.

The review spoke to representatives of the New Zealand Audiological Society (NZAS), which is the professional body responsible for registration of all practising audiologists in New Zealand. Although there is no statutory requirement for audiologists to join their register, they told us that in practice no audiologist would be employed in a public-funded health centre without registration because it has become a standard practice. They operate a system based on certificates of practice for specialist skills, including one specifically for practising in paediatric audiology. Once an audiologist has completed the training course, including an independent assessment of their skills, they are required to demonstrate their fitness to practise by evidencing sufficient hours of practice or undergoing a review of their ability every 3 years in order to continue working in the field. NZAS told this review that the certificate of practice model was now being introduced in South Australia, following issues identified there in children’s hearing services.

Professional representation

There are multiple separate organisations representing professionals in audiology. This review has heard that this has, at times, made it difficult for audiologists to raise concerns at a national level in a consistent and coherent way. It has also made it more complicated for national bodies to engage effectively with a representative sample of the audiology workforce.

Organisations that represent audiology professionals in children’s hearing services include:

• British Academy of Audiology (BAA)
• British Society of Audiology (BSA)
• British Society of Hearing Aid Audiologists (BSHAA)
• Association of Independent Hearing Healthcare Professionals (AIHHP)
• National Community Hearing Association (NCHA)

There are 2 additional organisations which represent doctors working alongside audiologists in children’s hearing services:

• British Association of Audiovestibular Physicians (BAAP)
• British Association of Paediatricians in Audiology (BAPA)

Where concerns have been raised by the individual organisations representing professionals in audiology, and on occasion, by several of them acting together, this has not led to local or national action. For example, in October 2020, a number of these bodies collaborated to produce a Rapid Review into Paediatric Audiology in England (see reference 20) The Rapid Review highlighted many of the issues referenced in this review, but this review has found no evidence that meaningful local or national action was taken in response until the publication of the report into service failures at NHS Lothian in December 2021. 

Effective professional representation in other medical fields is usually achieved by means of a royal college or faculty. This review has heard the National School of Healthcare Science described by NHS England as a deanery for the healthcare sciences and the Academy for Healthcare Science as a royal college for healthcare scientists, but these descriptions do not match those given by the organisations themselves or by audiologists working in the NHS. These structures are therefore not operating in those roles, even if they were originally intended to do so.

Recommendation 3: professional registration of audiologists must be a requirement in the NHS and relationships between national organisations and organisations representing audiologists should be reset and formalised

The new organisation (DHSC and NHS England) should work with the organisations which represent audiologists and with NHS trusts to require all audiologists to be registered on a single professional register, which is operated by an appropriate body on a non-statutory basis.

The numerous organisations representing professionals in audiology should merge to create a single body responsible for engagement with national institutions and developing appropriate guidance, training and curricula for audiologists. This body should play a role in developing and maintaining a single professional register of audiologists.

The new organisation (DHSC and NHS England) should establish clear policy responsibility for healthcare sciences, including audiology, and publish a Charter setting out expectations on both sides for engagement between the relevant organisations representing professionals in audiology and the new organisation (DHSC and NHS England).

Network models of delivery

This review has heard from stakeholder interviews that some audiology services are too small to remain viable and that some continue to operate despite known issues in service quality because there is no alternative available. The review also heard through the call for evidence about the need for services to be as close to home as possible with strong links to other community services.

CfE PR-096:

Services [for] children should be in the community rather than in large hospital sites. They should have close ties with other professionals who work with children in the community - e.g. SLT (speech and language therapist), paediatricians, schools.

Deafness in children is highly correlated with prematurity, deprivation and with associated congenital anomalies. Deaf children can require multiple, regular appointments - for example, to take new moulds of their ears for hearing aids as they grow.

The NHS England PHSIP communications describe the process of redesigning the delivery model for children’s hearing services in order to ensure services are large enough to operate safely (see reference 21). It will be a challenge to design services that are local to families and meet consistently high standards of care. This review believes that ‘networks of care’ are the model most likely to achieve the desired outcomes, in contrast to a ‘hub and spoke’ model. This review has heard that a ‘hub and spoke’ model has drawbacks for a service like audiology where small spokes can easily become isolated from the main hub. Rather than a number of small, satellite services which ‘report in’ to a larger hub, a network model could offer a single service which delivers care across multiple sites. The network service would be overseen by a lead provider. There are a few children’s hearing services in England which already operate in a similar way.

One large teaching hospital already organises service delivery via a “model [which] provides clinical leadership and oversight for complex aspects of practice as well as assurances that clinicians delivering complex testing are working as part of a larger team and not working in isolation. Links with the wider healthcare science community improve engagement with new practice guidance and a “finger on the pulse” of new techniques. This provides a landscape for sharing and dissemination of knowledge and enables enrichment of clinical skills and enables development of clinicians in smaller centres by widening their sphere of practice in a safe and assured way with appropriate oversight.

Further benefits are that complex testing can be delivered at local hospitals and community diagnostic hubs, negating the need for patients to have to travel to larger diagnostic and/or specialist centres and receive care closer to home. This reduces the impact on families needing to travel long distances and reduces foot fall at main specialist hubs.

Issues to consider are defining roles and responsibilities, for example, who holds clinical accountability and responsibility for assurance of the audiology service. Who takes responsibility for and accountability for operational leadership of the service. Dependant on the type of service it is critical that there are comprehensive links with paediatrics, having an audiological vestibular physician (AVP) or paediatrician with a special interest in hearing loss, is required in the management of children with permanent childhood hearing loss.

With clearly defined roles and responsibilities and clear routes for communication in my experience, such a service can work well and benefits the patients and the staff that work within them.”

The benefits for those audiologists who choose to work within a network model would be increased opportunities for multidisciplinary working, improved rotation between clinics, the opportunity to learn from other audiologists, more resilience within the workforce to cover absence for training or sickness and more opportunities for mentorship and career development. This model will also offer more flexibility to members of the audiology workforce, but it will be important to consider individual audiologists’ circumstances. Some ICBs may be too large to accommodate regular travel from one end of a county to the other whereas others may be too small to create a large enough network to reap the potential benefits described here. Where this is not possible, ICBs should work with their providers to identify a model which achieves as many of these benefits as possible in their local area. Through the call for evidence, the review heard that some professionals were keen to work with and learn from other children’s hearing services.

CfE PR-109:

Paediatric teams across England don’t talk to each other enough and support each other enough by sharing good and new practices.

The call for evidence heard from professionals and individuals about the benefits of collaboration between different services, suggesting closer working relationships between audiologists, health professionals, Teachers of the Deaf and educational audiologists.

CfE PR-052:

We need to apply a consistent model where a medical professional with specialist training working closely with Audiologists, screeners, education and other medical professionals. This professional also understands the broader needs of the children to co-ordinate their care - a holistic approach.

Recommendation 4: children’s hearing services should be delivered by a network model, rather than a hub and spoke model

The new organisation (DHSC and NHS England) should work with ICBs to redesign the delivery model for children’s hearing services, creating networks which facilitate robust clinical supervision and peer review. The example of child safeguarding networks should be considered during the design process.

The new organisation (DHSC and NHS England) should work with ICBs to ensure services are of sufficient size that staff members can rotate and observe others in their clinical practice on a regular basis. Any unsafe services should be closed and service provision reallocated.

Leadership roles and escalation routes for healthcare scientists in trusts and ICBs

This review has heard that audiology departments in different trusts have different escalation and governance routes. While some are embedded in ENT or audiovestibular medicine services and report to a medical consultant, others might report to an allied health professional lead or to the medical lead of community services within a hospital trust. Other audiology services are delivered by NHS community trusts with different governance arrangements and oversight. This review understands that a similar situation exists for other healthcare scientists.

This review has heard from multiple audiologists and medical consultants involved in the children’s hearing services care pathway about the importance of positive, respectful working relationships between medical consultants and healthcare scientists. Where this works well, strong multidisciplinary teams work to achieve the best care outcomes for the affected children and staff are clear about their escalation pathways. Where it does not, typically a medical hierarchy exists which inevitably undervalues the key skills and expert knowledge of healthcare scientists and compromises opportunities to speak up or escalate concerns. Unsurprisingly, patient outcomes then suffer.

This review has heard from some stakeholders that children’s hearing services would be best served by having a responsible medical consultant accountable for the safety and quality of each service. However, this review believes that it is the mutual respect and joint working between disciplines which will produce high standards of safety and quality, rather than reinforcing a medical hierarchy. It is also important that healthcare scientists should have strong scientific leadership within NHS trusts in the form of qualified and registered consultant clinical scientists to oversee service delivery within a service network. It should be the ambition of every trust to have a senior healthcare scientist reporting to the executive team and trust board, representing all healthcare science specialties.

This review has interviewed several academics who have conducted research on the ways in which organisations and leaders develop systems and processes to ensure high quality of care. For example, Professor Mary Dixon-Woods has written about the concept of ‘priority thickets’, including in her evidence to the Thirlwall Inquiry, which describes the phenomenon by which important issues simply do not attract sufficient attention from the executive teams of relevant health organisations (in this case, NHS trusts and ICBs) due to the volume of competing priorities. As she writes, “priority thickets risk saturating organisations with external demands to the extent that the clarity of their own goals becomes obscured” (see reference 22). Her work, as well as that of Prof. Michael West and Dr Peter Lachman also emphasises the importance of an organisation demonstrating which issues can and should be voiced, whose responsibility is it to give voice to concerns and a leadership team who understand that their role is to listen.

Although there are relevant points of contact for discussing quality and safety concerns and commissioning contracts within ICBs, this review has heard from stakeholders interviewed that ICBs do not generally have structures in place to scrutinise diagnostic and treatment pathways in hearing services. This is understandable given the breadth of work they oversee. However, this review has also not heard of a trust or ICB having a chief healthcare science lead whose role would be to oversee the delivery of all healthcare science services and be responsible for their quality, manage their risks and escalate emerging issues to the attention of the executive team. It is the opinion of this review that such a role would be of benefit to ICBs in providing effective oversight of these services and ensuring they have appropriate representation in contract management and quality assurance processes.

This review has heard that there is little encouragement, little time and no ring-fenced funding for healthcare scientists to complete leadership or management training and that this differs from the resources and expectations of other healthcare professionals, for example, allied health professionals.

Recommendation 5: NHS trusts and ICBs should implement improved governance arrangements for audiology and apply these to other healthcare sciences

Every NHS trust should appoint a lead healthcare scientist who is responsible for reviewing KPIs across healthcare science professions, including audiology. This individual should be responsible for managing risks and issues in the relevant services and be required to report to the trust board at least twice a year.

Every ICB should have access to healthcare science expertise to support effective service commissioning.

Every NHS regional team should retain a regional healthcare scientist and ensure they have adequate training and support to manage risks and issues across all healthcare sciences, including managing incident response processes when needed.

Workforce data

The data that is collected nationally about the audiology workforce is approximate and does not allow for analysis of an audiologist’s level of qualification, specialty (for example, paediatric audiology versus adult audiology) or setting (for example, hospital audiology or ENT department, community-based service). The lack of robust workforce data currently makes it impossible to plan effectively for the future of the workforce or to assess the adequacy of the pipeline for future service provision. NHS England officials have confirmed that work is taking place to address this issue and ensure that the number of staff working as paediatric, adult or combined audiologists will be available for future analysis by the electronic staff record (ESR). This will not include data regarding level of qualification or care setting. 

Current data collected on the audiology workforce is outlined below:

Data collected by the NHS

According to NHS workforce data, as of April 2025, there were 1,563 FTE healthcare scientists working in audiological sciences in the NHS. This figure is used as an estimate of the number of audiologists working in the NHS, however, there may be some audiologists not captured in this data and some other types of ‘clinical scientists’ may have been captured (see reference 23).

Data collected by the Health and Care Professions Council

HCPC collects data on the number of ‘clinical scientists’ and ‘hearing aid dispensers’ registered with them. These are protected titles and HCPC acts as the statutory regulator for individuals holding either of those titles. The title ‘clinical scientist’ is common across all the healthcare sciences, not just audiology, and there is no distinction made in workforce data collected by HCPC which would distinguish those audiologists who work in adult hearing services versus children’s hearing services. As of 30 July 2025, HCPC data suggests they have 8,276 registered clinical scientists (of which some will be audiologists, and the others will belong to one of over 50 other healthcare sciences) and 4,693 registered hearing aid dispensers (see reference 24). Of these, HCPC data shows that 417 are registered as audiologists (see reference 25).

Survey conducted by the National Deaf Children’s Society

NDCS is the only organisation to publish workforce data relating specifically to staffing levels in children’s hearing services only, rather than audiology services as a whole. NDCS last published the results of their Listen Up survey of children’s hearing services in England in 2024 when services reported a total of 793 FTE audiologists and 96.7 FTE vacancies (see reference 26). In 2019, the same survey reported a total of 897 FTE audiologists and 38 FTE vacancies. In 2022, only 19 services (17%) had trainees in post (see reference 27).

Measuring quality and outcomes

National data collection about audiology services, referrals and treatment outcomes is poor and often absent. The only metric reported at national level is the DM01 waiting list figure, which is collected only in hospital-based services, combines adult and child audiology services and provides no breakdown by specialism or condition (for example tinnitus, vestibular problems) (see reference 28). There is no data collected at all on referral timelines or outcomes, so it is not possible to see, for example, how many children are referred within the timeline set out in NICE guidelines for glue ear or cochlear implants.

There is waiting time data collected for children on waiting lists in community audiology services, but there are data quality issues in keeping with much of community child health services, and so these statistics are described as experimental (see reference 29).

There is also no national reporting of the services and treatments offered per department. This review has heard that depending on the budget available to the service, different types of hearing aid will be offered to children with the same condition in different NHS trusts and that the eligibility for cochlear implants also varies by NHS trust.

Professionals responding to the call for evidence identified the need to use KPIs to monitor and improve services. KPIs could also provide benchmarking and motivation for services to improve, as set out by professionals responding to the call for evidence.

CfE PR-019:

Services lack motivation to improve, and families remain uninformed - risking unequal care for deaf children across England and the failings as have now come to the forefront.

The review concluded that there is currently no reliable data in the children’s hearing care pathway which is a staggering situation in 2025 and means there is little assurance that a good service can be distinguished from a bad one.

National oversight of quality in service delivery

This review has been told that prior to the health system restructures which took place following the Health and Social Care Act 2012, national quality oversight of the entire audiology pathway from newborn hearing screening to treatment was provided by NHSP. No such national oversight has been in place since this time. One stakeholder interviewed by the review said that the “whole point of newborn screening is to detect profound deafness… so there’s no point doing newborn screening if the rest of the pathway doesn’t work”.

The ‘Review of patient safety across the health and care landscape’, published in July 2025, recommends an expanded role for the National Quality Board, and the development of a national quality strategy, including metrics for measuring quality of outcomes. The National Quality Board will also have responsibility for prioritising the many recommendations of inquiries and reviews, which otherwise risk “disempowering local provider boards and clinical teams, where safety responsibility must sit every day.” (See reference 17)

It is the view of this review that the recommendation to “revamp, revitalise and significantly enhance the role of the National Quality Board” will be an important step in providing effective oversight of the quality of children’s hearing services going forwards.

Workforce morale and workplace culture

This review has heard from individual audiologists who have seen or experienced examples of bullying, stress-related illness, stress-related early retirement and poor morale in audiology services. The current crisis in the children’s hearing services care pathway has undoubtedly contributed to poor morale and staff shortages.

The Francis Inquiry into Mid Staffordshire Hospital highlighted the concept of moral injury in healthcare staff. This review heard from several audiologists about the sense of being complicit in poor care and thus being in some way responsible for causing harm to children. This sense of moral injury has led to negative consequences on staff health and wellbeing, as well as staff retention. One described trying to access the resources funded by NHS England for audiology staff wellbeing but found that this was not possible.

This review has heard differing views from audiologists about priorities that reflect a wider issue with workplace culture. At least one audiologist interviewed suggested that improving safety and quality was of less importance to them than getting through their waiting lists, despite being well aware of the risks of harm attached to poor-quality services. Others felt that the focus on waiting list targets was dangerous as it does not permit risk stratification of patients.

CfE PR-140:

The focus of many Trusts is on achievement of DM01 targets, so the effort has had to be concentrated on new patients at the expense of follow up audiology patients. This poses a huge clinical risk as children with permanent childhood hearing loss may be hidden amongst overdue follow up waiting lists.

There is a significant cultural challenge to overcome if the current audiology workforce is to be supported to transform children’s hearing services for the better.

CfE PR-102:

I would not recommend NHS Audiology as a place to work for anyone. I feel completely let down and left with lack of trust from our service users who are rightly frustrated with the constant wait times and lack of staff able to assist them with their hearing needs.

Through the call for evidence the review heard that numerous professionals emphatically reported decreased staff morale and wellbeing because of the review.

Recommendation 6: improved data on individual children’s hearing services should be used by NHS trusts and ICBs to monitor service quality and outcomes

The new organisation (DHSC and NHS England) should act to implement the recommendations of the recent ‘Review of patient safety across the health and care landscape’ immediately and reform the role of the National Quality Board.

The new organisation (DHSC and NHS England) should identify a number of KPIs to measure the performance of children’s hearing services and require ICBs and/or NHS trusts to report against these and publish them annually.

NHS trusts and ICBs should put in place robust data analysis and governance arrangements to review these KPIs and address any issues arising on a regular basis as part of their quality management systems.

The new organisation (DHSC and NHS England) should issue and publish the results of a benchmarking survey into the provision of different treatment options (in particular different types of hearing aids and eligibility criteria for cochlear implants) for deaf children across England and work with NICE to issue updated relevant guidance to help standardise care.

Training of new audiologists

There are different education and training pathways to becoming an audiologist, ranging from Higher Education Diplomas to Masters degree programmes (detail is provided in annex D). As set out earlier in this section, there is no single professional register for audiologists in England and the training pathways offer different registration options. Professionals responding to the call for evidence raised concerns that degree programmes did not include enough training and experience in paediatrics.

Stakeholders interviewed by the review also expressed concern about the number of new graduates from the Scientist Training Programme and Practitioner Training Programme schemes who choose to work in the independent sector, rather than in the NHS and suggested a minimum NHS employment period for new audiologists.

CfE PR-035:

Paediatric Audiology is complex and family centered as compared to Adult Audiology. However currently Audiologists in UK are not trained for paediatric audiology when they graduate. There is also national shortage of paediatric audiologists and they are in demand. This makes it very hard to recruit a Band 5 (new) paediatric audiologist. We often have to recruit Band 6 Adult Audiologist and train them for at least a year which is difficult in most children’s hearing service as you need extra staff to train and see increased waiting lists as a result.

CfE PR-022:

Audiologists need proper paediatric training included within their degree.

Specialist training

There is one specialist (PhD level) training course available for those audiologists who wish to develop additional expertise. Graduates of the Higher Specialist Scientist Training (HSST) Audiological Sciences course are eligible to join the voluntary register of Higher Specialist Scientist Register administered by the Academy of Healthcare Science (AHCS).

Equivalence of audiology qualifications

There is currently no clear comparison of qualifications in audiology between the UK and other countries. Equivalence of audiology qualifications would make it much easier for audiology services in England to hire graduates from abroad. The review has heard from audiologists who have explained that international graduates from countries such as South Africa, New Zealand and Australia are better prepared to work unsupervised in children’s hearing services than their UK counterparts. For example, this review has heard that in New Zealand audiologists working with children are expected to obtain a paediatric certificate to ensure clinical competency, which includes requirements for supervised practice in paediatric audiology. Despite this, the review heard that these international graduates often struggle to know whether they should join the statutory register for Clinical Scientists or the voluntary register for Clinical Physiologists.

Continuous professional development

In any highly skilled career, it is essential to undertake CPD and training to ensure an individual remains up to date on the latest developments and has a chance to refresh and build on their knowledge base. In most careers, CPD is directly linked to professional registration. In medicine, doctors are required to evidence their ongoing CPD as part of their annual appraisal, which in turn informs their 5-yearly revalidation with the General Medical Council. The Medical Royal Colleges provide advice about appropriate CPD and host courses and content to support their members with this activity.

Although audiologists registered with the HCPC are required to meet published standards and complete CPD, there is no equivalent process for those registered with AHCS. This review has also heard that many audiologists do not have the means of accessing CPD training through their NHS trusts due to a lack of ringfenced funding. During the time of the review, the review heard from a large children’s audiology service in a major teaching hospital that a decision had been made to freeze the CPD budget for all healthcare scientists as part of a cost savings drive (this was not the case for allied health professionals, nurses and doctors in that trust).

CfE ORG-014:

There is no identified national CPD funding for Healthcare Scientists, necessitating reliance on limited charitable funding or personal funding by colleagues.

Advanced practice is an additional qualification available to registered healthcare professionals, including issuing prescriptions and ordering radiological investigations (see reference 30). This review understands that clinical scientists in audiology are not currently eligible for advanced practice. This review has been told that this creates gaps in the referral pathway for deaf children. For example, this review heard from one senior audiologist who described the frustration of not being able to order MRI brain scans for children who had been investigated in their healthcare science-led audiology service. To prevent a further delay for this audiologist’s patients, they had to ask an ENT colleague to order the MRI scans.

Professionals and organisations responding to the call for evidence were clear about needing time, support and funding to undertake training. The need to upskill staff was mentioned frequently, specifically caring for children with complex needs, the use of new technologies and working with multidisciplinary teams.

CfE PR-156:

Staff training opportunities are limited within audiology and more so with paediatric work.

CfE PR-162:

I received training through the STP programme, however I have had no further chances for further training via courses or workshops.

Recommendation 7: undergraduate and postgraduate training pathways for audiologists working in children’s hearing services need wholescale review and redesign, as does the approach to continuous professional development (CPD)

The organisation responsible for maintaining the single professional register for audiologists should require all its members to complete regular CPD, funded by their NHS trust.

The new organisation (DHSC and NHS England) should commission the National School of Healthcare Science to redesign the undergraduate and postgraduate training pathways and funding arrangements for audiology to ensure sufficient training in paediatric speciality for paediatric audiologists, develop standards for the curriculum and independent assessment of diagnostic testing ability.

The new organisation (DHSC and NHS England) should commission work to develop appropriate CPD training modules for audiologists, including on quality assurance and safety standards in children’s hearing services. This should include the involvement the National School of Healthcare Science and the organisations representing professionals in audiology.

The new organisation (DHSC and NHS England) should consider possible ways in which audiologists could demonstrate competence to train in Advanced Practice.

The new organisation (DHSC and NHS England) should consider asking the proposed College of Executive and Clinical Leadership (see reference 4) to design a systematic approach to leadership and management training in NHS service delivery, including the professional development of healthcare scientists.

Investment in research and the potential of new technologies

The National Institute for Health and Care Research (NIHR) is one of the main funding bodies for research into health and social care. This review has heard that NIHR receive very few applications for research in audiology.

This review has heard evidence to suggest that audiology is a field rich with possibility for the application of new technologies, machine learning and AI, especially with regard to supporting the interpretation of complex diagnostic tests. However, this review heard of numerous obstacles and frustrations, such as equipment and estate that was not to a high enough standard to enable the research individual services were looking to undertake, and a lack of clinical academics in audiology to write grants and conduct the studies.

CfE PR-004:

We are struggling to conduct gold standard research (ie clinical trials) with the outdated and broken clinic equipment available.

The recent focus on improving children’s hearing services has pushed research and innovation further to the bottom of the priority list, for understandable but regrettable reasons.

Recommendation 8: national research funding bodies should invest in research activity and capacity in audiology

National research funding bodies should encourage research to realise the potential offered by machine learning, data analysis and other technologies in children’s hearing services.

6. Avoiding future service failures in similar services

Throughout the review, there were many stakeholder conversations that triggered wider thinking about healthcare delivery within the NHS. Children’s hearing services, and other similar services which attract little attention, investment and scrutiny but can pose serious risks to patients when they go wrong, should be considered as the ‘canary in the mine’ of the NHS. A quality oversight system that picks up issues in these areas will work for all areas.

There were moments in interviews when there were clear analogies with other care pathways thus giving the review opportunities to make conclusions that may be applicable to services and professional groups beyond the scope of children’s hearing services. It is important that the review share those findings and while it would have been ideal to go into more detail, there are some key themes that can be derived from the review work:

• children’s services rarely receive the same attention or scrutiny as adult healthcare services
• audiology is a healthcare science and many healthcare sciences have received little attention or scrutiny in recent years
• hearing services are often delivered in community settings and community services rarely received the same attention as hospital-based services
• children’s hearing services as a care pathway spans different specialities from maternity to audiology to ENT, speech and language therapy and many more - and the governance and oversight of the services are therefore fractured and when this happens, it puts services at greater risk of service failures

The review also heard concerns about other areas within audiology, for example, primary care audiology, audiology care in the independent sector and in adult audiology services.

The review then considered what specific factors leading to the failures in children’s hearing services may be relevant to other similar services:

Professional representation and training

The review found a number of specific factors in relation to professional representation and training that may be relevant to other similar services:

• professional governance and effective professional regulation are lacking
• professional training for new practitioners is considered by practising staff to be of low quality
• workforce planning is absent and overall staff retention is a problem
• workforce morale is low
• the profession does not have a clear voice or route to raise issues, for example, due to multiple organisations representing members of the workforce
• history of concerns raised by professionals which have been largely ignored

Conditions in the workplace

The review found a number of specific factors in relation to conditions in the workplace that may be relevant to other similar services:

• defined escalation routes for service issues at provider level are not in place
• oversight is not consistently provided at ICB, regional and national level for the quality of services delivered
• quality assurance and clinical audit processes are not standard practice for all services
• sufficient outcomes data is not collected and published across the treatment pathway to enable service delivery to be interrogated and improved by local services
• some services are unsafe or too small to offer adequate peer review and clinical supervision
• external inspection process for services is not in place and no regulator is giving the service their attention
• local commissioning is of variable quality and contracts are rarely reviewed or enforced by monitoring of KPIs
• research and innovation are largely absent

This review understands that NHS England is in the process of developing a ‘fragile services framework’. The current draft aims to help ICBs and NHS trusts to identify services which are “at risk of failure and unable to continue to function effectively within the next 6 to 12 months”. Indicative identification criteria cover workforce, quality, operational, commissioning and finance factors. This review welcomes the review and would like to see this work expand to encourage the identification of risk factors in services before they reach the point of near failure.

Recommendation 10: the next NHS Workforce Plan should include workforce modelling and recommendations specific to the healthcare science workforce, including audiology, and action should be taken to improve workforce culture and morale in children’s hearing services

The new organisation (DHSC and NHS England) should change the way workforce data is collected and coded to enable posts in all healthcare sciences, including audiology, to be identified by seniority, speciality and setting and enable effective workforce planning.

The new organisation (DHSC and NHS England) should adapt the NHS Staff Survey workforce codes so that responses from healthcare scientists can be identified by speciality (for example, audiology) for separate analysis, ensuring this would not compromise the anonymity of individual staff members in small services.

The successor or successors to the National Guardian’s Office should complete and publish a review into workplace culture in children’s hearing services and provide recommendations for measures to support the workforce. This should include consideration of whistleblowing, bullying, stress-related illness and stress-related early retirement in children’s hearing services.

Methodology

Overview

The review has a very specific focus on considering the response of NHS England to the service failures in children’s hearing services set out in the terms of reference.

While any failure in care is complicated and multifactorial, this review is limited to 3 specific areas:

• the response of DHSC and NHS England to service failures in children’s hearing services
• lessons learnt from the governance arrangements between NHS England and DHSC
• how learning from NHS England’s response may be used to improve responses to failures in similar services in the future

Approach to the review

Everyone who spoke to the independent review team has done so confidentially. Any attributed quotes which appear in this report have been approved by the individual. The independent review has not named any individuals in this report. Everyone who spoke to the independent review team has been encouraged to be open and honest.

The scope of this review did not include reviewing individual patient cases but where individuals have contacted the independent review team with queries about a child’s ongoing treatment, the independent review team have liaised with the programme team at NHS England to provide a response.

The independent review team assessed any possible conflicts of interest on an ongoing basis throughout the review and discussed these with the independent chair.

Despite the tight timeline available for this report, the independent review team have been committed to preparing a high-quality product, even if some conclusions must necessarily remain high level and require further work - the timeline for the review was accordingly extended, with the permission of the Secretary of State, to ensure that this would be the case.

Governance of the review

The independent chair was appointed directly by the Secretary of State for Health and Social Care. The senior civil servant sponsor for the review was Mark Joannides, Deputy Director of Community Health. Sir Richard Douglas, non-executive director at DHSC, acted as an informal advisor to the independent review.

A senior steering group was set up to support the delivery of the independent review but did not provide any formal comment on its findings or recommendations. The members of the senior steering group were invited to offer comment on selected findings or recommendations prior to publication but did not receive a copy of the draft report.

Methodology

Phase 1 - evidence gathering

Define methodology

Dr Camilla Kingdon worked with the independent review team to develop a methodology based around the following 4 sources of evidence:

• interviews with relevant stakeholders
• data requests from relevant organisations, including NHS England and DHSC
• focus groups with parents and family members of affected patients
• open call for evidence

Conduct interviews with relevant stakeholders

Stakeholders were identified for interview in the following categories:

• DHSC officials
• NHS England officials
• NHS commissioners
• ICB leaders
• members of the audiology workforce, or other services supporting deaf children and their families
• members of organisations with involvement in the registration, training or governance of the audiology workforce, or similar services
• organisations that inspect and accredit services
• academic experts in screening and audiology
• academic experts in medical leadership and culture, safety and quality
• representatives of professional audiology bodies in other countries
• organisations that represent patients and their families
• organisations with expertise in NHS system design

Issue data request to NHS England, DHSC and the Care Quality Commission

The independent review team requested relevant documents from NHS England, DHSC and the Care Quality Commission to inform the work of the review.

Launch a call for evidence

A call for evidence was launched on GOV.UK, inviting those affected by the services issues in children’s hearing services to share their reflections with the independent review team. It was open from 9 May until 2 June 2025.

The review team, supported by team of analysts from DHSC, used thematic analysis to identify themes and sentiment from the free text responses. Quantitative analysis was undertaken for the multiple-choice questions that were answered by individuals sharing their personal views.

Plan and deliver focus groups

The independent review team worked with the NDCS and analysts from DHSC to plan and deliver 2 focus groups with parents and family members of children who have used audiology services. Analysts used thematic analysis to identify themes.

Phase 2 - development of findings

Analyse themes from interviews conducted

The independent review team used the notes from each interview conducted to identify themes, reflections and examples relevant to each element of the terms of reference. These have been used to develop the findings and recommendations of this report.

Analyse information provided through data requests

The independent review team reviewed the documents provided by NHS England, DHSC and the Care Quality Commission to identify the timeline of events in scope of the review and to identify themes, insights and examples relevant to each element of the terms of reference. These have been used to inform the findings and recommendations of this report.

Develop findings and draft report

By combining the analysis of all sources of evidence for the review, the independent review team summarised the information collected with reference to the elements of the terms of reference of the review. The independent chair then worked with the independent review team to identify the findings and recommendations which appear in this report.

Seek input from critical friends and stakeholders of the review

Once the independent review team had produced draft findings and recommendations, these were tested with relevant stakeholders, including:

• DHSC officials
• NHS England officials
• members of the audiology profession
• members of organisations with involvement in the registration, training or governance of the audiology workforce, or similar services
• members of organisations that represent patients and their families, and organisations with expertise in NHS system design

The independent chair made the final decision on which findings and recommendations appear in this review.

Deliver final findings and recommendations

The final report was delivered by the independent chair to DHSC ministers.

Caveats

The review represents the result of extensive research into the audiology profession, the relationship between NHS England and DHSC and consideration of which risk factors may apply to other similar services. It is not a comprehensive study of these issues.

The independent review team has been reliant on the information provided to them and, sometimes, to colleagues in other organisations for ensuring its accuracy. Throughout the report, the team has endeavoured to indicate the source and level of certainty surrounding different pieces of information. Despite the efforts of the methodology set out below, it is impossible for the review team to know what they do not know.

The review team recognises that many views and perspectives will not have been included in this report. However, this report represents an honest attempt to engage with as many stakeholders as possible and to keep the patient’s perspective central to the work of the review team.

The review team used thematic analysis in considering the responses to the call for evidence and the focus groups. Thematic analysis is an inherently subjective process and dependent on individual researcher interpretations. However, the review team took steps to manage this through adopting a transparent and reflexive approach, sharing and discussing interpretations between social researchers supporting the review and the review team to identify potential bias.

Glossary

Academy for Healthcare Science (AHCS)

The single overarching body for the UK healthcare science workforce. The Academy For Healthcare Science works alongside the healthcare science professional bodies and professionals from the life science industry and clinical research practitioners.

Aetiology

The study of causes of a disease or condition in this case, the cause of a child’s hearing loss.

Association of Independent Hearing Healthcare Professionals (AIHHP)

The Association of Independent Hearing Healthcare Professionals is a professional membership organisation of professionals providing hearing assessments, hearing aid provision, hearing protection and other specialised services relating to hearing.

Attention deficit hyperactivity disorder (ADHD)

ADHD is defined by WHO as being characterised by a persistent pattern of inattention and/or hyperactivity-impulsivity that has a direct negative impact on academic, occupational, or social functioning, the level of which is outside the limits of normal variation expected for age and level of intellectual functioning.

Audiovestibular physician (AVP) or audiovestibular medicine

A medical doctor specialising in the diagnosis and management of hearing and balance disorders in adults and children. Audiovestibular medicine is the medical specialty.

Auditory brainstem response (ABR) test

A test which measures how the hearing nerves and brain respond to sounds.

Auditory processing disorder (APD)

Children with APD usually have typical levels of hearing but find it difficult to listen or make sense of sounds, particularly in environments with lots of background noise.

Autism spectrum disorder (ASD)

The medical name for autism. ASD is a neurological and developmental disorder that affects how people interact with others, communicate, learn and behave.

British Academy of Audiology (BAA)

The British Academy of Audiology is a membership organisation for professionals in hearing and balance, working to promote excellence in clinical knowledge and practice.

British Association of Audiovestibular Physicians (BAAP)

The British Association of Audiovestibular Physicians is a membership organisation for the specialty of audiovestibular medicine.

British Association of Paediatricians in Audiology (BAPA)

The British Association of Paediatricians in Audiology is a membership organisation representing paediatricians with an interest in children’s hearing.

British Sign Language (BSL)

BLS is the most common form of sign language used in the UK. 

British Society of Audiology (BSA)

The British Society of Audiology is a membership organisation for people with an interest in the latest science and its application in the field of hearing and balance. They produce professional guidance and good practice.

British Society of Hearing Aid Audiologists (BSHAA)

The British Society of Hearing Aid Audiologists is a professional body representing the independent hearing aid profession working in independent and multi-site clinics in the UK, Ireland and worldwide.

Care Quality Commission (CQC)

The Care Quality Commission is the independent regulator for health and adult social care in England.

Chief scientific officer (CSO)

The chief scientific officer in England is the head of profession for healthcare scientists working in the NHS and associated bodies and provides scientific advice across the health and care system.

College of Executive and Clinical Leadership

The 10 Year Health Plan for England: fit for the future established this body, which is intended to define and drive excellence in operational and clinical leadership.

Congenital deafness

Hearing loss that is present at birth.

Continuing professional development (CPD)

Ongoing learning and training undertaken by professionals to ensure the development and maintenance of the necessary knowledge, skills and attributes to practise effectively.

Cytomegalovirus (CMV) or congenital cytomegalovirus (congenital CMV)

A common virus. For most healthy children CMV does not cause any noticeable symptoms or long-term effects. If CMV is contracted while pregnant it can have long term impacts on the unborn baby. Congenital CMV is where a CMV infection is present from birth.

Department of Health and Social Care (DHSC)

DHSC is the UK government department responsible for health and adult social care policy.

Diagnostic waiting times and activity (DM01)

NHS England data on waiting times and activity for diagnostic services, collected and published monthly.

Ear, nose and throat specialty (ENT)

Surgical specialty involving diagnosis, medical and surgical management of diseases affecting these areas. Also referred to as otorhinolaryngology (ORL).

Electronic staff record (ESR)

Database of NHS workforce used for HR and payroll, as well as workforce planning.

Emergency preparedness, resilience and response (EPRR)

NHS England’s Emergency preparedness, resilience and response is the process of planning for and responding to various incidents and emergencies that could affect health or patient care.

Executive quality group

An NHS England executive level group that seeks to provide oversight and scrutiny of care quality across regions and receives regional quality insight from ICBs and providers. The group reports to NHS England’s Quality Committee - a board-level committee.

Glue ear

A common condition that occurs when fluid builds up in a child’s middle ear, which is the space behind the eardrum. The medical terms for glue ear are otitis media with effusion (OME) or secretory otitis media. Glue ear can affect one or both ears.

Health and Care Professions Council (HCPC)

The Health and Care Professions Council is the regulator for 15 health and care professions in the UK. HCPC’s role includes setting standards for professionals’ education, training and practice, approving programmes which professionals must complete to register, holding a register of professionals, and taking action if professionals on the register do not meet the relevant standards.

Higher Specialist Scientist Training (HSST) Programme

A 5-year training programme to gain a Doctoral level academic award which enables healthcare scientists train to become eligible to apply for available consultant scientist posts.

Improving Quality in Physiological Science (IQIPS)

A professionally led accreditation scheme with the aim of improving services, care and safety for patients undergoing physiological tests, examinations and procedures. It has been developed by the UK Accreditation Service.

Integrated care board (ICB)

Legal entities responsible for planning and commissioning health services for their local populations.

Key performance indicator (KPI)

Metrics which are used to measure and monitor performance.

Magnetic resonance imaging (MRI) scan

In audiology, MRI scans are used to investigate the structures of the inner ear and auditory pathways.

Multidisciplinary team (MDT)

Health and care professionals from different disciplines working together as a team to support patients.

National Community Hearing Association (NCHA)

The National Community Hearing Association is the professional representative body for primary care hearing care providers in the UK.

National Deaf Children’s Society (NDCS)

The National Deaf Children’s Society is the charity for deaf children with any level of hearing loss, providing support and advice for deaf children and their families.

National Institute for Health and Care Excellence (NICE)

NICE is an independent public body in England that provides evidence-based guidelines, quality standards, and information services for healthcare professionals, commissioners and managers.

National School of Healthcare Science

The National School of Healthcare Science is the part of NHS England with national responsibility for the management of the educational framework for training and development of healthcare scientists.

Newborn Hearing Screening Programme (NHSP)

A national programme that screens newborn babies and aims to identify permanent moderate, severe and profound deafness and hearing impairment. See more on Screening tests for you and your baby.

NHS board (Scotland)

NHS Scotland’s healthboards are legal entities responsible for the protection and the improvement of their population’s health and for the delivery of frontline healthcare services in Scotland.

NHS England

The executive non-departmental public body responsible for the overall management, planning, and delivery of healthcare services within the NHS in England. On 13 March 2025, the Secretary of State for Health and Social Care announced that NHS England would be brought into DHSC over the course of the next 2 years.

NHS England’s Paediatric Hearing Services Improvement Programme (PHSIP)

An England-wide programme set up within NHS England to conduct a nationally coordinated review of all paediatric audiology services to identify and recall babies and children at risk, and to support services in delivering quality improvement interventions.

NHS trust

A legal entity within the NHS in England responsible for providing healthcare services. There are several types of NHS trusts that provide specific services for example, acute, community, mental health, specialist and ambulance trusts.

Permanent childhood hearing impairment (PHCI)

Hearing loss that is present at birth (congenital) or develops during childhood and is not expected to improve without treatment.

Physiological sciences 

Healthcare scientists working in physiological sciences investigate the functioning of organ and/or body systems to diagnose abnormalities and find ways to restore function and/or reduce disabling consequences to the patient.

Practitioner training programme (PTP)

A 3-year BSc degree that combines academic learning with workplace-based training. Graduates are eligible to join the voluntary register for clinical physiologists, administered by the Academy of Healthcare Sciences (AHCS).

Public Health England (PHE)

Operating between 2013 and 2021, PHE was an executive agency of DHSC focused on protecting and improving the nation’s health and wellbeing and reducing health inequalities. 

Quality and Performance Committee

An NHS England executive level group that seeks to scrutinise quality, performance, workforce and finance issues. The group reports to NHS England’s Quality Committee which is a board-level committee.

Scientist Training Programme (STP)

A 3-year Masters degree programme overseen by the National School of Healthcare Science. Graduates are eligible to join the statutory register for clinical scientists, administered by HCPC.

Speech and language therapist (SLT and SALT)

Healthcare professionals who assess, diagnose and treat communication and swallowing difficulties in people of all ages.

Subject matter expert (SME)

In this report the term SME is used to refer to audiology professionals who have volunteered to support children’s hearing services in review, recall and reassessment as part of the PHSIP programme.

Teacher of the Deaf or Qualified Teacher of the Deaf (ToD or QToD)

A qualified teacher with the skills and knowledge required to provide quality teaching to mainstream learners and with the additional mandatory qualification and expertise in teaching deaf learners. See more about the role of the Qualified Teacher of Deaf Children and Young People - BATOD.

UK Accreditation Service (UKAS)

UKAS is the national accreditation body for the United Kingdom, appointed by government to assess and accredit organisations that provide services including certification, testing, inspection, calibration, validation and verification. UKAS developed the IQIPS accreditation for children’s hearing services.

Annex A: individuals who contributed their time and expertise to the review

This is a list of the individuals who contributed their time and expertise to the review. The review undertook 101 interviews - the list below is those who were happy to be named.

Professor Aidan Fowler, Interim Chief Inspector of Healthcare, Care Quality Commission

Dr Adrian Mairs, Consultant in Public Health, Public Health Agency Northern Ireland

Alison Morton, Chief Executive Officer, Institute of Health Visiting

Alison Worsley, Platform Lead - Develop and Influence, National Deaf Children’s Society

Alyson Bryant, Accreditation Specialist, United Kingdom Accreditation Service

Amy McLauchlan, Membership Committee, New Zealand Audiological Society, and Amplifon NZ Training Manager, Amplifon

Professor Andrew Rowland OBE, Honorary Professor (Children’s Rights, Law and Advocacy), University of Salford, and Officer for Child Protection, Royal College of Paediatrics and Child Health

Anita Grover, Chief Executive Officer, Auditory Verbal UK

Anna Sanders, Director, COVID-19 Inquiry Response Unit, DHSC

Anne Mackie, Deputy Director, Screening Operations and Quality Assurance, DHSC

Catherine Frances CB, Director General, Global and Public Health, DHSC

Charlie Cassell, Director, Operations and Strategy, National Guardian’s Office

Claire Benton, President, British Academy of Audiology

Dr Claire Fuller, Co-National Medical Director (Primary Care), NHS England

Crystal Rolfe, Director of Strategy, Royal National Institute for Deaf People

Policy officials, College of Audiologists and Speech-Language Pathologists of Ontario

Dr David Elliman, Clinical Adviser, UK National Screening Committee, and Consultant Community Paediatrician, Newborn Screening Programme, Great Ormond Street Hospital for Children NHS Foundation Trust

Dawn Bramham, Consultant Clinical Scientist and Head of Audiology, East and North Hertfordshire NHS Trust

Professor Dean Fathers, Professorial Fellow, Institute of Mental Health, Honorary Professor of Healthcare Leadership, the University of Nottingham, Visiting Professor of Resilience and Healthcare Leadership, Lincoln International Business School, College of Arts, Social Sciences and Humanities, the University of Lincoln, and Visiting Professor, Liverpool Hope University

Dr Doug Simkiss, Chair, British Association for Community Child Health, and Honorary Associate Clinical Professor in Child Health Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick

Duncan Burton, Chief Nursing Officer for England, NHS England

Edward Hughes, Chief Executive Officer, Council of Deans of Health

Dr Edward Morris CBE, Regional Medical Director, NHS England - East of England Region

Edward Moses, Director, Policy and Engagement - 10 Year Health Plan, DHSC

Edward Scully, Director, Primary and Community Health Care, DHSC

Ellen Schroder, Trust Chair, Great Ormond Street Hospital for Children NHS Foundation Trust

Graham Sutton, former Consultant Audiological Scientist, Newborn Hearing Screening Programme Centre, Public Health England

Gwen Carr, former National Programmes Lead, Antenatal and Newborn Screening, Public Health England

Gavin Larner, Director, NHS Workforce, DHSC

Harriet Oppenheimer, Chief Executive Officer, Royal National Institute for Deaf People

Professor Henrietta Hughes OBE, Patient Safety Commissioner, Office of the Patient Safety Commissioner

Baroness Hilary Cass OBE, Member of the House of Lords, UK Parliament

Helen Beazer, Deputy Director, National Immunisation Policy, DHSC

Professor Jacqueline Taylor MBE, Chair, National Audiology Review Group - Scotland, and Associate Medical Director, NHS Scotland Academy

Dr Jagjit Sethi, Regional Chief Scientific Officer - NHS England East of England, Regional Clinical Advisor for Physiological Sciences - NHS England Southeast

Sir James Mackey, Chief Executive Officer, NHS England

Janet Monkman, Chief Executive Officer, the Academy for Healthcare Science

Jason Yiannikkou, Director, System Oversight and Integration, DHSC

Jason Smalley, Consultant Clinical Scientist and Head of Audiology, Nottingham University Hospitals NHS Trust

Jennifer Benjamin, Deputy Director - Systems, Oversight and Integration, DHSC

Dr Jessica Sokolov, Regional Medical Director - Midlands, NHS England

John Day, Clinical Director of Audiology, Betsi Cadwaladr University Health Board

John Stewart CBE, National Director, Specialised Commissioning, NHS England

John Waters, Head of Paediatric Audiology, the Princess Alexandra Hospital NHS Trust, Harlow

Jonathan Marron CB, former Director General, Primary Care and Prevention, DHSC

Kathryn Knight, Clinical Lead for Adult and Paediatric Audiology, Barts Health NHS Trust

Katrina Light, Professional Advisor - Policy and Practice, New Zealand Audiological Society

Dr Kaukab Rajput, Consultant Paediatric Audiovestibular Physician, Great Ormond Street Hospital for Children NHS Foundation Trust

Keiran Joseph, Consultant Clinical Scientist and Clinical Lead in Paediatric Audiology, Guy’s and St Thomas’ NHS Foundation Trust

Kerri Farah, Head of Paediatric Audiology and Newborn Hearing Screening, Guy’s and St Thomas’ NHS Foundation Trust

Professor Kevin Munro, Ewing Professor of Audiology, Senior Investigator and Director at the National Institute of Health and Care Research (NIHR), Research for Patient Benefits (RfPB) Programme, Manchester Centre for Audiology and Deafness and NIHR Manchester Biomedical Research Centre, University of Manchester

Laura Booth, Operations Accreditation Specialist (Healthcare), United Kingdom Accreditation Service

Liz Ketch, Director, Early Years, Children and Families, DHSC

Professor Lucy Chappell Chief Scientific Adviser, DHSC, and Chief Executive Officer, National Institute for Health and Care Research (NIHR)

Professor Mary Dixon-Woods, Director, the Healthcare Improvement Studies Institute, and the Health Foundation Professor of Healthcare Improvement Studies, University of Cambridge

Matthew Day, Director, Clinical Commissioning, NHS England

Matthew Style, Director General, Secondary Care and Integration, DHSC

Professor Meghana Pandit, Co-National Medical Director (Secondary Care), NHS England

Michael Hobday, former Chief Policy Officer, National Deaf Children’s Society

Professor Michael West CBE, Professor of Organizational Psychology, Lancaster University Management School, Senior Visiting Fellow, The King’s Fund and Emeritus Professor, Aston University

Dr Michelle Foster, Regional Healthcare Science Lead Northeast and Yorkshire, NHS England, and Northeast and Yorkshire, Head of Audiology, Leeds Teaching Hospitals NHS Trust

Nicola Symes, Head of Trauma Programme of Care Specialised Commissioning, NHS England

Paul Macnaught, Director - Ministers, Accountability and Strategy, DHSC

Peter Bill MBE, Regional Healthcare Science Lead Midlands, NHS England

Dr Rakesh Tailor, Consultant Neurodevelopmental Paediatrician, Upton Hospital, Berkshire Healthcare NHS Foundation Trust

Dr Rhydian Phillips, Director, Diagnostics and Transport, NHS England

Richard Barker CBE, Senior Responsible Owner for the Transformation Programme, NHS England

Ruth Thomsen MBE, Regional Healthcare Science Lead London, NHS England

Ruth Vickerstaff, Clinical Scientist and Principal Audiologist, Guy’s and St Thomas’ NHS Foundation Trust

Professor Steve Turner, President, Royal College of Paediatrics and Child Health

Dr Sarah Hogan, Clinical Advisor, Auditory Verbal UK

Professor Dame Sue Hill, Chief Scientific Officer, NHS England

Professor Simon Kenny OBE, National Clinical Director, Children and Young People, NHS England

Professor Sir Steve Powis, former National Medical Director, NHS England

Rebecca Reeves-Jones, Lead Clinical Paediatric Audiologist, Children’s Community Audiology, Midlands Partnership University NHS Foundation Trust

Richard Meddings CBE, former Chair, NHS England

Samara Dar, Senior Paediatric Audiologist, Midlands Partnership University NHS Foundation Trust

Samantha Lear, Immediate Past President, British Academy of Audiology and Lead Clinical Scientist (Audiology), Sheffield Children’s NHS Foundation Trust

Sarah Norton, Deputy Director, Charging, Commissioning and Markets, DHSC

Sarah Woolnough, Chief Executive, King’s Fund

Seher Barrell, Chief of Staff to the National Medical Director and Head of Professional Leadership Medical Directorate, NHS England

Dr Shailaja Kottapalli, Executive Committee Member, British Association of Paediatricians in Audiology and Consultant Audiovestibular Physician, Mid-Cheshire Hospitals Foundation Trust

Simon Want, Head of Policy and Influencing (England), National Deaf Children’s Society

Dr Siobhán Brennan, Chair, British Society of Audiology

Susan Daniels OBE, former Chief Executive Officer, National Deaf Children’s Society

Tim Mitchell, President, Royal College of Surgeons of England

Victoria Bishop-Rowe, Head of Communications and Engagement, Auditory Verbal UK

William Vineall, Director - NHS Quality, Safety and Investigations, DHSC

Dr Yvette Oade CBE, former Regional Medical Director - North East and Yorkshire, NHS England

Annex B: overview of the care pathway for children’s hearing services 

Newborn hearing screening

This should be offered shortly after birth and is ideally done within the first 3 weeks after birth.

Referral to children’s hearing services

If results from the newborn hearing screening do not show a clear response, the baby will be referred into audiology services.

Diagnostic testing and identification of cause of deafness

Once referred, audiologists will confirm diagnosis for example, using ABR testing. If deafness is present, further tests will be undertaken to understand the cause of deafness, for example, testing for cytomegalovirus (CMV). Depending on how the audiology service is set up, this may require referral into a different service, which could be ENT, community paediatrics or audiovestibular medicine. 

Treatment

If hearing aids are required, the audiologist will fit appropriate hearing aids and set up regular follow ups. If appropriate, it is possible to be referred for an implant service where assessment by a multi-disciplinary team will consider suitability for implant.   

Further referrals

Alongside diagnostics and treatment, audiologists may make referrals into other support services, for example, for speech and language therapy and support from a Teacher of the Deaf.  

Other referral routes

Children can be referred to children’s hearing services through other routes, for example, if their parent or carer is concerned about their hearing, their GP might refer them for a hearing test. Health visitors screen children under the age of 5 years for a range of developmental issues, including deafness, and so may refer to hearing services. Some schools run hearing screening at school entry and some children may be referred to audiology services at that stage. Children who develop ‘glue ear’ or otitis media are likely to be seen by a GP before being referred to audiology services or ENT.  

Annex C: call for evidence - multiple-choice responses from individuals

The call for evidence asked individuals to rate how satisfied they were with aspects of the care their child had received. The results are set out below.

Figure 1: percentage of responses to the question ‘How satisfied were you with your overall experience of children’s audiology services?’

Response	Percentage of responses
Very satisfied	24
Satisfied	24
Neutral	16
Dissatisfied	15
Very dissatisfied	22

Figure 2: percentage of responses to the question ‘How satisfied were you with how quickly you were referred to additional sources of support?’

Response	Percentage of responses
Very satisfied	22
Satisfied	26
Neutral	14
Dissatisfied	13
Very dissatisfied	25

Figure 3: percentage of responses to the question ‘How satisfied were you with any additional support offered from other services?’

Response	Percentage of responses
Very satisfied	26
Satisfied	27
Neutral	16
Dissatisfied	14
Very dissatisfied	18

Figure 4: percentage of responses to the question ‘How satisfied were you with how any concerns you had were addressed during appointments with children’s audiology services?’

Response	Percentage of responses
Very satisfied	26
Satisfied	31
Neutral	16
Dissatisfied	14
Very dissatisfied	13

Figure 5: percentage of responses to the question ‘How satisfied were you with how your views and concerns were considered and taken into account during appointments with children’s audiology services?’

Response	Percentage of responses
Very satisfied	27
Satisfied	31
Neutral	12
Dissatisfied	14
Very dissatisfied	16

Figure 6: percentage of responses to the question ‘How satisfied were you with the explanations of results and treatments provided during your appointments?’

Response	Percentage of responses
Very satisfied	27
Satisfied	33
Neutral	13
Dissatisfied	11
Very dissatisfied	16

Figure 7: percentage of responses to the question ‘How satisfied were you with the support offered throughout your contact with children’s audiology services?’

Response	Percentage of responses
Very satisfied	25
Satisfied	25
Neutral	19
Dissatisfied	12
Very dissatisfied	19

Figure 8: percentage of responses to the question ‘How satisfied were you with the treatment provided for any hearing loss or deafness in children’s audiology services or ENT services?’

Response	Percentage of responses
Very satisfied	25
Satisfied	27
Neutral	14
Dissatisfied	13
Very dissatisfied	21

Figure 9: percentage of responses to the question ‘How satisfied were you with how quickly you received follow-up treatment in children’s audiology services or ear, nose and throat (ENT) services?’

Response	Percentage of responses
Very satisfied	23
Satisfied	23
Neutral	14
Dissatisfied	12
Very dissatisfied	27

Figure 10: percentage of responses to the question ‘How satisfied were you with how quickly you received a diagnosis?’

Response	Percentage of responses
Very satisfied	33
Satisfied	26
Neutral	9
Dissatisfied	11
Very dissatisfied	20

Figure 11: percentage of responses to the question ‘How satisfied were you with how quickly you received your first appointment in children’s audiology following either the newborn hearing screening test or initial hearing test?’

Response	Percentage of responses
Very satisfied	35
Satisfied	24
Neutral	9
Dissatisfied	13
Very dissatisfied	19

Figure 12: percentage of responses to the question ‘How satisfied were you with the experience of the initial hearing test?’

Response	Percentage of responses
Very satisfied	28
Satisfied	24
Neutral	18
Dissatisfied	12
Very dissatisfied	19

Figure 13: percentage of responses to the question ‘How satisfied were you with the experience of the newborn hearing screening test?’

Response	Percentage of responses
Very satisfied	36
Satisfied	28
Neutral	16
Dissatisfied	4
Very dissatisfied	16

Annex D: training new audiologists

In order to train as an audiologist, there are a number of routes available:

Scientist Training Programme (STP) (Level 7)

This 3-year Masters degree programme is overseen by the National School of Healthcare Science. Graduates are eligible to join the statutory register for clinical scientists, administered by the Health and Care Professions Council (HCPC). Successful applicants receive tuition funding, a Band 6 salary and a training grant for the full 3 years of the course.

This review has heard that the course itself was redesigned in 2012 to reduce the amount of clinical placement time and the time available for teaching specialist subjects, presumably on the understanding that individuals would then be supervised for a period in the workplace. Paediatric audiology is considered a specialist subject. This review has heard that graduates of this course may have received as little as half a day of teaching in paediatric audiology before applying to work in a children’s hearing services in the NHS at Band 7 grade.

This review has also heard that the assessment process for the STP is not sufficiently robust in determining a graduate’s ability to undertake hearing tests alone and that new graduates employed in children’s hearing services require extensive supervision. In terms of international comparison, this review has heard that UK graduates require far more postgraduate workplace clinical supervision than their better trained international peers, although this varies by country.

This review has been told that the number of places available on the STP programme each year is currently limited by the number of audiology departments willing to offer a place to an individual on the programme, rather than by central funding. For the academic year beginning in 2025, only 19 places are available, although 31 departments originally expressed interest.

Practitioner Training Programme (PTP) or alternative BSc Audiology degrees (Level 6)

Unlike degrees in nursing or physiotherapy, the NHS Learning Support Fund is not available for this degree, nor are graduate students able to access a second student loan. Unlike degrees in medicine, podiatry and speech and language therapy, no high-cost subject funding or health education supplement funding is provided by the Office for Students to universities offering undergraduate degrees in audiology to pay for the sound-proofed testing rooms and equipment needed to conduct hearing tests.

This review has heard that the number of universities offering this course is decreasing. It has also been told that there are no standards set for the curriculum content by the National School of Healthcare Science or by any of the organisations representing professionals in audiology.

Higher education diplomas, certificates and apprenticeships (Level 4 and 2)

A number of institutions offer diplomas, higher education certificates or apprenticeships to train individuals as Healthcare Science Assistants (Level 2) or Healthcare Science Associates (Level 4). Apprenticeships are assessed by the NHS England End-Point Assessment Organisation at the National School for Health Care Science for final competency sign off. Course graduates are eligible to join the relevant voluntary registers administered by the Academy of Healthcare Science (AHCS). Apprenticeships can be funded by the apprenticeship levy although this review has heard that children’s hearing services who want to take on apprentices are currently required to sacrifice clinical posts in order to fill them with apprentices, while reducing the clinical time available to those audiologists who will supervise and train the apprentice.

References

1. Department of Health. Review of early warning systems in the NHS (PDF, 3.6 MB) by the Department of Health’s National Quality Board, published February 2010 (archived).

2. Paediatric Innovation, Education and Research Network. Congenital CMV Guidelines, published May 2025.

3. Institute of Physics and Engineering in Medicine. Radiotherapy Workforce Census Summary Report 2021, page 2, published 2021.

4. Department of Health and Social Care. Fit for the future: 10 Year Health Plan for England, published 3 July 2025.

5. World Health Organization. Childhood hearing loss: strategies for prevention and care, published 2016 .

6. Delcenserie A, Genesee F and Champoux F. Exposure to sign language prior and after cochlear implantation increases language and cognitive skills in deaf children. Developmental Science 2024: volume 27, issue 4, pages 1 to 16 (accessed 16 July 2025).

7. Mercure, E, Bosworth, R Gliga T. (2025). Diverse language experiences in deaf infants and in hearing infants with deaf parents: 25 years of improved understanding and recognition. Infant Behavior and Development, 80, article 102103. Advance online publication.

8. NHS England. Delegation proposals for vaccination and screening, paper presented to NHS England’s Board for discussion and approval, 6 February 2025.

References 9, 10 and 11. NHS England, Paediatric Hearing Services Improvement Programme, published 31 August 2023. See the ‘System recommendations for immediate action’ and ‘Recommended actions for immediate implementation - letter’.

12. NHS England Addressing concerns in children’s hearing services, published 4 October 2024.

13. NHS England Paediatric Hearing Services Improvement Programme - operational guidance published 20 September 2024.

14. British Academy of Audiology, Review into NHS Lothian Paediatric Audiology, published 10 December 2021.

15. Letter sent from NHSP officials to National Deaf Children’s Society, September 2013.

16. Newborn Hearing Screening Programme, Annual standards data report for the period 1 April 2020 to 31 March 2021, section 8, published 12 January 2023.

17. Independent report, published by Department of Health and Social Care, Review of patient safety across the health and care landscape, published 7 July 2025.

18. UK Parliament written questions, answers and statements. Question for DHSC on paediatric audiology, tabled on 22 January 2024 and Question for DHSC on paediatric audiology on paediatric audiology, tabled on 28 February 2024.

19. National Deaf Children’s Society. What works: children’s hearing services working groups (PDF, 1,587 KB), published October 2019.

20. British Academy of Audiology. Rapid review into paediatric audiology, published 14 October 2020.

21. NHS England. Addressing concerns in children’s hearing services, published 4 October 2024.

22. Expert report of Mary Dixon-Woods. INQ0102624 - Report to the Thirlwall Inquiry: addressing part C of the Terms of Reference, published 28 June 2024.

23. NHS England. NHS workforce statistics, accessed July 2025.

24. Health and Care Professions Council. Register summary, accessed June 2025.

25. Number of active clinical scientist registrations with an audiology modality provided by HCPC 30 July 2025.

26. National Deaf Children’s Society. ‘Listen Up 2024 - England’ on the Listen Up reports page.

27. National Deaf Children’s Society. ‘Listen Up 2019’ on the Listen Up reports page.

28. NHS England. Monthly diagnostic waiting times and activity, accessed 2025.

29. NHS England. Community health services waiting lists, accessed 2025.

30. NHS England. Multi-professional framework for advanced practice in England, published May 2025. Framework introduced a terminology change whereby ‘advanced practice’ replaces ‘advanced clinical practice’ recognising that advanced practice takes place in a wide range of settings and professional contexts.