Where Are All the Audiologists? A UK Perspective on the Scarcity of Hearing Care Services
It is estimated that there are only around 1,000 audiologists in the UK private sector. In addition to the approximately 3,000 National Health Service (NHS) audiology professionals, this means that for the whole of the United Kingdom, the proportion of audiologists to members of the public is staggeringly small: just one per 16,805 people.
A hearing aid display in a high street audiology center.
Meanwhile, studies indicate that 1 in 5 adults in the UK have a bilateral hearing loss of 25 decibels (dB) or more, amounting to an astonishing 11 million people who suffer from some form of hearing impairment. This means that overall, for every individual who endures hearing loss, they are up against a further 2,749 others to be seen by an audiologist.
This situation is only likely to get worse. The Office for National Statistics (ONS) predicts that by 2035 roughly 14.2 million adults will have a hearing loss greater than 25 dB across the UK. As the population continues to age, this could even be a conservative estimate.
The knock-on effects of hearing loss
The effects of hearing loss do not end at a person’s ability to hear. Instead, the consequences are varied, and can impact areas of day-to-day life that one might not otherwise consider. Aside from communication difficulties, the loss of hearing can lead to increased social isolation, emotional distress, and mental health problems including depression and cognitive decline.
In addition, there’s a strong correlation between hearing loss and an increased risk of dementia. Indeed, people with even mild hearing loss are almost twice as likely to develop the condition according to a study from Lin, Metter, O’Brien et al. That same study concluded that risk for dementia is proportionate to the severity of your hearing loss: up to 3 times higher for moderate loss, and an astounding 5 times higher for profound loss, when compared to the average population.
Hearing loss is also associated with a wide range of chronic illnesses, and it may limit therapy and compliance with physician and pharmacy recommendations due to reduced communication ability and increased misunderstandings during treatment.
Even milder forms of hearing loss can have detrimental effects for wider society. A recent report has estimated that £25.5 billion (US$30.6 billion) of economic output is lost every year due to an increased use of health and social care services, unemployment, sick leave rates, and limited career progression as a result of hearing loss. Moreover, over 3 million people across the UK are thought to be living with untreated hearing loss at a cost of £8500 (US$10,200) per person.
With such a wide-ranging set of negative outcomes associated with hearing loss, the question must be why it is we see such an apparent dearth of audiologists in the country. Surely with this much demand, and this many adverse corollaries, one would expect either the government, NHS, or the private sector to step up to fill the gap.
The University of Manchester is a world leader in research and teaching of audiology.
Introducing the Audiology Degree
In some ways, they have. In 2002, a BSc (Hons) in Audiology – a 4-year degree including a 12-month clinical placement – was introduced to address both the shortage of audiologists and the need for high-skilled staff. This was part of the Modernising Hearing Aid Services (MHAS) program, and would be fully funded by the NHS, so there were no fees for students to pay, and means-tested bursaries were also available to help with living expenses. This was all to encourage young individuals to embark on a career in audiology by offering them free study at institutions like the University of Manchester, one of the first to be commissioned in the UK.
As expected, this did result in an influx of qualified audiologists, but not enough to subside the high demand. An NHS workforce project demonstrated that an additional 1700 audiologists were required to cope with the current pressures, and that this would take up to 10-15 years to achieve. The Royal National Institute of the Deaf (RNID) emphasized the importance of maintaining all substantial investments in audiology including staffing and the workforce. If this momentum was lost, there would be a risk that access to modernized audiology services would become further restricted due to ever-increasing waiting times and narrowing eligibility criteria. The Department of Health released funding (approx. £38 million) for 2005-06 to support the modernization of audiology, but there was a danger that this could be cut shortly thereafter.
The end of funding for the modernization of audiology services
And so, it was. In 2014, the NHS pulled the plug on funding for BSc Audiology for reasons never fully clarified. It was remodeled into BSc Healthcare Science (Audiology), and like any other degree, students would have to find a way to fund it themselves. The course was reduced from four years to three, and students would receive a general foundation in healthcare science before going on to specialize in Audiology in the second and final years. Then, in 2017, NHS bursaries for students of Audiology were also made a thing of the past, and BSc Healthcare Science (Audiology) was taken off the list of Allied Health Profession (AHP courses). To this day, only 11 of the 165 universities in the UK offer the course.
Job satisfaction rates for audiologists
Is it the lack of funding or is audiology simply not a well sought-after career? Certain surveys have revealed that audiologists are below average when it comes to job satisfaction levels, with one survey placing audiology in the bottom 23%. Audiology does generally make for a fast-paced career. It must be noted, however, that public and private sectors of audiology are different worlds entirely.
First, private audiologists do not experience the many plights faced by those working in the public sector. With no time or financial constraints, private audiologists can offer personalized experiences, better aftercare, and a wider range of products to customers. This may explain why customer satisfaction levels with independent hearing providers are around 86%, according to the latest Which Report, which is essentially the same as ratings for US audiologists (90%) as reported in MarkeTrak 2022.
Since private audiologists can deliver more effective and efficient levels of customer service, they are more likely to deal with more pleasant and satisfied clients, contributing to higher job satisfaction levels. It should also be noted that a plethora of research demonstrates the importance of aftercare and aural rehabilitation (AR) in hearing acceptance and satisfaction, and time constraints at the NHS sometimes necessitate cutting corners in AR.
Second, NHS audiologists are plagued by long waiting lists, financial constraints, problems with hearing aid suitability, and frustrated customers. For this reason, it is almost certain that they feel the impact of the shortage to a greater extent, despite there being a higher number of public audiologists than private. The ratio of NHS audiologists compared to those in the private sector may even explain why audiology falls below average when it comes to job satisfaction levels. Perhaps it is not the role itself, but the circumstances surrounding the role.
The impacts of the audiology staffing shortage
The shortage of audiologists coupled with the high demand has led to increased waiting times in many areas of hearing care. As a result, the NHS has struggled to provide the capacity necessary to meet demand. Without a sufficient workforce, audiologists will not be able to deliver effective and efficient services to patients.
If 11 million people currently experience some degree of hearing loss in the UK, that works out to roughly 157,000 individuals per city. With only 4000 audiologists comprising both the public and private sector, there are a meager 57 audiologists per city in comparison.
The shortage of audiologists extends beyond the UK and appears to be a global issue. To complicate matters further, the World Health Organization (WHO) has estimated that 1 billion young adults are at risk of permanent, unavoidable hearing loss due to unsafe listening practices. As rates continue to rise, hearing loss could become unmanageable if there aren’t enough audiologists to cope with the demand.
The increasing use of private providers
That said, the private sector is already helping with the delivery of hearing aids to NHS patients, and the long waiting times are also encouraging those who can afford private hearing care to do so. In October 2003, the Public Private Partnership (PPP) was set up to enable NHS audiology services to supplement their own capacity as part of the wider MHAS programme.
The PPP contract stipulated that staff employed to provide services under the PPP must be registered hearing aid dispensers and should be fully trained to the same level as audiologists within the partner NHS trust. Staff providing services for the PPP also had to comply with the provisions of the Hearing Aid Council’s code of practice. The PPP ended in March 2007, but the Department of Health promised to continue procuring audiology capacity through Independent Sector Treatment Centre (ISTC) schemes.
Five years later, the Any Qualified Provider (AQP) program came into play. This is a type of NHS contract that allows non-NHS as well as NHS organizations to provide NHS services, and it aims to encourage more people to have their hearing tested. A registered GP must first refer the patient, and they can then choose from a list of qualified providers who meet NHS service quality requirements, prices, and contractual obligations.
This program not only allows accredited high street providers of hearing services to offer customers free NHS hearing aids, but also offers the public a wider choice of hearing care providers that meet the requirements and prices of the NHS. However, in the face of yet another adversity, there are also not enough people training and qualifying within the private sector to help meet NHS demands. As noted, the ratio of NHS audiologists compared to those who work in the private sector is 3:1, so it is vital that more private audiologists are procured to both maintain and strengthen the AQP scheme.
On the other hand, AQP does have its drawbacks, as there have been various incidences where patients have walked into their perceived NHS appointments expecting to receive a free hearing assessment and hearing aid but are instead pushed towards buying hearing aids. This is against AQP’s code of practice.
Is this “backdoor” NHS privatization?
The backdoor privatization of the NHS is already a sensitive topic, but it must be noted that during Covid-19, it was announced earwax removal (syringing) would no longer be a service available from the NHS. It was stated that those who require the service must now go through private providers, even though this is a service many cannot afford. The average cost for an earwax removal falls anywhere between £50-300 (about US$60-350) which undeniably squeezes the pockets of low earners.
The same goes for hearing aids: many individuals with hearing loss would prefer to go private and avoid the absurdly long waiting lists for the NHS but cannot afford the costs. It is no secret that hearing aids are expensive, with prices ranging anywhere between £500-3500 (US$600-4200).
Furthermore, the privatization of the earwax removal service has opened the floodgates for a range of other health problems. It is forcing many individuals to try and remove the earwax themselves which can be dangerous. Using items like cotton buds/swabs can result in punctured eardrums and significant injury.
It is also blurring the lines to whether a hearing difficulty is due to a hearing loss, earwax or conductive loss, or a more serious health condition. For example, impacted earwax can be a side effect of a pre-existing (and unknown) health condition; however, these newfound costs are preventing people from consulting healthcare professionals who could identify a more serious health problem at an earlier stage.
About one-fifth (19%) of the UK population was aged 65 or over in 2019, or around 12.3 million people. The number of people in this age group increased by 23% between 2009 and 2019, at a time when the whole entire UK population grew by only 7%.
Alleviating the audiologist staffing shortage in the UK – and globally
In a last effort to provide some more answers for the dearth of audiologists, is it possible there are more audiologists retiring or leaving the field than those qualifying? Or are young people simply not aware of the avenues available to embark on a career in audiology?
It has been said that some independent hearing providers are starting to roll out both fast-track and in-house training programs to generate more audiologists. While this is certainly a positive development in emboldening young people to study Audiology at university, the lack of financial incentives continue to discourage them. This is a field of healthcare that is in dire need of bodies to survive, and so a clear path to alleviate the shortage must be established.
Although this discussion has been confined to the UK, the problem is global. For example, there are an estimated 14,600 audiologists and 10,000 hearing aid specialists in the United States for a population of 329 million. This works out at 1 hearing care professional per 14,000 people. In 2013, Windmill and Freeman demonstrated that to meet US consumer demand, the number of new audiologists entering the field would need to increase by 50% and the attrition rate of people leaving the field after graduation would need to decrease from 40% to 20%. This research was conducted almost a decade ago, so we can only imagine what the situation is today. That said, the Over-the-Counter Hearing Aid Act (passed in 2017 but at this writing still being finalized by FDA) may be of some assistance to the problem, as it is allows those with mild-moderate hearing loss to purchase hearing aids directly over the counter at a lower cost.
In 2021, WHO’s World Report on Hearing estimated that 93% of low-income and 76% of lower-middle income countries have less than 1 audiologist per 1 million people.
With rates of hearing loss rising at unprecedented levels across the world, the shortage of audiologists is nothing short of terrifying. It certainly would appear that a hearing loss crisis is among us, and it is up to audiology to find a way out.
Thanks to HearingTracker audiologist Matthew Allsop of Harley Street Hearing in London for his review and kind suggestions for this article.
I am a Ph.D. clinical Audiologist in private practice for over 40 years. Your article was a great read! Over the years we have learned the importance of proper diagnosis of hearing loss and the need for proper fitting of great hearing devices and follow up care. Great Hearing Care is great Health Care.