Written evidence submitted by Specsavers (FGP0100)


In addition to being the largest provider of NHS primary care optometry services in the UK, Specsavers is the largest provider of NHS community audiology services (primarily for people with age-related hearing loss) in England and are currently commissioned by over 100 CCGs and provide approximately 37% of the NHS’ community audiology capacity. In 2019/20 (pre-pandemic) we assessed over 150,000 NHS patients for hearing loss and, where indicated fitted them with hearing aids and supported them through the rehabilitation process. 

We wish to bring to the Committee’s attention our concern regarding the inappropriate use of GPs as administrative gatekeepers for NHS community service. This represents an avoidable misuse of GPs’ time and is detrimental to patients and providers of NHS community audiology services. We suspect that the same situation occurs in relation to a range of other NHS community services. The solution is to remove the GP as the gatekeeper for community services where their involvement is purely administrative and, adopt a process of self-referral.

At present, most, but not all, of our NHS audiology contracts require a GP referral into the service. GPs are not trained or equipped to perform hearing loss assessment, so this is entirely an administrative process. We believe it is inappropriate and costly to use GPs as administrative gatekeepers and a misuse of their clinical capacity. We have been supported by the Royal College of GPs and the former Chair of the BMA GPs Committee in encouraging commissioners to implement patient self-referral for adults with suspected age-related hearing loss. Some NHS commissioners express concern that removing the GP as gatekeeper will lead to uncontrolled demand, however, there is no evidence of this in areas where patient self-referral has been implemented with demand broadly stable (such as in Coventry and Derbyshire), but the locus of care shifting as more patients exercise their right to choose community, rather than hospital-based, services. In addition, self-referral has additional benefits for the NHS and patients, including patients accessing care quicker, allowing GPs to prioritise those patients that require a GP appointment to access secondary care services. With general practices, involvement with the rollout of Covid-19 vaccinations and boosters, the need to protect GP appointment slots is critical with serious diseases such as cancer on the rise and at risk of not being spotted due to the backlog of waiting times.

Some commissioners express concern that self-referral will be less safe for patients, despite the fact that it was endorsed by NHS England in its Hearing Loss Commissioning Framework, is supported by the GP and audiology professional bodies, and reflects the fact that GPs are not trained or equipped to detect “referrable conditions” (hearing loss related to other causes and  / or aural / audiological co-morbidities which need to referred to an ENT surgeon) while community audiologists are, and can refer the patient on to hospital, with the benefit of a full assessment.

Approximately, 94% of adults with hearing loss have uncomplicated, age-related hearing loss and can safely be treated in the community. Moreover, all independent providers on these NHS contracts are also NHS Primary Care Optometry contractors with the necessary administrative and clinical governance arrangements to deal with patient self-referral – which is the norm in primary care. The requirement for the GP to act as a gatekeeper for community audiology services places an unnecessary burden on GP appointment time and conflicts with the purpose of The GP 5 year Forward View. Our belief is that allowing patients to self-refer into the service consistently across the UK will enable better patient care, remove barriers to accessing audiology services, and will free up appointment availability in general practice for those patients requiring a diagnosis and treatment plan only a General Practitioner can provide.

Terms of Reference:

  1. What are the main barriers to accessing general practice and how can these be tackled?

We have no view on the main barriers to access general practice but do believe that an effective way to improve access would be to increase capacity by removing the use of GPs as administrative gatekeepers to NHS community services. In the case of community audiology, we estimate that this represents over 400,000 wasted appointments per annum. We believe this can be tackled effectively by encouraging commissioners to implement patient self-referral for adults with suspected age-related hearing loss. This has successfully been done in some areas of the UK already, resulting in no noted uncontrolled demand but has seen the locus of care shifting as more patients exercise their right to choose community, rather than hospital-based, services.

  1. To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?

We support the Government’s plan, but believe that it needs to go further, specifically removing the use of GPs as administrative gatekeepers to NHS community services including community audiology to free our GPs up to provide expert advice and support for patients, rather than administrative referrals.

  1. What are the impacts when patients are unable to access general practice using their preferred method?

As a provider of community audiology services, we understand the communication difficulties those with a hearing loss have. If patients are not able to access a face-to-face appointment, or have to be triaged via a telephone call, there may be an increased reluctance to access help and support leading to unmet need. Uncorrected hearing loss leads to social isolation, deteriorating mental health, increased cognitive impairment and loss of independence. [NHS England and Department of Health, Action Plan on Hearing Loss, 2015]


  1. What role does having a named GP—and being able to see that GP—play in providing patients with the continuity of care they need?

We have no view in relation to this question.

  1. What are the main challenges facing general practice in the next 5 years?

The aging population will drive growing demand for hearing loss, and other routine NHS community services, and therefore unnecessary GP referrals, unless they can be switched to a patient self-referral wherever it is appropriate to do so, such as in community audiology services.

  1. How does regional variation shape the challenges facing general practice in different parts of England, including rural areas?

Inconsistent commissioning models for NHS community audiology, and other community services, leads to GP practices in some localities having much higher administrative burdens than others. A consistent national commissioning model for these services would avoid this.    

  1. What part should general practice play in the prevention agenda?

We have no view in relation to this question.

  1. What can be done to reduce bureaucracy and burnout, and improve morale, in general practice? 

Remove the requirement for referrals for community-based services where a GP is being used as an administrative gatekeeper for the service, such as with NHS community audiology services.

  1. How can the current model of general practice be improved to make it more sustainable in the long term? In particular:

The current (2016) NHS England commissioning guidance on community audiology recommends CCGs consider commissioning on a self-referral basis. We have the benefit of experience and data from the current self-referral areas, and temporary arrangements that were put in place by some CCGs during “lockdown”, to show that self-referral for community audiology is safe and does not open a floodgate of demand. Unfounded anticipation of uncontrolled demand is, we suspect, the main reason why CCGs insist on GP referrals. Of course, if it was the case that a CCG has high levels of unmet need then meeting, not supressing, that demand would actually be the right thing to do.

To this end, we have over a several years submitted proposals to the Secretaries of State for Health and their ministers, NHS England, and all CCGs that commission community audiology to switch to self-referral. We have been supported in this by Dr Richard Vautrey as Chair of the BMA GPs’ committee and have recently engaged with Ed Waller at NHS England to whom we have submitted data on the limited impact of self-referral on demand for community audiology. We are also a member of the Independent Healthcare Providers Network of the NHS Confederation through whom we have advanced the same argument to DHSC and NHS EI in relation to a number of other low-risk, routine community services – which some CCGs do commission on a self-referral basis, but most don’t.


  1. Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?

No comment to add for this question.

  1. Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated and integrated care?

No comment to add for this question.

  1. Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs?

No comment to add for this question.

  1. To what extent has general practice been able to work in effective partnerships with other professions within primary care and beyond to free more GP time for patient care?

Based on NHS England’s own data we believe that NHS community audiology referrals alone generate 450,000 - 500,000 GP appointments per annum, purely for administrative purposes. This seems like inappropriate use of a GP’s time and expertise, on the basis of a flawed premise and with significant “opportunity cost” to the NHS (i.e., the loss of whatever else the GP could be doing) and our patients. If we consider all the other services where the same conditions apply, the opportunity is there to create over a million extra GP appointments per annum with no additional pressure on GPs.

Additional comments:


Dec 2021