Managing the transition to universal neonatal hearing screening--the missing link.

Despite our best intentions it is going to take several years (probably 3-5 years) before we have a UK-wide Universal Neonatal Hearing Screening (UNHS) service. Between now and then we have a responsibility to improve the quality of existing service provision for the one thousand additional deaf children appearing every year in the UK. The 3000-5000 deaf children born between now and the advent of full UNHS coverage form the missing link as services scale down, or in some cases prematurely abolish the health visitor distraction tests (HVDT). There is little evidence of enthusiastic attempts to improve the support given to health visitors except in a few districts and many feel despondent and in limbo as the new system of UNHS approaches. We are witnessing disappointing results with the HVDT because of a general failure to adhere to well defined standards for good practice. Sadly the published report of good achievements from the HVDT are outnumbered by the reports of unsatisfactory performance and the misguided conclusion is often drawn that there is something wrong with the distraction test as a technique rather than with its particular application within individual service contexts. The reports which have demonstrated poor results have rarely explained what steps have been taken (if any) to improve the standards of practice to bring them in line with services with proven better track records. If services had made a concerted effort to comply with well defined standards of good practice in the past we would be witnessing a much more satisfactory situation in the community health service. The two articles in the June edition of the British Journal of Audiology by Fonseca et al. (1999) and by Sutton and Scanlon (1999) illustrate the point I am making. They both demonstrate unsatisfactory levels of achievement in a total of nine services and they both draw the correct conclusion that the introduction of UNHS should help to improve the situation. They do not, however, address the short-term need to bring their service in line with better performing services. Sutton and Scanlon’s study compared a poorly performing HVDT (42% sensitivity) with a novel and very thorough surveillance (vigilance) approach and they reported little difference in the performance of the two approaches. Thus what they have shown is that a very well applied surveillance approach works no better than a badly applied HVDT approach and this comes as no surprise. In an earlier commentary on their work (McCormick, 1990), I suggested that their efforts might be better applied in an attempt to bring their HVDT sensitivity (42%) in line with the 88% sensitivity sustained over many years in our service as reported by Davis and Wood (1992). It is of relevance to note that the data used in Sutton and Scanlon’s HVDT study was obtained over the period 1984-1988 and this pre-dated the availability of national training materials prepared specifically for health visitors (the book for health visitors Screening f o r Hearing Impairment in Young Children, 1988, and the Department of Health commissioned video training package Screening and Surveillance for Hearing-impairment, 1987). These materials offered an opportunity for a national standard to be set but very few services injected the effort or enthusiasm needed to improve their services. The study by Fonseca et al. (1999) demonstrated poor results from nine centres and the authors criticized the techniques they used without explaining the immediate steps they were taking to address the deficiencies in the short term. They did not compare their results with the range of published work reporting better success elsewhere, for example Watkins (1990), McCormick (1988), Davis and Wood (1992), Wood, Davis and McCormick (1997). Fonseca et al. cast doubt on the value of the parental awareness form implying that it delayed identification of childhood deafness. This is an extraordinary