PhoneAbility

3. Who Are The Consumers?

Professor Adrian Davies - MRC Institute of Hearing Research, Nottingham

I think that the issues you have just been discussing are really pertinent and ripe for our times now. It is a pity that, within the modernisation of hearing aid services, we did not have time and effort devoted towards better information for people, to give them choices. I think it is a poor reflection on what we have done that choice seems to have been relegated to something that is thought to be an expensive extra, when it should be the very nub of what we want to do.

"Modern and dependable communication for all!" and "Whose customer is it anyway" are not necessarily the best statement to make at this meeting and I think that part of (I would hope) your job is to make these statements clearer and more focused. I posed a question as well. Really, I think what we are talking about is modern and dependable communication for all. It is not just hearing impaired people that have a difficulty hearing on a mobile phone or in communication in busy places.

This morning, as I was trying to concentrate on my message here, there were fifteen or so mobile phone conversations going in various different tones, from very high frequency, high-stressed sort of executive, to people in a very relaxed style telling their children how to make breakfast! It is not just hearing impaired people that have a difficulty with communication. I think the more embracing you can make it, and the more radical you can make it, in terms of making people think about the huge benefits there are in trying to solve problems for hearing impaired people, the spin-offs for everybody else are so huge that they cannot resist making those changes.

Year	25+	35+	45+	65+	95+
1995	72,399	42,764	23,932	7,535	1,454
2005	81,536	48,642	26,928	8,378	1,518
2015	90,588	54,465	30,372	9,509	1,655
2025	100,192	60,963	34,009	10,620	1,803

Table 1. The estimated number of people (1000s) aged 18 years and older in Europe with hearing impairment as a function of year and severity in the better ear (0.5, 1, 2, 4kHz average dBHL)

Just to report back some of the statistics that all of you really know, firstly, Table 1 shows the number of people in Europe who have a hearing impairment at a particular level, and we are talking about the better-hearing ear. I would estimate that, in 2005, 48 million people in Europe have a hearing impairment in their better ear that really impedes their communication ability i.e. 35 dB+. It is the level at which I would suggest that a hearing aid is incredibly helpful to people who have a cochlear hearing loss. This figure is going to grow over the next 25 years. Whole population growth in Europe may be 5%, but the growth of hearing impairment at that level is 42%.

Currently, although we have what I think is the most stretched hearing aid service in Europe, because we have modernised it, still less than one in three people gets access to decent amplification for their hearing problem. When I said, jokingly, one in five, it is actually one in five, because one in five people have a hearing problem in one or other ear. It is not just the extent to which your better ear is impaired that is hugely important. Orientation of sound and ability to integrate sound over the two is very important. Therefore, maybe one in five people has difficulty. So, the challenge is really quite awesome.

We have modernised our hearing service, we are very proud of that in the Department of Health and in the NHS, and all involved, but, just to stand still we think that we need 42% more service. We have had a huge investment, going probably from £50 million a year to maybe to as much as £120 million a year in the last three years. We are not going to get that rate of investment again, so we have to think of ways in which we can tackle that problem. That is why I say, "Who is the customer anyway, and how do we provide this information to everybody?" If we went for bust, I think we would need a 300% expansion, and we are not going to get that!

What do I think are the major issues? I think the major thing we should concentrate on is communication. Face-to-face communication is very important, particularly in families, but more and more it is face-to-face communication with noise in the background. That is important. There is a focus here about the use of the telephone; whether it is the traditional telephone or the mobile telephone; whether it is going to be a streamed video/audio data sort of link, or whatever. We are going to get that, and we are going to have to integrate with the Internet to get the services that are available.

I still feel that we can drive a lot of this by also thinking about the needs that children have; the 20,000 children who are hearing impaired. I think that their communication issues are huge. Sharing our professional resource is huge. Some of the technological gains we can get there can apply across the whole field. This issue of choice is really important for children, but we have to flag up the choice for parents and adults in how they tackle this issue.

Jeff Bashton, one of the Social Services people at the Department of Health, is blind. He knows that we have planned to replace all children's analogue hearing aids with digital hearing aids over a two-year period. He was absolutely amazed that there was no policy to replace the large number of analogue hearing aids used by adults with digital hearing aids because they are being rationed.

This is something over which those people effectively have no choice unless they get up and do something about it. They are disenfranchised in a modernised service. That is a huge issue to me, and Jeff saw that immediately, but, of course, we need the money, and the major block is the personnel to deal with it.

How do we deal with the needs that hearing impaired people have? Well, we have a tool called the Glasgow Hearing Aid Benefit Profile, which we have used within the modernised service. I want to tell you a bit about the data from that. Obviously I think personal devices, hearing aids, are somewhat limited because they are not getting to the people who need them, whether that is in the NHS or the private sector. That is a limited approach, and we have to look broader than that.

We have to look at amplification and other forms of signal processing, which are important to people, so that we can have devices that enable communication, whether they are Bluetooth devices or WIFI devices, that can be programmed for each individual's ability to hear. Not just their profile in terms of their hearing thresholds, but maybe looking at other elements of signal processing that we can do to the signal, to make it more comprehensible. Removing noise, for instance, in terms of being able to get better segregation of speech.

Can we tailor the devices that we make to individual people, to individual groups? Can we make the broadcast signal more robust? Can we shape that signal to be more accessible to the individual? Can we maintain within that individual an environmental awareness? How many times have you walked into a tree as you were going along with a mobile phone to your ear? We need to work on these things so that the solutions are out there. We need to lobby to get those solutions delivered.

As well as devices like that, we need to think carefully about the design of our infrastructure, the design of our homes and the design of our work places. There is an awful lot that we can do in configuring those to make communication easier and better, and we do not do that. Not enough attention is paid to that and, as a result, we are struggling to communicate in environments that your best friend would not want to impose on you, so the only way to communicate is to be really close to people, and I think that has implications itself.

That is my party political broadcast. Now I want to go on to a little bit of data about our ability to benefit from amplification. This is a study that was started a long time ago and has not yet been fully published. It was derived from a study that wanted to screen people for hearing problems early on in life. (Early in life means 55, which is a good age to start.)

Fig. 1 The benefit obtained with a hearing aid in the quiet with increasing hearing loss using the Four Alternative Auditory Feature Test (FAAF)

Fig.1 shows that when your hearing loss gets to 30-35dB, you get significantly more benefit from amplification using a signal at 55dB in zero signal to noise. What we see is that people can benefit from amplification in the population quite substantially.

Fig. 2 Percentage of people 55-74 years of age with significant benefit from amplification as a function of gender, age and aided status

Fig 2 shows the overall impact that hearing aids have had on 55-74 year-olds. Again, the young population (55-59) here shows that 25% of people in that population could benefit from amplification. They do not have a hearing problem, but they can benefit from amplification. 5% of those people are helped by current personal amplification and 20% are not.

Whether you are in the industry to sell hearing aids or whatever, there is a huge job to do there, because those people we have shown can benefit from amplification. It does change with age, it changes with whether you are a man or a woman, but there is a huge job to do. There are huge implications, technically, in terms of service delivery and image. If we think about making communication better rather than, "What I cannot do because I am hearing impaired or hearing disadvantaged," I think the image will become much stronger.

We need to think about our information systems, and how we work with them. We need to think about new models of service. Can we look at other industries, other ways of thinking about things, in terms of opticians, delivery of domiciliary services, dentistry? They are not all successes, but they have a different way of dealing with the issues.

Can we learn from the way that phone companies communicate, the media industry communicates, and the way that pan-national companies communicate? People will be developing a lot of advanced communication methods. We need to look at that as to how it can benefit the population as well. The idea here is to go towards some meaningful partnerships with the end users. The main elements here are really looking at the professionals who are there, and how they can influence things. Things like the good information leaflet are really important. They should be properly delivered; not just put in the hand, saying, "Go away and read this," but with a proper explanation of issues.

Forming those professional alliances, commercial alliances are so important in delivering the services, and then working to get a better patient and client lobby together, so that, when you spot the issue, you can deliver it to the commercial sector and professional sector in a meaningful way. Not just a quick hit and gone, but working in real partnership to get something that is a long-term relationship.

Where are the barriers to this? How do we assess them? Is the technology itself becoming a barrier, or is it going to be helpful to us? One of the main issues here was an image thing. When James Strachan, Chief Executive of RNID, went to see the Minister, he made it quite clear that the digital revolution could deliver the end of an antiquated technical solution to providing hearing aids. I think that worked, and it caught on, but how do we push this next big idea?

I tried that with the slogans "Mobile -- communicate now" or "Hear IT now." It is your job to come together and ask, "How do we communicate that? What image do we want to take? How focused can we be in setting out a clear, simple target?"
We wanted to replace analogue hearing aids with digital ones and we wanted to put a better rehabilitative structure in place, but, yes, we could work with that, because having that clear, simple message meant that funding and ideas were flowing. You have to think about how to punch in there with a good, clear message.

These are some of the ideas that I have had. Obviously early screening helps. Early awareness helps. If people are more aware of the problems that they have with communication, and with hearing and with listening, then they will be more mobilised to do something about it, whether buying a product, presenting to a GP or, hopefully, having a direct access hearing service in the near future.

We need to be able to promote better strategies to deal with personal needs. We do not want a block solution. We want something that meets our need, and we want it to meet it now. We do not want to wait for months to solve that problem; we want to do it now. If you have to wait, it demotivates, and it makes things much more difficult. We need to have a better image to tackle this communication problem, and we need to use all the modern signal processing strategies, so that what we do actually works. I suppose that is a sort of self-interested thing because that implies some research and development.

I want to talk in the ten minutes left about some of the data I have. Yes, it is old; yes, we need to do something about replacing it; but I would like to bring out some of the points that it makes. Some of that data was collected in the 1980s. We asked about ease of use of the phone in a postal questionnaire, and we asked about the use of the phone on the left ear and on the right ear, in a clinical questionnaire, and collected audiological and demographic information.

We do not have any reliable, up-to-date information on the use of mobile phones, wireless home phones, DECT and other products. I think that is something that needs to be done. We have some other information from recent surveys I have undertaken about people's use of the telephone when they have a hearing aid, but none on the wider issue that is so important, so maybe we do need to think about doing this again.

Age group	none	some	moderate	great
<30	81.5%	16.1%	2.1%	.4%
30-39	78.9%	17.6%	2.8%	.6%
40-49	71.4%	23.1%	4.6%	1.0%
50-59	64.4%	27.9%	6.2%	1.5%
60-69	58.9%	31.2%	7.7%	2.2%
70-79	50.1%	33.9%	10.0%	6.1%
80-89	41.2%	29.7%	17.2%	11.9%
90-99	25.0%	26.9%	21.2%	26.9%
Overall	69.1%	23.6%	5.3%	2.0%

Table 2. The percentage of people in the adult population who report problems in using the telephone. The data is from the National Study of Hearing 1995 and therefore there is no data on mobile or satellite video phones

The bottom line as shown in Table 2 is that 23% of the adult population in Great Britain said that they had some difficulty using a phone, 5.3% said they had moderate difficulty and 2% said they had great difficulty using a phone. As you can see by age group, only 25% of 90-99-year-olds said that they had no difficulty using the phone and only half of 70-79-year-olds said they had no difficulty. It is a huge problem for those populations, and the younger populations as well.

Fig 3. Responses to the question "Do you have a problem using the phone" for those with any problem and those with moderate problems

Fig, 3 shows responses to the question "Do you have any problem using the phone?" expressed as a function of age group. You can see it grows over the age groups, and it is not really different for men or for women. If you have a moderate or greater problem using the phone, then you can see that the age at which it takes off is around about the 60s to 70s.

Fig 4. Hearing in noise when using the telephone, all people with problems and those with moderate problems

If we ask people, "Do you have a problem hearing in noise?" (is there anybody here who does not have a problem hearing in noise?), this really separates people out. Whether they are aged 30, 40, 50, 60 or 70, 40% of people say they have difficulty hearing in noise. We know that 23% of the adult population say they have difficulty using a phone. At least 40%, no matter what age, have difficulty using the phone in noise.

If we look at those with moderate problems, it is not just here in the elderly, in the 80s and 90s, but really across all age groups. If they say they have a difficulty hearing in noise, that difficulty could be because they have a middle-ear problem, because they have a problem in the cochlea, or because they have difficulty processing sound in the brain. A lot of people have that -- whether they are slightly dyslexic or have specific language impairment -- particularly if they might have some of the cognitive problems associated with ageing. It is the central problem that is the issue. A clear signal reducing the noise helps everybody; it is not just some of the people that it helps.

If we look at the level of hearing impairment, which is across the bottom axis, for those who can use the phone on their right ear with ease, we are down to about 10-12dB. If they have some difficulty using the phone, they are at 27dB. If they have great difficulty, they are out at 40dB or more. For people who say they have some difficulty using their phone -- and a lot of people say they have some difficulty - it is more than likely they have a 30dB or so hearing loss that would tremendously benefit from proper amplification.

What I have tried to do here is say, "If you have any difficulty with the phone", and look at specific degrees of hearing impairment. We see that, if you have a hearing impairment of less than 20dB, reasonably good hearing, then you are down towards the bottom. 20% of people have some difficulty using the phone. But for a 20-25dB hearing loss, which we would not think as being clinically relevant, then almost 60% of people have a difficulty using the phone. It is a huge problem. If you took 20dB, you are talking about 30% of the adult population which has that degree of hearing loss. 60% of those, almost 20% then of the whole population, has a difficulty using the phone.

I have never been able to show anything that, in terms of hearing loss, affected people's happiness, and I was just looking through my book(Adrian Davis (1995) Hearing in Adults, Whurr Publishers ltd, London) which is a difficult thing to do because it is a bit heavy! I saw that we had asked a question about people's happiness, but I had never shown that hearing impairment could have an effect upon it. I thought, "Wouldn't it be interesting to tabulate whether use of the phone or ability to use the phone had an impact on whether people were happy or not."

Fig 5. The proportion of people who are unhappy because they have difficulty in using the phone

Fig. 5 shows that for two age groups in the 51-80 year old range, it is interesting that there is very little difference across the groups. For younger people with moderate or great difficulty using the phone, they have huge amounts of unhappiness. It is on a 7-point scale, so I have taken those who were terribly unhappy, greatly unhappy and moderately unhappy. With elderly or older people there is not so much of an impact. This was done in the 1980s, so it may have moved on, because, as we know, lifestyles have changed a lot in those 20 years, but this is incredible evidence that not being able to use the phone, particularly in the younger age groups, can really impact their quality of life. That is a very important message I wanted to take home.

Does a hearing aid help with your phone communication? In the modernised hearing service, we asked people about this as part of the SADL, Satisfaction and Amplification in Daily Living, and in the Glasgow Hearing Aid Benefit Profile. In Fig.6 you can see a small group that were tremendously pleased with their hearing aid's ability to help with the phone, but half of the people really either had no benefit at all, or little benefit, they thought, from their hearing aids.

Fig 6. The proportion of people who find that a hearing aid helps them to communicate over the telephone

I wanted to show the bottom line really in the Glasgow Hearing Aid Benefit Profile, which does not take the use of the phone as one of the four major categories that it asks about, but there are categories that the individual can volunteer. One in four of them volunteered that their hearing problem interferes with their use of the phone, and that a hearing aid has helped in some way, Table 3.

Site	Phone mention	Total	Percent
Bath	72	445	16.18
Birm	171	759	22.53
Brad	293	1010	29.01
Camb	394	1494	26.37
Leed	433	1842	23.51
Nott	539	1934	27.87
Read	376	1458	25.79
Rntn	317	1225	25.88
Shre	378	1112	33.99
Whip	124	759	16.34
Winc	78	756	10.32
Wind	485	1884	25.74
Yarm	339	1069	31.71
TOTAL	3999	15747	25.40

Table 3. Numbers of people volunteering the view that their hearing problem interferes with the use of the telephone

So, there are major issues with our hearing service. First, access. People need to be more aware about their communication needs and their hearing problems. We need to be more effective in what we do about those problems. We need to be more aware of environmental issues, and how we can use other ways of helping people to benefit in communication. We need better communication devices, better phones and better ways of dealing with them.
We need much less variability in provision of information and of services.

We need to think about the choice issue; responsiveness to individual communication needs, using environmental aids, where appropriate. We have a slogan: "Doing nothing is not an option!"

Hearing problems will increase hugely in the next 25 years. Hearing aids confer some benefit - do not get me wrong, they really do help people in their communication needs -- but we have to think more radically about how we would help all those people who do not have access, and who probably cannot get access in our current system. We need to increase access to amplification and signal enhancement -- not just with individual devices, but in other ways --through phones and awareness.

We need access to quality products right across the range. For instance, with phone management systems or call centres, whatever you want to call them, they could be a cornerstone for making people more aware of the issue and to make better services more accessible. If they are structured properly, they can actually help people with communication needs.

In conclusion, we know, and we must continue to press that unmanaged hearing problems are a major public health issue for this country. In particular, we need to keep those in the forefront, by improvement, to show a better competitive advantage across all of our business requirements and all of our personal services requirements. Poor hearing affects communications, particularly over phones, particularly in noisy environments. People who cannot use phones properly, I would suggest, do have their quality of life impinged upon. They are unhappy. We need to tailor devices to meet those people's needs, and there's a huge potential for all of you who want to set up a business and provide people with that.

We need to think about the environmental consequences and the infrastructure; we need to think about quality products that people can appreciate, not just hearing aids; and we need to look at the growing communication needs of those who are hard of hearing, because some of the technological improvements will be driven by that.

I thought, "Shall I recommend something?" I do not know. We certainly need better information about the problem. We need to get that information of what helps out to the public. We need to be able to use our information to be able to provide a good image, so that we can lobby in a more focused way, so that we can get better public services, and get people to take the risk to build up public services that actually do provide help for those who are hard of hearing.

Discussion

NEW SPEAKER: I was just wondering about Bluetooth. I have heard about it vaguely. Could it be explained?

PROFESSOR DAVIS: Bluetooth is a way of wireless communication between a device like this mobile phone and maybe a hearing aid or a hearing aid-like device. Some people probably know much more about this than me. At the moment, it might have a 30-foot sort of transmission capability. In hospitals, particularly with the new-born hearing screening programme that I work with, we are trying very hard to lobby for better WIFI standards.

I think it is an answer to some of the communication problems. There is a firm called Sound ID in California, who have developed a Bluetooth device that will enable you to profile the hearing impairment or hearing sensitivity of the ear, so that you can actually structure a signal much better. They have taken that as a business idea. I gave them some advice some years ago. It basically looks like a large hearing aid and it can be programmed to an individual.

Their task was to make it much smaller, like an ITE aid. Basically, you could have your phone, or whatever, on the desk or in your pocket, and there would be some signal processing done in the device that would render it much easier to understand and cut out the background noise.

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