PhoneAbility

8. Panel Discussion With Questions From the Floor

Chairman Laraine Callow - Chair Hearing Concern
PANEL:
John Barnes - Telecommunications Committee, Hearing Concern
Professor Patrick Roe - Chairman COST 219 Project, EPFL University of Lausanne, Switzerland;
Stephen Shaw - NHS Purchasing and Supply Agency
Dave Barratt - BT Disability and Age Action

GRAHAM FROST, P.C WERTH Ltd: I saw the presentation from Dave Barratt with concern and was worried that it might represent something that has happened a lot in this field recently, which is the lack of communication between industries.

My concern was that hearing aids now with digital signal processing strategies, which is the area that I work in, are predominantly optimised to amplify and, if necessary, compress in a non-linear manner, and on certain devices to expand and to increase conversational speech at 1 metre. If somebody using a hearing aid takes a telephone handset, which then has compressed speech, inevitably the evidence suggests that will lead to reduced discrimination, because you will have, in effect, a doubling of the compression.

What was interesting was that John Barnes was talking about the signal level arriving at the handset typically being higher than that in normal conversational speech. Because the hearing aid is designed to optimise at conversation speech level, you should perhaps be looking at reducing the speech level arriving at the handset for the hearing aid user.

A normal hearing individual will very often gain an advantage of having a slightly raised level. Very often they will listen to a television or a radio at a level that is above conversational speech, really to cover or mask any other effects.
I am concerned that, if you go down this route, you need to think very carefully about interactions with the signal processing which is going on within the hearing aid.

DAVE BARRETT: I totally agree with what you are saying there. To be honest with you, we can bring the level down as well, but we have got to the stage now where we are not audiologists, and we are not hearing aid manufacturers, or anything like that, and we want to set up partnerships with people who will find out what the best way forward with this is.

What you say, I am sure is quite correct, and it may be that our signal processing does not require that, in which case the person using the hearing aid would not put the number in and would not use any of that signal processing. It is an option that they can or can't use.

What I would like to say, if you are happy with this, is our technical guy asked me to find out some names of people whom he might like to talk to

JOHN BARNES: Graham, you mentioned double compression, and I think you are probably right to be worried a little. However, I know at the Speech Transmission laboratories in Harlow (STL) where I used to work, we did experiments in the '60s where we put AGC on the envelope of speech, so that instead of it going up and down 15dB, as it normally does, we kept it horizontal. We preserved everything else about the speech. We found that the articulation levels went up. That was interesting for us. I do not think we ever published the information, but that was what we found.

Secondly, over a face-to-face conversation, normally we are using two ears, and the preferred listening levels are changed between one ear listening and two-ear listening. In ITU, we have found there is a difference of 12dB in preferred listening levels for two ears, and it goes down by 12dB compared with one ear. I know that does not necessarily agree with some other work which has been done, but that is what we found. We need to be careful about face-to-face conversations and handset conversations, because of one-ear and two-ear listening differences coming in as well.

GRAHAM FROST: Just to respond to that, we are optimising for that sort of listening environment, so to detract from that could have a negative effect. I am not saying your arguments are not sound, but I am concerned as to the lack of working together, and what Dave Barratt said has reinforced the need for the different disciplines to work together.

STEPHEN SHAW: It is a large problem, in that many organisations and industry sections work in isolation; not just in this area, but in many. We need to start bridging those gaps and working together, so that the complementary technologies and services provide the best benefit. It's no use hearing aid manufacturers working in a different direction to telecommunication providers in this industry. As with a lot of other disabled industries, a wheelchair manufacturer will not take into account a lot of other technologies that disabled users may need, so the whole collaboration issue needs raising up the agenda. It is a valid point that Graham makes.

PATRICK ROE: I just have one remark. This kind of compression you were thinking of may still be useful for some people who are not wearing hearing aids, so there might still be a use for that. Then, if you have the choice of either dialling up the numbers, you might, if you worked with the hearing aid industry, actually be able to find a combination that's also good for people who wear hearing aids.

DAVE BARRETT: I totally agree, you have to have choice. If one method suits you, it is pointless going down another route, but if you can get a complement of the two to work, it is ideal.

JIM POTHECARY, HEARING CONCERN: Let us just come back a bit. In 1993, the Radio Communications Agency wrote a report that said that digital mobile phones were going to cause a problem for hearing aid wearers. Way back just before 1996, John Hart, before he died, said the Telecommunications Committee was actually trying to get something done about the problem by lobbying. We are now looking at 2004 and still talking about it.

Is it not about time somebody somewhere. in government, in the charities, in the departments of the Government, actually did something about it instead of still talking about it? Can somebody please have a crack at where we go from here to resolve the problem, to actually do something about it?

STEPHEN SHAW: Yes. I think it is a very good point. Ten years is far too long. I think, traditionally, the National Health Service has worked with a remit of try and improve technologies at no extra cost, whereas now we are looking to introduce superior technologies at no extra cost, and also bringing in new features.

We have now, in the digital contract that supplies all the hearing aids to the NHS, two main suppliers in Siemens and Oticon. We have strategic partnerships with both of those organisations, and there is no reason why we cannot put this topic on the agenda and drive it forward with them. At the same time, within the Purchasing and Supply Agency, we are heavily involved in telecommunications.

I can talk to some of my opposite numbers and find out the exact position from their suppliers, and perhaps we can bring the two sets of suppliers together to look at a way forward, even just in the UK NHS to start with. As a very large provider of both telecommunications and hearing aids, we have the purchasing power to drive the agenda, so let's use it.

The RNID are heavily involved. The Department of Health are heavily involved, as is the Medical Research Council, Professor Adrian Davis. I think now the groups are in place to drive it forward, so I take on board what you said, and I will put it on the next agenda when we meet the suppliers in the very near future. I would welcome input from other members of the audience today as to how we can take it forward.

PATRICK ROE: I would just say, I think there has been some movement since 1993. We have heard this morning that the hearing aid industry has greatly improved the immunity to interference, and I think you are talking about the interference problem and how hearing aids can be used with mobile phones. We have heard there is a 33dB improvement in immunity, which is a huge improvement. Maybe that has not been matched yet by the manufacturers of mobile phones to the same degree, but there are solutions that have been proposed.

So, we have heard of neck loops taking the antenna away from the hearing aid, and there are phones out there where a solution has been found. I agree that we are still talking about it, but we can at least today say, "Well, there are improvements. There have been solutions found." Also, in the States, they have taken action. They have put in legislation.

I just want to react a bit to what Mike Martin read in Tony Shipley's paper about legislation not being really a feasible possibility in Europe. I do not know whether I would go as far as that. I think legislation can be a tool, if we are talking of government action possibly, but also through regulation.

I have an example in Switzerland, where through the regulator, when the licence came up for the universal service provider to take up the licence, they wrote into the licence an obligation to pay the cost of running the Swiss relay service. If Swiss Com wanted to take the licence, they had to pay for the relay service. The regulator does have powers to implement things. I would not like to give the impression that there is no role to play for legislation through regulation. That's another area where some action is being taken on specific topics, and maybe we need to think of other areas where this could be done. I think that is a very good question to raise.

JOHN BARNES: I want to underline, effectively, what has been said. The hearing aid industry has certainly done an awful lot already. Telephone manufacturers, clearly, can do more. Obviously there are mobile handsets out there that do not interfere so much with hearing aids as some others. I just wonder whether there is any patent protection that is preventing other manufacturers taking up some of the same ideas.

One of the ideas that I suppose has been kicked around, obviously moving the ear away, but why have the antenna up the top anyway? Why not down at the bottom near the mouth, where it is further away from the ear. Perhaps there are good answers, but it will be interesting to know.

MIKE MARTIN: I do agree with Patrick Roe that Tony Shipley appeared to be somewhat negative about legislation, but I think we must be very clear to separate legislation from regulation. Legislation is done at a EU level and it is very broad brush. But I am talking about the national regulators. I think that both DTI and Oftel , and possibly Ofcom now but hopefully not, have been very timid about the use of legislation.

If you look in the COST 219 book 'Bridging the Gap', you will find a survey of all of the EU countries. You will see that there is great disparity from country to country as to how they have applied legislation. Some have said, "It is not a problem. We will have this, that and the other." Others like the UK say, "No way. You are having what you have got and nothing more." I think you have to be very careful. I really do think that meetings like this should take it forward so that the needs are shown.

The other point I would like to pick up is, on the question of industries talking to each other, you have the NHS, but your customers are the audiological professionals. You do not get down to the needs in general of the end consumer, which is the hearing aid user.
I think the end consumer tends to get forgotten, so it is a question of who do people talk to. It's no good saying, "Well, our chief executive talks to your chief executive." The talking must be at the right level.

Furthermore, in COST 219, it has been clearly identified that there must also be conversations at the highest policy level, but it's the product managers on the sales side who actually probably have a bigger say than anybody at the end of the day. It is a question of who is talking to who. Again, to pick up Jim Pothercary's point, this has not been going on 10 years; it's been going on 20 years. We really need to do something now.

JIM POTHECARY: I will come back on two points. The first point is that the Telecommunications Committee, and many others, were following up with the Radio Communications Agency possible solutions for the problem and putting something in force that will actually bring about the solution. That seems to have been abandoned.

Now, I would like to know that Hearing Concern and PhoneAbility would get together and follow up with the NHS and with Ofcom to reinstate that committee; to reinstate a forum, which was a formal government forum, to analyse the solutions and put them in place. That is the first thing.

When we come to the technology, and the feeling that the hearing aid instrument manufacturers have done quite a lot towards ameliorating the problem, I think it is very hit and miss. The hearing aid manufacturers, as I see it, had to improve their devices to make them more acceptable for situations like this, where people need to hear more clearly in background noise situations.
They had to go to digital technology. That brought about an improvement in the reduction of interference. Digital technology processes the signal in a totally different way.

I do not think it was done with any specific intention of improving the situation regarding interference. It was done for another reason. For mobile phone manufacturers, moving an aerial in a different position was only to make it more acceptable for an oyster-type mobile phone. It had nothing to do, on both sides, as I see it, with solving the problem of interference. So, please, can somebody follow up a forum to solve the problem? Thank you.

SOEREN LARSEN: The reason why the mobile phone manufacturers do not move the antenna down is very simple. If you ask them, they say, "No. We will get interference with our circuits. When you have the antenna upwards, you interfere with the hearing aid. When you move it down, you interfere with our own microphone and amplifier." That is the reason.

STEPHEN SHAW: I go back to something Mike Martin raised about the end user requirements. I completely agree, historically, the NHS audiologists were our key contact. However, since the introduction of the modernising hearing aid services initiative, there are numerous organisations with a lot of user contact that are heavily involved, and we are looking at the features and functions that are being requested by the end user and building that into the high specifications.

If you look at the products that are now available on the National Health Service, they are in a significant number of instances better than those being sold privately, so we are no longer have a dumbed-down specification. We are high in specification to meet the end user requirements, and I think we owe a lot to the charitable organisations for the fact that we are in that position now. The end user requirements are key to decision-making now.

GRAHAM FROST: Very briefly, a short response to the comment about the implementation of digital technology, in that it was perhaps more susceptible to interference. In fact the most susceptible components to interference in most hearing aids are those components which remain analogue, which can be connecting leads or transducers or other components, so it is not coincidental with the implementation of digital technology in hearing aids. We are more aware because of some of the changes in technologies in mobile phones.

The other thing I wanted to look at was that, this afternoon, the panel discussion has moved and placed emphasis very much on technology. I do not think we should overlook the need for education. We need to advise the hearing impaired individual of appropriate use of what facilities and resources they do have access to.

It was mentioned this morning that this information is available from BT and on the Internet. Well, on my recollection of working in the health service, the 70-year-old lady going for a hearing aid does not want to go back and surf the Internet! She does not want to make phone calls with a device that she is not familiar with, or is unsure of how to use and switch the telecoil on, and if she does then everything else goes quiet. "Why is that, and how do I get back to the microphone again?" is then the question. We need this education and to make information available. If there are better phones, then make that information available.

We mentioned about the IRIL rating for interference immunity or interference susceptibility, whichever way you want to read it, for hearing aids. That information is available to audiologists on data sheets, but I cannot recall picking up a brochure for a Nokia mobile phone and it states a figure that relates to the possible interference level with a hearing aid or with a reference device. So, if, hand in hand, we had an equivalent to IRIL on the mobile phone, the person purchasing it, maybe a hearing aid user could make a judgment as to how that may or may not be compatible with a hearing aid. So let us not forget the overall information, and providing information to the hearing impaired user.

PATRICK ROE: I would just like to reinforce the importance of education, awareness and information. I remember one of the participants in COST 219 was always saying how important it was also to inform the carers and all the people around, and the success of take-up of any new technology was often linked to the fact that there was a network of people who knew about it and who were there to respond to any questions. Otherwise people would try it out, they do not know how to work it, and it is thrown away. This is a very important issue.

How you actually find solutions to the work and get the information out there is not a simple thing. Each area maybe has different solutions, but it is one that, certainly within COST 219, we are very aware of. Dave, I am sure you have good ideas about how to do that.

DAVE BARRETT: Yes. There was a bit about BT putting information on the Intranet. That was due to demand from people who wore hearing aids because they were not informed how it should be done. I totally agree that we should not expect people to go on there to find it, but I would also say I would not expect people to have to come to the Intranet site to find that information out, when it should have been given at source.

We speak to people, and we will say, "This will work in the T position", and they say, "What's the T position?" Our people are telling people how to use the hearing aid in the T position. You are right, it should not be on there for people to go to but, when it is the only thing you can do, it is better than nothing.

STEPHEN SHAW: It is difficult to put every single bit of information into a workable user guide. If you actually look at a lot of the user guides for hearing aids these days, it is more like a novel, whereas it used to be a few sides of A4, at best. We really do have to look at the information that's in those documents and, even today, I have met several people who have said, "Let's get together to look at putting out either a leaflet a flyer, or something that can be handed out to everyone within the NHS clinics together." Simple things like tips for using a mobile phone with a hearing aid; how to get the best results. It's not there.

The booklet the NHS uses is very out of date and still relates to old analogue technology some ten years ago. It needs updating, we have to look at it, but, in the days where government are pulling away from doing things that other people can do, we now have to bring the manufacturers into play to ensure that we have a standard document that is useful for everyone. We can work on these solutions. (Dave Barratt made the commentthat a 70-year-old will not go home to use the Internet. They are the most common users of the Internet!)

I think we have to put the key information on to the handout, but also other sites where they can find useful information, and make them readily available. If we put everything in one booklet, it will go in the drawer and never be used. I think we need to do that for both the hearing aid and the telecommunications side. It is a valid point you make there.

NEW SPEAKER: I cannot resist this. To the gentleman who buys the hearing aids. I see a lot of people who are elderly, and they have terrible trouble manipulating their T switches. Do you purchase nowadays remote-controlled hearing aids for people in that position?

STEPHEN SHAW: The NHS can purchase hearing aids with remote controls. It's not a common prescription. Again, the manufacturers have tried to make the products more aesthetically pleasing and ergonomically usable. However, in this day and age, when the cry is, "Smaller, smaller, smaller," it is more and more difficult, so we have to look at those alternative technologies.
A lot of the suppliers are moving away from remote control because they found the uptake so small, even in the private sector, but it is something we need to take on board. Maybe even if just one of the main models has that facility, we need to make the option available. It is a valid point.

NEW SPEAKER: Actually, the last questioner covered what I wanted to know, and that was how to make use of the T switch easier for people. Obviously I meet a lot of people who are later in their years, and they cannot manipulate that switch. They find it far too difficult

The final thing I would comment on is clarity. All my clients complain about, "Yes, fine, I've got amplification now, but I do not have clarity."

JACK SANDOVER, HEARING CONCERN: The lady has just asked one of the questions I wanted to ask. Can I just put one to Stephen Shaw, a rather nasty one? The Hearing Direct service that you have, the new service where you have a follow-up programme, I gather it is undertaken over the telephone. As you can see from this sort of audience, a lot of us have problems on the telephone. Have you got a way round that?

STEPHEN SHAW: I do not know, is the answer. It is part of the modernisation scheme. It is a trial that they are running in several hospitals. The preliminary results were very positive. I presume they must have found a way round the difficulty. It is an enquiry that I will make, and I will feed it back in to the forum.

JANE FARLOW, HARROW COUNCIL: Talking about remote controls, I am a digital hearing aid user and I have a remote control. I think you have to make certain you are eligible to have remote control, if you have dexterity problems in your hands, which I have, because I have a second disability. Depending on the audiologist, he will recommend you have the remote control.
I have information on this Phonak model. It is very useful, because often I have to go out to assess people, particularly older people, and they have arthritis in their hands. I give them the information, but I tell them not to buy them, and advise they go to audiology and get advice there. It is a very strict eligibility for this.

MICHAEL MITCHELSON, TRUSTEE, RNID: I want to pick up on the Hearing Direct question. I went and visited the Hearing Direct location, in my trustee capacity, about a month ago. The NHS department that sees the patient does the Glasgow Hearing Aid Benefit Profile, the questionnaire of difficulties that they are having, before fitting.

One of the questions they ask is, "How do you cope on the phone?" If they say, "I cannot cope on the phone," they are not referred to Hearing Direct, and have a department appointment. If they cope OK on the phone, Hearing Direct contacts them at a pre-arranged date and time, run through a half an hour questionnaire with them over the phone, and then, if they are happy, the patient is happy, the call centre operator is happy, they then discharge them. If there are any concerns on the patient side or the call centre side, they then automatically book an appointment straight back with the department that first issued the hearing aid.

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