Audacity Issue 6

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Audacity ...a British Society of Audiology Publication

issue 6 May 2015 ..........................

SPECIAL FOCUS

Hearing aid provision in the NHS 12 Auditory training can improve cognition and communication....

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Under Pressure: NHS Audiology across the UK.

47 The Dichotic Hearing Test - a brief history

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audacity@thebsa.org.uk ................................. www.thebsa.org.uk

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Editorial

A

s I sit and contemplate the futility and failures of political pundits and pollsters, I appreciate even more the value and

positive contribution that professionals in Audiology make to society. What will 5 more years of a stronger Conservative government bring to our profession – will it be more of the same? Welcome to the ‘Political’ edition of Audacity! We cannot escape the decisions of policy makers and commissioners and the effects they have are a focal point in our extended ‘Hearsay’ section. Excellent articles by Chris Wood from Action on Hearing Loss and John Day, BSA Council lead on Advisory Issues, describe the ‘rationing’ and ‘pressure’ currently facing many NHS audiology services. Their articles make for rather sobering reading but they do give us recommendations and advice on how to influence commissioning decisions. One such recommendation is to collect and share outcomes data and improve clinical and academic research. The BSA is uniquely positioned to bring this together as its members stretch across the clinical and academic communities. This diversity in membership is evident within the pages of Audacity

Whatever the next 5 years brings, the BSA will be there to champion audiology in all its forms and it will strive to uphold and further advance the positive contribution audiology makes to society – what will pollsters do?

where politics moves to science in ‘Featured Articles’ which looks at modulation, compression and auditory training, and then to academia in ‘Research Round-up’ where Mike Akeroyd tells us about the history and future of the MRC Institute of Hearing Research. We also cover clinical issues and take time to examine audiology in Malawi. We have our regular contributions from the BSA special interest groups and Dion Jones and Amanda Hall have their ears to the ground to provide us with the latest from all forms of media.

Martin O’Driscoll Editor-in-Chief On behalf of the editorial team E: martin.odriscoll@cmft.nhs.uk

editorial

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Contents meet the editorial team...

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Editorial

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Chairman’s Message

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SIG Segment

Martin O’Driscoll

Huw Cooper

information and updates from BSA Special Interest Groups Section Editor: Martin O’Driscoll / E: martin.odriscoll@cmft.nhs.uk

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Knowledge Learning Practice Impact

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Featured Articles

information and updates from the BSA Professional Practice Committee (PPC) and the Learning and Events Group (LEG) Section Editor: Rachel Booth / E: rachel.booth@cmft.nhs.uk

expert writing about topical areas in audiology Section Editors: Martin O’Driscoll / E: martin.odriscoll@cmft.nhs.uk

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Martin O’Driscoll E: martin.odriscoll@cmft.nhs.uk

Rachel Booth E: rachel.booth@cmft.nhs.uk

Rachel Booth / E: rachel.booth@cmft.nhs.uk

Hearsay

News from Regional Groups and BSA Members Section Editor: Danny Kearney / E: danny.kearney@cmft.nhs.uk

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Ear Reach

find out about the latest charity and humanitarian work going on within audiology, both in the UK and abroad, with some opportunities for you to get involved. Section Editor: Jenny Griffin / E: jenny.griffin@cmft.nhs.uk

Audacity is published by: The British Society of Audiology 80 Brighton Road, Reading, RG6 1PS, UK. E: audacity@thebsa.org.uk | W: www.thebsa.org.uk Design: Pinpoint Scotland Ltd

E: audacity@thebsa.org.uk

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Dion Jones E: dion.jones@cmft.nhs.uk

Jenny Griffin E: jenny.griffin@cmft.nhs.uk

W: www.thebsa.org.uk

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welcome to

Audacity ....a British Society of Audiology Publication

meet the editorial team...

37 Ear Globe

an opportunity to learn more about audiology around the world. Explore a different country in every issue! Section Editor: Julie Reading / E: Julie.reading@cmft.nhs.uk

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Lunch & Learn

a summary of the latest bite size online seminars for you to get your teeth into! Section Editor: Shahad Howe / E: shahad.howe@cmft.nhs.uk

Rachel Hopkins E: rachel.hopkins@cmft.nhs.uk

42 Ear to the Ground

a guide to all things Ear-related in the media‌ Section Editor: Dion Jones / E: dion.jones@cmft.nhs.uk

47 Clinical Catch-up

Short articles on relevant clinical topics Section Editor: Rachel Hopkins / E: rachel.hopkins@cmft.nhs.uk Shahad Howe E: shahad.howe@cmft.nhs.uk

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Research Round-up

a spotlight on major ongoing research projects in the Audiology community worldwide. Section Editor: Rachel Hopkins / E: rachel.hopkins@cmft.nhs.uk

Essentials

Key information for the membership Section Editor: Danny Kearney / E: danny.kearney@cmft.nhs.uk Danny Kearney E: danny.kearney@cmft.nhs.uk

The British Society of Audiology publishes Audacity as a means of communicating information among its members about all aspects of audiology and related topics. Audacity accepts contributions, features and news articles concerning a wide range of clinical and research activities. Articles typically emphasise practical rather than theoretical material. Audacity welcomes announcements, enquiries for information and letters to the editor. Letters may be in response to material in Audacity or may relate to professional issues. Submissions may be subject to editorial review and alteration for clarity and brevity. Please email audacity@thebsa.org.uk for further information. Audacity is published in May and December. Contributions should preferably be emailed to: audacity@thebsa.org.uk or sent to; The Editor, Audacity, 80 Brighton Road, Reading, RG6 1PS. Views expressed in Audacity do not necessarily reflect those of The British Society of Audiology, or of the editors. The Society does not necessarily endorse the content of advertisements or non-Society documents included with their mailings. The Society reserves the right to refuse to circulate advertisements, without having to state a reason.

W: www.thebsa.org.uk

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Julie Reading E: julie.reading@cmft.nhs.uk

E: audacity@thebsa.org.uk

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chairman’s message

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Chairman’s Message - May 2015 Dear Members Knowledge, Learning, Practice, Impact: these are the key head-

attract much greater numbers of our members from all back-

ings within the BSA’s logo and they neatly sum up the raison

grounds than in recent years. Full details will follow imminent-

d’être of the society- indeed they are probably the best de-

ly! Meanwhile, the two-day ‘basic science’ meeting in Cardiff in

scription of the BSA’s ‘brand’, if we have one. The concept of a

September this year, organised by John Culling, will be an im-

‘brand’ may seem alien to a scientific and learned society and

portant forum for scientists, researchers and clinicians to hear

more appropriate for the commercial world, but it does help

about and debate the latest findings in audiology and hearing

a great deal to define our aims and objectives. These will be

science- with plenty of opportunity for discussion, interaction

explored and developed in more detail at the council strategy

and of course socialising!

day on May 15th, which will be a great opportunity for all of our trustees and advisors to get to know each other better,

Some turnover in BSA council membership is inevitable, and

plan the BSA’s strategy for the next 12-24 months, and to

the recent resignation of two trustees means that we are now

define roles for everyone involved; the success of the society

looking for ‘new blood’ – please consider coming on board;

depends on the enthusiasm and ideas of its members and

this is a real chance to get involved and be part of a great

council. The day will be led by our new Operations Manager

team that can help the BSA continue on its journey of mod-

Laura Turton, who, since her recent appointment, has amply

ernisation and ever-increasing impact. If you want to find out

demonstrated her apparently boundless energy, rapid under-

more - please get in touch soon!

standing of what the BSA needs, and ability to get things donejust what the society needs and indeed I for one now wonder how we ever managed without her. As ever, the BSA has a full and active programme of learning events throughout this year and next (see our constantly updated website for all the details). The regular ‘lunch and learn’

Best wishes to all our members and everyone in the audiology and hearing science community.

talks are an important resource and I would urge anyone who hasn’t got hooked on them to get into the habit - they work particularly well when watched as a group as part of regular team training, when the talk can lead to sometimes lively discussion and debate! The ‘big’ learning event in the BSA calendar is the annual conference (AC), and the council recently made the momentous decision to move the timing of the AC to the spring – so the next AC will be in April 2016. The overwhelming feeling was that the time has come for a significant re-launch of the AC, at a new time of year (well away from other large UK audiology conferences), in a new,

Huw Cooper Chairman

improved format. I think this is an exciting opportunity to put on a great new conference, organised in close collaboration with the BSA SIGs (Special Interest Groups)- so there will be something for everyone; my hope is that this new AC will become the ‘can’t miss’ audiology event of the year and will

chairman’s message

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SIG segment

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SIG Segment Information and updates from BSA Special Interest Groups

BSA Special Interest Group

BSA Auditory Processing Disorder (APD) Special Interest Group Pauline Grant, Chair, Auditory Processing Disorder (APD) SIG

The updated APD Position Statement and Management Guidelines for APD should be peer reviewed and finalised soon. Thanks to Dave Moore & Nicci Campbell who are leading on these respectively. Both papers will be available on the website. The current documents remain on the APD pages and provide very good information and advice. Both documents have been referenced in the Canadian APD Statement and there is no doubt that the work of the APD SIG is helping to shape international thinking. Thanks to Dilys Treherne for her work on the new Children’s APD leaflet, which will be available this year. Johanna Barry attended our SIG meeting in January to discuss early feedback on the ECLiPSE (Evaluation of Children’s Listening & Processing Skills). Dave Moore joined our meeting on Skype – as he has for the last few meetings since he moved to his new post in Cincinnati.

Johanna and Dave (MRC Institute of Hearing Research) have led this project. It will provide a valuable contribution to the clinical assessment of APD. More information can be found at: www.ihr.mrc.ac.uk/pages/studies/epic-q/ index. We continue to develop our international links with APD professionals in Australia, the USA, Germany, Canada and New Zealand. We are highlighting the news (reported in the previous edition) that the National Foundation for the Deaf in NZ views the perceived lack of APD services in their country as breaching the UN Convention on the Rights of Persons with Disabilities. We continue to fulfil our aim of “Getting the APD message out there”. Since the last edition: • Nicci Campbell organised a highly successful Information Day for Parents and Professionals at Southampton University in November 2014. • Our London Family & Professionals Information Day was held at Queen Square on March 14th 2015 with one hundred and twenty participants – many of whom travelled long distances, including from Scotland, Ireland and Wales. Feedback has been very positive and the day inspired the launch of a Family Support Network, which will be steered by Andrew Strivens, our

SIG segment

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SIG segment

8 Parent Adviser on the SIG. We are enormously grateful to Phonak who sponsored the day and helped us to provide all refreshments and lunch. Parents appreciated the opportunity of hands-on experience of technology and tools to develop listening skills which was provided by all the exhibitors; Phonak, Oticon, GN Resound and Learning Solutions. All speakers donated their time to present and offer advice on the day; thanks to Tony Sirimanna, Doris Bamiou, Stuart Rosen, Pauline Grant, Kelvin Wakeham, Sandra Duncan and Dilys Treherne. Mellissa Levitt gave an inspirational talk on her experience as a sufferer of APD and Andrew Strivens explained a ‘Father’s Journey”. • A further event in the South West is planned. We aim to offer events like this more widely at minimal cost – reflecting our firm belief in the importance of sharing knowledge, supporting families and encouraging a multi-disciplinary approach to the management of APD. More information about APD and its members is available on the BSA website.

BSA Balance (BIG) Special Interest Group Debbie Cane, Chair, Balance Interest Group (BIG) SIG E: debbie.cane@ royalberkshire.nhs.uk

More change at BIG! Albert Coelho has stood down from the steering committee, and I would like to thank him for all his input over the years. Thank you to those of you that have expressed interest in becoming a member of the steering committee. Successful applicants will be informed after our next meeting (April) and we will look forward to meeting you at our subsequent meetings. At this meeting Katy Morgan (Addenbrooke’s Hospital) will take over as Chair of BIG, with Andrew Wilkinson (University Hospitals Bristol) as Vice Chair. I wish them well in their new posts. The work of BIG has continued much as before, albeit at a somewhat slower speed due to reduced committee numbers and their heavy clinical workload. The BPPV testing protocol is due to go on the BSA website for member comment following final publication of the Eye movement assessment protocol. We continue to welcome contributions to the BIG section of the BSA

website, and hope to have a way of sharing anonymised case histories amongst members for comments soon.

BSA Adult Rehabilitation (ARIG) Special Interest Group Lucy Handscomb, Chair, Adult Rehabilitation (ARIG) SIG E: l.handscomb@ucl.ac.uk

Current Projects We are continuing to work on our survey of adult rehabilitation services. It has taken us some time to strike a balance between putting in sufficiently detailed questions to obtain useful information and not overburdening the busy clinicians who will be our respondents! Progress is being made, however, and finding out how aural rehabilitation looks in the UK at the moment seems doubly important in the run-up to the election and impending further changes to the structure of the NHS. We are also beginning work on a revised edition of BSA’s guidance document: Principles of Rehabilitation, in collaboration with the PPC. We welcome the recent publication of the Department of Health’s Action Plan on Hearing Loss, which recognises hearing loss as a long term condition requiring ongoing care and support and which emphasises patient-centred care and shared decision making. We will be using this document to inform our updating of BSA guidelines. Future Projects We welcome the opportunity for SIGs to play a greater role in BSA’s annual conference and very much look forward to putting together a rehabilitation stream for people to attend. This is a great opportunity to promote aural rehabilitation and enable clinicians and researchers alike to further their knowledge and improve their skills. We also hope to build on our links with existing local groups with an interest in rehabilitation. If you are a member of such a group (many of which started out as regional hearing therapy groups) we would be delighted to hear from you. Lucy Handscomb will be representing ARIG at BSA’s strategy day in May. Lucy Handscomb Chair Adult Rehabilitation Interest Group Contact: l.handscomb@ucl.ac.uk

SIG segment

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9 BSA special interest group for cognition in hearing. Piers Dawes, Chair of Cognition in Hearing SIG

Listening Effort by the SIG) • Develop BSA assessment and treatment guidelines for adults with learning disabilities and adults with dementia. If you would like to join the SIG and be added to the mailing list, or suggest an activity for the SIG, please feel free to email me piers.dawes@manchester.ac.uk

E: pier.dawes@manchester.ac.uk

BSA Electrophysiology SIG The aim of the special interest group for cognition in hearing is to promote research in and raise awareness of new developments on cognitive issues in hearing science, assessment and intervention. Since our last update, we have completed a survey of audiologists to identify areas related to hearing and cognition of particular interest.The survey was designed and led by Clare Howard and Christian Fulgrabe. Survey results will be published in a future edition of Audacity and will be used to plan future SIG activities. We have promoted an initiative by the James Lind Alliance Priority Setting Partnership (led by Dr Helen Henshaw and colleagues) to identify research priorities related to prevention, diagnosis and treatment of mild-moderate hearing loss. The first round of the survey is now complete.The SIG will promote the second round of the survey in May 2015, where the aim is to discover which of the questions identified in round one are seen as being the most important for research. (To find out more, see http://www.hearinglink.org/james-lind-alliancepriority-setting-partnership). The SIG also published an article in the BSA Audacity magazine by Dr Piers Dawes on “Can hearing aids prevent cognitive decline and dementia?” The SIG helped with organisation of Journal clubs on hearing loss and dementia, co-ordinated by Jane Wild and Sarah Bent. The clubs were to take place in Manchester, Cardiff and Brighton during March-April. However, the club at Brighton has been cancelled due to insufficient registrations. The SIG has drafted proposals for development of assessment and treatment guidelines for adults with learning disabilities (Siobhan Brennan) and adults with dementia (Sarah Bent). Some upcoming goals for 2015-2016 are: • Release of the results of the clinician survey in Audacity magazine. • Discussion groups on topics related to cognition in hearing (details to be confirmed; focus on topics identified in the clinician survey) • A workshop on measurement of ‘listening effort’ and ‘listening fatigue’ at Manchester University • Discussion white paper on hearing loss and dementia for IJA (following the format of the discussion paper on

Siobhán Brennan, Chair, Electrophysiology SIG E: siobhan.k.brennan@sth.nhs.uk

It’s been a busy and exciting time for the Electrophysiology SIG. One of the major priorities of the SIG is the production of informative and clear guidance documentation for auditory electrophysiological techniques. The new Practice Guidance of Cortical Auditory Evoked Potential Testing edited by Guy Lightfoot has now been submitted to the BSA PPC. There will be the opportunity for the BSA membership to comment on this document. Work also continues on the guidance document focusing on ABRs in older children and in theatre conditions. At the most recent SIG meeting in January at Great Ormond Street Hospital in London, future topics for documents of use to clinicians in auditory electrophysiology were discussed. At the same time as the CAEP document was published,, a training day on the use of CAEP in adults and children was held in Birmingham and well attended. In light of the positive feedback from this event it is hoped that the event will be repeated. More training days in auditory electrophysiology techniques that will not duplicate existing well established courses are also being considered. Other work includes the completion of a document on the Principles of Peer Review and the formation of a working group to produce a guidance document for diagnostic OAEs across age ranges. This will build on the OAE Guidance written by the NHSP Clinical Group. An update to the current ASSR guidance is also being planned. It is likely that the next meeting will be held in Birmingham in November. For any further information on the work of the Electrophysiology SIG do contact Siobhan Brennan at siobhan.k.brennan@sth.nhs.uk

SIG segment

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knowledge learning practice impact

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Knowledge Learning Practice Impact BSA Learning and Events Group Update Mel Ferguson Lead, Learning and Events Group E: melanie.ferguson@ nottingham.ac.uk

One of the special things about the BSA that brings real value to the organisation for both clinicians and researchers are the SIGs – that’s special interest groups to you and me, not Marlboro, Woodbines or B&H. Many of the SIGs have played a blinder over the last six months with some great events, which have been so popular they were effectively a ‘sell out’. • The Birmingham venue in January was bursting at the seams for the Cortical Evoked Potential Measurement in Children and Adult meeting, organised by Siobhan Brennan and Steve Bell and the Electrophysiology SIG. • Ditto for the London APD Family and Professionals Information Day run by Pauline Grant and the APD SIG. This event was different because as the title suggests the focus was on families affected by APD. This reflects an addition we made last year to the new LEG Terms of Reference (which I know you will all have studied with great intent on the website) where patients were included in our targeted groups to participate in networking and learning opportunities. • The Cognition and Hearing SIG worked with Jane Wild (LEG) who organised our second series of Journal Clubs on Hearing and Dementia, following on from the two successful Adult Hearing Screening JCs in Nottingham and the Annual Conference. These were held in Manchester, another maxed out event, and Brighton, thanks to Piers Dawes and Sam Blakemore and their dementia colleagues. By the time Audacity is published two events organised by LEG will have been run – the “What does the Future have in Store for Us all?” Aka the Political Event. This event held in Warrington in April focussed on some of the big gamechanging issues affecting audiology (along with some of the Lightning Updates). The second is the Twilight Series meeting on Comorbidities of Hearing Loss (diabetes, dementia and dual sensory impairment), held in Wrexham in April, with guest speaker Sarah Mamo from Frank Lin’s lab at John Hopkins beaming in. Organised by our LEG stalwarts Chris, Jane, Roulla and er, me.

The Lunch and Learn e-seminars are going from strength to strength (see later in this issue). Recent international speakers were Harvey Dillon, Kathy Pichora-Fuller, and De Wet Swanepoel. Our ratings figures have almost doubled from this time last year where they were running around 350-400 views, with the latest by De Wet pulling in over 777 views at last count! (Although Dawna Lewis broke the all-comers record around the time the NStaffs CCG news broke last summer with her talk on mild hearing loss, albeit in children). A recent contributor, Marshall Chasin, is now advertising LnL within the Canadian Academy of Audiology. I’m delighted to have Christine Yoshinago-Itano, from Colorado give the Summer Special. Her keynote lecture on the birth and evolution of newborn hearing screening at the recent American Auditory Society meeting was truly inspiring. So, to the future. The big news is that the Annual Conference is undergoing a makeover. Based on feedback and comments from the survey held last autumn, the AC is now to be held in April so the two big audiology conferences, BSA and BAA,are broadly equidistant. The new schedule will be a three day event with a basic science day, followed by two days of translational and clinical research and developments.The latter will have strong input from the SIGs. The venue and dates will be advertised imminently. The view of the BSA Council is that these changes will encourage a greater number of clinical delegates, encourage a greater mix of researchers and clinicians, and bring dedicated poster time that our basic science colleagues value so much. The LEG, as ever, has been kept out of mischief by their sterling efforts in getting these events out there. Thanks to my fantastic colleagues Chris Cartwright, Jane Wild and Roulla Katiri, welcome back to Shahad Howe after having her baby, and welcome aboard to Debi Vickers, the LEG newbie. Future events – see the BSA website for details: 3-4th September Cardiff, Basic Auditory Science - the cutting edge 10th September PAIG conference, Birmingham, !Talk! - Talk - ?Talk? Changing how we communicate 12th October Twilight Series, New Perspectives on Paediatric Habilitation, venue tbc

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11 Professional Practice Committee Update Graham Frost, BSc, MSc, MIOA, MIET, RHAD Technical Consultant Chairman, PPC E: ppcadmin@thebsa.org.uk

Anyone who has recently visited the “Resources” pages of the BSA website may have noticed the addition of a number of new documents. I am delighted that one of these, the “Tinnitus in Children Practice Guidance” document, has now been published and, on behalf of the BSA, I would like to thank and congratulate all those who have contributed to producing this very comprehensive and much needed publication. In the introduction to the document it states, “This practice guidance has been written on the basis of the evidence base where it is available, and from the clinical experience and practice of the working party members. Our aim is that the practical and pragmatic advice offered will enable others to develop their clinical skills in tinnitus management with children, and that in turn this will lead to further clinical developments, research, and ultimately a firm evidence base for the management of tinnitus in children.” This practice guidance is intended for the wide range of professionals who may be involved in the management of a child with tinnitus. This can include audiologists, medical professionals, nurses, hearing therapists, educational audiologists, teachers of the deaf, psychologists and other mental health professionals. Some sections are of more relevance to specific professionals than others A series of Newborn Hearing Screening Programme Guidelines and Protocols has also been added to the resource document list. The responsibility for the ongoing maintenance of these documents, which were developed by the NHSP Clinical Group as part of the NHSP Programme, has now been assigned to the BSA and, at their meeting in March, these documents were formally approved by the BSA Council. As such, they will now be subject to the BSA PPC document review programme. Also recently added to the Resources pages of the website is a list of those currently providing BSA accredited short courses. Those providing courses which adhere to BSA Minimum Training Standards and Guidelines on Training are actively encouraged to submit their course details to the BSA PPC for approval and accreditation, which together with

external course moderation visits from a PPC appointed representative, helps towards ensuring the competency in both appropriate knowledge and skill of those successfully completing the BSA accredited course. With the widespread practice of screening hearing function of neonates and children, which has included the adoption of routine screening of all newborn children, particularly in many EU Countries, it has long been recognised that there is an urgent need for ear simulators which reflect the acoustic properties of non-adult ears. Ear simulators are readily available for adults but currently not for neonates, infants or young children. Access to ear simulators appropriate for other age groups and typical ear canal volumes would not only facilitate more accurate characterisation and calibration of both screening and diagnostic measurement and test stimuli, but also reference systems for the development of hearing aids and other devices which may be used in the rehabilitation of the young, or those with physical ear anomalies. This issue is currently being addressed within the framework of the European Metrology Research Programme (EMRP), which promotes innovation and research within the European Community, as part of a project entitled “Metrology for a universal ear simulator and the perception of non-audible sound” (EARS). A neonatal ear simulator for screening applications was identified as having greatest priority and a prototype device has already been developed as part of this project and it is currently being extensively evaluated. David Canning, a co-opted member of the PPC and who currently represents the BSA and the PPC on the British Standards Institute Technical Committee EPL/029 “Electroacoustic” which is responsible for the development of IEC standards relating to Audiometric equipment, ear simulators and hearing aids, is actively participating in this project and I am sure would value any input with regard to both future clinical trials and potential ear simulator applications. We would greatly appreciate hearing from anyone wishing to contribute to the activities of the PPC.

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featured articles

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Auditory training can improve cognition and communication in challenging conditions CD

Author and Correspondence Melanie Ferguson, PhD NIHR Nottingham Hearing Biomedical Research Unit E: melanie.ferguson@nottingham.ac.uk

In 2013, Helen Henshaw and I published a systematic review on the efficacy of computer-based auditory training in adults with hearing loss (Henshaw and Ferguson, 2013a), and demonstrated that the published evidence was very low to moderate and not robust. Reasons for this included failure to include a control group, and a lack of randomisation, power calculation, and participant and tester blinding. Recommendations for future studies included using ecologically valid training environments (e.g. at home), performance-related feedback and adequate reporting of adherence to the intervention and retention of learning. We concluded that there was a need for high-quality evidence to further examine the efficacy of auditory training for people with hearing loss. Along with our colleagues Dave Moore and Dan Clark, we addressed many of these issues in one of our early training studies, and last summer published an original research article in Ear and Hearing entitled “Benefits of phoneme discrimination training in a randomized controlled trial of 50-74 year olds with mild hearing loss� (Ferguson et al., 2014). Fast forward to a cold dark night at the office in early February when an email from Ear and Hearing pinged into my inbox. Assuming it was the reviews of a recently submitted paper, I parked it for a while (peer reviews should on occasion come with a hazard warning regarding raised blood pressure). When

Fig. 1. Study design: randomised controlled trial.

I finally girded my loins and opened up the email, I saw that our phoneme discrimination paper had won the Editors’ Award 2014 for its outstanding contribution to the literature on hearing and balance. This was based on advancing the basic understanding of hearing and balance as well as seeking to translate this knowledge into future clinical practice. We were of course delighted, particularly as Ear and Hearing was rated as the top Otolaryngology journal at the time of publication, with an impact factor of 3.2. A brief summary of the study is described below. The full paper is open access so can be readily downloaded from sites such as Google Scholar, Pubmed or ResearchGate. The aims of the study were to (i) evaluate the efficacy of phoneme discrimination training for hearing and cognitive abilities of adults with symmetrical, mild sensorineural hearing loss, and (ii) determine adherence of users with a self-administered, computer and game-based auditory training programme, delivered in the home via loan laptops. Participants were aged 50-74 years, had not adopted hearing aids, and were recruited through GP practices. There was a mix of computer skills; competent users (38.5%), beginners (45.5%), and never used a computer (16%). A total of 44 participants were included, according to a power calculation based on a speech perception test. A randomised controlled trial (RCT) with repeated measures and crossover design was used. With the exception of systematic reviews, RCTs are considered the higher form of evidence (see Wong and Hickson, 2012). Participants took part in the study over an 8-12 week period (Fig.1). The Immediate Training group (n=23) trained during weeks 1-4. A second waitlist Delayed Training group (n=21) did no training during weeks 1-4, which acted as the control period, but then trained during weeks 5-8. The training was a phoneme discrimination task (e.g. /e/-/a/), presented in an adaptive 3 interval - 3 alternate forced choice, odd-one out paradigm. Feedback as to the correct answer was given after each trial. Participants were asked to train for 15 minutes/day, 6 days/week, for 4 weeks (total 6 hours). Effects of training were assessed using several outcome measures, including speech perception (sentence in 8 Hz-modulated noise, digit triplet in speech-shaped noise), cognition, specifically attention (Test of Everyday Attention)

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featured articles

13 but not all people with mild hearing loss. These results, together with those of other studies that used different training stimuli, suggest that auditory training may facilitate cognitive skills that index executive function and the self-perception of hearing difficulty in challenging situations. The development of cognitive skills may be more important than the development of sensory skills for improving communication and speech perception in everyday life. However, the improvements were modest. Finally, outcome measures need to be appropriately challenging to be sensitive to the effects of training. Following on from this study, we have completed two further studies in adult hearing aid users with mild to moderate hearing loss. One assessed the effect of auditory training on complex outcome measures that are relevant to everyday life, such as competing speech (Henshaw and Ferguson, 2014.). The other is a registered clinical RCT that evaluated the benefits of working memory training (Henshaw and Ferguson, 2013b). A summary of this program of research is due to be published shortly (Ferguson and Henshaw, in press).

Helen Henshaw, Mel Ferguson and Dave Moore receiving the Ear and Hearing Editors Award at the 42nd American Auditory Society Conference in Arizona

and working memory (Digit Span, Visual Letter Monitoring), and self-report of hearing disability (Glasgow Hearing Aid Benefit Profile). These were obtained for both groups during weeks 0, 4, and 8, and for the Delayed Training group only at week 12. Results were reported according to the CONSORT guidelines (Schulz et al., 2010), which provides full and transparent information about how the study was undertaken. Robust phoneme discrimination (on-task) learning was shown for both groups (p<.001), with the largest improvements for those phoneme pairs that were the most difficult to discriminate at the outset. Pre- to post-training, the Immediate Training group showed moderate, significant improvements (p < .001) on self-report of overall hearing disability, specifically for the most challenging situation, ‘having a conversation in a group , with a large effect size, but not for the other pre-defined situations. For cognition, there were significant improvements (p < .01) with moderate effect sizes for a dual (divided) test of attention but not for a single attention test, and for a complex working memory measure (visual letter monitoring) but not a simple measure (digit span). The common feature across the measures that showed a significant pre- to post-training improvement was they were all tasks that draw upon executive functions, whereas tests that did not show improvements were less cognitively demanding. Executive function is an umbrella term for cognitive processes that regulate, control and manage other cognitive processes such as attention and working memory, inhibition, updating and task switching (Chan et al., 2008). Finally, training did not result in consistent improvements in speech perception in noise. Of the measures that showed a significant improvement, between 52% and 75% of participants showed a positive improvement. There was no evidence of any test-retest effects for the control period in the Delayed Training group. At four weeks post-training, significant retention of benefits was shown for all on-task and generalised measures. Improved divided attention and reduced self-reported hearing difficulties were significantly correlated (r = .79, p < .01). In conclusion, phoneme discrimination training benefits some

References 1. Chan, R.C.K., Shum, D., Toulopoulou, T., and Chen, E.Y.H. (2008). Assessment of executive functions: Review of instruments and identification of critical issues. Archives of Clinical Neuropsychology 23, 201-216. 2. Ferguson, M.A., and Henshaw, H. (in press). Auditory training can improve working memory, attention and communication in adverse conditions for adults with hearing loss. Frontiers in Auditory Cognitive Neuroscience. 3. Ferguson, M.A., Henshaw, H., Clark, D., and Moore, D. (2014). Benefits of phoneme discrimination training in a randomized controlled trial of 50–74 year olds with mild hearing loss. Ear & Hearing 35, e110-121. 4. Henshaw, H., and Ferguson, M.A. (2013a). Efficacy of individual computer-based auditory training for people with hearing loss: a systematic review of the evidence. PloS One 8, e62836. 5. Henshaw, H., and Ferguson, M.A. (2013b). Working memory training for adult hearing aid users: study protocol for a double-blind randomized active controlled trial. Trials 14, 417. 6. Henshaw, H., and Ferguson, M.A. (Year). “Assessing the benefits of auditory training to real-world listening: identifying appropriate and sensitive outcomes.” in: Proceedings of ISAAR 2013: Auditory Plasticity - Listening with the Brain. 4th symposium on Auditory and Audiological Research, eds. T. Dau, S. Santurette, J.C. Dalsgaard, L. Trangjaerg, T. Andersen & T. Poulsen: The Danavox Jubilee Foundation). 7. Schulz, K.F., Altman, D.G., and Moher, D. (2010). CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMJ 340. 8. Wong, L.L., and Hickson, L. (2012). Evidence-based practice in audiology: Evaluating Interventions for Children and Adults with Hearing Impairment. Plural Publishing.

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Modulation in all things : the frontier beyond audibility CD

Author and Correspondence Michael Stone, MA, PhD Senior Research Fellow in Audiology and Hearing Sciences School of Psychological Sciences, University of Manchester, M13 9PL and Audiology Department, Peter Mount Building, Central Manchester NHS Foundation Trust. E:michael.stone@manchester.ac.uk

Take home message

“The problems of preservation of information between the transmitting mouth and the receiving brain”

Introduction Consider an alarm siren. The act of switching it on conveys information: an action needs to be taken. While it continues to sound, no new information is being transmitted. When it ceases, new information is conveyed: either the required action has been taken or the power supply to the alarm has been depleted or destroyed. New information only appears at the onset and offset of the alarm. The process of turning something on or off, or more generally, varying its level, is called amplitude modulation (AM). Although other forms of modulation exist, here we refer only to AM. Modulation is very important for conveying acoustic information such as in speech or music. (The nature of the “information” conveyed in the modulations of John Cage’s piece 4’33” is best left to an after-dinner discussion at a BSA conference). Modulation cannot exist on its own; it needs a “carrier”, the siren in our earlier example, onto which is impressed the modulation, the simple act of turning it on and off. In speech, air passing through a constriction of the vocal tract produces the

carrier, in the form of acoustic energy. If the constriction is at the larynx, the energy is tonal in nature, otherwise a noise, frication, is produced. However,

without any movement of the tongue, teeth or lips (the articulators), this acoustic energy carries little informa-

tion. Articulator movement modulates the energy of the acoustic sources as it progresses along the vocal tract. Figure 1 shows the time course of pressure variations of the word “eventually”, as pronounced by an antipodean.The blue trace shows up properties of the carrier, such as the regular pulsing of voicing between 150 and 300 millisecs, or the roughness of frication between 300 and 400 millisecs. The red trace shows the modulation of the carrier applied by the articulators. This modulation is generally fairly slow compared vibrations associated with the voicing or frication, but does occupy a range of rates. Sometimes the articulators move slowly, as when the lips move between the /e/ and /n/ in Fig. 1 (200 to 300 millisecs), and sometimes faster as when the teeth open to release the built-up pressure when moving between the /v/ and the /e/, (150 to 180 millisecs in Fig. 1). Rosen (1992) proposed a framework to describe the function of the different rates of modulations, splitting them into a range of 2 to 50 Hz, which convey segmentation cues and prosody, and the range of 50 to 500 Hz, which largely conveys pitch. Note that although these ranges are described in Hz, they do not represent the acoustic frequency of the signal, but the rate

Figure 1

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15 at which the modulation is varying the level of the carrier (the voicing or frication). To avoid confusion, here we use the concepts of modulation rate and acoustic frequency, to describe the different properties of the signal, even though we describe both in units of Hz. Predicting the intelligibility of speech in communication systems Understanding what features of speech need to be preserved as well as predicting the resulting intelligibility after their transmission through electro-acoustic systems such as telephones, public address systems or hearing prostheses has kept scientists and engineers well employed since the early days of the telephone. The Speech Intelligibility Index (SII, ANSI, 1997) is a much-simplified model from its predecessors. However, it provides a quick and useful indicator of when communication difficulties may arise. It is based on measuring what proportion of speech cues in the audio frequency range are both audible and also exceed any background noise. Although one may know the proportion of the speech cues that are preserved, this does not immediately translate to a prediction of intelligibility. For example, in a difficult listening situation, sentences are much easier to understand than isolated words, because the context of the surrounding words helps to fill in the blanks. Putting that in numbers, only about one quarter of the articulation needs to be audible for the intelligibility of sentence material to reach 90%, but the intelligibility of isolated words would only be around 60% (French & Steinberg, 1947). That such little articulation needs to be present demonstrates how robust speech is to the presence of distortions. However, when distortions are present, drastically reducing the articulation of the speech even in quiet, only a small amount of extra distortion, such as background noise, causes intelligibility rapidly to disappear. One “working” example of such can be found on the platforms of Manchester’s Piccadilly railway station (alternative examples are available elsewhere).

For all its usefulness, the SII performs poorly when other factors are not taken into account, such as the type of background noise, whether fluctuating or continuous (Rhebergen and Versfeld, 2005), or the proficiency of the listener. For example, cochlear implantees obtain less intelligibility from speech presented with word production rates at which normal-hearing listeners can easily cope (Boyle et al., 2013). More recent models for predicting speech intelligibility still use the concept of the audibility of the signal above the background noise, but in the unfamiliar domain of modulation rate rather than audio frequency as used by the SII. These models, (e.g. Dubbelboer & Houtgast, 2008; Jørgenson & Dau, 2011), are more complex than the SII, but reflect a growing awareness of the importance of modulations to intelligibility. For example, for the same energy and spread in acoustic frequency, an interfering noise with large modulations can be about 7 dB more disruptive at masking a speech signal than a noise constructed to have negligible modulation (Stone & Moore, 2014). Modulations are a property not to be ignored. Applicability to audiology Hearing prostheses employ a range of signal processing techniques to transmit the dynamics and complexity of the real world through the degraded hearing system in order to achieve both audibility and discriminability of the signal. What do we mean by this? Consider an extremely fast-acting automatic volume control (AVC) designed to produce an output that is always audible to the user. The enormous dynamic range from rustling wind to raging rock concert, would always have the same reproduced level. Consequently, no matter what variation in level (modulation) was present on the input signal, the output signal would have no modulation. The signal may always be audible, but would carry little information (a situation approximated by the “loudness maximisers” used by many commercial radio stations and producers of popular music). The diametric alternative of having amplification with no AVC,

preserves discriminability, but only for the narrow range of input levels which manage to achieve audibility. Clearly, some compromises are necessary for a useful real-world device. Hearing prostheses contain multiple dynamic processing systems such as adaptive directional microphones, noise reduction, dynamic range compression (DRC) and feedback suppression. They all operate by manipulating the modulations in various frequency regions of the acoustic signal. Some modulations are intentionally reduced, such as by DRC, while others are enhanced, such as by noise reduction. The speed over which these manipulations are performed is mostly a choice of the designer of the prosthesis, but apply mostly to the 2-50 Hz range of modulation rates. If short time constants are used then a wider range of modulation rates are affected; if the time constants are long, then only slower modulation rates are affected. The audio-frequency-based SII would have little to offer in guiding design decisions, hence the need for the modulation models. Finally: two legs good, four legs bad ? The human in the loop Two landmark papers by Gatehouse et al. (2006a,b), demonstrated that choice of effective settings on a hearing aid requires not just the audiogram, but also an assessment of the cognitive abilities and the lifestyle of the patient. Another factor to add to the mix is age: older people appear to be less sensitive to the fine-time information contained acoustic carrier signals (Grose and Mamo, 2010). Consequently, one would expect them to be more reliant than younger people on the modulation cues. One patient group, cochlear implantees, rely almost exclusively on the modulations since the carrier information is mostly discarded by the device processing. Although speech is not the only signal that people listen to, it is a useful benchmark for the effectiveness of a communication system. A “sound-bite” take-home message would obscure the underlying intricacies of the problem of

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16 preservation of information between the transmitting mouth and the receiving brain. Finally, let’s not forget the final “human in the loop”: the audiologist making intelligent adjustments to a fitting in response to patient feedback.

www.thebsa.org.uk

References 1. ANSI (1997) ANSI S3.5-1997, American National Standard Methods for Calculation of the Speech Intelligibility Index. American National Standards Institute, New York. 2. Boyle PJ, Nunn TB, O’Connor AF, and Moore BCJ (2013) STARR: a speech test for evaluation of the effectiveness of auditory prostheses under realistic conditions. Ear Hear. 34:203-212. 3. Dubbelboer F, and Houtgast T (2008). The concept of signal-to-noise ratio in the modulation domain and speech intelligibility. J. Acoust. Soc. Am.124:3937–3946. 4. French NR, and Steinberg JC (1947). Factors governing the intelligibility of speech sounds. J. Acoust. Soc. Am. 19:90–119. 5. Füllgrabe C, Stone MA and BCJ Moore (2009) Contribution of very low amplitude-modulation rates to intelligibility in a competing-speech task. J. Acoust. Soc. Am. 125:12771280. 6. Gatehouse S, Naylor G, Elberling C. (2006a) Linear and nonlinear hearing aid fittings: 1. Patterns of benefit. Internat J Audiol 45:130-152. 7. Gatehouse S, Naylor G, Elberling C. (2006b) Linear and nonlinear hearing aid fittings: 2. Patterns of candidature. Internat J Audiol 45:153-171. 8. Grose JH and Mamo SK (2010) Processing of temporal fine

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structure as a function of age. Ear Hear. 31:755-760. 9. Jørgensen S, and Dau T (2011). Predicting speech intelligibility based on the signal-to-noise envelope power ratio after modulation-frequency selective processing. J. Acoust. Soc. Am. 130:1475–1487. 10. Rosen S, 1992. Temporal information is speech: acoustic, auditory, and linguistic aspects. Phil. Trans. Roy. Soc. Lond. B 336:367-373. 11. Rhebergen KS and Versfeld NJ (2005) A Speech Intelligibility Index-based approach to predict the speech recep-

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tion threshold for sentences in fluctuating noise for normal-hearing listeners. J. Acoust. Soc. Am. 117:2181-2192. 12. Stone MA and Moore BCJ (2014) On the near non-existence of “pure” energetic masking release for speech. J.

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17

Using the ASSE test to evaluate hearing aid fitting in children CD

Authors and Correspondence Sally Harman, MSc CS Senior Clinical Scientist (Audiology) Audiology, Bradford Royal Infirmary, BD9 6RJ E: sally.harman@bthft.nhs.uk T: 01274 364827

Sara Morgan, MSc CS Senior Clinical Scientist (Audiology) Audiology Bradford Royal Infirmary, BD9 6RJ E: sara.morgan@bthft.nhs.uk T: 01274 364827

Rob Gardner, MSc CS Consultant Clinical Scientist (Audiology) Audiology, Bradford Royal Infirmary, BD9 6RJ

Take home message Standard aided outcome measures may not provide sufficient information, to the audiologist and other professionals, about a child’s ability to detect and discriminate speech sounds clearly. Phoneme tests which rely on audition only should supplement the standard test battery, and alternatives considered if a child appears to be struggling.

As part of our routine evaluation of children with hearing aids we have started to utilise the Auditory Speech Stimuli Evaluation (ASSE) test. ASSE can be used with all children capable of behavioural testing, i.e. 6 months development age and up. It is a test that has minimal cognitive bias and is language independent, unlike word or sentence material. The principle of ASSE is to test a patient’s ability to detect phonemes and discriminate

between paired phonemes. Non Linear Frequency compression hearing aids (NLFC) came into routine use within our department several years ago. NLFC aids are promoted as a way of improving a patient’s audibility of high-pitched sounds and fricatives such as /s/ /sh/ and /f/ by compressing them into an area of increased audibility. Our assumption had been that the detection of these phonemes should therefore not be problematic, but we were keen to see if the compression of the high pitch sounds would have any impact on the children’s ability to discriminate, especially between high frequency pairs such as /s/-/sh/. The first part of the ASSE test is used to evaluate whether the child can detect each of the phonemes (/i/ /a/ /u/ /z/ /s/ /m/ /v/ /sh/). The second part evaluates the child’s ability to discriminate between seven paired phonemes (/i/-/a/, /u/-/a/, /u/-/i/, /z/-/s/, /m/-/z/, /s/-/sh/, /v/-/z/). The stimuli phoneme is presented at random in a series of repetitive background phonemes, at 65dBHL with a roving +/-3dB to remove intensity cues; any pairs that included a phoneme the child was unable to detect were removed from this part of the test. Twenty-nine children with stable sensori-neural hearing losses completed both detection and discrimination lists. The children were all long term users of NLFC, bilaterally aided, and their hearing aids were verified in a test box before testing to ensure they were working within technical specification. Very

Verification is not enough to ensure children have sufficient audibility; evaluation is required. quickly we began to notice that although some children were experiencing no difficulty in completing detection and discrimination lists, others were really struggling. We therefore decided to review these results in more detail to see if there was any commonality between those who were unable to complete the test, and if there were any adjustments that could be made to improve results

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18 There were eighteen children who scored 100% on detection and discrimination, and when we reviewed their audiograms they had average mild or moderate hearing losses (BSA, 2011) in at least their better ear. Their better ear audiograms are plotted in figure 1. The remaining eleven children were found to have average severe or profound hearing losses in at least their better ear. Their better ear audiograms have been plotted in figure. 2. Figure 1.

When we reviewed the detection data of the eleven children, we found five could not detect /s/. Four more children could not detect /s/ and at least one other phoneme (/sh/,/z/, /v/) meaning only two children who had severe/ profound hearing loss could detect /s/ when it was presented at 65dBHL. Figure 3. shows the detection results for all children. When we review the discrimination data there were only two of the seven pairs that all eleven children could correctly discriminate between (/i/-/a/ and /u/-/a/).

Figure 2.

The pairs: /z/-/s/, /s/-/sh/, /m/-/z/ and /v//z/ could not be tested with all eleven children as they contained one or more phonemes which the children had not been able to detect. Of all the pairs tested, there were two surprise results. Even though all the children had been able to detect /u/ and /i/ only two children could discriminate between them. Of the children who could detect /v/ and /z/ no one could hear the difference between these two phonemes. Figure 4. shows the discrimination results for these eleven children. The spectral analysis of the phonemes indicated that the pairs which caused no difficulty depended on low frequency hearing ability, and the pairs that had caused difficulty required the child to be able to hear from 2kHz upwards.

Figure 3.

Conclusion These results relating to the children

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19 with severe and profound hearing losses were unexpected. We had assumed that they would have no significant difficulty completing both aspects of the ASSE test as their hearing aids were set to target (DSL v5), they had acceptable McCormick toy test scores and their parents, teachers or speech & language therapists prior to testing had not raised any concerns.The results have therefore highlighted the fact that paediatric audiology clinicians cannot simply take the above information as confirmation of successful hearing aid fitting; further phoneme testing, both detection and discrimination, are a necessary outcome measure. As a result of these findings we contacted other involved professionals, who informed us that some of the children had known concerns regarding their learning and speech development, but which had been assumed was unrelated to their hearing. We have three hypotheses why the children with severe and profound losses were unable to do ASSE testing: 1. Dead regions: Given the level of loss the TENS test would not be able to confirm or disprove this.

Figure 4.

plant (CI) centre is that increasing the dynamic range between threshold and comfort level improves a CI user’s ability to discriminate on the ASSE test. At severe to profound hearing levels the opportunity to increase the dynamic range on a hearing aid is minimal and therefore we are limited to what we can achieve if it turns out the dynamic range is a dominant factor. Research is currently being carried out looking at the cochlear implant referral guidelines which suggests a relaxation to a 2 point average of ≼85dBHL at 2 & 4kHz, or a 4 point average of ≼80dBHL at 0.5, 1, 2, & 4kH (R.Lovett & D.Vickers 2015). Interestingly, all eleven children with severe and profound losses would meet this relaxed version of the criteria.

2. The NLFC settings are distorting the frequency cues: We contacted the hearing aid manufacturer for advice who suggested trialling stronger and weaker settings. The few children who have attended further appointments have repeated the ASSE with stronger settings, weaker settings, and with the NFLC deactivated. We have seen no improvement in their ability to complete ASSE. We would have liked to explore this further, and with more children, however attendance for appointments has been poor.

Of our eleven children, nine have been advised to go for, or went for, CI assessment off these results; four of which have had or are in process of getting implanted, three were discharged as they were felt to be functionally too good on the CI test battery, one did not want assessment and one left the area.

3. The dynamic range provided by hearing aids is not enough to access the intensity cues required to discriminate between phoneme pairs. Anecdotal evidence from clinicians who work at the local Cochlear Im-

We are continuing to utilise ASSE testing to assess children at their annual review as this review has highlighted the importance of using other outcome measures, particularly those that rely solely on audibility.

References 1. BSA, 2011. Recommended Procedure, Pure-tone air-conduction and bone-conduction threshold audiometry with and without masking 2. Lovett RE1, Vickers DA, Summerfield AQ. Ear Hear. 2015 Jan;36(1):14-23. Bilateral cochlear implantation for hearing-impaired children: criterion of candidacy derived from an observational study.

Look out for Assistive Devices in the next issue of Audacity

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20

Hearing Aid Rationing ties of this: 1. Exclude patients on the grounds of lifestyle or other factors, and 2. exclude procedures that are thought to be of low value, such as tonsillectomy. We might therefore appreciate why commissioners will scrutinise health interventions to identify targets for potential rationing. John Day, Consultant Clinical Scientist. BSA Trustee and Council Lead on Advisory Issues

Introduction Since summer 2014 the BSA has been aware of formal plans by NHS commissioners in England to limit access to hearing aids by adults. This article will provide the background to and basis of these proposals. As a consequence, there are some lessons for the future which will be discussed in the context of recent publication of key documents concerned with Audiology Services in England. The article is accompanied by referenced material for use by members to help influence and respond to challenges from those allocating NHS resources in the UK. Definition and context Let’s start with a definition of Rationing: ‘a limited amount of something that one person is allowed to have, especially when there is not much of it available’. In the current period of public sector austerity we have seen health sector inflation driven by increased demand, run up against restricted NHS funding, creating a widely reported funding gap of £30bn by 2020/21, of which an estimated £22bn is planned to be achieved through efficiencies. The financial challenge and pressure to find solutions is extreme across the UK NHS. So, in a healthcare context, rationing is one way by which commissioners can help balance budgets, now and in the future. There are two varie-

Why are hearing aids a target? Aside from the emergence of rationing in healthcare, what has prompted the spotlight to be directed at adult hearing aid provision at this particular time? It is perhaps more than a coincidence that the three CCGs that have been most prominent in exploring forms of rationing, North Staffordshire, Kernow and North, East & West Devon have also all adopted Any Qualified Provider (AQP). The recent Monitor Report on NHS hearing aid services in England, refers to increased demand and expenditure as a by-product of AQP. Indeed, a representative of one of these CCGs has disclosed that over a 2 year period since introduction of AQP, hearing aid expenditure had increased from £800K to £2m per year in the CCG area. It might be expected that significant additional costs at a time of reduced funding is likely to attract attention and prompt rationing. Note, although this article has referred to ‘rationing’, the term may not be used overtly by NHS commissioners, or politicians, but could exist under the guise of ‘eligibility criteria’ and ‘candidacy’ etc. Additionally, it would perhaps be naive to assume that rationing of hearing aids for adults has not already taken place. Indeed, there is some evidence that limited numbers of individual English Trusts have adopted similar candidacy criteria over several years at a very local level, perhaps driven by cost saving initiatives. There is also an argument that existing GP ‘gate-keeping’ also provides a mechanism for rationing through limiting

access to Audiology services. However, what marks out the recent commissioner (CCG) proposals is that they reflect overt decision-making to target hearing aid provision within an overall healthcare rationing agenda – each has attracted a significant response from national stakeholder groups and media attention. Those of us who manage and defend budgets for NHS Audiology services will be particularly aware of the competing demands for limited resources from other elements of healthcare at a local level. High profile gaps in care are increasingly evident, regularly attracting media attention. These include long waits at A&E departments and high cost cancer treatments. These are literally ‘years to life’ components of the NHS that demand attention and resources that inadvertently detract from other interventions such as hearing aid provision that ‘add life to years’. The point here, is that when looking for interventions to ration, the list will already be limited by exclusions. Subjective effects may also be influential; the personal value judgments and preconceptions of commissioners may also play a part when deciding on which interventions should even be considered for rationing. BSA contribution and experience to date How has the BSA contributed? As a learned society, the BSA is not representing the interests of any one profession. Furthermore, the BSA has been able to draw on the expertise of individuals in the research, academia and clinical practice to shape our contributions. This is evident in the detailed evidence-based response to commissioners. Collaboration with the stakeholder groups, including Action on Hearing Loss, the BAA and local contacts, has been a positive to take from developments to date.

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21 Updates on the progress of rationing proposals by individual CCGs has been provided through the BSA website News section and emails where you can look for further detail. In short, the varied proposals have included limiting bilateral provision and use of audiometric fences to ration hearing aids. The BSA has responded with letters to CCGs and the Minister for Health, Freedom of information (FOI) requests and representation at local events. There has been some local and national media interest to date. The North Staffordshire CCG took the approach of using a ‘Modified Portsmouth Scorecard’ which uses a number of factors to appraise interventions against available evidence and policies, so as to guide commissioning decisions. The BSA and other stakeholder groups have concerns over the process and conduct of this CCG in reaching their decision to implement eligibility criteria that are planned to commence October 2015. The BSA is particularly concerned at errors in analysis of the scientific literature/evidence base and consequently, underscoring of hearing aids as an intervention against the scorecard factors. Additionally, tools such as the Portsmouth Scorecard are geared towards appraising new interventions. This is also true of much evidence on efficacy of interventions; research efforts are directed at the new rather than the established, ‘proven in practice’ interventions – which has put hearing aid provision at something of a disadvantage. Going forward, what are the lessons? Whilst those working in the field of Audiology can readily convince each other that hearing aids are an effective healthcare intervention, the reality of course is that in a competitive environment we need to convince outsiders. This will require cogent evidence from the literature and patient reported outcome measurements. With respect to the latter, Audiology is potentially well placed compared to other disciplines. In terms of evidence, the evidence base is probably not

unhealthy compared with other disciplines but needs to be better given the scrutiny that we face. What can be done nationally and locally to survive and perhaps thrive, in a rationing environment? • Stating the obvious; we need to i) ensure that our interventions are more effective and ii) demonstrate that they are. Reduction in non-use of hearing aids should be a priority, as whatever the reason, non-use of hearing aids is not perceived as a sign of prudent use of health resources; notwithstanding similar wastage with other interventions eg medications. The ‘offer’ to patients perhaps needs to be more nuanced than just hearing aid fitting, requiring discussion of alternatives and identifying those who would benefit from those alternatives. In short, effectiveness can only improve if we have more motivated, engaged and informed patients. In turn, this will require description within a quality standard setting and in service specifications for commissioning purposes. A focus on holistic rehabilitation rather than hearing aid fitting would also be concordant with evolving person-centred care and co-production across the UK NHS, positioning our interventions as progressive and favourable in the eyes of commissioners. In terms of demonstrating effectiveness of interventions; across healthcare, Patient Reported Outcome Measures (PROMS) are an acknowledged tool to assess efficacy of interventions. Applied to cohorts of audiology patients at a local level, they would enable services to provide commissioners with persuasive local data demonstrating efficacy of interventions. • Work with third sector and user groups at a national and local level – we typically have a long term engagement with our patients, there are many of them and they are our allies in arguing for resources.

• Research priorities should be influenced by the rationing agenda to provide the evidence base to improve and demonstrate the efficacy of our interventions. This will include identifying associations with emerging high profile healthcare themes such as dementia. • We need to take a positive and pro-active stance with those controlling resourcing decisions locally whether commissioners in England or NHS policy leads elsewhere. We need to underscore our case with reference to national policy documents such as the English Action Plan on Hearing Loss and the Monitor Repor t. These are government documents highlighting the impact of hearing loss and vir tues of intervention. Additionally, the former document states: ‘there are plans for the National Institute for Health and Care Excellence (NICE) to develop a clinical guideline and quality standard for Adult Onset Hearing Loss to help standardise and ensure effective, high quality, commissioning and provision of adult hearing loss services. Development of the clinical guideline is provisionally scheduled to begin in 2016 with production of the quality standard to follow.’ This is obviously a seminal piece of work that the BSA and membership will need to contribute to. Fundamentally, hearing aid provision is a cost effective intervention yet we need to be persuasive and provide cogent arguments/evidence to commissioners. The document presented below has been adapted from material presented by the BSA to inform commissioners over the last year, on the merits of hearing aid provision. It could be used as a framework to shape argument for resources locally and to guide research priority setting. It will need to be updated as new evidence becomes available.

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22 Influencing Commissioning Decisions: Information on Candidacy for and Efficacy of Hearing Aids Hearing aid candidacy Identification of successful candidates for hearing aids is multifactorial, requiring Audiology professionals to make judgements based upon each patient’s specific hearing needs, motivation, lifestyle, the audiogram and other factors such as presence of tinnitus. Professionals make such complex judgements mindful of the potential benefit that can be afforded by hearing aid technology complemented by other elements of hearing rehabilitation. Given this, the application of an audiometric ‘fence’ to ration this intervention is regarded as a crude and ineffective starting point - in practice, the profile of the hearing loss at different frequencies, the profile of loss for both ears and hearing at other frequencies are also considered when determining suitability for hearing aid fitting. The BSA believes that the inherently complex decision-making on amplification should be left to the well-informed professional taking a holistic approach. It is well established and agreed that the proportion of the hearing impaired population using hearing aids is well below the level who would gain benefit (even when defined by audiometric levels). This discrepancy in part, may relate to under-referral. However, it also likely relates to an aversion to hearing aid use (associated with the stigma of hearing loss and hearing aid use) and failure to recognize hearing difficulties, particularly the impact on others. In short, hearing impaired adults presenting to Audiologists have demonstrated that they are sufficiently motivated by seeking help for their hearing difficulties and consenting to referral. Health benefits afforded by hearing aids. Evidence supporting amplification is presented in the reference list (below), providing a sample of key items from the scientific literature, which has been summarised under the following headings:

i)

Benefits of early amplification: It is well recognised that providing hearing aids to someone early is more beneficial than waiting. The UK Health Technology Assessment (1) reported that ‘those identified early had greater benefit than those of the same age and hearing impairment who were fitted with hearing aids later’ (p. 145). This reflects in part age-related co-morbidities (eg reduced manual dexterity) impacting on use, satisfaction and benefit from hearing aids, but also likely neuro-degenerative effects associated with underuse of the auditory pathway. Therefore, continued auditory stimulation and familiarization with hearing aids for those with mild losses can be regarded as preventing more disabling hearing impairment if hearing aids were provided many years later – as would be the case if the variation proposal were implemented. There is a clear secondary impact too; withdrawal of hearing aid fitting to those with mild hearing loss would impact adversely on those ultimately presenting for first hearing aid fitting later in life with severe losses.

ii) Magnitude of health improvement. A UK Health Technology Assessment (1) found a significant improvement on the generic quality of life indicator the Health Utilities Index (HUI) of 0.075 (95% CI 0.038 to 0.112) for individuals fitted with hearing aids from mild losses onwards. Other studies (2,3,4) have reported HUI-3 improvements from hearing aids are 0.06, 0.12, and 0.08, respectively.There are also well established impacts of hearing aid use on condition specific measures (5, 6). In terms of scale, we know that hearing impairment is within the top 20 health conditions identified in the WHO Global Burden of Disease initiative (20). iii) Strength and quality of evidence. Most randomised controlled trials (RCTs) of hearing aids compare their features or fittings (7). There are few RCTs investigating the effectiveness of hearing aids per se. This is because their benefits are long recognized and demonstrated, and in today’s research funding climate it is doubtful that any grant funder would fund a RCT to show the benefit of hearing aids. In many ways a hearing aid is the ‘best-proven’ intervention for hearing loss, which in a UK context provides difficulties in performing an ethical RCT study. However, two available RCTs have demonstrated clear benefits of hearing aids to hearing-related quality of life (8,9).

Aside from the research evidence base, we believe that it also important to consider practice-based evidence. Audiology has been at the forefront in the use of patient reported outcomes measures (PROMS) within service delivery. Extensive use of research validated PROMS is used to manage individual patients and monitor impact of interventions across cohorts of patients. Data such as from the Glasgow Hearing Aid Benefit Profile (10) should be available from the local services.

iv) Health economic measures. The cost effectiveness ratio (or cost per Quality Adjusted Life Year, QALY) is an equation used commonly in health economics to determine and compare cost benefits of interventions. It is the ratio of costs to benefits, where the benefits are measured in QALYs. Where a comparison is made with an existing intervention an incremental cost effec-

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23 associated with lower paid occupations (17) and those from lower socio-economic groups (18). As a group they may be expected to predominate in areas of deprivation. This provides for an underlying health inequality associated with hearing loss. At a local level, the mix of people accessing free NHS hearing aid services is further weighted towards those who would be unable to purchase private hearing aids. Limiting access to NHS hearing aids would leave individuals faced with the option of unmanaged hearing loss with adverse impact on their communication, health and well-being, or payment for a private hearing aid. Withdrawal of NHS free hearing aids services would increase inequalities and also lead to inequity in health.

tiveness ratio (ICER) can be calculated. So for the intervention of hearing aid provision, if the base case is no hearing aid provision (or any other alternatives) then the ICER for bilateral hearing aid provision is c£1300 (2012 data)*. Interventions with ICER estimates up to £20,000-£30,000 are considered acceptable by NICE (11), so on this basis hearing aid provision is very cost effective.

*calculated from supplementary data table 6 presented with reference (12).

Opportunity Cost is the cost per head of population who will potentially benefit from the development. The tariff costs for hearing aid provision and support, familiar in England, can be used here and are low by comparison with annual costs of other interventions. For illustration, a non-generic drug to manage chronic health conditions would typically cost £1300-2000 per year.

v) Prevention of future illness. There is increasing evidence of an independent association between hearing loss, declining cognitive function (13) and dementia (14). Hearing aid use has been associated with better cognition (15) and evidence of the benefit of hearing aids on communication (see above). Consequently, a reasonable hypothesis is that hearing aids will slow the rate of cognitive decline that would ordinarily lead to a diagnosis of dementia. This is having an important influence on the research field: it has catalyzed it into a ‘hot topic’, and many groups are now studying hearing loss and cognition.

Given the scale of impact and burden of dementia on individuals, their carers and society, as well as its current prominence on the health-care planning agenda, it would be quite imprudent to limit an intervention that has a positive impact on communication ability in the elderly.

vi) Benefits for people with existing health problems. Amplification has a positive impact for people with existing health conditions such as depression (9) and dementia (16). If people can hear and understand better then they can manage their other morbidities so much better, as well as reduce the disability and handicap they might develop in the future. It also reduces barriers to communications with their doctors or other health-care providers: indeed, one could argue that good communication is fundamental to all health care. Hearing aids should be available to support all with mild hearing loss to i) mitigate the impact of other health problems (e.g. depression) and ii) optimise outcomes of other healthcare interventions.

Inequalities would be a particular issue in areas of the UK which have an industrial and associated industrial noise heritage. Lifetime noise exposure at work has been established for decades as a primary factor in hearing loss (19), so we would expect that there could be a relatively high proportion of hearing-impaired people in such areas. In the absence of any detailed surveys of the prevalence of hearing loss at a local level, estimates can only be based upon national figures (20). In short, ensuring an adequate provision of hearing aids to a local population will help address health inequalities associated with hearing loss.

viii) Delivering national and local requirements/ targets.

Hearing impairment is within the top 20 health conditions identified in the WHO Global Burden of Disease initiative (21), it should be regarded as a prominent health condition included in local health priorities. Reflecting this, at a national level NHS England and the Department of Health has produced a guidance document Action Plan on Hearing Loss (22). This describes the impact of hearing loss and challenges presented and sets out policy objectives to address. The document provides a link to national/political objectives eg, ‘The government’s ambition is to support older people to stay independent and in their homes for longer avoiding unnecessary admission to hospital or entry into care. Hearing is a major factor in maintaining independence and achieving healthy ageing’.

Similarly, at a local level there will likely be health and local government policies/initiatives that would be compromised by rationing of hearing aids. These might relate to the health and well-being of the older population; also with reference to allowing individuals to live independently.

vii) Addressing health inequalities. The impact of hearing loss is not randomly spread; it predominates in the elderly, those who have had more noisy work

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24 References 1. Davis A, Smith P, Ferguson M, Stephens D, Gianopoulos I. 2007. Acceptability, benefit and cost of early screening for hearing disability: a study of potential screening tests and models. Health Technol Assess. 2007; 11(42). 2. Barton GR, Bankart J, Davis AC, Summerfield QA. Comparing utility scores before and after hearing-aid provision: results according to the EQ-5D, HUI3 and SF-6D. Appl Health Econ Health Policy. 2004;3(2):103-5.

12. Morris A E et al. An economic evaluation of screening 60 to 70-year old adults for hearing loss. Journal of Public Health. 2012; 35(1):139-146. 13. Lin F, et al. Hearing Loss and Cognitive Decline in Older Adults. JAMA Intern. Med. 2013; 173: 293-99. 14. Lin F, et al. Hearing loss and incident dementia. Archives of Neurology, 2011; 68(2):214-220.

3. Grutters JP, Joore MA, van der Horst F, Verschuure H, Dreschler WA, Anteunis LJ. Choosing between measures: comparison of EQ-5D, HUI2 and HUI3 in persons with hearing complaints. Qual Life Res. 2007; 16:1439–1449.

15. Dawes P, et al. Hearing loss and cognition: The role of hearing aids, social isolation and depression. PLoS ONE. 2015. Published on line March 11. 10(3): e0119616.doi:10.1371/ journal.pone.0119616

4. Swan IR, Guy FH, Akeroyd MA. Health-related quality of life before and after management in adults referred to otolaryngology: rospective national study. Clin Otolaryngol. Feb 2012; 37(1): 35-43.

16. Palmer CV, Adams SW, Bourgeois M, Durrant J, & Rossi M. Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting. J Speech Lang Hear Res, 1999;42:312-328.

5. Chisolm TH et al. A systematic review of health-related quality of life and hearing aids: final report of the American Academy of Audiology Task Force on the health-related quality of life benefits of amplification in adults. J. Am. Acad. Audiol. 2007; 18:151-83.

17. Lutman ME & Spencer HS. Occupational noise and demographic factors in hearing. Acta Otolryngol Suppl, 476, 74-84.

6. Bainbridge K and Wallhagen M. Hearing Loss in an Aging American Population: Extent, Impact, and Management. Annu Rev Public Health. 2014; 35:139–52. 7. Metselaar M, et al. Self-reported disability and handicap after hearing-aid fitting and benefit of hearing aids: comparison of fitting procedures, degree of hearing loss, experience with hearing aids and uni- and bilateral fittings. Eur Arch Otorhinolaryngol. 2009; 266:907–917. 8. Mulrow C D et al. Quality-of-Life Changes and Hearing Impairment: A Randomized Trial. Ann Intern Med. 1990;113(3):188-194. 9. Yueh B et al. Randomized Trial of Amplification Strategies 001 – Arch Otol Head and Neck Surgery, vol 127. 10. Gatehouse, S. A self-report outcome measure for the evaluation of hearing-aid fittings and services, Health Bulletin, 1999; 57:424-436.

18. Ecob R, et al. Is the relationship of social class to change in hearing threshold levels from childhood to middle age explained by noise, smoking, and drinking behaviour? International Journal of Audiology. 2008;47:100-108. 19. Taylor W, Pearson J, Mair A, Burns W. Study of noise and hearing in jute weaving. J Acoust Soc Am. 1965;38:113-20. 20. Foreman K, Akeroyd MA, Holman JA. Updated calculations of the number of adults in England, Scotland and Wales with a hearing loss MRC. 2013. Institute of Hearing Research, Scottish Section poster presentation at BSA Conference. 21. Murray CJ, et al. UK health performance: findings of the Global Burden of Disease Study. The Lancet. 2013. Published on line March 5. http//dx.doi.org/10.1016/S01406736(13)60355-4. 22. NHS England and Department of Health. Action Plan on Hearing Loss. 2015. http://www.england.nhs.uk/wp-content/ uploads/2015/03/act-plan-hearing-loss-upd.pdf

11. NICE. Guide to the methods of technology appraisal. 2013 http://www.nice.org.uk/article/pmg9/resources/non-guidanceguide-to-the-methods-of-technology-appraisal-2013-pdf

Bibliography Rationing in the NHS. Policy Briefing No 2. Nuffield Trust 2015. ISBN 978-1-905030-96-5 Malek M. Implementing QALYs. 2001. Hayward Medical Communications. NHS adult hearing aid services in England: exploring how choice is working for patients. Monitor. 2015. Publication code: IRREP 02/15 Lowe C. Under pressure: NHS Audiology Across the UK. Action on Hearing Loss. 2015.

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Under Pressure: NHS Audiology across the UK Action on Hearing Loss recently published new research looking at the UK-wide provision of NHS audiology services. The report, ‘Under Pressure: NHS Audiology across the UK’, shows that some NHS audiology teams face cuts to services and others are under significant pressure, but also provides examples of good practice and makes clear recommendations as to what governments, commissioners, academics, audiologists and charities such as ourselves can do.

Chris Wood PhD, Senior Research and Policy Officer Action on Hearing Loss 19-23 Featherstone Street, London, EC1Y 8SL E: Chris.wood@hearingloss.org.uk

As John Day’s article in this edition clearly sets out, some Clinical Commissioning Groups (CCGs) have proposed major cuts to hearing aid provision. North Staffordshire CCG’s ‘eligibility criteria’ for hearing aids, which will lead to two thirds of people who currently get hearing aids no longer receiving them, will be introduced from this October. Action on Hearing Loss has been working with the BSA, BAA, and organisations from the private, public and voluntary sectors to campaign against these cuts, and we will continue to do so. Our ‘Under Pressure’ report looked at the other type of changes to service provision that John Day mentions – where due to budget pressures or increasing demand for services, individual audiology providers reduce or alter the service they provide. We wanted to identify the level of service being provided across the UK, to understand the full impact of these pressures and to help us in our campaigning, as well as to share and promote good practice. We received responses to our freedom of information request or survey from 140 NHS providers across the UK. This included 116 responses from NHS Trusts providing adult audiology services in England, 13 responses from the 14 NHS Health Boards in Scotland, 7 responses from the 7 Health Boards in Wales, and 4 responses from the 5 Health and Social Care Trusts in Northern Ireland. Our research looked only at the provision of audiology services by NHS providers; we did not ask questions of private or voluntary sector providers delivering audiology services in England through NHS contracts, under Any Qualified Provider or other local commissioning arrangements. In this article I outline a summary of the main findings and recommendations - you can read the full findings of our research from across the UK, along with all our recommendations and the examples of good practice we found, at www.actiononhearingloss.org.uk/underpressure

Budget cuts and increased demand We found that two in every five (41%) providers who responded have had to reduce the scope or quality of their service as a result of budget cuts and/or increased demand. The principal ways in which services have been affected are: increased waiting times, increased time to reassessment, reduced availability of home visits, reduced overall number of staff and reduced follow-up appointments (see table 1 for full details of changes).

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26 Table 1 Changes to service observed by Audiology providers who responded

increased demand has impacted on their service over the last two years. It is particularly worrying that many places that are struggling to cope with increased demand have also been hit by budget cuts. One in six providers (16%) had their budget reduced over the last two years even though increased demand was already forcing them to reduce the service that they provide. Variation in provision along the audiology pathway Our research asked providers about each stage of the pathway, from accessing audiology through to hearing aid fitting, outcome measurement, signposting to other services, follow up, aftercare and re-assessment. We found that there is large variation in what is routinely provided. Firstly, we asked providers what percentage of patients were seen within their country’s target waiting time, according to their latest available figures.

Overall, 30% of NHS audiology providers who responded have had their budgets reduced in real terms in the last two years. In some cases, savings have been made without impacting on the scope or quality of service provision, but in the vast majority of cases budget cuts have translated into a direct impact on the service that patients are offered. 71% of providers with reduced budgets have seen a noticeable reduction in the service they provide. Further squeezes on budgets are expected over the coming year – around onefifth (19%) of providers were already aware of budget reductions planned for the next 12 months, including one provider each in Scotland, Wales and Northern Ireland, and 24 providers in England.

All but five English trusts stated that 90% of patients or more were seen within the target waiting time. In Wales, all but one provider stated that 90% of patients or more were seen within the 14-week target waiting time. In Scotland and Northern Ireland, however, our findings suggest more cause for concern, with three of the 13 Scottish providers and two of the four Northern Irish providers missing their country’s respective waiting-time targets for more than one in 10 patients. Across the UK, one-quarter of providers noted that waiting times had increased over the last two years. We also asked providers about their appointments, and hearing aid provision. In order to deliver appointments that meet quality standards and IQIPs, services need to have enough qualified staff and the right specialist expertise. Appointments must be long enough for audiologists to provide the full treatment, information and support that patients require 1. Eight per

Increased demand has also been a key factor affecting many services. Onethird of providers indicated that increased demand is directly impacting on the scope or quality of service that they are able to provide. This factor was particularly widespread in Scotland, with 69% of providers noting that

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27 cent of providers told us that, in the last two years, appointment lengths had been reduced. Fifteen per cent noted reductions in workforce numbers; and six per cent noted reductions in the average qualification level of professional staff. Many older people cannot get to audiology appointments because they have other medical conditions, so home visits are increasingly important. Fifteen per cent of providers said the number of home visits had actually gone down.This trend must be reversed so that isolated, housebound people can access the support they need. After they are assessed, most people with hearing loss are provided with hearing aids – although alarmingly our research did find that six Audiology providers (out of the 140 who responded) do not provide two hearing aids as standard. We are engaging with the providers and commissioners involved, and we will work with the rest of the sector to campaign for two hearing aids to be provided wherever clinically appropriate. There is good evidence showing the benefits of fitting two hearing aids, and restricting provision in this way will only lead to higher costs to the person’s wellbeing and to the NHS. Measuring outcomes is required by quality standards across the UK, and other Action on Hearing Loss research has found that patients want audiologists to measure the impact they are having, for example on patient satisfaction, levels of hearing aid use and ability to communicate. This will help providers to see if and how a service is responding to patients’ needs, and whether they need to make improvements. Outcomes data is also increasingly important in enabling services to make the case for proper funding, and to demonstrate to commissioners the impact they’re having2. Many providers develop individual management plans with their patients – which can be a good way of deciding on and measuring the outcomes that matter to patients. But we found that only 44% of providers who use individual management plans always measure the outcomes of these plans. Our research found that the vast majority of providers signpost or refer patients to other services that may help them, from counselling and support groups to lipreading classes and information about benefits. After the assessment and hearing aid fitting, however, only half of providers offer face-to-face follow-up to all patients, and this is one of the first services that providers look to cut when budgets are squeezed. Without proper follow-up to help them adjust, many patients will not get the full benefit from their hearing aids, and may stop using them – so this can have major impacts on patients and reduce the cost effectiveness of the service. Furthermore, although all providers offer aftercare, not all offer it in the most convenient and accessible way, particularly for older patients. For example, less than half (47%) offer aftercare in care homes. All services should take steps to reach patients in their own homes, care homes and in the community, to ensure they get the best out of their hearing

aids. Finally, less than a third of providers (31%) offer automatic re-assessment – quality standards suggest that this should be automatically offered after three years. Our recommendations As a result of this research, as well as the high profile campaign against hearing aid restrictions in North Staffordshire, we are calling for proper investment in audiology services across the UK to meet the needs of the ageing population. Budget cuts and increasing demand have made it impossible for some providers to maintain their service, and this will have major impacts on patients. To ensure consistent and high quality services are provided, Action on Hearing Loss is calling for quality standards to be implemented and enforced across the UK, for evidence-based local decision making, and for campaigns to raise awareness of hearing loss and its impacts. We will be pushing for hearing loss to be taken seriously and services properly funded, and we’ll continue to undertake research and promote good practice, but we’re also looking to the audiology community to: •

Collect and share outcomes data and improve clinical and academic research, to improve the quality of services and to show the impacts they are having. Ensure that patients are able to access aftercare and other forms of support. Follow national quality standards and guidance, particularly around waiting times, bilateral hearing aid provision, follow up appointments and automatic reassessment. Share examples of good practice and involve patients in planning services to continuously improve quality.

• •

As part of the project we asked audiologists to share examples of the innovative ways they were making efficiency savings and improving the quality of services.These are available along with the full findings of the report at: www.actiononhearingloss.org. uk/underpressure References 1 In a separate study, we asked 156 patients what they consider essential in an audiology service. Respondents rated the provision of verified hearing aid fittings and information about hearing aid support as two of the top three most important elements of the service. Deloitte Economics/ Action on Hearing Loss (2013) Evaluation framework for Adult Hearing Services in England.

Our evaluation framework provides free guidance and a toolkit to help with measuring outcomes.This is available at: www.actiononhearingloss.org.uk/evaluationframework

2

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BSA Learning Events Group – Political Event Report This event was organised by the BSA Learning Events Group (LEG) and focussed on the political challenges facing audiology now and in the future. Amongst those attending were representatives from NHS audiology departments, independent audiology providers, Research Institutions, Action Danny Kearney on Hearing Loss (AoHL), Senior Audiologist The British Society of Hearing Aid Audiologists (BSHAA), Hearing Aid Manufacturers and the National Community Hearing Association (NCHA). Delegates were welcomed to the event, hosted by Phonak at their offices in Warrington, by Graham Hilton (Phonak UK, Professional Services Manager). Mel Ferguson of the BSA Learning Events Group then provided an overview of the programme. Paul Breckell, Chief Executive of AoHL, began by considering the current challenges and pressures facing audiology services in the UK. This included findings from research conducted by AoHL, which assessed the provision of NHS audiology services across the UK. This indicated that 30% of NHS audiology services have had their budgets reduced in the last two years, but also that services had experienced an increase in demand. The consequences of this in many cases were increases in waiting times and reduced appointment lengths. The research produced a number of recommendations for delivering high-quality audiology services for example ensuring national quality standards are in place and that these standards are enforced. More details about this research can be found in Chris Wood’s article in this section and the full report, ‘Under Pressure: NHS Audiology Across the UK’ can be found on the AoHL website: http://www.actiononhearingloss.org.uk/underpressure.aspx Following this John Day (Consultant Clinical Scientist and Clinical Director of Audiology Betsi Cadwaladr University Hospital Board, North Wales) spoke about the context of hearing aid rationing and the specific examples where this has occurred. The most notable example of this has been the rationing proposed by the North Staffordshire Clinical Commissioning Group (CCG) but also Kernow (Cornwall and the Isles of Scilly) CCG and Northern, Eastern and Western Devon CCG. The presentation discussed the evidence put forward to the North Staffordshire CCG and how their use of the modified Portsmouth Scorecard to aid in their decisions was challenged by the BSA and other stakeholders. The lessons learnt from this process were also highlighted. These included making sure

that interventions are effective and making sure CCGs make decisions based on local evidence and demands. This was followed by a presentation about alternate service delivery models by Jonathon Parsons, Consultant Clinical Scientist and Managing Director of Chime Social Enterprise based in Exeter, Mid and East Devon. The particular service delivery model discussed was that of a Social Enterprise. This is an organisation where any financial surplus is invested back for the benefit of its social aims, which for Chime is providing a service for hearing impaired patients. The presentation gave an insight into the creation of Chime and its similarities and differences compared to an NHS Audiology service. The NHS Audiology service in Exeter, Mid and East Devon used the Government Right to Request scheme to become a Social Enterprise. The main similarities are that they have NHS contracts to provide adult and paediatric audiology services free at the point of delivery, including an AQP contract for adult hearing aid services. The staff have the same NHS employment terms and conditions but they also own a stake in the Enterprise and the service is controlled by its own board. Financially any surplus is invested directly into the Audiology service rather than being redistributed to other services or used to fund other parts of a trust. This surplus can be used to buy in expertise, develop the service and expand into new areas. It is an enterprise that appears to be working and growing in Exeter, Mid and East Devon, but could this be replicated elsewhere and why haven’t other NHS Audiology services made this transition? This can be partly answered by how difficult the process can be and the work required in setting up a social enterprise. It also relies on local support and the skills to negotiate with NHS partners to make it viable. However once it is created there is a community of organisations that are geared up specifically to help social enterprises and the service has greater freedom to make decisions, increase efficiency and develop. The day continued with presentations around the theme of Workforce Skills and Training. Firstly Peter Sydserff, President of BSHAA, spoke about current demand for Audiology services in the context of the current Audiology workforce. Then David Welbourn CEO of BSHAA discussed the theme of professionalism amongst NHS Audiologists and Independent Hearing Aid dispensers and the development and maintenance of professional standards in the workforce. He also produced a flow diagram representing the potential downward cycle of those with untreated hearing loss showing the detrimental health and financial consequences that can occur. Another area covered during the event was the role of hear-

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29 ing aid manufacturers in providing technological innovations. Michael Boretzki (Research Program Manager at Phonak) discussed innovations that could be used to streamline the fitting and fine-tuning of hearing aids whilst also providing greater individualisation and optimisation of the hearing aid fitting. He also spoke about the need for Audiologists to engage with the engineers responsible for designing hearing aids and programming software. He highlighted how there are lots of parameters available to the engineers and they need feedback and guidance from front line clinicians in order to understand what is needed and what adjustments patient’s commonly require. Mel Ferguson spoke about the use of Evidence Based Medicine as tool to provide high quality services and to demonstrate to CCGs the case against hearing aid rationing. Alongside this was discussion about the hierarchy of evidence and the need for research to have a greater impact on clinical practice. Harjit Sandhu from National Community Hearing Association (NCHA) gave an overview of the recently published report by Monitor, the sector regulator for health services in England. A key aim of the report was to understand how choice has been working in relation to adult hearing services funded by the NHS. The report highlights positives, like patients often

having more choice and easier access to services and negatives like the difficulties and costs associated with the provider qualification process. This report is available at the following website: https://www.gov.uk/government/publications/ nhs-adult-hearing-services-in-england-exploring-howchoice-is-working-for-patients The event then involved group work with the aim of discussing the key priorities for providing sustainable Audiological services. The key themes from the group discussions were the need to provide high quality services that offer value, that are evidence based and use robust outcome measures. Overall the speakers helped to evolve the discussion and provided some interesting perspectives. The take home message was that action is needed by Audiology services to ensure they are sustainable in the future. The NHS is likely to experience continued financial pressure and growing demands so services need to provide value. Nationally steps need to be taken to produce quality standards so that providers can make a stronger case to commissioners for appropriate levels of funding to deliver high quality, comprehensive audiology services.

Meet your BSA Operations Manager

Laura Turton Operations Manager 80 Brighton Road Reading T: 0118 9660622

I followed the concept of the Operations Manager position through the Chairman’s updates last year. I thought back then what a pivotal role the BSA was developing. I was delighted to accept the position and particularly liked the opportunity to develop this new role within the BSA.

Prior to accepting this position, I practiced clinical audiology across the Midlands for over 12 years. My clinical special interest was in diagnostic and rehabilitative support for adults with a severe and profound hearing loss. I strongly believe that patients require a high quality service and that this is possible based on BSA standards and through new emerging research. I chair the British Academy of Audiology’s Service Quality Committee and now hold the responsibility of being the representative for this committee on the BSA’s Professional Practice Committee. For the last 3 years, I have worked as a senior manager in the voluntary sector and I feel

this work has given me a breadth of experience I can now apply to the BSA. I have been in post since the end of February and have spent much of the first few weeks understanding the way the BSA works through spending time with the officers from the Council and the other trustees and advisors. I have now grasped the organisation’s aims and structure through understanding the different committees, Special Interest Groups and advisor roles. This induction time has provided me with a solid basis to progress some of the new strategic work the Council is looking at in the coming months. It has also highlighted how vibrant the activity of the BSA currently is; the learning events group have developed a diverse set of events for different interests and learning styles; with twilight lectures, day events run by the SIGs, lunch and learn webinars and lightning updates.The editors of Audacity continue to produce a really interesting and diverse content to the magazine and the website continues to develop and feeds in to our social media presence. The Special Interest Groups all have thorough plans for the coming year and are strengthened by their members from a range of disciplines. Equally, the BSA continues to be committed to expanding the research knowledge on hearing science, which is evident through the grant opportunities funded through the Stuart Gatehouse legacy.

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30 BSA Twilight Series Meeting – Comorbidities of Hearing Loss: Impact of Dementia, Diabetes and Visual Impairment Stephanie Greer, M.Sc.

Pre-Registration Clinical Scientist (Audiology) Wrexham Maelor Hospital Croesnewydd Road Wrexham, LL13 7TD E: stephanie.greer@wales.nhs.uk T: 01978 725304

The evening of Thursday 23rd April saw the latest in the BSA Twilight meetings being held at Wrexham Maelor Hospital. This was the first time that the Twilight series had crossed the border into Wales and a warm welcome was received by all – Croeso i Gymru! The topic for the meeting was “Comorbidities of hearing loss” and an interesting programme had been put together by the organisers including aspects of dementia, diabetes and dual sensory impairment. Twenty-six delegates from organisations including NHS Audiology departments, private dispensers and research units were treated to innovative talks on the latest research and clinical developments in the field. The meeting was chaired by John Day and thanks were given to Phonak, Oticon and ReSound for sponsoring the event. The first talk was presented by Dr Sara K. Mamo who came to us via videolink from John Hopkins University in Baltimore to give a public health perspective on age-related hearing loss and cognitive decline. Dr Mamo began by giving an introduction to hearing loss, cognitive load, brain structure/function and social isolation and their relationship to impaired cognitive functioning and dementia in older adults. She then gave an overview of two ongoing studies in America: the Health, Aging and Body Composition (HealthABC) study and Baltimore Longitudinal Study of Aging (BLSA) the latter of which has been running for nearly 60 years. These studies have shown a faster rate of cognitive decline with a greater risk of dementia for participants with hearing loss when compared to those with normal hearing. Participants with hearing loss also showed greater grey matter atrophy in neuroimaging studies. Dr Mamo then went on to discuss how we can best manage age-related hearing loss in the community. She described a community-based project called Baltimore HEARS which aims at providing accessible and affordable hearing interventions including education, aural rehabilitation and provision of an amplification device (Pocket Talker or ear-level instrument). These principles have recently been introduced into the dementia population including an initial hearing screen. Positive feedback from caregivers showed the impact that this approach had improving social communication and engagement. The talk was well received by the

audience with many interesting and insightful discussions being held during the following Q & A session. After a short break we returned to hear Dr Maret Lepplan talking about diabetes mellitus and hearing impairment (making me regret the cakes I had during the interval!). During day-today clinical work we all regularly come across patients who have diabetes but I myself have never really considered the interaction between this condition and hearing loss. Dr Lepplan explained that hearing loss is over twice as common in diabetics than in the general population and that this hearing impairment is usually a gradual progressive, bilateral high-frequency sensorineural loss. There have also been cases of sudden-onset sensorineural hearing loss attributed to diabetes. The hearing impairment is due to inadequate supply of glucose to the cochlea causing changes to hair cell functioning, as well as retrocochlear changes including auditory neuropathy and diabetic encephalopathy. Dr Lepplan gave advice on aiding considerations for diabetic patients including dexterity issues due to peripheral neuropathy and dual sensory impairment. This led nicely into the final talk of the evening given by Donna Corrigan of Sense. After a brief introduction to the work of the Sense charity, Ms Corrigan gave a passionate talk on the experiences of deafblind people and how we can modify our practice to best suit their needs. Sense estimates that there are 394,000 people in the UK living with deafblindness where the combination of hearing and visual impairment causes difficulties with communication, mobility and access to information. In our roles as Audiologists we are all aware of the practical, social and emotional impacts of hearing impairment on our patients but Ms Corrigan gave examples of how parallel visual problems can add to these challenges. For a deafblind patient the visit to the Audiology department can be a difficult experience. Ms Corrigan explained how even simple things such as variation in carpet colour when entering a clinic room can make it problematic to navigate this may be perceived as a step. Lastly Ms Corrigan introduced the audience to a new e-learning resource designed for Audiologists which is due to be launched by Sense later this year. This gives information on deafblindness and ensuring that services are accessible, as well as advice on hearing aid management strategies for these patients.The concept was very well received by delegates and we look forward to its release. This final presentation brought an end to what was a highly successful and informative evening of talks. The meeting helped me to see how my role as an Audiologist fits within the patient’s wider clinical picture and factors which should be taken into account for patients with comorbidities. I look forward to the next BSA Twilight Series Meeting “New Perspectives on Paediatric Habilitiation” on Thursday 12th November 2015 (details TBC).

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Delivering life-changing interventions for people with all levels of hearing loss CD

Author and Correspondence Dr Lorraine Gailey, BSSc, PhD, Dip CCS CEO, Hearing Link, Hearing Link, 27-28 The Waterfront, Eastbourne, East Sussex, BN23 5UZ, UK. E: lorraine.gailey@ hearinglink.org W: www.hearinglink.org Intensive Rehabilitation Programme - Cardiff

Hearing Link has been delivering lifechanging interventions for people with all levels of hearing loss for over 75 years, initially as two organisations namely Hearing Concern and the LINK Centre for Deafened People, but since 2008 as one organisation Hearing Link. The LINK Centre’s reputation for supporting deafened adults has been recognised since 1972 when we first began to offer our Intensive Rehabilitation Programme, a course specifically designed for those living with a severe to profound hearing loss. Today, recognition that this specialist programme is one of the key interventions in the rehabilitation of deafened adults in the UK remains strong, particularly amongst professionals in the Audiological sector. Hearing Concern’s remit embraced support for a wider range of hearing losses, and Hearing Link’s current range of Self Management Programme - Glasgow

programmes reflects this broader range as well as programmes for profoundly deafened adults.

while being delivered for the most part by highly-trained volunteers with personal experience of living with hearing loss.

Our services have been developed to respond flexibly to the needs of people struggling to take control of their hearing loss and make the positive changes in their lives that will help them to adjust to and overcome the practical and emotional challenges they face. All our services aim to enable our beneficiaries to rediscover themselves and help reclaim their identity.

Intensive Rehabilitation Programme (IRP) The IRP is a residential programme for up to seven deafened adults and their families. This course is designed to develop an individual’s ability to manage hearing loss through information, social and emotional support, communication strategies, technological solutions and signposting to other support services.

We recognise that people need different types of support at different stages in their hearing loss journey. To cater for these needs today, we have a five-service offering that varies from week-long intensive residential support to one-off meetings with individuals. These are outlined below. They all offer valuable information, support and solutions, and they have in common the fact that they are carefully evaluated and professionally monitored,

A central focus of this five-day programme is the emotional impact of, and adjustment to, acquired hearing loss and effective facilitation of peer and ongoing support. The value of this programme cannot be over-emphasised. Evidence of its impact is addressed in a recent study carried out by colleagues at The Ear Foundation entitled: ‘Intensive Rehabilitation Programme: Qualitative Research’ (Mulla, Harrigan & Archbold, 2014).

Self Management Programme - Northern Ireland

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33 The authors undertook pre and post-programme interviews and focus groups with participants and family members who attended a programme in three different locations in the UK. The research offers a deeper insight into the impact of attending this programme and demonstrates the important place this programme has in the rehabilitation of adults living with hearing loss. The full report is available on request. “The IRP provides world-class rehabilitation for deafened adults and includes important elements, like having access to counsellors for all attending including significant others/ family members, that make the IRP ahead of the times.” Dr Imran Mulla, Head of Research and Clinical Services,The Ear Foundation Self Management Programmes (SMP) Our peer-led Self Management Programme is for adults with any severity of hearing loss who describe high levels of disability in their lives. It offers them, together with their partners or families, a way to find the right practical solutions for them. Participants (typically up to 25 in a group) go on a journey of discovery together. Content covers a broad range of subjects and gently allows individuals to explore their issues and challenges in a safe and supportive environment, learning from the experiences of our trained volunteer facilitators, as well as from each other. They attend three sessions in total, held over six to 12 weeks. Typically sessions are held 2-4 weeks apart so participants can experiment with the tips gained from fellow attendees and facilitators at the previous session and test which ones work for them. Throughout the programme, participants

are actively encouraged to set goals with achievable targets – all aimed at encouraging self management of their progress to taking control of their life with hearing loss.

of their hearing loss. This may be a very specific issue or a more general need for example feeling very isolated due to their hearing loss.

Hearing Link has been running these Self Management Programmes across the UK for almost 15 years and in this time has delivered them in a variety of ways to suit the group attending the programme. A number of programmes are planned in every country of the UK for 2015. More details are available on our website.

The CSV is there to discuss possibilities and options with the individual who has hearing loss and also their family. The aim is to support the patient to take control of the decision-making process leading to a solution that will work for them. Information is offered about local services and resources as well as on Hearing Link services, leading to more appropriate and effective utilisation of services both locally and nationally by the beneficiary.

Link-Up Programmes (LUP) LUP, the newest to our suite of rehabilitation programmes, is designed for up to 20 families with some pre-existing coping strategies. It typically includes people who have attended a previous Hearing Link programme or developed skills through working with other health and/or social care professionals or over time at their own pace. It is suitable for people with any degree of hearing loss. This programme is run over two days, commonly a weekend, and is facilitated by volunteers with hearing loss. Through group exercises and sharing of personal experiences, participants increase their information and knowledge about communication issues. Facilitators help them to develop their pre-existing abilities, motivate them to set and attain personal goals and develop peer networks for ongoing support. We piloted three programmes in 2014 of which one was for a specific aetiology group and have four planned in 2015. Community Support Volunteers Our Community Support Volunteer (CSV) network provides one-on-one peer support for anyone who presents with a particular need arising from the effects

The aim is that this support will help develop the patient’s confidence and willingness to take steps to re-integrate in local life and feel more connected to other people with hearing loss. Helpdesk Our Helpdesk acts as an authoritative signpost for information and advice for both qualified experts, as well as your patients. It is a free service and is staffed by a dedicated, trained team of volunteers who have experience of hearing loss directly or through a family member. Using their personal experiences and wealth of knowledge they offer solutions on a variety of topics around hearing loss, such as where to find a local lipreading class or what types of assistive equipment and technology area available to aid communication.These interactions may be a single contact, sporadic or ongoing support over an extended period of time. It is available to everyone wherever they live in the UK, though electronic means, phone/SMS, and letter.

Link-Up Programme - Eastbourne

Further information The role of our volunteers is to create an environment for talking openly and recognising the challenges that are commonly shared. Unique to Hearing Link, it’s this that truly makes a difference. If you would like to find out more about our specialist services that draw on the experiences of our trained volunteers and how they can help you support your patients, then contact our Helpdesk – it’s easy to get in touch. Email: helpdesk@hearinglink.org; or call Tel/Text: 0300 111 1113.

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The Ear Foundation: A Third Sector organisation “landing the technology in the community”...

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Author and Correspondence Sue Archbold, PhD, Chief Executive, The Ear Foundation, 83 Sherwin Road, Nottingham, NG7 2FB, UK. E: sue@earfoundation.org.uk Take home message Landing the technology in the community... Almost all deaf children, young people and adults have the possibility today to access the latest technology providing useful hearing – so all should be well? Maybe not... All too often however, there is a gap between the potential and the reality of today’s hearing technologies – which is where The Ear Foundation comes in.

We know that hearing loss, whether in childhood or adulthood, can have devastating consequences for both the individual and family. Deafness in childhood has a huge impact on the acquisition of spoken language, and on educational attainment and later employment. In adulthood, it is linked to unemployment, isolation, depression, dementia and higher usage of GP and social services. Yet the hearing technologies we have today can revolutionise the lives of those with hearing loss, if they are given access to them and use them effectively. All too often however, there is a gap between the potential and the reality of today’s hearing technologies – which is where The Ear Foundation comes in. In 1989, cochlear implantation for children was highly controversial and no funding was available on the NHS; The Ear Foundation funded the first operations for children and established the Nottingham Paediatric Cochlear Implant Programme, working with the Institute of Hearing Research (MRC) to provide the evidence for the NHS to establish a national programme.

Now, cochlear implants for children are routinely available; what is the role of The Ear Foundation? In the twenty five years we have been in existence the technologies available have changed hugely and we also now have Universal Newborn Hearing Screening, radically reducing the mean age of diagnosis and fitting of hearing aids. Almost all deaf children, young people and adults have the possibility today to access the latest technology providing useful hearing – so all should be well? Maybe not... Hearing loss in the UK affects over 10 million people. The demands of our growing and aging population with greater than ever need for communication, expecting to work longer, set in the context of changing service delivery and increasing financial pressures, is leading to audiological services being under huge pressure. In addition, hearing loss is unusual in its very broad impact, not only on audiological services, but on educational, medical and social care services. In spite of this, the impact of hearing loss is still under-recognised, with hearing loss omitted from the first White Paper

Learning to use technology with friends

of this government, with people having a 10 year delay in seeking help for hearing loss, with only one in three of those who could benefit from hearing aids receiving them, and with the current proposals by several Clinical Commissioning Groups (CCGs) to cut audiological services. In the UK as a whole, Third Sector, voluntary, organisations are increasingly influential – one only has to listen to BBC’s Radio Four programme, TODAY, to realise this. NICE have commented that the technology appraisal for cochlear implantation was highly effective as it combined input from professional groups, industry and Third Sector organisations. Patient Public Involvement (PPI) is increasingly important in academia and in health care with the user or patient view regularly sought and the emphasis on evidence-based practice. Research proposals routinely

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35 request evidence of patient involvement. Yet, all too often, patients or users are used only as focus groups, or to advise on questionnaire design or recruitment, rather than to provide the impetus for research and its value. Third Sector organisations are close to the people they represent, can be flexible and responsive, and have increasing roles today. They can influence where it is difficult for professional and industry groups to do so, as their efforts may be seen as self –serving. However, Third Sector organisations cannot represent the needs of their users alone- they need the information and experience of those running services and of those developing and providing the technology – ensuring that their advice, information and resources are entirely up-to-date. Working together we can be more effective. Effective joint working is evidenced by the recent work of the Hearing Loss and Deafness Alliance, by the campaign for the publication of the Action Plan for Hearing Loss and by protests against cuts to hearing services. Third Sector organisations can rally swift responses to the challenges faced by professionals and users. Set against this background, what does The Ear Foundation do? We have always had the vision that the best technology must be well managed in the community to be effective. The Ear Foundation works with those with a hearing loss of all ages, and with all hearing technologies. Our aim is to bridge the gap between the clinics where hearing technologies are fitted, and home, school and work where they are used in daily life. All too Chatting to Kris English about our work for adults

Working together we can be more effective.

The Ear Foundation’s four integrated programmes

often the technology is well fitted in the clinic and all is well there...but when they get home or to school or work, all may not be well. How many hearing aids end up in the drawer, or the technology isn’t used to its full potential. People don’t remember what they were told, they are worried about the technology, or just need a bit more time to adjust to their hearing loss. We provide our services in Nottingham, with partners nationally and internationally – in reality and increasingly virtually via the web. We provide:

• Our family and user-led research programme, specialising in qualitative research to influence policy and practice.

• Our family programme, reaching over 1000 families per year, and those of all ages; • A continuing education programme, reaching over 3,500 delegates per year, on all continents, and including our community education programme, of advocacy and lobbying; • Our sound advice clinical services, providing additional services for children and adults;

Uniquely combining our expertise in these four areas ensures our services are up-to-date, informed by the latest research, but, most importantly, grounded in the needs of families and users. Each area of our work influences the other – with, for example, our research programme influenced by our family services, and the needs that arise there. If you visit our website you will find several areas which may be of interest, both to professionals and patients: • Our family programme, providing information and support for all ages using today’s hearing and communication technologies , with downloadable resources; • Our education programme, providing regular up-to-the minute conferences

Trying Fm systems

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36 and workshops on the latest technologies in a multi-professional setting, virtual focussed conferences, non-professional counselling courses for audiologists with Kris English; • Our research programme with topics which are user led and have a major dissemination programme in the form of accessible booklets – freely available from our website. Our poster, with Hearing Link, Qualitative Evaluation of Intensive Rehabilitation Program for Adults with Hearing Loss, won the Poster Prize at BAA in 2014; • Our Sound Advice service where we provide multi-professional assessments for children, and additional services for young people and adults, complementary to NHS services, where they can find out what is available, try out assistive devices and have time to think about their communication needs at home, school and work;

A GP flyer

Report available from the Ear Foundation

• Our advocacy and lobbying programme, with a current focus on raising awareness of the impact of hearing loss, and the cost of NOT addressing hearing loss, rather than the cost of providing hearing services. Our leaflets for GP surgeries and for pharmacies are proving popular.

As Einstein said:

In this changing world, one thing which doesn’t change: the impact of deafness, whether as a child or adult, is huge, but often subtle. As one of our adults said: “you lose total self-esteem, you don’t want to mix, anything like that because that’s what deafness does to you.”

counted; that’s the bit we can do.

And that’s why we are here and growing: we have a new building, Sound Space, where the latest hearing technologies will be available to see and learn about in a family friendly environment. The technology needs managing but the everyday needs of deaf children, young people and adults need recognition in today’s challenging context.

“Everything that can be counted does not necessarily count; everything that counts cannot necessarily be counted.” Let’s remember some of the most important things cannot be

Further reading: Archbold, S, Lamb, B, O’Neill C, Atkins J (2014) The Real Cost of Adult Hearing Loss. available from www.earfoundation.org.uk Under pressure (2015) report by Action on Hearing Loss. www.actiononhearingloss.org.uk English, K., & Archbold, S. (2014). Measuring the effectiveness of a counseling workshop. International Journal of Audiology, 53(2), 115-120.

Submit an article We welcome the submission of articles on relevant clinical, research and academic or other themes within Audiology. The reader may not always be an expert or have previous interest in your specialist area and the article is an opportunity to increase the knowledge base and interest in new areas of audiology. We are keen to publish articles that present alternative or challenging themes that will encourage and provoke debate. www.thebsa.org.uk/audacity/submit-article/

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Audiology in Malawi FACTFILE... Population: 16.4 million (2013) Total Area: 118,484 km2 Capital: Lilongwe Prevalence of disabling hearing impairment in adults: 6.4% (WHO estimate, 2012) Average life expectancy: 55 yrs

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Author and Correspondence Helen Brough

Audiology Department Box 94 Addenbrooke’s Hospital Hills Road Cambridge E: Helen.brough@addenbrookes.nhs.uk

Biography Helen Brough graduated from the MSc Audiology programme at the University of Manchester in 2009. She completed her CCC in Manchester before moving to Addenbrooke’s Hospital, Cambridge, to train under the HTS scheme. She currently works as a senior audiologist at Addenbrooke’s and spent three months last year volunteering in the audiology clinic in Lilongwe, Malawi and intends to return later this year. She has a particular interest in humanitarian audiology and working with people with learning disabilities.

Malawi has recently been declared the poorest country in the world (world bank statistics, 2013) and the majority of the population have little access to even basic medical facilities. In Malawi, hearing loss is often from preventable causes, such as cerebral malaria, mumps and measles. With an average life expectancy of 55 (world bank statistics, 2012), presbycusis is not the common condition it is in the UK. Poor health conditions and lack of access and availability of antibiotics contribute to many people having hearing losses related to middle ear infections which have resulted in permanent discharge. HIV is common, and is accompanied by an increased risk of middle ear disease. There are just three audiologists in Malawi – Peter and Rebecca Bartlett from Australia run the African Bible Colleges (ABC) Hearing Clinic and Training Centre in the capital Lilongwe, and Courtney Caron, an American, is developing an audiology clinic in Blantyre at the Queen Elizabeth Central Hospital, alongside Wakisa Mulwafu, Malawi’s only ENT surgeon.

“There are just three audiologists in Malawi” Lilongwe The ABC Hearing clinic has been running for just over a year, and offers high-quality adult and paediatric audiology assessments and rehabilitation. The Bartletts offered a free two-year training course to six ABC students, who now work as audi-

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38 ology assistants at the clinic. The service runs bilingually, with staff meetings and training in English, and most consultations being carried out in Chichewa, the local language of the region. Two staff members have been trained to make hard acrylic earmoulds on-site; this has the advantage that a patient can be assessed, have earmoulds made and hearing aids fitted all on the same day, which is very important for patients who may have travelled for a day or more in order to reach the clinic.

“With an average life expectancy of 55, presbycusis is not the common condition it is in the UK” Resources Much of the equipment is donated, and the hearing aid stock, both digital and analogue, is almost all second-hand, donated from overseas. The clinic is generously supported by SoundSeekers, who provided a HARK (a specially-adapted mobile hearing clinic) and the Sonova Hear the World Foundation, who have supported the clinic since 2011 and provided a paediatric sound booth with VRA, an adult sound booth, ABR equipment and other vital audiological equipment. They have also supplied funding for an audiotrailer containing two test booths, which can be towed by the HARK. The mobile hearing clinic is used to take the audiology team to remote locations all over the country, bringing primary ear care and audiology services to those who need it most. Care pathways There is no formal referral route into audiology services. Most patients self-refer or are advised by a clinical officer to have an audiology assessment. There is no newborn hearing screening programme in Malawi. Electrophysiological testing is carried out; however this is primarily for difficult-to-test older children. At the ABC clinic there are two care pathways: community and private. All patients are charged for the care they receive in order to encourage them to value the service offered, Mwasoni (assistant audiologist) carries out primary ear care at the ABC clinic

however no-one is turned away because of lack of money. Community patients are charged a minimal rate and are fitted with reconditioned hearing aids. Booking appointments is not a common practice in Malawi – most people do not have access to a telephone and poor literacy is common – and so drop-in consultations for community patients is the norm. There is a small stock of new hearing aids available for the few patients who have private health insurance. The ABC clinic also runs industrial hearing screening programmes for private companies. The income from the industrial screening and the private patients is used, alongside generous donations from the Sonova Hear the World Foundation, to finance the outreach work. Outreaches The ABC clinic is committed to providing free audiological support for all the students at two schools for the Deaf, in Embangweni and Karonga. A team travels in the HARK to visit the schools and carry out audiological assessments and provide hearing aids. One afternoon each week is also used to carry out free outreach clinics in different places around Lilongwe, and there are other occasional outreaches arranged in conjunction with charities working across the country. Currently, the audiology teams in Lilongwe and Blantyre are working together in conjunction with the charity CBM to provide outreach services in remote villages in the Ncheu district.

“In 2014, the first two children in Malawi received cochlear implants” Funding for the ABC clinic The audiologists are volunteers through Ears Inc, a Christian audiology charity in Australia, and are financially supported by the charity, churches and friends. There is no financial support provided by the government.The Malawian clinical staff salaries are paid for by the industrial screening and private work. Gospel and Mwasoni (assistant audiologists from ABC) take a patient’s history in the back of the HARK

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39 Blantyre Courtney Caron started work with some assistant audiologists in Blantyre in June 2014 and is aiming to build a hearing clinic following the blueprint for the building designed by the Bartletts for Lilongwe. She is supported by SoundSeekers UK who are funding the provision of a state-of-the-art audiology facility; they plan to break ground in the next few months. Challenges in Malawi The audiology teams provide an excellent service, however water shortages and power cuts are common. A major question remains around the long term follow up for patients attending the clinics. Many people have no address or telephone number, and so following patients up after hearing aid fittings is a big challenge. Maropa (ABC staff member) carries out aided soundfield testing

Training The Bartletts are in the process of developing a BSc Audiology course at ABC which they hope will be accredited by the Malawi Medical Council; they currently have five students in the first year of this course. In addition, SoundSeekers are generously providing funding for two audiology assistants – one from Lilongwe, one from Blantyre – to take an MSc Audiology course in the UK; they will become the first Malawian audiologists, and on completion of the course will further develop their clinical practice in Blantyre. ABC Hearing Clinic also hopes to send two more audiology assistants to do this Masters course and is currently seeking funding to make this possible.

The need for more audiologists in Malawi is significant. The training plans currently in place for the assistant audiologists are excellent, and the current projects are well-managed and sustainable, yet much more could be done with more willing workers. References: • World Bank Statistics, 2012. Life expectancy at birth, http:// data.worldbank.org/indicator/SP.DYN.LE00.IN, retrieved 27 March 2015. • World Bank Statistics, 2013. GDP per capita. http://data. worldbank.org/indicator/NY.GDP.PCAP.CD?order=wbapi_data_value_2011%20wbapi_data_value&sor t=asc, retrieved 27 March 2015

Audiologists from overseas are required to register to practise in Malawi, and can do this by providing the Medical Council with evidence of qualifications gained.

Audacity

Latest News In 2014, the first two children in Malawi received cochlear implants, with the support of Med-El in the UK, Germany and South Africa. Both children became profoundly deaf from malaria four years ago. They are progressing incredibly well; the older boy of 15 has recently returned to school and is overjoyed by this, even though he returned to a class with children four years his junior. He understands speech extremely well without visual cues and is even able to use the telephone.

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"Tectorial membrane in a 'near live' position on top of the outer hair cell steriocilia. Photo courtesy of Andrew Forge, UCL Ear Institute."

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Research The ABC clinic has recently been carrying out research into hearing loss in the paediatric HIV population which was presented at the 2014 Coalition for Global Hearing Health conference in Oxford.

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Contact the Editorial Team at: audacity@thebsa.org.uk

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Lunch and Learn CD

Facilitators and Correspondence

Shahad Howe Clinical Scientist, Manchester Royal Infirmary

Christopher Cartwright Professional Marketing Manager, Phonak

E: Shahad.howe@cmft.nhs.uk

E: Chris.cartwright@phonak.com

BSA Lunch and Learn eSeminars

An exciting series of online presentations covering current topics of interest and clinically relevant research findings in Audiology and related professions, free of charge to all BSA members and non-members.

Recent bites

Coming up on the menu

These and other earlier seminars are available to access at www.thebsa.org.uk and http://www.phonaknhs.co.uk/news/news-archive/ You may need to request connection through Firewalls with your local IT department for your first eLearning experience.

To go live on the first Monday of every month for access by the emailed link, via the BAA or Audiology Northwest England Facebook pages, or archived at www.thebsa.org.uk and http://www.phonaknhs.co.uk/news/news-archive. You may need to request connection through Firewalls with your local IT department for your first eLearning experience.

February 2015

Hearing-assistive devices in single-sided deafness: which device and what benefits? › Dr. Pádraig Kitterick, PhD Senior Research Fellow, Faculty of Medicine & Health Sciences, Nottingham Hearing Biomedical Research Unit, UK.

May 2015

March 2015

June 2015

April 2015

July 2015

Access to hearing health – capitalising on the mobile revolution. › Professor De Wet Swanepoel, PhD Department of Speech-Language Pathology and Audiology , University of Pretoria, South Africa

Effect of cognitive load on speech perception. › Professor Sven Mattys, PhD Department of Psychology, University of York, UK.

If you would like to contribute a seminar, have any queries or would like regular email updates, please email one of the facilitators above.

Assessing the role of questionnaires in the assessment of auditory processing disorder › Dr. Johanna Barry, PhD Principal Clinical Scientist, MRC Institute of Hearing Research, Nottingham, UK.

Advances in Testing – There is more to the vestibular system than the horizontal semi-circular canal. › Dr Jas Sandhu, Academic Foundation Doctor, University of Sheffield Teaching Hospitals, UK.

Coding of acoustic information in the auditory pathway › Professor Alan R Palmer, PhD Director of the MRC Institute of Hearing Research, Nottingham, UK.

Summer Special

Paediatric Screening › Christine Yoshinaga-Itano

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42

Ear to the ground

for all things ear-related in the media The biggest story in Audiology over the past few months has been the decision of North Staffs CCG to ration hearing aids, with the consequences of this decision resounding through the media. These pieces are a focal point of this edition of Ear to the Ground, with the reaction on social media gauged by Amanda Hall in her Twitterarty piece. Away from the debate about hearing aid provision, there are tales of tattoos, views on vuvuzelas and a story about subtitling. Twitterarty considers other recent political releases and references Action on Hearing Loss’s promotion of Deaf Awareness week 2015.

North Staffs confirm cuts

It is impossible not to mention in this section the decision by North Staffs CCG to cut hearing aid provision for patients with mild hearing loss. However, contrary to previous proposals, patients with moderate loss may continue with provision if they can demonstrate that their loss has a “functional impact” on their lives. The changes mean that around a quarter of the people currently eligible for hearing aids will no longer be provided with care. Though it is likely most in the Audiology community will have read this news, a local report summarising the changes can be found at http://www.stokesentinel.co.uk/NHS-hearing-aids-scrapped-Newcastle-Staffs/story-26121148-detail/story.html

A parable for our times

An interesting comment piece in the Guardian recently made some stark points about the decision of the North Staffordshire Clinical Commissioning Group to refuse NHS hearing aids for patients with mild hearing losses. The piece describes the decision as a parable for Britain’s short term health policy, and concisely presents the argument for the cost effectiveness of hearing aid provision. The piece doesn’t focus solely on North Staffs, also discussing the change in CCGs’ attitudes towards cochlear implantation. Read the thought provoking piece at http://www.theguardian.com/commentisfree/2015/feb/09/ hearing-aids-health-policy-austerity-nhs

Devon cuts U-Turn

On a brighter note, the Northern, Eastern and Western Devon CCG have halted their plans to cut hearing aid provision, having previously considering limiting hearing aids to one per patient. As reported in the Pulse, the CCG are quoted as recognizing the benefit of a second hearing aid and therefore not implementing the previous position to restrict the funding of hearing aids. Read the article, which includes the quote from NEW Devon CCG, at http://www.pulsetoday.co.uk/news/ commissioning-news/ccg-drops-plan-to-ration-hearing-aids/20008880.article#.VSQzsfnF-So

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43 The dangers of loud music

An uninspiring headline for audiology professionals, perhaps, but the Independent warn of the dangers of overexposure to loud noise via personal listening devices. They describe a warning from the WHO that 1.1 billion 12-25 year olds are risking sensorineural hearing loss and tinnitus by listening for too long to music at volumes exceeding 85 dBSPL. It is promising to see information well known in the profession being given space in the press, to better inform a wider audience on aural safety. Read the article at http://www.independent.co.uk/life-style/health-and-families/ health-news/children-warned-to-not-listen-to-music-for-more-than-one-hour-a-day -10076200.html?origin=internalSearch

Better late than never…

A mere 4 years, 7 months and 16 days after the final of the 2010 football World Cup, the World Health Organization has decreed that the vuvuzela may be damaging to fans’ hearing. The plastic trumpets, which rose to prominence in the World Cup in South Africa, are reported by the BBC to be capable of sounds levels of 120 decibels (though it’s not clear whether this is measured in sound pressure level or hearing level!). While the instruments are banned in most European stadia, the WHO’s recommendation for a global ban will no doubt be music to the ears of long-suffering fans with a season ticket next to a vuvuzela player. The article can be read at http://www.bbc.co.uk/sport/0/football/31662333

Facts about wax

While healthcare professionals with an interest in the ear have known about the advantages of cerumen for a long time, most clinicians will be well aware of the widespread public perception that “earwax is bad”. A recent article on the BBC News website attempts to wipe out this myth with ‘5 things you didn’t know about earwax’. Beyond the usual information about its migratory and anti-microbial properties, the article explains how cerumen can sometimes be used as a pollution monitor and how earwax differs by ethnicity. Read the full article at http://www.bbc.co.uk/news/health-26527266

Hearing aids for your iPhone

In an article sponsored by Amplifon, the Telegraph report on the linkup between ReSound and Apple which will allow hearing aid patients to control their hearing aids from their phone or tablet. The public are informed in this article about the ability to adjust the settings of a hearing aid through an app. It also explains how hearing aids can be used to stream audio from another device via Bluetooth technology. Though the article reads a bit like an advert for one specific product, which is currently available in the private sector, it will leave patients more informed about the potential of wireless accessories for their hearing aids. Read the article at http://www.telegraph.co.uk/sponsored/health/hearing-aids/11425467/hi-tech-hearing-aids.html

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44 “Isla miss her lover power”

The Guardian highlight a report published by communications watchdog, Ofcom, which states that the quality of subtitling for live TV leads to those who rely on it having an inferior experience. It explains that across terrestrial TV, over 200 programmes have live subtitling, and that current technology means that mistakes and omissions are not uncommon. A source (or perhaps “sauce”) from Ofcom maintains that ensuring a good quality of experience for hard of hearing viewers is a priority for Ofcom. Read the full article at http://www.theguardian.com/media/2015/jan/28/ subtitling-errors-can-make-live-tv-unwatchable-says-ofcom

40 year old switch on

A video published by the Mirror depicts the cochlear implant switch on of a deaf-blind lady with Usher syndrome. Jo Milne, who wrote a book about her experience with implants called “Breaking the Silence”, breaks into tears at the sound of the Audiologist’s voice. The article has an uplifting feel, and perhaps the book may give comfort to some patients about to undergo cochlear implantation. To read more of Jo’s story and to see the video, visit http://www.mirror.co.uk/news/real-life-stories/ watch-deaf-blind-woman-recall-emotional-5188638

Tattooed implant

The Mirror report on a picture which went viral on social media of a tattoo that a father had to match his daughter’s cochlear implant. The dad who has the tattoo remains unknown, according the the article, but a picture of his tattoo next to his daughter wearing her implant was shared by thousands across Twitter and Facebook within hours of surfacing. Read the article that accompanies the picture at http://www.mirror.co.uk/news/uk-news/ loving-dad-gets-touching-tattoo-5264778

Facebook “f ” Logo

CMYK / .eps

Facebook “f ” Logo

CMYK / .eps

Don’t forget that any piece that appears on a news website can be commented on or shared via social media, allowing the reader to add their voice to a debate and pass the story to friends and colleagues.

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45

Twitterarty @HallAmandJ introduces you to the audiology Twitter community

North Staffordshire. As expected there was a lot of twitter discussion around the recent decision by the North Staffordshire CCG to restrict patient access to hearing aids

Kathleen @kathleenlhill . Mar 5 @AudioWorldnews @radicalaud @NHSNorthStaffs has now decided to ration hearing aids. Proposal passed on Wed 4 Mar

This edition of Twitterarty looks at recent twitter feeds of some of the charities and organisations supporting people with hearing loss, tinnitus and balance problems. We focus on tweets relating to campaigns as well as those promoting events and resources for patients and professionals.

S J Watson @SJ_Watson . Mar 4 A disastrous decision for those with hearing impairment in N Staffordshire but I fear it’s the thin end of the wedge dlvr.it/8qbNI3

David Williams @dwilliamsHSJ . Mar 9 CCG becomes 1st to ration access to hearing aids. Saves £200k per year, or 0.08pc of its total budget. hsj.co.uk/hsj-local/ccgs...

Audiology Worldnews @AudioWorldnews . Mar 6 Universal condemnation for the first NHS CCG that plans to cut h/a provision in the UK. audiology-worldnews.com/focus-on/1274-... #AudPeeps #NStaffs

Jason Smalley @bostonshirede . Mar 4 Evidence for that? RT @daveblackhurst2: N staffs ccg chair mark shapley says 40 percent of hearing aids issued never used . @SentinelStaffs

BritishSocAudiology @BSAudiology1 . Mar 5 Incase you haven’t heard: bad news for those with #hearingloss. No aids for mild, pass a test for mod loss stokesentinel.co.uk/NHS-hearing-ai... #AudPeeps

Audiology Tweets @LoveHertz_Audio . Mar 10 Disappointing news from North Staffs. Mild and mod loss should be treated to get best from the hearing aid journey

Audiology Worldnews @AudioWorldnews . Mar 6 #AudPeeps around the world - a question. ‘40% h/aids are unworn’ - can anyone actually reference this figure please? #NStaffs

Richard Blogger @richardblogger . Mar 9 Cannot believe NorthStaffs rationing hearing aids was clinical decisn. Aids for moderate loss improve wellbeing - no Dr wld damage wellbeing

HelenPryce @HelenPryce . Mar 10 #northstaffs CCG to use dated handicap to determine who gets a hearing aid rather than patient preferences and #sdm. Preferences matter.

Graham Sutton @radicalaud . Mar 5 Who will administer HHEI eligibility test? GP or Audiologist? Justifiable to brief patients carefully about the implications I think.

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46 Action Plan on Hearing Loss The North Staffs decision is at odds with the recent publication of the DH Action Plan on Hearing Loss:

Vicki Kirwin @KidsAudiologist . 11h The long awaited #ActionPlanOnHearingLoss is published! england.nhs. uk/2015/03/23/hea... #AudPeeps

Join us on Twitter @BSAudiology1

ActionOnHearingLoss @ActionOnHearing . 7h Launched, long-awaited Gov strategy on hearing loss. Will it lead to positive action or gather dust on a shelf? buff.ly/1bnWGsG

Monitor report on AQP And another government publication on hearing loss, this time on AQP and choice Monitor @MonitorUpdate . Mar 5 @NICEcomms: read our report on how choice works for adult hearing services: bit.ly/1B9HSWE. #NHS

Action on Hearing Loss Away from politics, Action on Hearing Loss have been promoting Deaf Awareness Week with top tips for each day. ActionOnHearingLoss @ActionOnHearing . May 5 Follow us during #DAW15 for our top communication tips for being more deaf aware! #DeafAwarenessWeek

Follow us on Twitter to keep up to date with BSA courses, meetings and conferences. Find out about relevant events and conferences worldwide; as well as all the latest news from the world of audiology.

Why not give twitter a try. A good place to start is by following the British Society of Audiology @BSAudiology1

Get involved by sharing meeting photos and contributing to regular discussion points and surveys.

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The Dichotic Hearing Test a brief history CD

Author and Correspondence Dale Hewitt (Audiologist, Portsmouth Hospitals Trust) Audiology, Queen Alexandra Hospital, Cosham, Portsmouth, PO6 3LY E: dale.hewitt@porthosp.nhs.uk

Take Home message “Recent research suggests it is possible to develop dichotic hearing training that can help not only with higher scores in a dichotic test, but also with reducing difficulties hearing speech in noise.” 50 years ago Doreen Kimura published a brain asymmetry research paper which concluded that: “Due to the greater effectiveness of the crossed pathways, melodies arriving at the left ear are more efficiently transmitted to the right temporal lobe, an area most important for their perception, than are melodies arriving at the right ear. An analogous but opposite effect occurs for verbal material presented to the two ears. Thus the left-right differences which occur in the present study reflect an asymmetry of function in the two cerebral hemispheres.” (Kimura, 1964) In later studies she and other colleagues with verbal stimuli in normal subjects discovered further asymmetry of hemshow a right ear advantage (REA). This ispheric function such as a right hemiis attributed to the left hemisphere lansphere superiority for environmental guage specialization and to the domsounds (dripping taps, flushing toilets, inance of the contralateral auditory ...), a left hemisphere superiority for the pathway. Speech arriving at the right identification of emotional tone (happy, hemisphere (from the left ear) requires sad, ...), and a right hemisphere superiorcallosal transfer to the left hemisphere ity for visual determination of line-orienand therefore takes longer to arrive at tation and point localisation in Right Ear Advantage: A direct pathway to the Left Hemisphere space. Several of her papers beProcessing Auditory Cortex came “citation classics” and are still being cited 50 years later. The primary research tool used by Kimura was the dichotic listening test. Two similar sounds are simultaneously presented, one to each ear.The listener has to verbally repeat both sounds. (An alternative task is to repeat the single sound presented to a specified ear.) Dichotic tests

the speech processing areas. The Kimura model requires that contralateral auditory pathways dominate over ipsilateral, and subsequent studies have shown that the left ear contralateral pathway inhibits the right ear ipsilateral pathway; with greater inhibition occurring in the more difficult listening environments (Della Penna S et al, 2007). From the beginning it was clear that functional asymmetry of the brain meant that the Corpus Callosum (CC), which connects together the homologous areas of the two hemispheres, plays a critical role in the perception of sound and speech. Recent studies have shed light on this close relationship between REA scores and the transfer of auditory information between the two hemispheres (Bamiou D-E et al, 2007). Right ear scores are high at a relatively young age and reach their peak (of almost 100%) by the age of around 10 years. At 10 years, left ear scores are lagging behind at around 75%. There is a slow improvement however, and at around 20 years of age the left ear scores are almost as good as the right ear scores.This loss of clear advantage of the right ear continues for several years. Around approximately 50 years of age, although scores begin to drop for both ears, the scores for the left Speech ear fall faster and once again a distinct right ear advantage establishes itself. Left ear scores drop to the 75% mark at around 70 years, while it is another 10 years for the right ear scores to reach this level (Jerger J et al, 1994). Dichotic Test scores are highly dependent on the integrity of the Corpus Callosum (CC). Lesions in the posterior of

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48 learn auditory training software for deficit-specific remediation of binaural processing deficits in children: preliminary findings. Journal American Academy Audiology 22(10), 2011. 3. Della Penna S, Brancucci A, Babiloni C, Franciotti R, Pizzella V, Rossi D, Corpus Callosum: more than 200 million heavily myelinated axons that interconnect corresponding areas in both hemispheres.

Torquati K, Rossini P, Romani G. Lateralization of dichotic speech stimuli is based on specific auditory path-

the CC usually result in worse left ear scores. The peaking of the left ear scores at around 20 years coincides with the developmental maturity of the CC. At middle age the CC begins to reduce in size, and this age marks the beginning of the fall of the left ear scores (Musiek F et al, 2011).

Dichotic Tests can therefore be used as a measure of the maturation of auditory inter-hemispheric connectivity, as well as the

original purpose of investigating asymmetry of function between the two cerebral hemispheres (Westerhausen R, and Hugdahl K, 2008). Over the last half-century many thousands of studies have used the behavioural dichotic test to investigate sound perception and its neuroanatomy. And even though we now have electroencephalography, magnetoencephalography, near-infrared spectroscopy, chronometric single pulse transcranial-magnetic stimulation and the many flavours of MRI (including fmri, mean diffusivity, fractional anisotropy, DTI tractography), the dichotic test continues to be a valuable tool. For example, recent research has shown that when adults experience repeated dichotic tests which require them to attend only to the speech sounds presented to the left ear (and ignore those presented to the right ear) these left ear scores will improve over time. This “training” enables them to improve their left ear scores in the standard dichotic test which requires listening to sounds presented to both ears (Soveri A et al, 2013).

And as for the audiological clinic dichotic tests are frequently used as part of the battery of tests for Auditory Processing disorder (APD). Children who seem to struggle hearing in noise yet have normal pure tone audiometry scores are frequently found to have a larger right ear advantage than their peers. Given that it seems that left ear scores mature along with Corpus Callosum (CC) inter-hemispheric structures it is a reasonable assumption that low left ear scores may reflect some form of delay in CC maturation. Similarly it is not unreasonable to expect that prolonged episodes of ear infections such as “glue ear” disrupt the maturation of the CC inter-hemispheric structures needed for dichotic hearing (Farah R et al, 2014).

way

interactions:

neuromagnetic

evidence, Cerebral Cortex 17(10), 2007. 4. Farah R, Schmithorst V, Keith R, Holland S. Altered white matter microstructure underlies listening difficulties in children suspected of auditory processing disorders. Brain and Behavior 4(4), 2014. 5. Jerger J, Chmiel R, Allen J, Wilson A. Effects of Age and Gender on Dichotic Sentence Identification. Ear & Hearing 15(4), 1994. 6. Kimura D. Left-right differences in the perception of melodies, Quarterly Journal of Experimental Psychology 16, 1964.

Both of the above recent uses of the dichotic test make a case for an increased usage in the Audiology Clinic. Such testing would help identify those children who are failing to develop their dichotic hearing as fast as their peers, those young adults whose dichotic hearing did not reach full maturity, and those older adults whose dichotic hearing is beginning to fail. Recent research, including that above suggests it is possible to develop dichotic hearing training that can help not only with higher scores in a dichotic test, but also with reducing difficulties hearing speech in noise. And that adults as well as children can be helped (Cameron S and Dillon H, 2011).

7. Lebel C and Beaulieu C. Longitudinal

References 1. Bamiou D-E, Sisodiya S, Musiek F, Lux L. The role of the interhemispheric pathway in hearing, Brain Research Reviews 56, 2007. 2. Cameron S and Dillon H. Development and evaluation of the LiSN &

10. Westerhausen R and Hugdahl K. The

Development of Human Brain Wiring Continues from Childhood into Adulthood. The Journal of Neuroscience 31(30), 2011. 8. Musiek F and Weihing J. Perspectives on dichotic listening and the corpus callosum. Brain and Cognition 76(2), 2011. 9. Soveri A, Tallus J, Laine M, Nyberg L, Bäckman L, Hugdahl K, Tuomainen J, Westerhausen R, Hämäläinen H. Modulation of Auditory Attention by Training: Evidence From Dichotic Listening Experimental Psychology 60(1), 2013. corpus callosum in dichotic listening studies of hemispheric asymmetry: A review of clinical and experimental evidence. Neuroscience and Biobehavioral Reviews 32, 2008.

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Training the Carers... Hearing aid support for Adults with Learning Disabilities CD

Author and Correspondence Areesa Javed MSc Audiology Student

Dr SiobhĂĄn Brennan Lead Clinical Scientist (Audiology) Regional Department of Neurotology, Sheffield Teaching Hospitals E: siobhan.brennan@sth.nhs.uk

Background When offering amplification to a client with a learning disability (LD), particularly those for whom another person will be supporting their hearing aid (HA) use, consideration ought to be given to the impact that this will have on their carer. This could be a family member or a member of a professional care team. There is evidence to suggest that because of the additional work re-quired in supporting HA use for an individual with a learning disability, amplification may not necessarily be a positive influence on the life of their carer (Dubb 2012, McShea, 2015). Additionally, looking at the experiences of the Sheffield Hearing and Learning Impairment Service, some patients were not benefiting from their HAs because of the difficulties that carers were having with their maintenance. For clients who live in residential care homes at which there are multiple people involved in their care, they are typically accompanied to their Audiology appointment

staff as possible. There were several aims of this training. Firstly, it was important to inform carers of the importance of HA use for those with LDs to improve motivation to persevere. This is often a fundamental reason for the uptake of HAs to be low in those needing care (Newsam 2010). This information was provided mainly through facts and figures regarding ear health and LDs. Secondly, information on basic cleaning and maintenance of HAs was provided. Thirdly and crucially, the issues that carers face with regards to HA use that may prevent them from being beneficial were established.

with a single carer. The carer can be different for each appointment. It became apparent that the information given to the client and their carer was not necessarily being disseminated effectively to the other members of the care team. McShea’s (2015) interviews with car-ers found that they felt that specific areas for training should be addressed. These included information on ear care, behavioural clues, troubleshooting and many more. This lack of information not only negatively impacts the client themselves, but also the service as a high number of appointments were spent reiterating guidance on HA use and replacing batteries. For these reasons Sheffield Teaching Hospitals’ Patient Partnership provided a Volunteer who offered training sessions on HA use to care homes for adults with learning disabilities in Sheffield.

Lack of HA support by carers increased the negative impacts hearing loss can have on an individual. These impacts were largely communicative and cause great difficulty for the individual with a LD (Carvill 2001). An example of this includes a particular care home where carers were unaware of the need for battery changes and cleaning of moulds. The former resulted in constant use of an inactive aid. This was only recognised when the HA user attended a training session (specifically for those with LDs) at his place of work. The care home was subsequently contacted to arrange training sessions but also to inform them of simple maintenance points. Having completed training with the care team, a weekly battery log was put in place to inform all of the team of when to check the batteries. This has resulted in a more effective way of monitoring the HA but also informed the team of the importance of a working aid.

Training Provision We worked with four care homes for those with learning disabilities (LDs) and aimed to train as many members of their

In terms of the training sessions, they typically lasted 40-50 minutes with 4-13 members of staff per session. Due to shift patterns it was necessary to pro-

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50 vide multiple sessions to each residence so that all members of staff were offered the training. Depending on staff numbers, the total number of sessions required to train all staff varied. A care home with 20-25 members of staff completed all training in 5 sessions whereas one with 60+ members of staff required many more. Even after all staff members were trained, the option of refresher/more sessions was made available, especially if staff turnover was high.

The basic format of the training consisted of: • Developing an initial understanding of HA use within the care home. • Carers highlighting any problems they were facing • HA controls and mould use explanation • HA cleaning and battery checking/ changing • Troubleshooting • Practical session • Hearing loss and LDs discussion including: o Why HAs will differ from person to person according to their hearing loss. o Ways in which carers can support communication for those with a hearing loss. o Basic discussion of symptoms and ear health related issues to look out for amongst clients.

Outcomes Feedback from carers that received the training was overall very positive, with many indicating that the training had increased their awareness of HA use and importance of maintenance. Common points that arose were that clients find HAs exceptionally fiddly, which results in more work in terms of persistence for carers. Many clients were said to pull out tubing which caused huge problems from a maintenance perspective. Carers

highlighted that many of the clients who were elderly and recently been given HAs, struggled to adjust and thus resulted in a greater reluctance to wear them. This compared to those issued with them earlier who tended to find the devices very effective and heavily relied on them for communicative purposes.

The main point to take from the feedback from carers was the fact that little information provided to carers resulted in greater difficulty with HAs. In terms of benefits of HAs for people with LDs, carers who were trained agreed that communicative and social benefits became apparent with constant use. In some cases it was difficult for carers to see the positives in using a HA especially if clients had managed hearing and communicating without one for so long. Moreover, in many of the care

homes individual client factors were emphasised, with each person responding to HAs differently. Carers felt that the training had been very useful and enabled them to be more aware of the ear health in general and possible hearing/ ear issues in other clients. They also felt it helped them to maintain the aids for those already using them. Overall it was apparent that with a little more information for carers the difficulties they face can be reduced. It is vital to highlight the importance of communication support for those with possible hearing issues but also ways to note any possible problems for people with LDs not already using aids. Lastly, in order to ensure positive use of HAs, regular input from healthcare services is needed to deal with the issues they face and may arise. Future Delivery Despite generally positive outcomes being reported by carers and observed by clinicians the next stage will be to quantify these outcomes so that future training can be more accurately tailored to the needs of the carers and their clients.

References 1. Dubb (2012) Impact of Hearing Aid Fitting on Carer Quality of Life HaLD Meeting 2. McShea L (2015) Support Workers for Adults with Learning Disabilities and Hearing Loss; Their Current Knowledge and Training Needs. BAA Magazine P8-10 3. Newsam H, Walley RM, McKie K (2010) Sensory Impairment in Adults with Intellectu-al Disabilities – An Exploration of the Awareness and Practives of Social Care Providers. Journal of Policy & Practice in Intellectual Disabilities 7(3) 211-220 4. Carvill (2001) Sensory Impairments, intellectual disability and psychiatry. Jnl of Intel-lectual Disability Research 45(6) 467-483

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To deliver continuous, timely and relevant education on the art and science of best practice hearing care provision. Phonak is delighted to announce the introduction of its Academy education programme. The Academy has been developed to ensure all professionals involved in the multifaceted process of hearing care provision will have consistent access to high quality learning opportunities delivered, where appropriate, by recognised key opinion leaders and associated professionals in their respective fields of expertise. The expansive programme will be delivered via traditional face-to-face lectures and, to ensure time or geographical limitations do not pose a barrier to accessibility or quality of content, our industry leading virtual classroom: e-learn. Audacity May 15 (Conflicted copy from Caroline iMac on 2015-05-21).indd 51

We will also develop departmental training plans in conjunction with the Academy and your Regional Sales Manager. The accreditation of CPD points will also be applied to relevant courses throughout the programmes so please be aware of this also. To register and receive your free welcome pack, please visit the brand new Phonak Academy website at:

www.phonakacademy.co.uk

21/05/2015 12:51


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Help shape the future of mild-moderate hearing loss research CD

Author and Correspondence Author and Correspondence Dr Helen Henshaw Senior Research Fellow and PSP Coordinator NIHR Nottingham Hearing Biomedical Research Unit, University of Nottingham E: helen.henshaw@nottingham.ac.uk

A James Lind Alliance Priority Setting Partnership is underway to help shape the future of research into mild-moderate hearing loss. Who is the Priority Setting Partnership (PSP)? JLA Advisor David Crowe explains: “The James Lind Alliance (JLA), a non-profit making initiative funded by the National Institute for Health Research (NIHR),

Partnership steering group members taken whilst attending the BAA conference in November 2014 (Bournemouth). From Left-Right, Steering Group Member (organisation represented) Melanie Ferguson, (NIHR Nottingham Hearing Biomedical Research Unit) Barry Downes, (British Society of Hearing Aid Audiologists (BSHAA))

• •

aims to bring patients, carers, family members and healthcare professionals together to identify and prioritise research questions. This PSP has been set up to identify unanswered questions about mild to moderate hearing loss: its prevention, diagnosis, treatment, care and support.” The Partnership brings together Hearing Link, Action on Hearing Loss, the British Society of Audiology, the British Academy of Audiology, the British Society of Hearing Aid Audiologists, the ENT Cochrane Group and Cochrane UK, and is coordinated by the NIHR Nottingham Hearing Biomedical Research Unit. It offers people whose lives have been touched by hearing loss the opportunity to take part in a national research priority setting exercise to help to shape the future of mild-moderate hearing loss research. How can the Partnership help inform research? Hearing loss research topics have typically been decided upon by researchers in universities. This Partnership is important for redressing the balance of power by enabling those who really understand the issues surrounding mild-moderate hearing loss

• Helen Pryce, (British Society of Audiology (BSA)) • Helen Henshaw, (NIHR Nottingham Hearing Biomedical Research Unit) • Linda Sharkey, (Hearing Link) • Vinaya Manchaiah, (ex-British Academy of Audiology (BAA))

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to have their say. The Partnership is keen to hear the views not only of people with direct or indirect experience of hearing loss, but also their friends, family members and professionals working in this area. Hearing Link are the UK organisation for people with hearing loss and their families - and the user organisation for the Partnership. Linda Sharkey, Hearing Link’s UK director, said: “I think that this Priority Setting Partnership on mild to moderate hearing loss is really important, because there is probably still much to learn about the effects, impact of and treatments for this range of hearing loss. We want people who experience hearing loss, patients, family members and clinicians to be part of this process, because they hold a level of insight into this issue that is much sought-after and needed.” An initial survey (Round 1; November 2014 – January 2015) gathered over 1,200 ‘unanswered questions’ about the prevention, diagnosis and management (treatment) of mild to moderate hearing loss. These questions are currently being grouped into themes to derive ‘indicative’ questions that may be answered by future research. How can I get involved? A second survey (Round 2) will be launched Spring 2015. This offers people with hearing loss, their friends, family and clinicians, the opportunity to identify the questions generated in Round 1 in terms of which are the most important to be answered by research. A final priority setting workshop will be held in Birmingham

in September 2015, where the ‘Top 10’ most important questions for mild-moderate hearing loss research will be agreed. The Partnership will ensure that the outputs of this process are brought to the attention of research funders, research commissioners and policy makers, to enable future research to answer the priority questions for mild to moderate hearing loss that are aligned to individuals’ needs. Access Survey Round 2 (Spring 2015) here: https://www.surveymonkey.com/s/jla-hearing2 Register your interest in attending the final prioritisation workshop (September 2015 in Birmingham, UK): JLAhearing@nottingham.ac.uk Follow us on Twitter: @JLAhearing, or Join us on Facebook Website: http://www.hearinglink.org/ james-lind-alliance-priority-setting-partnership The National Institute for Health Research (NIHR) Nottingham Hearing Biomedical Research Unit is a partnership between University of Nottingham, Nottingham University Hospitals Trust and Medical Research Council Institute of Hearing Research. This research is part funded by the Nottingham Hospitals Charity and the remainder is funded by the NIHR. The authors declare no conflicts of interest.

To find out about the The BSA Applied Research Grant Scheme go to page 57

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A short history of and a long future for the MRC Institute of Hearing Research CD

Author and Correspondence Professor Michael A Akeroyd, Director E: maa@ihr.gla.ac.uk

The MRC Institute of Hearing Research (IHR) was created by Act of Parliament. It’s purpose was set by clause 24 in the 1970 Chronically Sick and Disabled Persons Act: “The Secretary of State shall collate and present evidence to the Medical Research Council on the need for an institute for hearing research, such institute to have the general function of coordinating and promoting research on hearing and assistance to the deaf and hard of hearing.” This clause was due to the late Lord (Jack) Ashley, then Parliamentary Private Secretary to Secretary of State for Health and Social Services, Barbara Castle. After some years of wrangling and controversy, with arguments both for and against an institute (e.g. Rawson, 1973; Beagley et al. 1973), IHR was founded on January 1st 1977. Mark Haggard, then a Professor at Queen’s University in Belfast, was appointed as its first Director, aged just 34.

IHR’s structure was unique: a headquarters in Nottingham and outstations in teaching hospitals in England (Nottingham, Southampton), Wales (Cardiff), and Scotland (Glasgow). The reason for this unusual structure was to fulfil IHR’s primary initial function, to conduct the National Study of Hearing (e.g., Davis, 1989, 1995; Haggard et 1981).This was a major, multi-centre epidemiological study of the causes and prevalence of hearing loss in the UK adult population. It was a double-sampled population study, using, for the first stage, the electoral register as the primary sampling frame and employing 30,000 postal questionnaires. For the second stage more detailed psychophysical and clinical assessments such as audiometry and otoscopy were conducted on over 7000 subjects. The second-stage samples were chosen such that the results could be projected back into the general population. The resulting publication, “Hearing in Adults” (Davis, 1995) is still the main — and possibly only — source for data on the many aspects of the prevalence of hearing loss in adults, and it is also the primary source of the “1 in 7” (or “1 in 6”, depending on who you ask) maxim that is often used as a succinct summary of the numbers of hearing impaired adults in the United Kingdom (see Akeroyd et al., 2014, for an update to the calculations). From its very start IHR has been involved in other auditory research outwith the National Study of Hearing. It is perhaps fair to say that every aspect of hearing has, at some point, been studied by a scientist or clinician based at IHR – excepting only

IHR’s main building on the campus of the University of Nottingham. It was opened in 1981, and has been extended twice since then

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55 the details of cochlear function. IHR is still one of the few labs in the world that can conduct truly interdisciplinary experimental research on the brain mechanisms of hearing and the associated cognitive and multisensory processes. A short list of its scientific highlights over the last four decades demonstrates the breadth of IHR research: the National Study of Hearing; the identification of the first deafness gene; fundamental work on the neurophysiological basis of binaural hearing; the discovery of Comodulation Masking Release; the development of standard speech tests (such as the ASL sentences, FAAF words, and the Automated Toy Test); “sparse sampling” and noise cancellation for fMRI; the Glasgow questionnaires of the GBI, GHABP, and SSQ; the evaluation of the national cochlear implant program; the instigation of universal neonatal screening. The impact of this research has been considerable, not least in what IHR has made for the toolkit of all hearing scientists or clinicians. The speech tests and questionnaires are well known, but there are also less-familiar, specialised products such as the click box for the Preyer reflex and Matlab software for auditory motion-tracking. The development of new methods and innovative technologies is still a key part of IHR’s programme: the latest include ECLiPS, a questionnaire designed to assess listening skills in children, and TAIL, a computerized test of auditory attention for adults and children. IHR research is still wide in scope and multidisciplinary in nature, as demonstrated by the titles of some of IHR’s papers already published this year: “Tinnitus-related changes in the inferior colliculus”, “Age-group differences in speech identification”, “The neural substrate for binaural masking level differences”, “The role of bias in perceptual learning”, “Audiovisual integration in children”, “The Just-Noticeable Difference in Speechto-Noise Ratio”, and “Source space estimation of oscillatory power” (respectively, Berger and Coomber, 2015; Füllgrabe et

al., 2015; Gilbert et al, 2015; Jones et al, 2015; Maidment et al, 2015; McShefferty et al., 2015; and Zobay et al., 2015). In 2002 Mark Haggard left IHR to return to Cambridge. He was succeeded by Professor David Moore, then at Oxford University, who focused IHR on the “Auditory Brain”, which was a shorthand for the study of all neural processing occurring at and above the level of the auditory nerve, and its perceptual and clinical consequences. He also played a key role in the foundation of the NIHR Nottingham Hearing Biomedical Research Unit (NHBRU), now led by Professor Deborah Hall. He left IHR in 2013, to go to Cincinnati, whereupon Professor Alan Palmer became the third Director of IHR. I am following Alan, starting as Director this month. In many ways this is a homecoming for me: I previously worked at IHR Nottingham as a postdoctoral scientist in the 1990s, as part of Professor Quentin Summerfield’s group, and was, until March this year, the Director of the Scottish Section in Glasgow, which I moved to in 2002 to work with Professor Stuart Gatehouse, who was Scientist-in-Charge at the Section from 1982 to his untimely death in 2007. IHR’s work is divided into a number of research themes, each led by a programme leader. Currently they are in the structure and function of the auditory pathway (Professor Alan Palmer), neural correlates and computation (Dr Chris Sumner), auditory processing and encoding (Dr Katrin Krumbholz) and impairment and disability (myself). This structure is in flux, however, as we will be expanding our science by appointing new programme leaders and groups this year, so giving the opportunity for the next generation of scientists to work at IHR. We also committed to training future scientists: we receive a number of fully funded MRC PhD studentships every year, for which we get applicants from all over the UK and beyond. Indeed, IHR

The 24-loudspeaker ring in the new labs of the Scottish Section, Glasgow

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56 has made a huge contribution to training of UK auditory scientists whether at PhD student, postdoctoral scientist or senior scientist level; our alumni include many of the current leaders of hearing research in the UK and across the world, including Dr Bob Carlyon (MRC CBU), Professor John Culling (Cardiff), Professor Deborah Hall (NIHR NHBRU), Professor Joseph Hall (North Carolina), Professor Christian Lorenzi (Paris), Professor David McAlpine (UCL), Professor Adrian Rees (Newcastle), Professor Bernhard Seeber (Munich), Professor Richard Tyler (Iowa), and Dr Ian Winter (Cambridge). Many other internationally distinguished scientists have been programme leaders at IHR, including Professors Greg Bok, Ross Coles, Adrian Davis, Stefan Debener, Deborah Hall, Mark Lutman, Karen Steel, Quentin Summerfield, and Roger Thornton.

to solve, for adults and children with (or without) hearing losses the questions of “What do they hear of the world?”, “What do they miss?”, “What can be done about it?”, and, underpinning all these, “How do we hear?”

IHR currently operates from three sites. Its headquarters are on the campus of Nottingham University, it has a clinical section in the Queens Medical Centre in Nottingham, and the Scottish Section is located in Glasgow Royal Infirmary. The various groups maintain close links through regular travel and video links. This structure provides IHR with both a basic research core and vital, direct links to clinical needs. It also gives it collaborative potential with the universities in Nottingham and Glasgow. All IHR sites have fully-equipped laboratories for cutting-edge hearing science, including, among others, new state-of-the-art laboratories of the Scottish Section in Glasgow, which allow for the testing and measuring listening in complex environments, recreating the acoustics of nearly any conceivable situation while tracking how people move as they listen. IHR led the refurbishment of the anechoic chamber at the University of Nottingham, and the staff also have access to the world-class neuroimaging facilities at the Sir Peter Mansfield Magnetic Resonance Centre. The closest working relationship is with NHBRU, which offers perfect opportunities to tie in closely with research for patient benefit and clinical trials, and its scientists and clinicians have expertise that complements IHR’s.

References 1. Akeroyd MA, Foreman K, Holman JA (2014) Estimates of the number of adults in England, Wales, and Scotland with a hearing loss. International Journal of Audiology, 53, 60-61. 2. Beagley HA, Fisch L, Hinchcliffe R, Knight JJ (1973) Comments upon the Rawson Report. British Journal of Audiology, 7:58-64. 3. Berger JI, Coomber B (2015) Tinnitus-related changes in the inferior colliculus. Frontiers in Neurology 6:61.Davis AC (1989). The prevalence of hearing impairment and reported hearing disability among adults in Great Britain. International Journal of Epidemiology, 18, 911-917. 4. Davis AC (1995). Hearing in Adults. London: Whurr. 5. Füllgrabe C, Moore BC, Stone MA (2015) Age-group differences in speech identification despite matched audiometrically normal hearing: contributions from auditory temporal processing and cognition. Frontiers in Aging Neuroscience 6:347. 6. Gilbert HJ, Shackleton TM, Krumbholz K, Palmer AR (2015) The neural substrate for binaural masking level differences in the auditory cortex. Journal of Neuroscience, 35, 209-220. 7. Haggard M, Gatehouse S, & Davis AC (1981). The high prevalence of hearing disorders and its implications for services in the U.K. British Journal of Audiology, 15, 241-251. 8. Jones PR Ratcliffe N Moore DR Amitay S (2015) The role of bias in perceptual learning. Journal of Experimental Psychology: Learning, Memory, and Cognition, in press 9. Maidment DW, Kang HJ, Stewart HJ, Amitay S (2015) Audiovisual integration in children listening to spectrally degraded speech. Journal of Speech, Language, and Hearing Research, 58, 61-68. 10. McShefferty D, Whitmer WM, Akeroyd MA (2015) The Just-Noticeable Difference in Speech-to-Noise Ratio. Trends in Hearing 19 11. Rawson A. 1973. Deafness: Report of a Departmental Enquiry into the Promotion of Research. London: H.M. Stationery Office. 12. Zobay O, Palmer AR, Hall DA, Sereda M, Adjamian P (2015) Source space estimation of oscillatory power and brain connectivity in tinnitus. PloS One 10, e0120123.

Across all the UK hearing-science laboratories, IHR has a unique funding model, as it receives most of its funds from the intramural programs of the Medical Research Council as well as for the Scottish Section in Glasgow, a major contribution from the Chief Scientist Office. This funding is reviewed every five years. The review is rigorous and tough, as it has to be, but IHR has an excellent record of maintaining funding since 1977. IHR staff also apply for external grant funding, and recent awards have come from BBSRC, EPSRC, and Action on Hearing Loss. Many of these are collaborations with scientists worldwide. IHR continues as an interdisciplinary research institute, conducting experimental research on hearing impairment in adults and children underpinned by basic science into the brain mechanisms of hearing. We will always strive to do auditory science of the highest quality, continually championing the most exciting, innovative research, hoping to discover new phenomena and to further their explanations, while also developing innovative new methods and interventions. The questions motivating IHR’s scientific research are the scientific “Grand Challenges” in hearing:

In summary, IHR has a prominent and distinguished scientific history and is looking forward to an exciting and long-term future. If you are interested in being a part of that future as a student, clinician, scientist, or collaborator, all helping to discover new science from basic to applied, then please get in contact!

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The BSA Applied Research Grant Scheme Research is creative work undertaken on a systematic basis in order to increase knowledge, establish facts and reach conclusions. Asking and answering questions, and adding to the evidence base of audiological practice, is fundamental to the advancement of our field. Scientists are expected to ask questions. However, even if research is not part of the typical daily routine of an audiologist, it is likely that everyone working within the clinical field of audiology has thought of a question related to their practice at some point in their careers. Many of these questions are probably not investigated and thus, remain unanswered. This is despite the fact that if a practice related question has been asked it is likely that the answer will be useful, be it on a global scale, for example ‘can we cure hearing loss?’, or on a more individualised or restricted level such as ‘why is this patient not responding to aural/ vestibular rehabilitation?’ or ‘what can be done to improve this service?’

Since 2007, the BSA in conjunction with the MRC Institute of Hearing Research (IHR) has made available an annual fund of £20,000 for research projects (£5000 maximum per project) involving BSA members. This BSA Applied Research Grant scheme facilitates progress of the field by supporting projects solely related and pertinent to audiology. The scheme provides a unique source of support for small scale (but not necessarily small in terms of impact) applied research projects in areas relevant to hearing, tinnitus and/or balance. What can be funded? All applications in applied research areas relevant to hearing, tinnitus and/ or balance will be considered. Emphasis will be placed on certain areas including, but not limited to, collaborative projects between clinicians and scientists, under-researched areas and projects aimed at harnessing the clinical experience of BSA members. For further details please refer to the application guidance on the BSA website.

So, if you have asked yourself or a colleague an audiology related question, why not try and answer it?

How to apply? Go to the BSA website (http://www.thebsa.org.uk/ bsa-applied-research-grant/) to download an application pack, including the application form and guidance or contact the BSA office on bsa@thebsa.org.uk

Opportunities for 2015/16 Application deadlines 11 September 2015 (midnight) 11 March 2016 (midnight) The application form will be available from 1 June 2015

How is the funding allocated? Grants are scored (by members of the BSA Research Fund Steering Committee) and funded on the basis of: • scientific quality (rationale and method) • roles and relevant expertise of the research team • full details and justifications of costs; value for money • importance to applied research in hearing, tinnitus, and/or balance; relevance to key areas To date, the success rate for relevant applications is approximately 1 in 4 What has been funded previously? Since 2008, approximately £100,000 has been awarded, supporting 29 diverse audiology related projects with funding ranging from £1428 to £5000. Successful projects have utilised a range of methodologies and focused on a range of topics including:

Evidence based practice is the integration of best research evidence with clinical expertise and patient values (Sackett, 2000)

• service provision o The influence of advances in hearing aid technology on models

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58 o

of service delivery for hearing impaired adults in the NHS, £4908 Development of a patient decision aid for shared decision making in adult audiology services, £4485

o

• hearing aid fitting and outcomes o Consensus on hearing-aid fitting candidature for mild hearing loss with and without tinnitus: Delphi review, £1428 o Can cortical auditory evoked potentials reliably measure access to speech using frequency compression hearing aids? £2940 o Development and evaluation of an interactive video tutorial for hearing aid users and their communication partners, £4296

sound induced vestibular evoked myogenic potentials, £3000 Study of ocular and cervical vestibular evoked myogenic potentials in healthy school-age children, £3000

Who is on the panel? Dr Heather Fortnum (Chair) (heather.fortnum@nottingham.ac.uk)

• diseases/disorders o Otosclerosis: Evaluating candidate genes identified by whole exome sequencing in a cohort of familial otosclerosis patients, £4967 o What is important to parents of children with glue ear?, £4960 o Imaging Auditory Pathways in children with Auditory Neuropathy Spectrum Disorder, £3263 o Watchful waiting and tinnitus: a systematic review and meta-analysis, £3201 o Management of paediatric tinnitus: a survey of working practice in the UK, £1903

• diagnostic/investigative tools o Repeatability of neck and lower limb

Dr Michael Akeroyd (Representing MRC) Prof Dave Furness (BSA member) Dr Amanda Hall (BSA member) Dr Ruth Brooke (BSA member) Dr Claire Fielden (BSA member)

If you have any questions, please contact Heather Fortnum or any member of the review panel

Previous

digital versions of Audacity are available at:

www.thebsa.org.uk Audacity Dec13_Layout 1 05/12/2013 14:00 Page 1

Audacity Apr14_Layout 1 08/04/2014 11:45 Page 1

Audacity

Audacity

...a British Society of Audiology Publication

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AUD AUG14 cover_Layout 1 29/07/2014 09:03 Page 1

...a British Society of Audiology Publication

issue 3 april 2014 ................................

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Audacity ...a British Society of Audiology Publication

issue 4 August 2014 ................................

Audacity ...a British Society of Audiology Publication

issue 5 December 2014 ..................................

Online access

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Infant sucking Response

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Plasticity following short-term unilateral hearing loss

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Psychoacoustics and beyond

OAEs: they just keep coming back

w ne

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If all you have is a hammer...’

bsa

website

www.thebsa.org.uk

New website for the BSA www.thebsa.org.uk

50 The Role of the School Entry Hearing Screen....

explores new ideas

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46

Research Round-up:

54

A trip to Bangladesh

Audiology in India

resources

audacity@thebsa.org.uk

British Society of Audiology

www.thebsa.org.uk

KNOWLEDGE | LEARNING | PRACTICE | IMPACT

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DEAFinitely Inclusive Sport

Goodbye to Brian Moore and the Auditory Perception Group

audacity@thebsa.org.uk

................................. www.thebsa.org.uk

British Society of Audiology KNOWLEDGE | LEARNING | PRACTICE | IMPACT

audacity@thebsa.org.uk

................................. www.thebsa.org.uk

British Society of Audiology KNOWLEDGE | LEARNING | PRACTICE | IMPACT

audacity@thebsa.org.uk

................................. www.thebsa.org.uk

"Tectorial membrane in a 'near live' position on top of the outer hair cell steriocilia. Photo courtesy of Andrew Forge, UCL Ear Institute."

30 Tinnitus in Children

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essentials

59

Essentials Council Members / Meeting Dates Officers

Dr Martin O’Driscoll (Audacity)

Dr Huw Cooper – Chairman

Miss Tracey Twomey

Dr Helen Pryce

Mrs Elizabeth Midgley – Vice Chairperson Prof. Kevin Munro – Immediate Past Chairman Prof David Furness – Secretary Dr Graham Sutton – Treasurer

Council Advisors Ms Siobhan Brennan (Electrophysiology SIG) Miss Debbie Cane (BIG) Prof. Adrian Davis (IJA)

Elected Trustees

Dr Piers Dawes (Cognition & Hearing) Dr Melanie Ferguson (LEG)

Dr Michael Akeroyd

Mr Graham Frost (PPC)

Mr Peter Byrom

Ms Pauline Grant (APD)

Mrs Nicci Campbell

Ms Lucy Handscomb (ARIG)

Mr Chris Cartwright

Mr Sebastian Hendricks (Acting Chair of PAIG)

Mr John Day

Mrs Kathryn Lewis (BSA North Branch)

Dr Heather Fortnum (RFSCo) Retired May 2015

Miss Charlotte Turtle (New Members)

Mr Gareth Smith

Dr Peter West (IJA)

BSA Meeting Dates for 2015 Tuesday 16th June - Birmingham Thursday 3rd September - Cardiff (TBC) Tuesday 8th December - Birmingham (TBC) Council from 11.00am to 4.30pm

Professional Practice Committee Meeting Dates 2015 Monday 7th September Monday 23rd November (All dates to be confirmed)

For further information, please contact BSA Admin Office Tel: 0118 966 0622 Fax: 0118 935 1915 Email: bsa@thebsa.org.uk Web: www.thebsa.org.uk

Meeting dates and venues may be liable to change... essentials

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Essentials Examination Passes The following students have passed accredited BSA courses over recent months:

BSA Certificate in Otoscopy & Impression Taking (Adults & over 5’s) (Audio-Training) Michelle Turnbull Calvin Stevens Christopher Connor Natalie Ormsby Lee Davison Jenny Murfin Oliver Lloyd Connor Baker Naomi Stella Cally Pocock George Jobin Ben Horner David King

James van Litsenborgh

Maria Waller

Saúl Maté-Cid Karl Schroder Garnet Newman Jonathan Beeks David Chimley Richard Farnhill Zsanett Cservari Melanie Campbell Terry Williams Melanie Harding

Ryan Clark

BSA Certificate in Industrial Audiometry (Audio-Training) Maria Waller Ralph Higson Adrian Cunliffe Phil Taylor

David Cox

BSA Certificate in Basic Audiometry & Tympanometry (Hidden Hearing) Roz Clarke Donna Goldie Jane Lennon Kerry Livingstone

Congratulations to all candidates Details of all accredited course providers, together with information on providing accredited courses, are available from the BSA office and via the BSA website www.thebsa.org.uk. The BSA also retains a list of delegates who have completed accredited courses.

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Essentials Sponsor Members The partnership with Sponsor members of the British Society of Audiology (BSA) is of fundamental importance to the Society. As the largest multidisciplinary society concerned with hearing and balance in the UK, the BSA seeks to include commercial colleagues and organisations in its mission to promote knowledge, research and clinical practice in these areas. Being a Sponsor member places an organisation in close dialogue with senior members of the BSA, supporting meetings and publications. The outworking of this are yearly meetings between the Officers of the BSA and the Sponsor members to share information and perspectives on the strategic direction of the BSA. Sponsor members have direct input to the Programmes Committee, and their input is especially valued in the organisation of meetings and supporting exhibitions, these being a crucial element of successful events. ACOUSTIC METROLOGY LIMITED Manufacturers of VRA systems. Repair service of Audiometers, tympanometers and acoustics instruments. E: info@a-met.com W: www.a-met.com

INDUSTRIAL ACOUSTICS COMPANY LTD World leader in the design, supply and installation of high performance, state-of-the-art of Audiometric Rooms. E: info@iac-acoustics.com W: www.industrialacoustics.com/uk

SIEMENS HEARING INSTRUMENTS LIMITED Leader in the provision of digital hearing systems to the NHS and private hearing aids dispensers. E: info-hearingaids.shi.ukhealthcare@ siemens.com

AMPLIVOX LIMITED Amplivox provides a range of audiological products and services that combine innovation and reliability E: n.court@amplivox.ltd.uk W: www.amplivox.ltd.uk

OTICON LIMITED Oticon designs and manufactures both hearing solutions for adults, and specialized paediatric instruments. E: info@oticon.co.uk W: www.oticon.co.uk

SPECSAVERS Specsavers is largest provider of the free NHS digital hearing aids and 60% of its 17.3m customers in the UK are from the NHS. W: www.specsavers.co.uk

AUDITDATA LIMITED Auditdata provides office management systems for hearing clinics, innovative audiometry fitting systems, and hearing instrument testing. E: uksupport@auditdata.com W: www.auditdata.com

OTODYNAMICS LIMITED Otodynamics Ltd. pioneered OAE screening 25 years ago and sells a wide range of OAE screening and diagnostic instruments and makes in-house research and development its top priority E: sales@otodynamics.com W: www.otodynamics.com

STARKEY LABORATORIES LIMITED Provides information throughout the world about hearing loss, hearing aids and different types of hearing professionals. E: sales@starkey.co.uk W: www.starkey.co.uk

BIOSENSE MEDICAL LIMITED Biosense Medical supply specialist equipment for use in Audiology, Vestibular and Balance, Neurophysiology, Pressure Measurement, Human Movement and Biomechanics W: www.biosensemedical.com

PHONAK UK Phonak offers latest product information, an interactive content about hearing and a specific children section W: www.phonak.com

THE TINNITUS CLINIC The Tinnitus Clinic is the leading provider of the latest evidence-based tinnitus treatments in the UK. W: www.thetinnitusclinic.co.uk

ECKEL INDUSTRIES OF EUROPE LIMITED Eckel supply, design and install hemi (semi) and anechoic chambers. Further applications offered include Audiology Rooms and Suites. E: general@eckeleurope.co.uk W: www.eckeleurope.co.uk

PURETONE Limited Manufacturers of quality digital and analogue hearing aids, tinnitus management systems. E: info@puretone.net W: www.puretone.net

P C WERTH LIMITED PC Werth supplies calibrate and service the UK’s leading range of instruments for every diagnostic and audiology need. E: sales@pcwerth.co.uk W: www.pcwerth.co.uk

GUYMARK UK LIMITED Guymark is a distributor of GSI audiological equipment, Vivosonic ABR equipment and Micromedical Technologies balance equipment E: sales@guymark.com W: www.guymark.com

GN RESOUND LIMITED ReSound is part of GN ReSound Group, one of the world’s largest providers of hearing instruments and diagnostic audiological instrumentation E: iinfo@gnresound.co.uk W: www.gnresound.co.uk

THANK YOU FOR THE VALUABLE SUPPORTS

www.thebsa.org.uk

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Essentials Audacity Advertising rates ADVERTISING RATES : 2014 - 2015 Sponsors Non-Sponsors Half A4 colour Full A4 colour

£325 £545

£495 £845

Special Positions Full A4 Colour Outside Back Cove Full A4 Colour Inside Front Cover Inside/Outside Cover Sponsors ONLY Technology Update per issue

£915 £925 £215 £230

Flyer insert in Audacity Single A4 (flyer provided) Single A4 (B/W printed by BSA)

£645 £895

For further details, please contact the BSA Admin Office by email: bsa@thebsa.org.uk or Tel: 0118 966 0622

Combined Career Opportunity Full A4 in Audacity + Web listing + Bulk Email (commercial) Half A4 in Audacity + Web listing + Bulk Email (commercial) Full A4 colour in Audacity (unlimited words) + web listing Half A4 colour in Audacity (unlimited words) + web listing

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Quarter A4 colour (200 words) + web listing

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2015 - AUDACITY PUBLICATION SCHEDULE Advertisements

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