Updated: 15 June 2020
This statement provides an overview of the key issues affecting people who are deaf or have hearing loss in the context of the UK’s coronavirus response. It also sets out Action on Hearing Loss’ recommendations for action.
There are 12 million people in the UK with hearing loss, including an estimated 900,000 with severe or profound hearing loss. We know that it is older people who are at higher risk of becoming severely ill due to coronavirus. With more than 70% of people over the age of 70 living with hearing loss, the needs of this group must be taken into consideration in the UK’s response.
Due to the fast-moving nature of events and changing guidance, Action on Hearing Loss will update this statement on a rolling basis. If you would like to confirm that you have the latest version, or for further information, please contact:
Ayla Ozmen, Head of Research and Policy:
- 07787 538267
The issues covered in this position statement are:
- Accessibility of public health information
- Accessibility of health and social care services
- Accessibility of other essential services
- Face coverings and social distancing measures for the general public
- Audiology services
- Coronavirus Act
- Disability Employment: remote working and social distancing
- Loneliness and isolation
- Health outcomes
1. Accessibility of public health information
The Equality Act requires reasonable adjustments to be made to support disabled people, including providing information in an accessible format. The Accessible Information Standard (AIS) puts a legal requirement on all health and social care providers to provide information in people’s preferred format. People’s rights under this legislation must be upheld, even in these unprecedented times.
We welcome that the majority of audio public health messaging currently available is subtitled, though this isn’t always the case. A large proportion of current public health messaging also remains inaccessible to British Sign Language (BSL) users. For many of those whose first language is BSL, reading written English can be difficult. Critical information on the GOV.UK website for example, including recent information on testing, is not translated into BSL. In addition, the Government has been slow to develop BSL versions of vital mailings sent to the public, such as the shielding letter.
We welcome the Government’s publication of short BSL videos including basic public health information. The content of these videos, however, is extremely limited and they haven’t been widely disseminated. SignHealth, the Deaf health charity, has produced BSL versions of some public health information, though these haven’t been widely promoted by the Government and public health messaging will continue to evolve rapidly still with no clear plans for BSL interpretation or dissemination.
With regard to broadcast media, BSL versions of the day’s news are available at limited intervals of the day. With significant announcements being announced at short notice, however, timely access to information has become more important than ever. The Government’s decision to work with broadcasters to provide live BSL interpretation for the daily press conferences was therefore a very welcome step that should continue. There was, however, unfortunately no BSL interpretation for the critical announcement that took place on 23 March or for the Prime Minister’s return to work speech on 27 April. In addition, although the Government have now made the in-vision BSL interpreter for press conferences available for use by all broadcasters, this is not being adopted more widely and is still only featured on the BBC News channel and the Government’s own social media channels.
There also needs to be further clarity on the accessibility of the Government’s Test and Trace programme. The programme was announced as a new way of life and yet there is a lack of clarity about how people with hearing loss will use the system. Test and Trace will be unusual in that it will be a system where the state contacts the individual (either because they have tested positive or because somebody who has tested positive has named them as a contact) rather than where the individual gets in contact with the service. Whilst it is, therefore, welcome that the Government have provided an indication that there will be different contact methods in place, it is crucial that users’ needs are fully understood. This is especially important for hidden disabilities such as hearing loss. Many people will not know that someone they have been in contact with has a hearing loss – for example, our research shows over half of all people with hearing loss fail to disclose their condition to a colleague – and the system needs to ensure that these people are contacted appropriately.
There has also been no suggestion that the Test and Trace Programme has been made accessible to BSL users.
We, along with other leading disability charities, wrote to the Prime Minister calling for urgent action in this area. We are very pleased that as a result of this, a named senior lead has now been identified to lead work on accessible Government communications. On the request of the new lead, again in conjunction with other disability charities, we have produced a ‘shopping list’ of accessibility requirements for broadcasting, social media, websites, mailings, contact methods and apps.
The Government should work with the disability sector to ensure accessibility is built into all public health communications from the outset.
2. Accessibility of health and social care services
Remote appointments, PPE and communicating with people with hearing loss
People who are deaf or have hearing loss rely heavily on visual cues for effective communication. These include body language, gestures, facial expressions and lipreading. Being able to see lip patterns and facial expressions is also vital for those who communicate through BSL.
People are being encouraged, and choosing, to have health appointments over the telephone, but for many people with hearing loss, telephone conversations will be difficult or impossible. For some, in some circumstances, video conversations will also be difficult.
Under the AIS, all health and social care providers must identify, record and meet people’s specific communication needs, many of which will have, until now, been met by face to face contact.
Health services should consider the most appropriate means of providing interpretation to BSL users. Remote or video interpreting is not always appropriate for medical appointments, BSL is a 3D language and having medical jargon provided on a 2D screen increases the risk that miscommunications and misunderstandings will occur. We would not want to see a blanket policy to provide all interpretation remotely. Decisions need to be made in consultation with the patient and based on their communication needs. Service providers should utilise new guidance on working in medical settings during Covid-19 from the Association of Sign Language Interpreters (ASLI) when deciding how to provide interpretation to patients.
Our previous research showed that only 1 in 10 people with hearing loss had been asked about their communication needs in line with the AIS. In addition, we know that 9 million people have unaddressed hearing loss and people take an average of 10 years to seek help for their hearing loss. So many whose communication needs have not been identified will also struggle to communicate remotely and this too should be taken into account in the current context.
People who are deaf or have hearing loss have also told us that they are struggling to communicate with health and social care professionals during face to face consultations and interactions as a result of visual cues being masked by Personal Protective Equipment (PPE). Those health and social care professionals who themselves have hearing loss are also struggling with this barrier. Whilst we of course want to keep people as safe as possible and advocate following current public health guidance to ensure this, for some people with hearing loss in health and social care settings a safety risk can also be presented by inaccessible communication. Clarity on how to overcome this conflict is urgently needed.
As all hospital staff are now required to wear Type 1 or 2 surgical masks at all times, and all visitors and outpatients are expected to wear face coverings, this challenge has been significantly exacerbated. It also remains unclear how BSL interpreters are to work in this environment. Recent advice issued by the World Health Organisation states that if a policy of targeted continuous medical mask use is adopted, the disadvantages that this brings to people who are deaf or hard of hearing should be ‘carefully taken into account.’
We are aware of designers in the UK exploring options for the development of clinically safe transparent masks that enable lipreading. We are also supporting research into this area. Though Public Health England is yet to approve any clear mask available in the UK. In light of this challenge, we have been made aware of some health and social care services attempting to source masks with a clear window currently manufactured in the US and some are advocating the use of face shields alone. We understand, however, that the clear masks manufactured in the US are not currently approved for use in health and social care settings, as they do not provide adequate protection to staff. In addition, current Public Health England guidance does not recommend the use of face shields alone. We fear that in the absence of clear guidance on this from Public Health England, in some cases, PPE may also be inappropriately removed, in order to address this significant barrier.
In these exceptional circumstances and whilst ensuring adherence to current public health guidance, however, accessible standards must still be upheld. There are simple options that will improve the accessibility of services for those who are deaf or have hearing loss. These include adopting communication tips to ensure understanding in telephone conversations or when wearing PPE; using screens where possible; utilising Video Relay Services; and using written information as well as verbal. See our communication advice for health and social care professionals here. See also, communication advice produced in conjunction with other charities here.
Additional barriers are emerging as the lockdown begins to be eased however. Many healthcare settings are putting in place practices that will present additional barriers to people who are deaf or have hearing loss, such as screens in waiting areas.
In addition, as the lockdown is eased and the Government begin to reflect on what measures put in place during this period have worked well and should continue, there is a risk that remote services and further existing or anticipated barriers will be adopted for the long term without taking into consideration the needs of people who are deaf or have hearing loss.
Text and Video Relay
BT provides the only text relay system across the UK – its Relay UK system. Every communication provider is required to provide access to a text relay service under the Universal Service Obligation, which in effect means Relay UK. We know that where this service is not advertised as an optional contact method, however, many will assume it is not available. It is also important that staff receiving these calls know what to expect when using the service.
The Relay UK system is required to answer over 90% of calls within 15 seconds, and 95% of emergency calls within 5 seconds. With many now unable to access services or make appointments in person, this service is experiencing a substantial increase in demand. We have been made aware of waits of over an hour for health appointments, though understand that the service is now meeting targets again. We are continuing to monitor this situation.
SignHealth and InterpreterNow are now providing a free on demand video relay service, ‘BSL Health Access’, for UK health services during the current situation. As with text relay services, however, we know that if these services are not clearly advertised, many will be unaware this option is available.
It is also crucial that essential social care services provided by local authorities or voluntary sector organisations provide access via video relay. We welcome that the NHS volunteer responder helpline is now accessible via video relay and Action on Hearing Loss is an approved referrer to the service.
The Government should provide clarity on the safety and viability of PPE that allows for lipreading in health and social care settings.
The Government should issue guidance for health and social care providers on how to fulfil duties under the Accessible Information Standard in the context of widespread PPE usage.
The Government and professional bodies should promote awareness of the prevalence of hearing loss in those at risk of becoming severely ill with coronavirus, and simple options for meeting communication needs, amongst health and social care professionals.
The Government and health and social care commissioners and providers should consider the unintended consequences for disabled people of new measures put in place when easing the lockdown and beyond.
BT should provide continuous monitoring of the KPIs for the Relay UK system.
The Government should ensure that where telephone line contact methods are advertised, text and video relay services are also advertised and staff are trained in their use.
3. Accessibility of other essential services
We are aware that people in at risk groups, including those for whom shielding is recommended, are struggling to access essentials such as food and medicine. The Office for National Statistics (ONS) report on coronavirus and the social impacts on disabled people showed that concerns about access to essentials tended to be most frequent among those with hearing- or dexterity-related impairments. People who are deaf or have hearing loss have told us that they are unable to list themselves as a priority for supermarket deliveries as the only point of contact is the telephone. As the majority of over 70 year olds will have some form of hearing loss, it is essential that other accessible communication channels are provided and advertised.
It is also important that people with hearing loss are considered when shops and services re-open with social distancing measures in place. The use of facemasks, social distancing and Perspex screens in retail outlets will create new barriers for people with hearing loss. In addition, shops will be implementing measures like queuing and one-way systems which will need to be actively communicated to customers; any failure to make these adjustments accessible to people with hearing loss could see them inadvertently break the rules and suffer social consequences such as peer policing.
The guidance issued by the Department for Business, Energy and Industrial Strategy makes limited references to disability and the need to make reasonable adjustments on behalf of either staff or customers. The guidance needs to ensure that outlets are aware of the need to practice deaf and disability awareness and shows where barriers can be overcome – for example by reducing background noise and using induction loops. The guidance also encourages stores to utilise ‘social distancing champions’ and position colleagues to manager customer flow; staff undertaking these roles should have received deaf awareness training and know how to communicate effectively.
The Government should work with supermarkets and other essential service providers to ensure that people with disabilities are not excluded from accessing essential services.
The Government should ensure that the guidance issued to retail outlets includes information on how to mitigate the barriers caused by social distancing on people with hearing loss, and that staff given prominent roles to support people using outlets in new ways have received deaf awareness training.
4. Face coverings and social distancing measures for the general public
The Government is advising that people should consider wearing a face covering in enclosed spaces where social distancing is not always possible and they come into contact with others that they do not normally meet. In addition, the Government is strongly urging members of the public to wear face coverings when they attend hospitals as outpatients or visitors, and face coverings are now mandatory for the general public on public transport.
We welcome the legislation and Government guidance which explicitly states that those travelling with or providing assistance to people who rely on lipreading to communicate, as well as others with a ‘reasonable excuse’, are not required to wear face coverings on public transport. As hearing loss is a hidden disability, however, many remain concerned that they will face abuse or negative reactions from the public for removing face coverings to communicate with friends or family who are deaf or have hearing loss.
We are aware of a limited supply of face coverings with clear panels, which allow for lipreading, available for purchase in the UK. We are also aware that other such face coverings are in the process of being designed and tested. In the absence of widespread availability of such face coverings, however, some members of the public and employers have chosen to use face shields or make their own face coverings with clear panels at home. There are a number of links available online that demonstrate how to make these. Although we are aware that some such face coverings steam up, preventing lipreading and that others may reduce the sound level of some frequencies in speech, adding an additional challenge for people with hearing loss, people with hearing loss have overwhelmingly reported that such face coverings are more helpful for them in communicating with people than the standard coverings used. Much of the general public, including employers and those working in the community, however, are unaware of the existence or need for such face coverings. There has also been no clarity on whether there are any safety issues associated with wearing face coverings with clear panels. It is also unclear whether purchasing and wearing face shields is in line with Government recommendations for public usage and whether this would undermine supply for health and social care settings.
Social distancing itself also presents a communication barrier to people with hearing loss, as the added distance reduces sound levels. People with hearing loss have also reported some members of the public adopting measures, such as avoiding facing people when speaking, which also present challenges for people with hearing loss. In addition, the screens increasingly being used in shops and reception areas can present a further barrier if the needs of people with hearing loss are not considered.
In light of these significant challenges, deaf awareness amongst the public becomes even more vital than ever and many of the tips we suggest for use by health and social care professionals can be adopted by other services. We have also produced tips for use by the general public.
The Government should raise awareness amongst the general public and transport operators of the exemptions to mandatory face covering on public transport, including exemptions for those travelling with or providing assistance to people who rely on lipreading to communicate, as well as others with a ‘reasonable excuse’.
The Government should provide clarity on and improve awareness of the face covering options that are safe and available to make and purchase.
The Government should consider the unintended consequences for disabled people of new measures put in place when easing the lockdown and beyond.
Employers and the general public should be aware of the challenges faced by people with hearing loss and adopt tips to meet communication needs.
5. Audiology services
Hearing aids are a lifeline for so many people and, for some, are the only way they can access sound. As people, especially the over 70s, continue to self-isolate, those who wear hearing aids rely on communicating with loved ones over the telephone and receiving the news via the radio or television. So working hearing aids are essential. Hearing aids do need regular basic maintenance and can stop working for a number of reasons but fortunately these can all be easily rectified by an audiologist, trained volunteer or, with appropriate guidance and equipment, at home by the patient or their relative(s).
Guidance issued by NHS England and Improvement (NHSEI) sets out how providers of community services can release capacity to support the Covid-19 preparedness and response. This guidance includes a partial stop in the delivery of audiology services for all non-essential treatment until July 2020. Essential hearing aid maintenance and remote appointments, in addition to urgent treatment for idiopathic sudden hearing loss and foreign bodies in the ear canal, for example, should continue to be provided. Further to this, joint guidance from the largest professional bodies in audiology has recently been published, which encourages audiology providers to resume elements of service provision where possible. The guidance emphasises triaging all patients remotely before inviting to a face to face appointment and prioritising patients based on “audiological need”, where their hearing loss is having a negative impact on their quality of life.
Although there is some variation in availability of NHS audiology services, many are offering appointments remotely, via telephone or video call, and most are providing an essential service for urgent hearing aid repairs or replacement batteries via post. A number of providers have resumed their services remotely, utilising video call technology and remote programming software, available in a number of NHS hearing aids. Encouragingly, many patients who have been able to receive care remotely have been comfortable using new technology with appropriate guidance and support. A number of high street audiology providers are also maintaining a limited service providing appointments remotely, batteries and hearing aid repair via post.
Cochlear Implant Services
As a result of the need to release capacity and mitigate risk of transmission, all elective NHS operations were cancelled, including cochlear implantation surgery. NHS England and Improvement has published surgical prioritisation guidance which sets out how operations should be prioritised as elective surgeries resume. We welcome that this guidance recognises the need for urgent cochlear implantation, in cases such as those at risk of cochlear ossification post-meningitis and pre-lingual deafness. This has been further clarified in guidance from ENT UK, stating that these cases should be implanted within 1 month.
Cochlear implant centres and advocacy groups have expressed concern over cochlear implantation surgery within the wider context of surgical prioritisation post Covid-19. There are concerns of a reduction in non-urgent adult implantations as other life-saving operations are prioritised. Furthermore, the guidance from ENT UK has not stipulated a time frame in which to carry out non-urgent cochlear implant surgery. This is especially concerning when it is estimated that around only 5% of adults in the UK who could benefit from a cochlear implant actually have one. Recent efforts from cochlear implant advocacy groups have been focused on increasing uptake and the effects of Covid-19 have the potential to reverse this vital work.
For existing cochlear implant users, or those post-implantation, we are aware that many implant centres have cancelled most face to face appointments, only providing urgent repair services. Some implant centres have begun providing remote appointments, including for cochlear implant switch-on and tuning. Encouragingly, many patients have been able to receive care remotely and are comfortable using new technology.
Audiology services should facilitate remote delivery where possible and appropriate, ensuring those who cannot access remote delivery are prioritised when face-to-face services resume.
NHS Trusts should treat specific cases of cochlear implantation surgery as a priority and ensure non-urgent implantation is prioritised as elective surgeries resume.
6. Coronavirus Act
The Coronavirus Act diminishes the duties on Local Authorities in Part 1 of the Care Act 2014 to assess needs for care and support, and to meet those needs. The Act replaces these duties with a power to meet needs for care and support, underpinned by a duty to meet those needs where not to do so would be a breach of an individual’s human rights.
The Government should ensure that the application of new powers under the Coronavirus Act are proportionately delivered and time bound.
7. Disability Employment: remote working and social distancing
Society’s response to Coronavirus has radically changed the way we are working. This has largely been caused by the closure of workplaces, remote working and the imposition of social distancing and other safety measures for workplaces which have either remained open or are now beginning to re-open across England. These changes have created additional barriers for many disabled people, including those living with deafness and hearing loss, which threatens to undermine their employment prospects. Even before the crisis, people with hearing loss were marginalised in the workplace and our research demonstrates that poor employer attitudes and a lack of support and guidance on making reasonable adjustments has denied people with hearing loss the opportunities their talents deserve.
We fear that without the provision of clear guidance and additional support for employers, disabled people, including those with hearing loss and deafness, will suffer redundancy, unemployment and furloughing disproportionately during this crisis.
Additional barriers for people living with deafness and hearing loss
On 12 May the UK Government issued guidance to workplaces in England setting out how to work safely during the coronavirus pandemic with a view to reopening a number of workplaces. The Government produced eight guides covering different types of workplaces. These contained advice which would impose noticeable barriers for some people with deafness and hearing loss. Relevant advice which could make working life harder for people with hearing loss includes:
- people work back-to-back rather than facing each other
- physical barriers are erected between workstations
- face masks can help reduce transmissions
- people to be stationed two meters apart
Each of the guidance documents states:
“This guidance does not supersede any legal obligations relating to health and safety, employment or equalities and it is important that as a business or an employer you continue to comply with your existing obligations, including those relating to individuals with protected characteristics. It contains non-statutory guidance to take into account when complying with these existing obligations.”
However the guidance makes no direct reference to disability or reasonable adjustments and does not set out any advice or principles on how to reconcile situations where the needs of disabled people might clash with the advice on workplace safety.
It should also be noted that the number of people working from home has nearly quadrupled since the imposition of the lockdown and that this will also create new and different access requirements for people living with hearing loss. For many people the increased use of telephone and video conference will create barriers and mean that they will need new adjustments.
Action on Hearing Loss has provided advice and communication tips which respond to the barriers created by social distancing and homeworking.
Action on Hearing Loss has produced extensive research showing the problems that people with hearing loss face in the workplace, including: the lack of confidence that business leaders have in communicating to those with hearing loss, their inability to access information and support to understand disability employment and the steps they can take to support people, and the perception that people with hearing loss can be a health and safety risk. If employers struggle to respond to disability and hearing loss in normal times then it is even more essential in the current situation – where workplaces are having to be re-designed almost overnight – that they are provided access to simple advice. This guidance needs to contain advice on how to resolve conflicts between social distancing measures and the needs of disabled people. The Government should liaise with organisations, like Action on Hearing Loss, to produce tailored guidance which states how barriers created by social distancing can be overcome or mitigated for people with different disabilities. This information should be published through the Disability Confident scheme and signposted with the guidance from the Department for Energy and Industrial Strategy on safe working.
Access to Work
The closure of workplaces and imposition of new safety measures has had a major impact on the way people work and for disabled people this will require substantial changes in the support they receive through the Access to Work scheme. For many people who are deaf or have hearing loss, especially BSL users, their existing Access to Work package will no longer meet their needs, either in relation to the type or amount of support they require. For example, somebody with an allocation of in-person BSL interpretation will now need to consider remote interpreting, which might not be provided for in their existing grant.
We welcome the initial indications from the DWP that they are looking at these issues and that further guidance will be provided. We also welcome that a physical signature from a line manager is no longer required to process payments within the scheme.
It may also be that the requirement for homeworking and adjustment to workplace safety steps means that some people who didn’t previously require a grant from Access to Work will now need to access support from the scheme. For example, an individual who was able to use lipreading might now benefit from the provision to STTR because of the imposition of face coverings and physical barriers. The Government needs to ensure that both employers and employees are aware of the support that Access to Work can provide.
The UK Government’s guidance on reopening workplaces should recognise the needs of disabled staff by acknowledging it contains advice which will create additional barriers for those living with deafness and hearing loss and it has the potential to conflict with the duty of employers to make reasonable adjustments under the Equality Act. The Government should provide employers with principles to show how they resolve these problems.
With those principles in place, the Government should signpost to its existing (albeit limited) resources on disability employment and work with expert organisations, like us, to provide guidance on how to overcome or mitigate the additional barriers social distancing creates. This guidance should be promoted alongside guides to support disabled staff working remotely from home.
The Government should ensure that Access to Work offers flexibility to existing scheme users, in relation to both the support they receive and the way that the scheme is processed. This flexibility should be communicated to scheme users, and their employers, as soon as possible.
The Government should also promote Access to Work to be employers and employees so that people who need additional support for the first time because of remote working or social distancing are encouraged to make a claim.
8. Loneliness and isolation
Increased isolation will inevitably affect many people’s wellbeing and mental health due to a lack of social contact and difficulty accessing support. People who are deaf or have hearing loss are at greater risk of further isolation due to social distancing measures, as well as increased use of masks and face coverings.
Whilst initiatives to tackle social isolation during the pandemic are underway, these initiatives primarily involve moving support online. For BSL users and those with hearing loss this does not necessarily provide the same level of accessibility, especially for older people who might lack the necessary digital skills.
The ONS report on coronavirus and disability showed that just 14.7% of people with a hearing impairment reported visiting green spaces – the lowest percentage of all disabled groups. In addition, 54.8% of people with a hearing impairment reported leaving their home in the past week, compared to 80% of disabled people with a mental health impairment. Older age is associated with an increasing prevalence of some impairment types (for example, mobility or hearing impairments) and with decreasing likelihood to report leaving the home.
We welcome the Government’s new campaign to tackle loneliness during the coronavirus lockdown. We must remember, however, that the coronavirus pandemic will begin to recede, but unfortunately, loneliness and social isolation will remain for many who are deaf or have hearing loss.
The ONS should seek to examine controlling for age in future analysis of isolation amongst disabled people.
The Government should ensure that loneliness stays high on the agenda through the coronavirus pandemic and beyond.
9. Health outcomes
Public Health England has announced a review into the factors impacting health outcomes from coronavirus but the impact on disabled people isn’t in scope. Since the announcement of the review, there has been no public statement addressing this. We have been told that some data on learning disabilities and autism are to be included in the review, this is far from sufficient. We believe that it is imperative that the Government review the impact of coronavirus on all disabled people. It is vital that disabled people are properly included in our country’s recovery.
The Government should provide details of plans to assess the impact of coronavirus on disabled people.