Action on Hearing Loss – Written evidence (INQ0013)

3. Which developments in biomedical science are anticipated in the coming years, in time to contribute to the Government’s aim of five more years of healthy and independent life by 2035?

Significant progress is being made towards developing a new generation of medicines that promise to prevent various types of acquired hearing loss, regenerate and restore hearing, and reduce tinnitus. Over 70% of people aged over 70 experience hearing loss[1] impacting on quality of live and productivity. Hearing loss has also been linked to an increased risk of dementia.[2] These emerging treatments will transform how hearing loss is managed, making a key contribution to extending quality of live by 2035.

A recent review of emerging hearing therapeutics shows that there are over 20 treatments already in clinical trials and many more at preclinical stages of development.[3] The most advanced treatments are those to prevent or protect hearing with 37 treatments in development, followed by 16 regenerative therapies and 13 tinnitus treatments. Of course not all will progress to market, but assuming a similar attrition rate to other healthcare areas and the strength of the discovery pipeline, we expect there to be drug, gene and cell-based therapies available by 2035 to help reduce the incidence of age-related hearing loss and improve hearing amongst those already experiencing some degree of loss.

A specific example is a drug treatment being developed by Audion Therapeutics which is currently in phase II clinical trials in the UK. The drug triggers the regeneration of sensory hair cells within the cochlea. Degeneration of these cells is a common cause of hearing loss, including age-related. (https://www.regainyourhearing.eu/)

4. How complete is the understanding of behavioural determinants and social determinants of health in old age, and of demographic differences?

4.1. Demographic differences

The vast majority of people with hearing loss are over 50 years old and the prevalence increases with age. For example, more than 70% of those over 70 will have some degree of hearing loss.i Evidence suggests a higher incidence among not only older adults, but also men and those of lower socio-economic status.[4]

4.2. Behavioural determinants

Globally, hearing loss is ranked second when it comes to conditions contributing to years lived with disability.[5] There is strong evidence to suggest that hearing aid uptake improves health and wellbeing in later life. For example, if left untreated, hearing loss is associated with cognitive decline/dementia,ii increased risk of falls[6] and poorer mental health.[7] However, hearing aids have been shown to modify many of these risks,[8] making hearing aid uptake an important determinant of health and wellbeing later in life. Despite this evidence, people wait on average 10-years before seeking help for their hearing loss.[9] Understanding why this is, and which groups are least likely to engage with treatments is crucial to improving health and independence in old age. Existing literature suggests there are demographic differences in help-seeking behaviour and hearing aid uptake. For example, some research shows older lower SES males have lowest level of current hearing aid use.[10]

5. What technologies will be needed to facilitate treatments for ageing and ageing-related diseases, and what is their current state of readiness?

5.1. Drug delivery devices, for existing or future treatments

Devices that can deliver drugs to a specific and localised area are much needed in the treatment of conditions such as hearing loss. Specifically, there is a need for technologies capable of delivering drugs to the inner ear. We have been funding a project with the company Otomagnetics (not a UK company) to develop a technology in which drugs can be linked to tiny iron particles and then pushed into the cochlea using magnets. The technology has not yet reached clinical trials, but we would expect it to do so in the next few years.

Similarly, there would be great benefit in developing methods for delivering drugs non-invasively. Currently inner ear drugs have to be administered via an injection through the ear drum which is expensive and painful. Delivering drugs to the inner ear using a different method would be more cost effective, eliminating the need for anaesthesia and operating rooms. It would also be less painful for patients, resulting in improved recovery time and better outcomes.

5.2. Technologies for monitoring conditions and providing personalised medical advice

There is great value to be gained from investing in the use of smartphones to monitor health and give advice. Currently there are several online hearing checks available. However, these are often provided by private companies to reach potential customers. Having an NHS hearing check available for use at home would give people with hearing loss access to trusted sources of information about their condition and they could be signposted to relevant services. It would also allow patients to avoid having to visit the GP and offer a direct route into services, reducing pressure on the health system whilst also reducing waiting times.

5.3. Technologies to improve diagnosis

Currently there are several barriers to people addressing their hearing loss, including low awareness of NHS hearing aid services amongst patients and GPs, and services being far away. Technology that provides a remote diagnostic service would remove these barriers and for those that are suitable, having a self-fitting option would increase the number of people who address their hearing loss.

Additionally, we need technologies better able to diagnose different types of hearing loss and indicate precisely what part of the auditory system is affected. These technologies will be vital in the future to ensure the right treatment is given to the right person (precision medicine). They are also needed to allow the right patients to be recruited into clinical trials of new treatments and monitor the outcomes of treatments being tested.

6. What technologies will be needed to help people to live independently for longer, with better health and wellbeing? What is the current state of readiness of these technologies, and what should be done to help older people to engage with them?

Technology has huge potential to assist in the delivery of healthcare and facilitate independent living for longer. For the growing number of older people living with age-related hearing loss, technology such as hearing loops can allow them to interact with public services, and digital communications offer an alternative for those who struggle to communicate via telephone. Having better access to reliable information in a range of formats has the potential to improve wellbeing and allow people to live independently for longer. As information on health and wellbeing becomes increasingly digital and inaccessible, care must be taken to engage older adults and empower them to be their own health advocates.

6.1. Telehealth

Physical infrastructure often fails to meet the needs of older people, especially with health conditions common to older age such as cognitive decline, reduced mobility and hearing loss. Health services can often be difficult to reach for older adults and transport can be prohibitively expensive. Telehealth has the potential to transform services, such as audiology, opening up access, especially to those who may live more rurally or be less mobile. It also presents an opportunity for cost savings, both to the service user and to the health and social care systems.[11]

Telehealth technology already exists. Technology is rapidly developing to remotely fit hearing aids or to facilitate self-fitting. This includes remote otoscopy, hearing tests, hearing aid fittings and fine tuning. For example, some private hearing aid providers offer devices that can be adjusted remotely by a professional, avoiding the need to visit a service. There are also hearing aid devices capable of monitoring your activity levels, along with other indicators of health, and feeding this information into an app.[12] While this technology has the potential to improve lives, costs are currently prohibitive for many and may exacerbate existing inequalities.

6.2. Smart homes

Smart homes offer the possibility to integrate accessibility solutions into everyday life, and monitor health and wellbeing with little effort. Assistive technology has the potential to help people to remain independent and in their own homes for longer. However, this shift requires sufficiently good internet access, as well as the ability to use the technology and troubleshoot any difficulties. In addition, adequate security measures must be taken to protect vulnerable people from having their data misused or keeping them safe from cybercrime.

6.3. Increasing engagement

Uptake of technology remains low among older populations when compared to other age groups,[13] but there is currently little in place to develop the necessary skills to boost confidence. In addition, low income households and those living in rural areas are less likely to have the internet access that a lot of technology is reliant on. xiii

• Older adults must be engaged in the design of technologies and should be part of user testing groups. They often have different needs, as a result of age-related changes in perceptual, motor and cognitive abilities and these should be identified in order to make devices more user-friendly.
• Time and money must be set aside to improve the skills and confidence of older people wanting to engage with technology. There should be a clear pathway for seeking advice and there must be ongoing support available.

7. How can technology be used to improve mental health and reduce loneliness for older people?

Addressing common age-related difficulties such as cognitive decline, hearing loss, and reduced mobility will be crucial in order to improve mental health and reduce social isolation. Unaddressed hearing loss in particular is linked to communication problems, exacerbating isolation and increasing the likelihood of mental ill-health.vii

Access to digital services improves a person’s ability to communicate with others. Basic digital skills can enable people to connect and communicate with family, friends and others in their community 14% more frequently. xiii This is especially important for older people who may not live near family.

Technologies, such as smartphones, assistive technology and AI, have enormous potential to overcome existing accessibility barriers that prevent older people, and in particular people with hearing loss, from interacting with services. Smart devices can provide vital visual information such as live speech to text transcription, making transport, entertainment and other services more accessible, which in turn reduces social isolation and modifies a person’s risk of developing cognitive impairments such as dementia.viii

8. What are the barriers to the development and implementation of these various technologies (considered in questions 5-7)?

Technologies such as smartphones and internet-based devices can be inaccessible to some older adults, who lack the confidence to use them or find them prohibitively expensive. This can leave many in this group without the tools to improve their health and reduce the social isolation they may be experiencing. Those who do have access to technology are less likely to be capable of upskilling themselves digitally and may be at higher risk of cybercrime as they are unfamiliar with internet security.

A large proportion of older people are still not online. This figure is declining but in 2018, 8% (4.3 million) of the population was estimated to have zero basic digital skills of which 76% were over the age of 65. A further 12% (6.4 million adults) were estimated to have limited abilities online. xiii In addition, disabled adults make up a large proportion of adults internet non-users. In 2017, 56% of adult non-users were disabled. xiii

1. What is needed to help overcome these barriers?

• Funding for older adults on lower income to access technology where it has the capacity to improve their health and wellbeing.
• Inclusive design in mainstream technology development: involving older adults in the development and testing of new technologies, to ensure their accessibility requirements are reflected and catered for.
• Digital training to upskill less digitally-confident older adults, and ensure they are aware of the accessibility features available to them.
• Better security for vulnerable adults online to boost confidence amongst this group.

b. To what extent do socio-economic factors affect access to, and acceptance of, scientific advice and use of technology by older people and those who care for them?

• Acceptance of technology is negatively associated with both increasing age and lower socio-economic status.[14] These two factors likely to interact and further exacerbate existing inequalities.
• Some of the impairments associated with ageing, such as to hearing, sight, mobility and cognitive function, also impact negatively on technology acceptance and adoption.[15] In fact, the ONS commented that “lower rates of internet usage among older age groups may in part reflect the fact that they are affected by access issues associated with age”. xiii
• Internet access increases with household income. For example, the ONS found that 51% of people earning between £6-10k have internet compared to 99% who earn over £41k. Of those adults without internet access, 8% reported that the costs associated with getting online are too high. xiii
• There is a steady and ongoing decline in households without internet connection. However, people living alone are less likely to have internet access, and this is especially true for older adults: 41% of households with a single adult aged over 65 years don’t have internet connection compared to 9% of single adults under 65.xiii

9. What opportunities are there for industry in the development of new technologies to help increase health span? In which areas of medical research and technology development does the UK excel?

The UK has a strong research base in hearing science from which we expect to see new biotech start-ups emerge able to drive both economic development and to deliver technologies and medicines to increase health span. A recent example is Rinri Therapeutics which was spun out of Sheffield University to develop and commercialise a stem cell therapy for regenerating hearing (https://rinri-therapeutics.com/).

There are also opportunities for large pharmaceutical companies. These companies already recognise the commercial opportunities that exist for effective hearing treatments, and stand ready to invest in the late stage clinical development of such treatments and in bringing them to market.

Finally, there are opportunities for specialised contract research organisations able to provide drug development and clinical trials services to support the development of hearing therapeutics. CILcare is an example of a company that has exploited this opportunity in France (https://www.cilcare.com/ ).

10. What more is required for the UK to benefit from commercialisation of its discoveries and inventions relating to healthy ageing, as envisioned by the Government’s Industrial Strategy?

The development of treatments and technologies to lessen the impact of hearing loss has huge potential to improve health span, stimulate economic growth and boost productivity. However, this is threatened by chronic underfunding of research in this area. The UK Health Research Analysis 2014, showed that the UK’s main public research funders spent just £12.3 million on research into ‘ear’ conditions in 2014. In comparison £22.7 million was invested in ‘eye’ conditions. Initiatives are needed to increase investment in UK hearing research in line with the scale of the issue. Such approaches have transformed the search for treatments for dementia. Similar action is now needed to ensure the UK can lead the discovery and development of therapeutics to address hearing loss and address a major healthcare issue.

11. How feasible is the Government’s aim to provide five more years of health and independence in old age by 2035?

There is a wealth of existing technology with the potential to allow people to live healthier, more independent lives for longer. However, there must be increased efforts to encourage better take up and engagement. For example, hearing aids are a highly cost-effective and readily-available technology, and their use is linked to reduced risk of dementia and cognitive decline, as well as improved mental health and wellbeing.[16] Similarly, the technology exists to make homes more accessible for older adults with changing needs, and to help people with sensory loss to interact with services. Despite this, promotion of these technologies is inadequate, and many older people are simply unaware of their benefits.

a. What strategies will be needed to achieve the Government’s aim?

• A plan to promote earlier intervention of certain age-related conditions, for example through improved awareness amongst health practitioners and the public, and the introduction of screening;
• More investment in the use of telehealth to increase the accessibility of health and social care services, and improve efficiency;
• Commitment to increased funding for research into age-related conditions and the development of technology to promote health and independence.

b. What policies would be required, and what are their potential costs and benefits?

11(b).1. Hearing screening programme for older adults (e.g. as part of the NHS Health Check)

• Hearing loss affects more than 11 million people in the UK, mostly age related. An aging population means numbers will rise to 15.6 million by 2035.ix Unaddressed hearing loss reduces quality of life and is associated with double the risk of depressionix and up to five times the risk of dementia.[17] Hearing aids have been shown to improve quality of life[18] and reduce rates of cognitive decline by 75%.[19]
• The financial cost of hearing loss to society is estimated to be £136 million per annum. This includes approximately £76 million per annum associated with additional use of GP services and £60 million associated with additional use of social care services. The net burden of illness in terms of reduced quality of life associated with hearing impairment was estimated to be around £26 billion in 2013.[20]
• In 2010, Action on Hearing Loss (then RNID) and London Economics published a cost-benefit analysis of introducing a universal screening programme for adult hearing loss.xix The study concluded that the benefit-cost ratio of the intervention was 8:1, meaning that for every £1 spent screening people at 65, £8 worth of benefit would be generated. These findings are reinforced by a 2012 study[21] which concluded “screening for bilateral hearing loss of at least 35 dB HL between the ages of 60 and 70 year, as proposed by Davis et al. is likely to be cost-effective.”
• Very high numbers of people continue to use and benefit from hearing aids once they receive them, usually around 80-90%[22] and 71% think they should have got them sooner.[23]

11(b).2. Better use of telehealth (e.g. in audiology)

• Benefits in terms of access for rural/remote communities, and those who are less mobile.
• Improved efficiency,xi helping NHS services to cope with increased demand as the general population lives longer and more people experience age-related conditions, such as hearing loss.
• Encourage self-care and agency amongst patients.

c. Which organisations need to be involved?

• 3rd sector organisations with links to older communities
• Sensory services
• Central government departments, including BEIS, DWP and DHSC
• PHE
• Academic and commercial research teams
• Health services and health professionals (e.g. audiologists and GPs)
• NHSE
• Social care providers
• Industry (e.g. producers of hearing instruments and health technology providers)

d. Who should lead the work?

The Department for Health and Social Care

12. To what extent are inequalities in healthy ageing, as well as differences in acceptance of technologies, a barrier to achieving the aims of the Government’s Ageing Society Grand Challenge?

1. To what extent could achieving the Government’s aim of five more years of healthy and independent life exacerbate, or reduce, these inequalities?

12(a).1. Risks:

• If not planned/executed appropriately, there is a risk of higher take up amongst already privileged groups when compared to others, contributing to a growing health gap;
• Access to the tools to improve health and wellbeing must not be a postcode lottery and should be promoted heavily in communities with poorer health outcomes;
• There is a risk that the technology developed to promote health and wellbeing could be prohibitively expensive to those who would most benefit from using it.

12(a).2. Opportunities:

• Increased use of telehealth could reach more people who are less mobile or living in rural communities, contributing to a reduction in health inequalities;
• Better access to assistive technology could allow more elderly people to stay in their homes who wouldn’t otherwise be able to afford other forms care and support;
• Initiatives to improve early detection of age-related conditions, such as hearing loss, and increase uptake and use of devices such as hearing aids amongst specific groups could reduce socioeconomic inequalities in health.xi

13. What would be the implications of a paradigm shift to people leading healthier lives for longer, and spending less time suffering ill health?

13.1. Economic impacts

• Reduction of national spend on social care: allowing people to stay in their own homes for longer would reduce the financial pressure of state funded care;

• Earlier identification of health and care needs would prevent unnecessary costs.
• E.g. There are significant links between hearing loss and other conditions, such as depression and dementia, which confer huge costs to society. However, early identification and use of hearing aids appear to modify these risks.xxiv

13.2. Time spent in work as opposed to in retirement

• Encouraging early intervention and preventative action on age-related conditions would enable many more people to continue working for longer.
• For example, there’s evidence that the use of hearing aids amongst those who could benefit allows people to stay in work for longer.[24]
• Estimates suggest that the UK economy loses £25 billion a year in productivity and unemployment due to hearing loss.[25] Unemployment rates for people with hearing loss are much higher compared to the national average with 30% of working age people with severe hearing loss unemployed.[26] Those with severe hearing loss who do not use hearing aids have unemployment rates nearly double those who do.
• It is estimated that by 2020, older people will account for approximately a third of the working population[27] and around three-quarters will have some kind of disability before the age of 68. At least 1 in 10 adults aged 40 to 69 will have a substantial hearing loss[28] and action will be needed to raise the general level of health, reduce health inequalities and provide the level of support needed if people are to work until this age.[29]
• Currently, a large proportion of people with hearing loss feel they are not adequately supported to stay in work, and therefore retire early. In our recent employment research, 60% of respondents said they had retired early. Of those, 56% said that their hearing loss was a factor in their decision.[30] Assistive technology and improved awareness among employers and the general population could lead to better retention of this group of employees, conferring a significant economic boost.

12 September 2019