Consultation responseImproving Lives – The Work, Health and Disability Green PaperDepartment for Work and Pensions and Department of HealthFebruary 2017

Contents

About usIntroduction to our responseBackgroundChapter 2: Supporting people into workChapter 4: Supporting employers to recruit with confidence and create healthy workplacesChapter 5: Supporting employment through health and high quality care for allFurther informationContact details

About us

Action on Hearing Loss is the charity formerly known as RNID. Our vision is of a world where deafness, hearing loss and tinnitus do not limit or label people and where people value and look after their hearing. We help people confronting deafness, tinnitus and hearing loss to live the life they choose. We enable them to take control of their lives and remove the barriers in their way. We give people support and care, develop technology and treatments and campaign for equality.

Our response will focus on key issues that relate to people with hearing loss. Throughout this response we use the term 'people with hearing loss' to refer to people with all levels of hearing loss, including people who are profoundly deaf. We are happy for the details of this response to be made public.

Introduction to our response

Action on Hearing Loss has responded to the sections of the Green Paper which have significance to the people we support.

We have responded to the section on Supporting people into work, in which we highlight the need for specialist employment support, which cannot be provided by large generic service

providers. Specialist support is more cost effective as it leads to better employment outcomes for people with hearing loss. We have used the example of our Specialist Employment Service in Wales, commissioned by DWP, which has shown to be a success. We have also commented on the role of Work Coaches and the importance of high-quality ongoing training to ensure they are well-equipped to support disabled people to achieve their employment outcomes. We have equally highlighted that Jobcentre Plus needs to review how it can reach out to a larger number of people, bearing in mind that people with hearing loss may face barriers in using the service, therefore, bypassing it, or missing out altogether on vital support.

In our response to chapter on the role of employers, we draw attention to the current issues around employer attitudes to hearing loss, in particular that employers do not know where to go for advice, or even that there is support already available to them. We make recommendations around the importance of a rigorous evaluation of the Disability Confident campaign to ensure its effectiveness; a publicity campaign for Disability Confident, and Access to Work; and the need to introduce a disability resource hub. We would also like to see an awareness campaign for the Equality Act, as recommended by the House of Lords Select Committee, so employers understand their obligations, and feel confident to have open conversations about disability with current or potential staff.

We have also responded to the chapter on Supporting employment through health and high quality care. This section is possibly the most complex as it addresses the issue of integrating health, care and employment services. We highlight the existing strategies and frameworks that, if implemented consistently across the country, would help commissioners and health professionals to consider work as a health outcome. We draw attention to the fact that decisions made in health commissioning can have an impact on a person’s ability to work, for example with the provision of hearing aids. Therefore, health commissioners should consider the wider picture when making commissioning decisions. However, strategies, such as the Action Plan on Hearing Loss, and the supportive commissioning framework, do include work as an outcome, and we want to see this used by all commissioners to achieve this aim.

We are happy to work with the Department for Work and Pensions and the Department of Health on future developments around the work and health agenda.

Background

Action on Hearing Loss welcomes the opportunity to contribute to the discussions in this Green Paper. We believe that this is the right time to consider work and health together, and the impact they have on each other, as this could ensure more people with hearing loss are able to achieve their potential in accessible and inclusive workplaces. Of the 11 million people in the UK with hearing loss, almost five million are of working age.1 Yet, as a direct result of the condition, someone with hearing loss can lose their job,2 or find it difficult to find one.3 We want to see all people with hearing loss who are willing and able to work in roles which mean they can fulfil their potential.

1 Action on Hearing Loss (2015), Hearing Matters: Why urgent action is needed on deafness, tinnitus and hearing loss across the UK, Action on Hearing Loss, London2 Matthews, L. (2011), Unlimited Potential: A research report into hearing loss in the workplace, Action on Hearing Loss, London3 RNID (2008), Opportunity Blocked: The employment experiences of deaf and hard of hearing people, RNID, London

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Hearing loss refers to all levels of the condition, and the needs of a person can depend on level of hearing loss. We estimate there to be around 6.7 million people who need hearing aids in the UK today, and just over 900,000 people who have severe to profound hearing loss.4 With regards to employment, it needs to be recognised that each person with hearing loss must be treated individually, and no one policy can be applied across the board. It does also mean, in the workplace, that the type of support or adaptations will vary widely, for example, a person with moderate hearing loss may benefit from moving desks to a quieter area, while a person who uses British Sign Language (BSL) will need a higher level of support, such as interpreters.

Hearing loss can have a serious impact on a person’s own finances and the wider economy. In 2014, The Ear Foundation calculated that, on average, people with hearing loss are paid £2,000 less per year than the general population – this amounts to an annual £4 billion in lost income across the UK.5 Estimates suggest that, in 2013, the UK economy lost £24.8 billion in potential economic output because too many people with hearing loss are unable to work.6 If nothing is done to address lower employment rates for those with hearing loss, by 2031 the UK economy will lose £38.6bn per year in potential economic output.

When the impact of hearing loss on quality of life and the costs to NHS and social care are also taken into account, The Ear Foundation calculated that the full economic cost of hearing loss across the UK is at least £30 billion per year.7

For these stark reasons, we welcome a new approach to employment support. The aim to close the disability employment gap is a positive step, which has the potential to see more people with hearing loss working in inclusive workplaces. We call on the government to move quickly following the end of the consultation period to introduce any necessary legislation, and implement changes. Delays will see more people with hearing loss struggling to find work, or retiring early, both circumstances bringing additional costs to the economy.

We are pleased with the coordinated nature of this Green Paper. We also believe that employers, health, care and employment services should work together to ensure more people with hearing loss are in work which suits them. Working together, with support from central government, is the best way to reach this ambition as soon as possible.

4 Action on Hearing Loss (2015), Hearing Matters: Why urgent action is needed on deafness, tinnitus and hearing loss across the UK, Action on Hearing Loss, London5 The Ear Foundation, 2014. The Real Cost of Adult Hearing Loss: Reducing its impact by increasing access to the latest hearing technologies. Nottingham: The Ear Foundation.6 International Longevity Centre (ILC) UK, 2013. Commission on Hearing Loss: Final report. London: ILC-UK.7 The Ear Foundation, 2014. The Real Cost of Adult Hearing Loss: Reducing its impact by increasing access to the latest hearing technologies. Nottingham: The Ear Foundation

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Chapter 2: Supporting people into work

1. Introduction

Action on Hearing Loss welcomes plans in the Green Paper to personalise employment support for disabled people. A lack of tailored support has been cited as one reason for people with hearing loss not engaging with Jobcentre Plus services in the past. Research in 2015 from Action on Hearing Loss Cymru found that Jobcentre Plus staff did not provide appropriate support specific to people with hearing loss. One research participant reported that Jobcentre Plus staff had been able to communicate with people with hearing loss in the past, but this is no longer the case.8 Another person, who wears bilateral hearing aids, shared a poor experience at the Jobcentre:

“It’s the way they treat you… They said, here’s a job you can apply for… in a telephone call centre… [Jobcentre Plus staff] are not trained… they don’t understand at all.”9

This quote highlights the urgent need for a tailored approach from Jobcentre Plus, but also the skills required by Work Coaches, which we discuss in this response, below.

We have concerns that the Green Paper does not address issues around reaching out to people who could benefit from using Jobcentre Plus services, but who do not for a variety of reasons. People with hearing loss can face barriers when they initially access services through Jobcentre Plus. There are a variety of methods for making initial contact with Jobcentre Plus (such as online, textphone and telephone); however, we have concerns, based on anecdotal evidence, that Jobcentre Plus may not communicate with people with hearing loss using their preferred method. Jobcentre Plus staff across the country inconsistently record information about hearing loss and the access requirements of individuals. Our service users have reported that they have missed phone calls, misheard details of an interview or missed the opportunity to be referred for employment support. In research for Action on Hearing Loss Cymru, one participant working in the health field described the difficulties with communication she and one of her clients had encountered at the Jobcentre:

“I had a client who was deaf and there was a problem with her benefits and we went down to the Job Centre together and explained it and they said you had to use the phone. So I explained we can’t use the phone because we’re both hearing impaired and we’re not able to use those phones. They didn’t know what to do with us.”10

Other methods of contact to Jobcentre Plus could be successful. For example, the introduction of the Video Relay Service (VRS) could have a positive impact on the experiences of people with hearing loss who use any Jobcentre Plus service, as well as making the processes more efficient. (VRS allows people who use British Sign Language (BSL) to place video calls, connecting to Jobcentre Plus services through a BSL interpreter.)

88 Boyce, T (2015), Able, ready to work … and deaf: The real stories of deaf people across Wales who despite everything can’t find work. Cardiff: Action on Hearing Loss Cymru99 Boyce, T (2015), Able, ready to work … and deaf: The real stories of deaf people across Wales who despite everything can’t find work. Cardiff, Action on Hearing Loss Cymru10 Boyce, T (2015), Able, ready to work … and deaf: The real stories of deaf people across Wales who despite everything can’t find work. Cardiff, Action on Hearing Loss Cymru

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Action on Hearing Loss believes that DWP must address the issue of inconsistent communication, along with other barriers to using Jobcentre Plus, as part of these employment support reforms.

Recommendation: We call on DWP to investigate and address barriers to people using Jobcentre Plus services, to ensure that as many people as possible can benefit from tailored support.

In answer to the questions below, we have provided evidence of successful employment support services for people with hearing loss.

2. Answers to specific questions

Part 1: Building Work Coach capability

1. DWP should introduce robust monitoring and evaluation processes for all Jobcentre Plus services

Action on Hearing Loss welcomes plans to increase the capacity of Work Coaches in supporting disabled people. Work Coaches will play in a key role in ensuring that people with hearing loss can access timely and appropriate support which will help them in looking for and gaining a job.

While we recognise the change of role for Disability Employment Advisers (DEAs) as set out in the Green Paper, we realise that they will have to carry a vast amount of knowledge of a variety of disabilities and health conditions in order to coach the Work Coaches. The Disability Employment Advisers must also have access to sources of support and information, which should include the third sector. We also see the benefits of the Work and Health Conversation, which will support individuals to identify their work goals before the Work Capability Assessment, but Work Coaches will need to have access to vast amounts of information in order for this conversation to be effective.

Recommendation: We call on the DWP to introduce robust monitoring and evaluation processes for all Jobcentre Plus services, based on personal work outcomes of individuals, to assure good-quality services.

How do we ensure that Jobcentres can support the provision of the right personal support at the right time for individuals?

Action on Hearing Loss recognises the need to start work and health conversations between individuals and Work Coaches as soon as possible, as this could ensure earlier access to appropriate interventions. However, all Jobcentre Plus staff must be prepared with knowledge of the local services and support that is available.

We believe that, for individuals to receive the right support at the right time, local Jobcentre Plus staff must develop close relationships with other local bodies, such as the local authority, GP services and third sector organisations. By doing so, they will be able to identify individuals who need support, as well as gain good knowledge of the services available locally. These could be health, social care, employment services, or other services, such as peer-to-peer support.

The Specialist Employment Advisors from Action on Hearing Loss’ Specialist Employment Services in Wales have proved successful in supporting deaf clients into work. Part of their success has been to build close relationships with local Jobcentre Plus staff in order to identify people who may benefit from using the service. This means that staff at local

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Jobcentres have a good understanding of the specialist employment service and can make timely referrals where appropriate. This information sharing also works the other way round; once the Work Coach has made a referral, Action on Hearing Loss contact the Work Coach to gather more information on the individual, what interventions have already been made, and the steps the individual has already taken to look for work.

Where strong relationships exist between Jobcentre Plus and Action on Hearing Loss, people with hearing loss have benefitted from timely referrals; however, the nature of these relationships is inconsistent across Jobcentres in Wales, which means that some people with hearing loss may miss out on accessing specialist services. Action on Hearing Loss believes that coordination between services and organisations is vital for ensuring individuals have support at the right time.

Recommendation: We recommend that Jobcentre Plus builds links with local health, social care and third sector organisations to ensure people with hearing loss are identified as potentially requiring an intervention and can access specialist support at the right time.

What specialist tools or support should we provide to Work Coaches to help them work with disabled people and people with health conditions?

1. Work Coaches are provided with awareness training in all disabilities, with a focus on hidden disabilities

To effectively support people with disabilities, Work Coaches will need to demonstrate empathy, and they may, on occasions, need to take a flexible approach in providing support to ensure the best possible work outcome for every disabled person. It may not always be possible to follow a standard pathway, or come from a position of simply ‘ticking the boxes’. Work Coaches must have some knowledge of the disability in order to understand the impact it can have on a person’s quality of life and wellbeing. With that knowledge they should then be able to identify innovative solutions to achieving an individual’s employment outcomes.

We recognise that this is challenging, and believe that Work Coaches must be adequately trained in supporting people with a wide variety of disabilities. Action on Hearing Loss and other organisations offer deaf awareness training courses that can markedly improve the skills and confidence of staff. We also have information for Jobcentre Plus staff available on our website: https://www.actiononhearingloss.org.uk/supporting-you/getting-help-from-the-jobcentre/for-jobcentres.aspx and we would like all Jobcentres to make this information available to their staff.

Recommendation: We recommend that Work Coaches are supported with a robust and consistent training package, which includes hearing loss, and access to ongoing support.

2. Jobcentre Plus should record the preferred communication methods of people who use its services

It is important that Work Coaches are aware of the preferred communication methods of people who are deaf or have hearing loss, and that they use this systematically, whenever contact is made with an individual. Our experience through supporting deaf clients as part of the Specialist Employment Service is that this is a critical aspect of delivery, as direct communication in the language of choice enables a better understanding of the client, builds a stronger relationship and leads to a better work outcome. This is a duty under the Equality Act 2010, but Action on Hearing Loss has anecdotal evidence of the incorrect communication support being provided. It is important to recognise that not all people with

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hearing loss are sign language users. We estimate that there are at least 24,000 people who use BSL as their main language, based on the 2011 census, while there are around 5 million people living with hearing loss of working age in the UK today.11Types of communication support include speech-to-text-reporters (STTR), notetakers, lipreading, hearing loops, and BSL interpreters.

Providing the wrong communication support, or no support at all, is both stressful for an individual and also incurs unnecessary costs for Jobcentre Plus. We believe that DWP should look to the example of the Accessible Information Standard introduced in the NHS to provide good practice on meeting the communication needs of people with hearing loss. The Standard defines the types of communication support, and minimum qualifications for communication professionals, which are not included in the Equality Act 2010. We would like to see an equivalent accessibility standard introduced to Jobcentre Plus.

Recommendation: We recommend Jobcentre Plus records the preferred communication methods of individuals with hearing loss who use their services, which will ensure that the correct communication methods are used each time contact is made.

Recommendation: We call on the government to introduce a communication standard to Jobcentre Plus, using the Accessible Information Standard as an example, to ensure people with hearing loss have access to information in their preferred communication method.

We also believe that there should be a number of Work Coaches who are able to converse directly in BSL, Sign Supported English or other communication methods. If this service is available at Jobcentre Plus, it is more likely to deliver good outcomes for deaf people, and will also be more cost effective, reducing the need for communication support.

Recommendation: We call on Jobcentre Plus to train or recruit a number of Work Coaches with BSL skills, providing cost-effective and reliable internal resources for communication support.

Part 2: Supporting people into work

What support should we offer to help those ‘in work’ stay in work and progress? How can we support employers?

1. The government should establish a disability information hub as a central point for all information on disability.

In research conducted by Action on Hearing Loss, survey respondents stated that employers and audiologists had been most helpful in providing support on managing hearing loss at work: just over two-fifths (46%) stated their employer had been either very or quite helpful, and a similar proportion (44%) reported their audiology department had been very or quite helpful. While these data are promising, a large proportion of certain information sources were not applicable. Nearly half (48%) of respondents identified Occupational Health (OH) departments as not applicable. This suggests that many of the survey respondents have never had any contact with an OH team. This could be because their employer is too small to have an Occupational Health team, the OH service did not cover hearing loss in the assessment, or they have not been referred.

11 Action on Hearing Loss (2015), Hearing Matters: Why urgent action is needed on deafness, tinnitus and hearing loss across the UK, Action on Hearing Loss, London

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When asked if they have carried out their own research to find information on managing hearing loss in the workplace, seven in ten (69%) respondents reported that they had.12 This could indicate that people with hearing loss feel they need to do their own research into support, as information is not readily available from other sources. While we do not expect employers to be experts in all disabilities or health conditions, they should have ready access to advice and information should they be seeking to recruit or retain a person with hearing loss.

Action on Hearing Loss believes that more could be made of the information on the gov.uk website. There is a lot of useful information listed, but it is dissipated across the website, and not all easy to find. We think that this information should be brought into a single hub, which should be promoted as part of a campaign, similar to the Workplace Pensions campaign. We also think there should be a telephone or email advice service available to employers who may have a quick or urgent question.

Recommendation: The DWP, as part of the Disability Confident campaign, should establish a disability information hub that consolidates all the information on the gov.uk website into a comprehensive guide on all disabilities, and includes details on where to find support. There should also be a free telephone helpline giving expert advice about employing disabled people, including people with hearing loss.

Signposting to potential equipment should also come from health professionals, such as audiology services. We have discussed these issues in our response to the section on ‘Supporting employment through high quality health and care for all’. In brief, audiology services should ask an individual about the impact of hearing loss on their work, and provide information or advice on support available in the workplace, such as Access to Work where necessary, or other suitable support, such as lipreading classes or assistive equipment. Health and care professionals could also benefit from access to a disability and employment information hub.

Recommendation: Once established, the Department of Health should promote the disability information hub to health and care professionals.

2. The government should initiate public information campaigns to raise awareness of Access to Work

Having access to assistive technology can support people with hearing loss in the workplace and help them to stay in work. Research by Action on Hearing Loss has found that the most commonly-used pieces of equipment are amplified telephones (48% of survey respondents had used this) and hearing loop systems (used by 30% of survey respondents).13

Communication support may also be required for people with hearing loss (this can be vital for ensuring people with hearing loss can access the workplace as an equal with hearing colleagues, and can include speech-to-text-reporters, notetakers, and BSL interpreters). A small percentage of respondents had benefitted from communication support – 9% had used a speech-to-text-reporter, and 7% had used a notetaker – these being the most common forms of communication support.14 When asked about adjustments at work, nearly a third 12 Arrowsmith (2014), Hidden Disadvantage: Why people with hearing loss are still losing out at work, Action on Hearing Loss, London13 Arrowsmith (2014), Hidden Disadvantage: Why people with hearing loss are still losing out at work, Action on Hearing Loss, London14 Arrowsmith (2014), Hidden Disadvantage: Why people with hearing loss are still losing out at work, Action on Hearing Loss, London

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(30%) of respondents had changes made to their work area.15 If people with hearing loss are not receiving information on managing their hearing loss at work, there could potentially be more people who could benefit from access to technology, equipment, or communication support.

We recognise that making adjustments in the workplace can seem daunting to employers, particularly if they assume that this would incur additional costs. However, our most recent research shows that employers lack an awareness of Access to Work, which could help them to meet any additional costs if these arise. In a YouGov poll we commissioned, we found that almost two-thirds (63%) of all business leaders had never heard of Access to Work,16 highlighting that the scheme remains ‘DWP’s best-kept secret’.

Recommendation: We recommend that the DWP embarks on a publicity campaign to ensure widespread awareness of Access to Work among employers.

Case study – Specialist support helping a person to progress in their career

Steven has benefitted from Action on Hearing Loss’ Moving On service in Scotland, and Access to Work has helped him progress at work.

25 year-old Steven, who is profoundly deaf and uses BSL, initially started on a 13-week placement at the Westerwood Hotel in April 2015 and has made such a positive impression that he was immediately taken on full-time as a kitchen porter and, five months on, is being promoted to Commis Chef.

Steven, who studied National Certificate (City and Guilds) in Bakery and Cookery at Motherwell College, was supported into his new career by Action on Hearing Loss Scotland’s Moving On service which helped develop his CV, enhance his job search skills and prepare him for job interviews. Moving On is funded by the Big Lottery Fund and supports young deaf or hard of hearing people aged 16-25 into employment, training and education.

Steven said: “I love my job as I have learnt many cooking techniques and I am looking forward to applying them in my new role as a Commis Chef!  Kitchens can be pressurised places and it is really important that you can work quickly and efficiently. Good communication is very important for me to do my job correctly – if you don’t know what is on order, things can go wrong!  

“I lipread, use basic signs and exchange notes by mobile phone with my colleagues to ensure I keep on top of what I need to do. My supervisor is learning BSL which is a great help as she will be able to communicate in ways that better meets my needs.

“It can be tough for people who are deaf to find work but knowing what you want to do and getting the right support makes life much easier. The advice I received from Moving On has been life-changing as it means I am now doing a job that I really want to do and no longer sitting at home losing my confidence. ”

Julie-Anne Leggate, Employment Advisor for Moving On, said: “Steven is determined to succeed in his career so I am pleased that he is being recognised for doing so well in his job

15 Arrowsmith (2014), Hidden Disadvantage: Why people with hearing loss are still losing out at work, Action on Hearing Loss, London16 Cook (2017) Working for Change: Improving attitudes to hearing loss in the workplace, Action on Hearing Loss, London

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and working towards fulfilling his potential. It’s great to see the Westerwood Hotel making adjustments – such as undertaking Deaf Awareness Training – and using Access to Work funding towards the cost of booking BSL interpreters. Those adjustments have been vital to help Steven to fully participate in conversations at work and continue his development to take on exciting new opportunities.”

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3. The government should look for opportunities to share good practice on employing people with hearing loss across small businesses

We commend the government for establishing the Disability Confident Business Leaders Group; however, to support people with hearing loss to progress, there must also be an opportunity for small businesses to share good practice. We believe that DWP should use existing bodies which represent small businesses, such as the Federation of Small Businesses and British Chambers of Commerce, to disseminate information on employing people with hearing loss. Not only can they share information on adjustments they have made, but there is the potential to highlight the benefits of employing people with hearing loss.

Recommendation: We recommend that DWP uses existing bodies which represent small businesses in order to disseminate information on employing people with hearing loss.

We also believe there is a role for professional bodies, membership organisations and trade unions to support in disseminating messages, and providing information on employing people with hearing loss. We recommend that the government engages with all these organisations to ensure that this happens.

Recommendation: We recommend that DWP engages with professional bodies, membership organisations, and trade unions to support in disseminating information on employing disabled people to their members.

Part 3: Improving access to employment support

Should we offer targeted health and employment support to individuals in the Support Group, and Universal Credit equivalent, where appropriate?

Action on Hearing Loss strongly believes that individuals in the Support Group and Universal Credit equivalent should be offered targeted health and employment support. We are aware that our Specialist Employment Services are only currently commissioned to support a small number of deaf people, or people who have hearing loss, and yet our record in supporting clients to work is impressive. Many more people would benefit from the services if referral rates were increased and resources were made available.

As well as our employment services, we have a range of care and support services across England and Wales. We provide flexible, short and long-term support for people of all ages. Everyone we support is deaf or deafblind, has a hearing loss, or has other communication needs. Our services include residential care, supported housing, community services and reablement services (these services support people to adapt to an acquired disability by learning or relearning skills necessary to live independently). Our outreach services offer support to more vulnerable people with complex and multiple needs, who may be furthest away from the jobs market, to become ‘job ready’ by providing them with access to training and volunteering opportunities. We believe that voluntary work should be considered a valid employment outcome for some people who are deaf or have a hearing loss, as volunteering is often the first step to finding paid work. However, people who are deaf or have a hearing loss can face barriers to volunteering if communication support is needed. We would recommend a review of Access to Work rules to better support people to access volunteering and to support them into employment.

Recommendation: We recommend that the DWP considers voluntary work as an acceptable work outcome for people furthest away from the job market.

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Recommendation: We call on DWP to review Access to Work so that the scheme can be used for people who undertake formal voluntary work as a step to finding paid work.

What type of support might be most effective and who should provide this? How might the voluntary sector and local partners be able to help this group?

Action on Hearing Loss believes that specialist employment services are most successful, for the very reason that they are specialist, and offer the support needed, which cannot be offered by generic service providers.

Our experience in Wales through the Specialist Employment Service is that direct service support by trained employment specialists who are able to communicate effectively with people who are deaf or have hearing loss delivers positive work outcomes more successfully than the generalist service approach.

In Scotland and in Wales, we provide a DWP Specialist Employability Service. This is an employment focussed programme that has been designed specifically to help people with disabilities to gain the skills needed to find and stay in work. Referrals for either 8 week support or 32 weeks of support are made through DWP Work Coaches to Doncaster Deaf Trust (the Prime Provider).

The key to the success of these services is offering a personalised approach. The full process can often be intense for the individual, but the outcomes are very good. In Wales, the service is run by two members of Action on Hearing Loss staff who both support clients face-to-face, and who can both use BSL. This is an important feature which engenders trust and a sense of shared experience between staff and clients, who feel more able to trust another person with similar personal experience of hearing loss or deafness, and who understands the barriers first hand.

The first stage of the personalised process is to assess the individual with hearing loss. The initial meeting that follows the assessment can take several hours, as the individual may have little experience of applying for jobs, or the world of work, and they may also lack confidence. The support can include how and where to look for work – the Specialist Employment Advisor will sit at the computer with the individual and talk them through how to search. The individual will also be supported to complete an application form, in an honest way, as they may not be able to communicate clearly in written English. If the individual is shortlisted, our service is able to support them through the process and even engage with the employer at this stage, giving the employer the opportunity to understand hearing loss and the needs of the individual. Colleagues from the service may also attend the interview with the individual.

Once the individual has secured a role, the Specialist Employment Service at Action on Hearing Loss continues to support both the employee and the employer, and is always on hand to take questions from both sides. As individuals may have little work experience, our specialist employment service will explain work terminology, such as ‘annual leave’, or ‘line manager’, to the individual, as well as the importance of good time-keeping, which is fundamental to retaining a job.

The service is built on strong communication, a deeper understanding of the client and a more flexible approach. Our experience is that this has led to better work outcomes for people who are deaf or have hearing loss and would strongly recommend expansion of this approach to support more deaf people into work. Not only is it a more person-centred approach and delivers better outcomes, it also is more cost-effective as having staff that can communicate directly with deaf people reduces the need for providing communication support.

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Recommendation: We call on commissioners of employment services to consider the needs of the local population, and commission services accordingly.

Recommendation: We recommend that Jobcentre Plus looks to refer clients to local specialist services, which can deliver better work outcomes for individuals than large, generic employment service providers.

Case study – JacobJacob is 32 years old, profoundly deaf and uses BSL to communicate. Until December 2016, he had never had a permanent job, and his confidence in finding work was very low, which he attributed to having not held a long-term job for many years. The Jobcentre established that he had an interest in working in catering, and the Jobcentre supported him to do some training, which meant he had some up-to-date experience on his CV. However, he still struggled to find work as he found it difficult to look for and apply for jobs.

He was referred to the Specialist Employment Service within Action on Hearing Loss in Wales through the Jobcentre Plus. The Specialist Employment Service assists people who are deaf or hard of hearing to find paid employment or training. The Specialist Employment Service was able to support him in looking for suitable jobs in the newspaper and online. The staff communicate with Jacob through BSL, and where necessary, through FaceTime or Skype. An opportunity finally came up at a local branch of McDonald’s, and his Employment Advisor helped Jacob with completing his job application and accompanied him to the interview.

Jacob was successful at the interview and has worked at McDonald’s since December 2016, and he really enjoys his work. His duties are cleaning and food preparation. He has a supportive manager and colleagues who are keen to learn sign language so they can communicate with him without the need for an interpreter. Jacob’s confidence has grown hugely, and the Specialist Employment Service can see the difference in him. Jacob says he values earning his own money, but above all, he enjoys being part of a team.

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Chapter 4: Supporting employers to recruit with confidence and create healthy workplaces

1. Introduction

Action on Hearing Loss welcomes the recognition in the Green Paper of the role of employers in supporting more disabled people, both in work and in finding employment. In 2014, Action on Hearing Loss published research in which employer attitudes to hearing loss were identified as a major barrier in the workplace. Employer attitudes were reported as the biggest barrier to employment by nearly eight out of ten (79%) of people with hearing loss who responded to our survey.17 Many respondents told us that they had retired early as they felt isolated or not appreciated at work. Over two-fifths (41%) of people with hearing loss who had retired early said this was related to their hearing loss, and the reasons given included difficulties in fulfilling day-to-day tasks, such as using the phone, or communication challenges with colleagues.18 One respondent to the 2014 survey said:

“I retired to remove the stress from my life. It was difficult to maintain good communications with my hearing peers in the workplace and I often felt under-valued and under-appreciated.”19

Following this, we have launched our Working for Change campaign which aims to increase the confidence of employers in recruiting and retaining people with hearing loss. Our report, Working for Change: Improving attitudes to hearing loss in the workplace, sets out the evidence behind employer attitudes to hearing loss, from the perspective of employers.20 Alongside this report, we have published a myth-busting guide for employers, Working for Change: Increasing confidence in employing people with hearing loss. This is a guide for employers, which dispels some of the common myths, and includes useful hints for employers. We believe that our Working for Change campaign contributes to the government’s Disability Confident campaign, and we recommend that government uses our specialist hearing loss resources to provide information to employers.

Later this year, the Department of Health and Department for Work & Pensions will publish, ‘What Works: Hearing Loss & Employment: A guide for employers to support people with hearing loss in the workplace’. The guide, supported by Action on Hearing Loss and other hearing loss charities, focuses on what employers can do to ensure people with hearing loss can work well and contribute their best in the workplace and provides useful hints on attracting, recruiting and retaining staff with hearing loss.

Much of the evidence in the sections below comes from our research for the Working for Change campaign.

2. Answers to specific questions

Part 1: Embedding good practices and supportive cultures

17 Arrowsmith (2014), Hidden Disadvantage: Why people with hearing loss are still losing out at work, Action on Hearing Loss, London18 Arrowsmith (2014), Hidden Disadvantage: Why people with hearing loss are still losing out at work, Action on Hearing Loss, London19 Arrowsmith (2014), Hidden Disadvantage: Why people with hearing loss are still losing out at work, Action on Hearing Loss, London20 Cook (2017) Working for Change: Improving attitudes to hearing loss in the workplace, Action on Hearing Loss, London

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What are the key barriers preventing employers of all sizes and sectors recruiting and retaining the talent of disabled people and people with health conditions?

Action on Hearing Loss conducted research which looks into the barriers to employing people with hearing loss. Firstly, our findings, published in January 2017, show that there is still a substantial number of employers who lack the confidence to employ people with hearing loss: according to a YouGov survey commissioned by us, just over a third (35%) of business leaders stated that they do not feel confident about their business employing a person with hearing loss.21 The government’s Disability Confident campaign offers one way in which employers can find useful resources to support their knowledge and understanding of hearing loss.

The second major barrier we identified in our research was a perceived lack of information and advice available. Over half (57%) of business leaders who responded to our YouGov poll agree that there is a lack of support or advice available for employers about employing people with hearing loss.22 We believe that employers should sign up to and engage in the Disability Confident campaign, which provide them with useful resources on attracting, recruiting and retaining staff with hearing loss, as well as recognising the efforts they make to be accessible. We recommend that the government undertakes a publicity campaign of Disability Confident to ensure that are employers are aware of it.

Finally, we found that employers are unaware of the support that is available to them. In our YouGov poll, we found that almost two-thirds (63%) of all business leaders had never heard of Access to Work,23 highlighting that the scheme remains ‘DWP’s best-kept secret’.24

Which measures would best support employers to recruit and retain the talent of disabled people and people with health conditions?

4. Government must introduce a rigorous evaluation and review processes of Disability Confident

Disability Confident is at the core of improving attitudes to disability at work. We laud the government for opening up the discussion on employer attitudes to disability in this Green Paper. However, we have concerns that there is no evaluation measure of Disability Confident. Without one, it is impossible to measure the number of disabled people who have found work, or been supported to remain in the workplace. Without a robust measure, we fear that employers will simply see Disability Confident as a box-ticking exercise. Furthermore, an evaluation process should underpin the whole Disability Confident scheme, and act as a baseline measure for any further developments.

We strongly welcome the idea of a disability index, as discussed in the Green Paper, as a measurement for Disability Confident. Paragraph 181 in the Green Paper states that Stonewall’s Equality Index has been successful in changing employer behaviours. Therefore, we believe that a Disability Index could have the potential to increase the

21 Cook (2017) Working for Change: Improving attitudes to hearing loss in the workplace, Action on Hearing Loss, London22 Cook (2017) Working for Change: Improving attitudes to hearing loss in the workplace, Action on Hearing Loss, London23 Cook (2017) Working for Change: Improving attitudes to hearing loss in the workplace, Action on Hearing Loss, London24 Work and Pensions Committee (2009), The Equality Bill: How disability fits within a single Equality Act. Available at: https://www.publications.parliament.uk/pa/cm200809/cmselect/cmworpen/158/158i.pdf [Accessed 12 December 2016]

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recruitment and retention of disabled people, and lead to longer-term behaviour change in the workforce.

Recommendation: We recommend that the DWP develops a rigorous and robust review process for Disability Confident to ensure businesses are delivering on their commitments.

Action on Hearing Loss believes that the government has a role to play in ensuring that disabled people can progress in work and secure senior roles. As a result of the targets set in the ‘Women on Boards review’, there are now more women than ever represented on FTSE 100 boards (BIS, 2015),25 which shows that with government backing, it is possible to increase diversity the workforce. We recommend that the government conducts a similar review of disability in the workforce, with a focus on enabling disabled people to progress in work, including into senior roles. Therefore, we welcome the proposal in the Green Paper that the government establishes a Disability Confident Business Leaders Group to increase employer engagement around employing disabled people.

Recommendation: We call on the government to conduct a review of disabled people in work, which would examine how disabled people progress in work, and secure senior roles.

5. The government should establish a disability information hub as a central point for all information on disability.

Action on Hearing Loss would welcome a one-stop shop for employers. In our research into employer attitudes to hearing loss, employers told us that there is a need for a source of reliable and easy to find information. One person told us:

[Employers need] a ready source of information so if something comes up and an employer thinks, ‘how do I do that?’, there’s somewhere they can turn to: a website or helpline.” Brad Taylor, Head of People, CIPD26

Action on Hearing Loss believes that more could be made of the information on the gov.uk website. There is a lot of useful information there, but it is dissipated across the website, and not all easy to find. We think that this information should be brought into a single hub, which should be promoted as part of a campaign, similar to the workplace pensions campaign. We also think that there should be a telephone or email advice service available to employers who may have a quick or urgent question.

Recommendation: The DWP, as part of the Disability Confident campaign, should establish a disability information hub that consolidates all the information on the gov.uk website into a comprehensive guide on all disabilities and details on where to find support. There should also be a free telephone helpline giving expert advice on employing disabled people, including people with hearing loss.

6. The government should initiate public information campaigns to raise awareness of Disability Confident and Access to Work

25 Woman on boards review (2015) Improving the gender balance on British boards. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/482059/BIS-15-585-women-on-boards-davies-review-5-year-summary-october-2015.pdf [Accessed 5 December 2016]26 Cook (2017) Working for Change: Improving attitudes to hearing loss in the workplace, Action on Hearing Loss, London

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Action on Hearing Loss supports information campaigns as a means of raising awareness of support available employers to recruit people with hearing loss, although this should not be seen as the only way of achieving the government ambition. We recommend that the government initiates three information campaigns as a matter of urgency. These are:

An information campaign on Disability Confident which is targeted at employers, encouraging them to take part and benefit from the resources available.

An information campaign on Disability Confident which is targeted at disabled people, informing them that Disability Confident has replaced Two Ticks. People with hearing loss must feel confident to apply for jobs with companies that may be sympathetic to their requirements in the workplace.

An information campaign on Access to Work. In our research, nearly two-thirds (63%) of business leaders who responded to our YouGov survey had never heard of the scheme. It is concerning that there could be many more disabled people who could benefit from Access to Work, but a lack of awareness means that employers may be worried about the additional costs of employing a disabled person.

Recommendation: We recommend that the DWP embarks on a publicity campaign to ensure widespread awareness of Disability Confident and Access to Work among employers.

There is also a role for the voluntary sector to play in supporting information campaigns. Awareness-raising campaigns, such as Action on Hearing Loss’ Working for Change campaign, can provide employers with specialist resources and good practice examples on a particular disability.

Recommendation: DWP should support awareness-raising campaigns from voluntary sector organisations, by promoting employer attitudes campaigns, and linking to high-quality specialist resources for employers.

7. The government should run an awareness campaign on the Equality Act 2010, and highlight how employers can use it effectively.

The businesses we spoke to for our research generally believe that a lack of confidence is reflected in workplaces nationwide. When we asked their reasons for this view, ‘fear’ was a commonly-used word – employers might fear offending someone with hearing loss, so they don’t ask the important questions about the individual’s needs. Or, there’s an assumption that it would be too costly or difficult to hire a person with hearing loss. This fear is born out of a lack of understanding of the Equality Act 2010. Action on Hearing Loss believes that it is reasonable for all employers to be aware of their duties under the Equality Act, and how they can effectively meet the needs of their employees. While the House of Lords recommended that the Equality and Human Rights Commission (EHRC) works with disability organisations to raise awareness of the Equality Act. The Lords also recommended that the EHRC should prepare a specific Code of Practice on reasonable adjustments to supplement the existing Equality Act Codes.27

Recommendation: The government should increase understanding of the Equality Act 2010 among employers through an awareness-raising campaign.

8. The government and employers need to develop strategies for supporting the ageing workforce.

Action on Hearing Loss has concerns that both the government and employers have not considered how they will support the ageing workforce. This is a matter of concern as many

27 House of Lords Select Committee on Equality Act 2010 and Disability (2016), The Equality Act 2010: the impact on disabled people, House of Lords, London

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employees who develop hearing loss while in work may feel they need to leave work or retire early. Previously, we found that over two-fifths (41%) of people with hearing loss who had retired early said this was related to their hearing loss.28In our YouGov poll, business leaders reported they don’t feel well-equipped to enable staff with hearing loss to stay productive in the workforce.29 Failing to retain staff could also lead employers to lose highly skilled and experienced employees, creating additional costs in the recruitment and training of new staff. The organisations involved in this research understood how important it is to keep skills and knowledge in an organisation.

Recommendation to employers: We call on employers to develop internal policies on retaining employees who develop age-related disabilities, including hearing loss, or health conditions. Policies could include flexible working, job sharing, utilising assistive technology or redeployment.

Recommendation to government: We recommend that DWP develops, as a priority, an information campaign on working into later life, in order to increase awareness of the ageing workforce and to highlight how employers can support their employees who develop a hearing loss while in employment.

Should there be a different approach for different sized organisations and different sectors?

Action on Hearing Loss agrees that there should be a different approach for different sized organisations and sectors. Our evidence and recommendations for this are explained below.

From our research into employer attitudes to hearing loss, we found that large companies have the infrastructure of HR and, possibly, occupational health teams, who can support managers.30 However, this is often not the case for small and medium enterprises. The government has a role, therefore, to provide good-quality, clear information to those organisations that do not have the infrastructure of larger businesses. Information on employing people with hearing loss could be disseminated from government to small businesses via British Chambers of Commerce and the Federation of Small Businesses. As well as working directly with local employers, advisers in Jobcentre Plus must also take advantage of these existing networks to provide support and advice to small businesses.

Recommendation: The DWP should use bodies which represent small businesses in order to disseminate information on employing people with hearing loss.

Analysis of the YouGov survey we commissioned also shows differences between sectors. For example, the higher percentages of business leaders who agreed that people with hearing loss are a health and safety risk in the workplace were from manufacturing (36%) and construction (42%).31 Business leaders from these sectors were also more likely to agree that there is a lack of information and advice available on employing people with

28 Arrowsmith (2014), Hidden Disadvantage: Why people with hearing loss are still losing out at work, Action on Hearing Loss, London29 Cook (2017) Working for Change: Improving attitudes to hearing loss in the workplace, Action on Hearing Loss, London30 Cook (2017) Working for Change: Improving attitudes to hearing loss in the workplace, Action on Hearing Loss, London31 YouGov (2016), Employers and hearing loss, on behalf of Action on Hearing Loss, YouGov, London (unpublished dataset). Total sample size was 618 adults (aged 18+). Fieldwork was undertaken between 4th - 8th April 2016. The survey was carried out online. The figures have been weighted and are representative of all senior decision makers in GB businesses.

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hearing loss than business leaders in office-based sectors.32 This serves to highlight that information and advice to employers must be tailored to different sectors.

Recommendation: Any one-stop shop for advice and information needs to be developed by the government must have the ability to provide tailored information to suit the size and sector and the business.

Part 2: Moving into work

How can existing government support be reformed to better support the recruitment and retention of disabled people and people with health conditions? Staying in or returning to work

Action on Hearing Loss believes that employment support must be tailored around individuals. Employers must also be given adequate support by specialist employment advisers, which can ensure the employment is sustainable.

Action on Hearing Loss offers employment support services in Wales, Scotland and Northern Ireland. In Scotland, our Moving On transitions service, funded by The Big Lottery Fund, supports 16-25 year olds who are deaf or have a hearing loss to take up work experience and move in to full-time employment, training or education. In Scotland and in Wales, we provide a DWP Specialist Employability Service. This is an employment focussed programme that has been designed specifically to help people with disabilities to gain the skills needed to find and stay in work. Referrals for either 8 week support or 32 weeks of support are made through DWP Work Coaches to Doncaster Deaf Trust (the Lead Partner).

We have found these services to be most effective where our Employment Advisers provide support to employers through the recruitment process and for a further six months.

Specialist employment support in Wales – the positive impact of supporting employers

Following the release of the research mentioned above by Action on Hearing Loss Cymru, they, along with Action on Hearing Loss Scotland, Doncaster Deaf Trust and Clarion launched a partnership service, closely supporting deaf and hard of hearing people to gain access to work or stay in their job, while also offering advice and support to businesses about employing deaf people.

The service is a two-year project, funded by the Department of Work and Pensions and is the only service of its kind in Wales. Without this, there is no support for deaf people looking for work in Wales.

All of our Employment Advisors are able to communicate through British Sign Language and directly support clients without the need for interpreters. Advisors support job seekers with searching and applying for jobs, building their CV, preparing for an interview and accessing training and work experience. The service also helps employers by providing information about deaf awareness training and giving advice about reasonable adjustments and the law.

32 YouGov (2016), Employers and hearing loss, on behalf of Action on Hearing Loss, YouGov, London (unpublished dataset)

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23-year old Sam Lazenbury from the Vale of Glamorgan is an example of how well this service can work. Sam is deaf, has a learning disability and a stammer. Matt Skinner, Specialist Employment Support Advisor, explained the case:

“Sam had been unsuccessful in job applications so far and was keen to enhance his CV in the hospitality industry. I arranged for him to attend a five-week food hygiene and hospitality training course. He then went on to take a first aid course, attend a ‘get into retail’ taster day at Marks and Spencer and completed a two-week placement at the Swalec Stadium, which led to some paid summer work.

“Sam successfully applied for a permanent vacancy as a hospitality assistant at the Wales Millennium Centre. Sam has been in this job for four months so far and has shown excellent commitment, reliability and motivation.”

Matt and the team will continue to support Sam and his employer until he has been in the job for at least six months.

Part 3: Staying in or returning to work

What good practice is already in place to support inclusive recruitment, promote health and wellbeing, prevent ill health and support people to return to work after periods of sickness absence?

We believe that, where organisations engage in disability-specific charters or standards offered by the voluntary sector, this can support inclusive recruitment, and promote health and wellbeing. Action on Hearing Loss offers a charter to companies, called the Louder than Words™ charter. In order to be awarded the charter mark, organisations need to ensure that their recruitment and employment practices are inclusive of people with hearing loss. While conducting research for the Working for Change campaign, we heard examples of how companies have changed their practices to include people with hearing loss. Both Wessex Water and Western Power Distribution successfully employ people with hearing loss. By going through the process of accreditation, they have had to examine their practices and environments in the workplace to ensure they are inclusive to people with hearing loss. Both organisations offer staff deaf awareness training and include information on hearing loss on their staff intranet. They have also both had to consider their fire evacuation procedures; Western Power Distribution has introduced flashing fire alarms in the staff toilets, while Wessex Water has a buddy system to ensure any member of staff with hearing loss leaves the building safely.

The following case studies show how the impact of gaining the Louder than Words™ charter has on inclusion in the workplace for people with hearing loss.

Case study – providing on-going support to staff who lose their hearing

Western Power Distribution employs a man who has had a hearing loss since he was a child and uses hearing aids but, as he gets older, his hearing is deteriorating further. Beverley Dwyer, Employee Relations Officer, explains: “We do have one colleague who works in a specialist role which requires formal training. Much of the role involves liaising with surveyors, architects, landowners and builders over the phone and face-to-face. Recently, he felt he was struggling to keep up with conversation in group meetings, as well as using

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the telephone. We don’t want to lose his skills and talent and so we have made adaptations, with support from Access to Work, which enable him to carry out his job. He now has a Roger Pen, a wireless microphone, which enhances speech, to use in meetings and an amplified telephone. Without these adaptations, he wouldn’t be able to continue in his role and we would lose a highly-skilled employee.”

Case study – making adjustments to employees with hearing loss

Katie works at Western Power Distribution in the customer contact centre. Most of the staff in the contact centre hot-desk, however, Katie has her own desk. The desk is away from the hum of air conditioning, and she has her own headset which was recommended by Access to Work.

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Chapter 5: Supporting employment though health and high quality care for all

1. IntroductionAction on Hearing Loss welcomes this section in the Green Paper and the recognition of the important role health and care professionals can play in supporting disabled people to find or remain in work. As the population ages, and more people work into later life, we believe it is important for health and care professionals to provide support and advice to individuals who wish to remain in work. Many respondents to our survey told us that they had retired early because they felt isolated or not appreciated at work. Over two-fifths (41%) of people with hearing loss who had retired early said this was related to their hearing loss, and the reasons given included difficulties in fulfilling day-to-day tasks, such as using the phone, or communication challenges with colleagues.33

DWP data published in August 2016 shows there are now 9.4 million people in work aged 50-74 in the UK.34 Over two-fifths (41.7%) of people over 50 have hearing loss, which means that the likelihood of people developing hearing loss while in work is high, particularly as the state pension age is rising. Steps must be taken to ensure that if people develop hearing loss while in employment, they can continue to work for as long as they wish. In our response to Chapter 4, we explained how employers can support people with hearing loss to remain in work, and in this section of our response, we detail the steps required in health and care sectors to achieve the same goal.

There are widespread variations in NHS and local authority hearing services and people with hearing loss often struggle to access education, employment, health and other vital services due to barriers to communication, a lack of awareness, or a lack of communication support or equipment. NHS hearing aids help people with hearing loss communicate, hearing loop systems and personal listeners help hearing aid wearers by reducing background noise, and other assistive equipment available through social services can aid hearing and communication. Social services support such as lipreading classes, assistive technology, counselling and befriending can support people to manage their hearing loss, some people with hearing loss require communications support (such as a British Sign Language interpreter), and staff can benefit from training to ensure they use simple communication tactics such as facing the person or reducing background noise to help with communication. This wide range of support and equipment is available through different services, so an integrated approach between health, social care and employment services is required. Contracting and incentivising services to improve outcomes for people can ensure that a holistic and integrated approach is taken. In the sections below, we explain how this integrated approach could ensure people with hearing loss are able to find or remain in work.

2. Answers to specific questions

33 Arrowsmith (2014), Hidden Disadvantage: Why people with hearing loss are still losing out at work, Action on Hearing Loss, London34 Department for Work and Pensions (2016), Employment Minister calls on businesses to create more opportunities for older workers. Available at: https://www.gov.uk/government/news/employment-minister-calls-on-businesses-to-create-more-opportunities-for-older-workers [Accessed 5 January 2017]

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We will be publishing guidance on developing Joint Strategic Needs Assessments later this year. The purpose of this JSNA guidance is to help local authorities and NHS commissioners meet their duty in the Action Plan on Hearing Loss to assess the hearing needs of local populations. It presents the latest data sources and evidence on the prevalence and impact of hearing loss, including the communication barriers people with hearing loss face in the workplace. It also provides information to help local authorities and NHS commissioners develop robust hearing needs assessments and take hearing loss into account when the assessing the needs of people with other conditions.

Part 4: Creating the right environment to join up work and health

1. Clinical Commissioning Groups and local authorities should include employment when developing joint strategic needs assessments (JSNA), and health and wellbeing strategies

Participation in work is already considered a wellbeing outcome in the Care Act 2014,35 and this Green Paper is considering work as a health outcome. Therefore, commissioners should recognise employment as an outcome when developing their local strategies, and consider how health and social care services can support people in work by providing support and equipment. Given the important part these services have to play in supporting people into work, outcomes related to gaining or keeping employment should be included in NHS and social care contracts. Commissioners should coordinate with Jobcentre Plus to identify the need for specialised employment support in their areas. The JSNA should also include plans for engaging with local employers to increase their confidence in employing disabled people. This could be achieved by working with local voluntary organisations and disabled people’s organisations which have knowledge and expertise in disabilities and which can work with employers to make them more disability confident.

Recommendation: We call on Clinical Commissioning Groups and local authorities to include employment when developing JSNA and health and wellbeing strategies.

2. Clinical Commissioning Groups and local authorities should base commissioning decisions around employment support on robust evidence

Commissioners should make commissioning decisions based on the evidence of what works and of local need, including around the increasing prevalence and impact of hearing loss. One in six people have hearing loss, and despite robust evidence of the benefits of NHS hearing aids, only one in three people who need hearing aids have sought help. Commissioners can use the Action on Hearing Loss population data tool to assess the hearing needs of local populations; with this tool, it is possible to assess the numbers of working age people with hearing loss who may require support or equipment from specialist services, or access to information or advice which would enable them to continue in, or find work.

Recommendation: We call on Clinical Commissioning Groups and local authorities to base commissioning decisions around employment support on local need and robust evidence.

3. Commissioners should use an outcomes-based approach to commissioning and adopt robust monitoring systems

35 Department of Health (2014), Care Act 2014: Statutory Guidance. Available at: https://www.gov.uk/government/publications/care-act-statutory-guidance/care-and-support-statutory-guidance#general-responsibilities-and-universal-services [Accessed 6 January 2017]

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Action on Hearing Loss welcomes the argument in the Green Paper that health and care professionals need to recognise work as a health outcome. Existing frameworks and guidelines across different disabilities have made clear that robust monitoring and analysis of relevant outcomes for disabled people can incentivise health and social care professionals to recognise the wider impacts of their disabilities and the need to support them in an integrated way. This is particularly the case for hearing loss, and we would like to see a wider and more consistent implementation of the relevant guidelines and frameworks. Examples of relevant guidelines and frameworks for people with hearing loss, and how these could be used, are described in the sections below.

Action Plan on Hearing LossSome small steps have already been taken to encourage health professionals and government departments to consider employment as a personal outcome for an individual with hearing loss. In March 2015, NHS England and the Department of Health published the cross-government Action Plan on Hearing Loss, which includes an objective on learning and working well with hearing loss. Objective 5 in the Action Plan on Hearing Loss is “to ensure that people of all ages with hearing loss of all severities are actively supported to participate fully in society, and are not limited in their potential to succeed in education, employment, family and community life, all facets of individual living, and in the pursuit of sport, leisure and other activities.”36 This recognition that hearing loss should not be a barrier to participation in work and society now needs to be recognised in the provision of health and social care services and the setting of health outcomes for patients.

NHS England published a commissioning framework for adult non-complex audiology services in 2016.37 This includes model service specifications, outcomes and indicators. For example, the service specifications set out in the commissioning framework for people with hearing loss includes outcomes for service providers, one of which is, “Access to clear guidance and information for service users and their families about the important role of hearing in maintaining effective communication and active engagement in a range of social and work settings, including advice on the range of support available.”38

Health and social care commissioners should use the commissioning framework for hearing loss services to encourage all service providers from employment, health and social care services to work together to improve outcomes for people with hearing loss and coordinate support, equipment and advice they give to people with hearing loss living in their area.

One of the key performance indicators in the commissioning framework on hearing loss is around reducing barriers and states that patients should experience, “An integrated patient pathway, which facilitates signposting to wider communication/social support services (where appropriate).”39 In audiology, services should be asking people who use the service about the impact of hearing loss on their work, and provide advice on support available in the workplace, such as Access to Work where necessary, or other suitable support, such as lipreading classes or assistive equipment. The same should be the case for other disabilities. However, research conducted by Action on Hearing Loss found that 85% of people with

36 NHS England (2015), Action Plan on Hearing Loss. Available at https://www.england.nhs.uk/wp-content/uploads/2015/03/act-plan-hearing-loss-upd.pdf [Accessed 5 January 2017]37 NHS England (2016), Commissioning Services for People with Hearing Loss: A framework for clinical commissioning groups. Available at: https://www.england.nhs.uk/wp-content/uploads/2016/07/HLCF.pdf [Accessed 5 January 2017]38 NHS England (2016), Service Specifications in the Commissioning Services for People with Hearing Loss: A Framework for Clinical Commissioning Groups. Available at: https://www.england.nhs.uk/wp-content/uploads/2015/03/HLCF-Se rvice-Spec-CP-CR.docx [Accessed 5 January 2017]39 NHS England (2016), Commissioning Services for People with Hearing Loss: A framework for clinical commissioning groups. Available at: https://www.england.nhs.uk/wp-content/uploads/2016/07/HLCF.pdf [Accessed 5 January 2017]

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hearing loss were not told about lipreading classes by their audiologist.40 In addition, in another piece of research from Action on Hearing Loss, only one in ten (10%) respondents said they heard about Access to Work from their audiologist, and only 1% were given information on the scheme from their GP.41 This data indicates that health professionals are not always considering employment outcomes for people with hearing loss, or signposting to appropriate sources of support which can mean that people are able to work. This must change, and commissioners should ensure services monitor outcomes for individuals, which include work outcomes, to ensure that they are providing all the information, equipment and support that people need, including employment support.

Aligning work outcomes and indicators between health and other services is very important for ensuring people’s needs are met. Commissioners should also ensure there are robust monitoring systems in place for collecting service providers’ feedback on how they are ensuring people are supported to remain in work.

Recommendation: We call on commissioners to use an outcomes-based approach to commissioning and adopt robust monitoring systems.

NICE GuidelinesThe National Institute for Health and Care Excellence (NICE) has developed guidance for employers which aims to promote employee wellbeing and improve the way disabilities and long term conditions are managed in the workplace: The draft NICE Healthy workplaces: improving employee mental and physical health and

wellbeing Quality Standard42 states that employee health should be a core organisational priority for businesses and also incorporated into performance measures and job specifications for line managers.

The NICE Workplace health: management practices guideline43 was recently amended to include specific recommendations for improving the health and wellbeing of older employees. The guideline now states that older employees should be provided with appropriate support to stay in work and participate in workforce training.

The NICE Workplace health: support for employees with disabilities and long term conditions guideline44 will also set out how employers should make adjustments and provide other support to make sure people with disabilities and long term condition are able to stay in or return to work.

Recommendation: We call on commissioners to encourage and promote the use of existing, or upcoming NICE guidelines which set out good practice in supporting disabled people or people with health conditions in the workplace.

4. The government and commissioners should incentivise health and social care providers to improve work outcomes

40 Arrowsmith (2016), Managing hearing loss when seeking or in employment, Action on Hearing Loss, London.41 Arrowsmith (2014), Hidden Disadvantage: Why people with hearing loss are still losing out at work, Action on Hearing Loss, London42 NICE (2016) Healthy workplaces: improving employee mental and physical health and wellbeing Quality Standard, GID-QS10014. Available at: https://www.nice.org.uk/guidance/indevelopment/gid-qs10014 43 NICE (2016) Workplace health: management practices, NG13. Available at https://www.nice.org.uk/guidance/ng13 44 NICE (2016) Workplace health: support for employees with disabilities and long term conditions, GID-PHG58. Available at: https://www.nice.org.uk/guidance/indevelopment/gid-phg58

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As well as incorporating work outcomes into plans for health services and ensuring they are monitored, improvement should also be incentivised so that services are as responsive as possible to what people need to be supported to gain and keep employment. The government and commissioners should lay out clear targets for improvement, and there should be mechanisms put in place which encourage these to be reached and to ensure they are reported on.

For example, targets relating to work outcomes should be included in strategic documents and work plans, such as local Health and Wellbeing Strategies and Sustainability and Transformation Plans, and work outcomes should feature as indicators of wellbeing in plans for other projects and pilots, where relevant.

Commissioners can use the formal processes, incentives and sanctions set out in the NHS Standard Contract to set high standards for providers and assure that commissioned services consider work outcomes. This includes Commissioning for Quality and Innovation indicators (CQUINs), and also the Local Quality Requirements and Quality Incentive Scheme. More detail on this is set out in the NHS Standard Contract service conditions for 2017/18 and 2018/19.

Providers across primary and secondary care should include targets relating to improvements in the scope of support offered and improvements in work outcomes in service delivery plans and staff objectives, to ensure that all relevant professionals are aware of the importance of making sure people are able to gain and keep employment and are considering this when supporting patients. In audiology, for example, commissioners could specify that work outcomes need to be measured and include key performance indicators relating to work in service specifications, which would incentivise providers and professionals to ensure patients are supported, such as being given information about assistive equipment, Access to Work, or lipreading classes.

Recommendation: We call on the government and commissioners to incentivise health and social care providers to improve work outcomes.

5. Commissioners should consider the wider impact of health and care commissioning decisions on work outcomes to ensure services achieve good results in health, care and employment for individuals

For people with hearing loss, there are interventions which could enable them to remain in work. If they can access these services, it could prevent them from needing more intensive support from Jobcentre Plus, or health and care services, such as mental health services. As the Green Paper recognises, the right work is good for mental health; however, if a person with hearing loss feels isolated at work as they are struggling to communicate, they may feel unable to stay in a job. People with hearing loss should have access to interventions which can support communication in the workplace, and which mean they can remain in work, or do not take long-term sick leave. We recommend that commissioners consider these wider implications when commissioning services. Two such examples are given below.

Provision of hearing aidsHearing aids are a cost effective treatment that helps people with hearing loss to communicate with other people, manage their own health, access education and stay in work:

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Robust evidence from systematic reviews and Randomised Control Trials (RCTs) shows that hearing aids improve quality of life and are the most effective form of treatment for people with hearing loss.45

Early intervention ensures people get the most benefit46 and in children, the use of hearing amplification is associated with better developmental outcomes, including speech, language and literacy.47

Evidence shows that two hearing aids should be provided for people with hearing loss in both ears.48

Nine out of ten people who use hearing aids benefit from them and use them regularly.49

There is also strong evidence that hearing aids improve overall health and wellbeing and reduce the risk of other health problems, and reduce or delay the need for high cost care:

Hearing aids have been shown to have a positive impact on overall health.50

Research shows that hearing aids reduce the risk of loneliness and depression.51

It noteworthy that the cost, on the NHS, of the pathway for a hearing aid assessment, fitting two hearing aid devices, two devices, follow up, and repairs is just under £400. This is equivalent to around 5 weeks’ Jobseekers’ Allowance (based on Jobseekers’ Allowance for the over 25s).52 We believe that it makes economic sense to provide hearing aids to people in work, where they would benefit from hearing aids in the workplace.

Despite the strong evidence on the benefits of hearing aids, research shows that many more people could benefit from hearing aids than are currently doing so. People wait on average

45 Chisholm et al, 2007. 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. Journal of American Academy of Audiology, 18, 151-183; Mulrow et al, 1992. Sustained benefits of hearing aids. Journal of Speech and Hearing Research, 35 (6), 1402-5; National Council on the Aging, 2000.The consequences of untreated hearing loss in older persons. Head and Neck Nursing, 18 (1), 12-16; Yueh et al, 2001. Randomized trial of amplification strategies. Archives of Otolaryngology - Head & Neck Surgery, 127 (10), 1197-204.46 Davis et al, 2007. Acceptability, benefit and costs of early screening for hearing disability: a study of potential screening tests and models. Health Technology Assessment, 2 (42).47 National Acoustic Labatories (NCL), 2016. The Longitudinal Outcomes of Children with Hearing Impairment Study; papers, presentation and articles. Available at: https://outcomes.nal.gov.au/papers.html Accessed 28th November 201648 Dreschler and Boymans, 1994. Clinical evaluation on the advantages of binaural hearing aid fittings. Audiologische Akustik, 5, 12-23; Kolber and Rosenhall, 2002. Horizontal localization and speech intelligibility. International Journal of Audiology, 41 (7), 395-400; Leeuw and Dreschler, 1991. Advantages of directional hearing and mircophones related to room acoustics. Audiology, 30 (6), 330-344.49 Perez E and Edmonds BA, 2012. A Systematic Review of Studies Measuring and Reporting Hearing Aid Usage in Older Adults since 1999: A Descriptive Summary of Measurement Tools. PLoS ONE 7 (3), e31831; European Hearing Instrument Manufacturers Association (EHIMA), 2015. Eurotrak Survey 201550 Dawes et al, 2015. Hearing aid use and long-term health outcomes. Hearing-aid use and long-term health outcomes: Hearing handicap, mental health, social engagement, cognitive function, physical health, and mortality. International journal of audiology, 54(11), 838-844.51 Acar et al, 2011. Effects of hearing aids on cognitive functions and depressive signs in elderly people. Archives of Gerontology and Geriatrics, 52 (3): 250-2;Pronk et al, 2011.Prospective effects of hearing status on loneliness and depression in older persons: identification of subgroups. International Journal of Audiology, 50 (12), 887-96; Dawes et al, 2015. Hearing Loss and Cognition: The Role of Hearing Aids, Social Isolation and Depression. PLoS ONE, 10 (3): e0119616; National Council on the Aging (2000) The consequences of untreated hearing loss in older persons. Head and Neck Nursing, 18 (1), 12-16.52 Monitor/NHS England (2016), 2016/17 National Tariff Payment System, Monitor, London

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ten years to seek help after they first notice symptoms53 so much more could be done to encourage more people to seek help earlier and get the support and equipment they need to manage their hearing loss at work. For example, health services and employers can work together to ensure that people get regular hearing checks as they get older, are aware of the impacts of hearing loss and how it can be effectively managed, and are encouraged to seek help and are directly referred to local services that can help.

This example highlights that commissioners must think of the impact health service provision can have on a person’s quality of life and employment outcomes.

Classes in developing new communication skillsLipreading classes teach people with hearing loss to recognise lip shapes and patterns and how to use context and facial expressions to help them make sense of conversations. Lipreading classes also provide information and advice on assistive technology and other services that can help people with hearing loss. They also provide an opportunity for people with hearing loss to meet, support each other and share their experiences.

Action on Hearing Loss’ Not Just Lip Service report identified a range of benefits lipreading classes can bring for people with hearing loss, such as:

Improvements in people’s ability to recognise lip shapes and patterns and a better understanding of communication skills to help people understand speech.

Increased confidence and assertiveness in talking to others about their hearing loss and asking them to change their behaviour to facilitate good communication.

Feeling less negative about their hearing loss and being able to manage their hearing loss better in social situations and in the workplace.54

Research suggests that many more lipreading classes are needed to meet the growing level of need. Research in 2010 shows that there are approximately 450 lipreading classes in England and Wales, enough for only 5,000 people.55 Some are not free, few are put on outside working hours, and lipreading-teacher-training opportunities are limited.

Helping to manage hearing loss when seeking or in employment

Action on Hearing Loss was funded by the Department of Business, Innovation and Skills (BIS) to test out innovative ways of delivering lipreading classes for working age people with hearing loss. The project trialled a series of support packages for people with hearing loss, including online resources on lipreading and hearing loss, drop in sessions and the delivery of information via textphone and email. The project found that online resources can improve access to information on lipreading and face-to-face interactions through workshops have an important role to play in encouraging people to seek help for their hearing loss. To find out more, please visit https://www.actiononhearingloss.org.uk/supporting-you/policy-research-and-influencing/research/managing-hearing-loss-when-seeking-or-in-employment.aspx

The example of lipreading classes for people with hearing loss clearly highlights that commissioners must think beyond immediate health and social care needs and solutions when commissioning services. The provision of broader information and support which help

53 Davis et al, 2007. Acceptability, benefit and costs of early screening for hearing disability: a study of potential screening tests and models. Health Technology Assessment, 2 (42).54 Ringham L, 2013. Not just lip service. Available from: www.actiononhearingloss.org.uk/notjustlipservice [Accessed 6 January 2017]55 RNID, 2010. Paying lip service. London: RNID.

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manage health conditions, such as lipreading classes, also offer opportunities for peer support, which can be important when looking for work.

Recommendation: We call on commissioners to consider the wider impact of health and care commissioning decisions on work outcomes to ensure services achieve good results in health, care and employment for individuals.

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Further information

Action on Hearing Loss (2015), Sound advice for employers and staff who have hearing loss, Action on Hearing Loss Scotland, Glasgow

Action on Hearing Loss (2015), Hearing Matters: Why urgent action is needed on deafness, tinnitus and hearing loss across the UK, Action on Hearing Loss, London

Action on Hearing Loss (2016), Guide to getting help from the Jobcentre – guide to Jobcentres, Action on Hearing Loss, London

Action on Hearing Loss (2017), Working for Change: Increasing confidence in employing people with hearing loss – A guide for employers. Action on Hearing Loss, London

Arrowsmith (2014), Hidden Disadvantage: Why people with hearing loss are still losing out at work. Action on Hearing Loss, London

Arrowsmith (2016), Managing hearing loss when seeking or in employment, Action on Hearing Loss, London

Cook (2017), Working for Change: Improving attitudes to hearing loss in the workplace. Action on Hearing Loss, London

NHS England (2015), Action Plan on Hearing Loss, NHS England, London

NHS England (2016), Commissioning Services for People with Hearing Loss: A framework for clinical commissioning groups, NHS England, London

NHS England (2016), Service Specifications in the Commissioning Services for People with Hearing Loss: A Framework for Clinical Commissioning Groups, NHS England, London

Contact details

For further information, please contact:Laura Cook, Senior Research and Policy OfficerTelephone: 020 7296 8229Email: laura.cook@hearingloss.org.uk

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