# Global Audiology/Europe/Isle of Man

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# General Information

The Isle of Man, also known simply as "Mann," is a self-governing Crown dependency in the Irish Sea between the islands of Great Britain and Ireland. The head of state is Queen Elizabeth II, who holds the title of Lord of Mann and is represented by a Lieutenant Governor. Foreign relations and defense are the responsibility of the British Government.
The island has been inhabited since before 6500 BC. The Gaelic cultural influence began in the 5th century, and the Manx language, a branch of the Gaelic languages, emerged. In 627, Northumbria conquered the Isle of Man along with most of Mercia. In the 9th century, Norsemen established the Kingdom of the Isles. Magnus III, King of Norway, was also known as King of Mann and the Isles between 1099 and 1103. In 1266, the island became part of Scotland under the Treaty of Perth after being ruled by Norway. After a period of alternating rule by the kings of Scotland and England, the island came under the feudal lordship of the English Crown in 1399. The lordship revested in the British Crown in 1765, but the island never became part of the Kingdom of Great Britain or its successor, the United Kingdom; it retained its status as an internally self-governing Crown dependency.
The Isle of Man is located in the middle of the northern Irish Sea, almost equidistant from England, Northern Ireland, Scotland (closest), and Wales (farthest). It is 52 kilometers (32 mi) long and, at its widest point, 22 kilometers (14 mi) wide. It has an area of around 572 square kilometers (221 square miles). Besides the island of Mann itself, the political unit of the Isle of Man includes some nearby small islands: the seasonally inhabited Calf of Man; Chicken Rock, on which stands an unmanned lighthouse; St. Patrick’s Isle; and St Michael’s Isle. The last two of these are connected to the main island by permanent roads or causeways.
At the 2011 census, the Isle of Man was home to 84,497 people, of whom 27,938 resided in the island’s capital, Douglas and 9,273 in the adjoining village of Onchan. The population rose by 5.5% between the 2006 and 2011 censuses. By country of birth, those born in the Isle of Man were the largest group (48.1%), while those born in the United Kingdom were the next largest group at 42.2% (35.9% in England, 3.2% in Scotland, 2% in Northern Ireland, and 1.1% in Wales), 1.9% in the Republic of Ireland, and 0.2% in the Channel Islands. The remaining 7.5% were born elsewhere in the world, with 2.4% coming from EU countries (other than the UK and Ireland). The census also reported 1,823 people who claim knowledge of the Manx language.
The United Kingdom is responsible for the island’s defense and, ultimately, for good governance and representing the island in international forums, while the island’s own parliament and government have competence over all domestic matters.
The island’s parliament, Tynwald, is claimed to have been in continuous existence since 979 or earlier, purportedly making it the oldest continuously governing body in the world, though evidence supports a much later date. Tynwald is a bicameral or tricameral legislature, comprising the House of Keys (directly elected by universal suffrage with a voting age of 16 years) and the Legislative Council (consisting of indirectly elected and ex-officio members). These two bodies meet in joint session as Tynwald Court.
The executive branch of government is the Council of Ministers, which is composed of members of Tynwald. It is headed by the Chief Minister, currently (2016) Howard Quayle MHK. Vice-regal functions of the Head of State are performed by a Lieutenant Governor.
Health and social care on the Isle of Man are the responsibility of the Department of Health and Social Care (Isle of Man). Healthcare is free for residents and visitors from the UK.
Offshore banking, manufacturing, and tourism form key sectors of the economy of the Isle of Man, a British Crown dependency in the Irish Sea.
The government’s policy of offering incentives to high-technology companies and financial institutions to locate on the island has expanded employment opportunities in high-income industries. As a result, agriculture and fishing, once the mainstays of the economy, now make declining contributions to the Island’s Gross Domestic Product(GDP). Banking and other services now contribute the great bulk of GDP. The stability of the Government and openness for business make the Isle of Man an attractive alternative jurisdiction (DAW Index ranked 3).
Trade is mostly with the United Kingdom. The Isle of Man has free access to European Union markets for goods but only restricted access for services, people, or financial products.
The Isle of Man is a low-tax economy with no capital gains tax, wealth tax, stamp duty, death duty, or inheritance tax, and income tax rates of 10% and 20%; corporation tax is 0%.
The culture of the Isle of Man is influenced by its Celtic and, to a lesser extent, its Norse origins, though its close proximity to the United Kingdom, popularity as a UK tourist destination, and recent mass immigration by British migrant workers have meant that British influence has been dominant since the Revestment period. Recent revival campaigns have attempted to preserve the surviving vestiges of Manx culture after a long period of Anglicization, and significant interest in the Manx language, history, and musical tradition has been the result.

# Incidence and Prevalence of Hearing Loss

Hearing loss affects over 10 million adults and 45,000 children in the UK. This equates to 1 in 6 of the population. By 2031, it is estimated that 14.5 million people in the UK, or approximately 1 in 5 of the population, will have a hearing loss. 1 The most common form of hearing loss is age-related, and the prevalence of deafness approximately doubles with every decade of life (Health, NHS England and Department of, 2015)
The incidence and prevalence of hearing loss on the Isle of Man mirror those of the UK (1 in 6). This means that using the 2011 population statistic of 84,497, there are approximately 14,082 people with hearing loss on the Isle of Man.

# Information About Audiology
### History

The Isle of Man has a government- or public-funded NHS service similar to that of the UK; however, the Isle of Man Health Service is not part of the UK NHS service. The health service on the island offers many of the same “free at the point of delivery” healthcare services as in the UK, although some specialist areas of medicine require off-island referral to specialist centers.
The government provides free, fully comprehensive diagnostic audiology, balance, and hearing aid services to registered residents on the island as part of its health service, which is paid for through taxation and national health insurance contributions. Any person of any age can access audiology services via GP referral, self-referral, or referral via the Ear, Nose, and Throat Department.
There are also five high-street hearing aid dispensers located around the island.
NHS Audiology availability on the island began at the same time as the UK, however, it was very rudimentary and basic until the mid-1980s, with just one room and one audiologist in addition to school screening. This service covered the entire population, including adults and children.
In 1985, an extra audiologist was recruited, and this single room, two staff member set-up continued until the mid-1990s, covering again both adults and children. In the late 1990s, the service split into an adult service and a children’s service, both based at the hospital but in different areas. Targeted neonatal screening also began in the special care baby unit.
In 2005, the island built a new hospital, and the adult service was relocated to a new, purpose-built, larger department with three staff. The children’s audiology clinic remained at the old hospital under different management, while the newborn screening service also relocated to the new hospital. This had the effect of fragmenting the service.
In 2005, children’s audiology began the provision of digital hearing aids, while the adult population waited a further 2 years for this to be implemented.
The main reason for historically low audiology staff numbers was that, until 2011, there was a cap on the number of people the government could employ due to economic reasons. This cap, however, was released in 2011, allowing the employment of a significant number of clinical, administrative, and screening personnel.
This also gives the opportunity to completely overhaul and reorganize the structure of audiology services, defragment and join up services, and thoroughly modernize the Islands audiology services. This was achieved and resulted in an award for the huge effort it took to achieve our objective.
Today, we have a modern audiology service with 10 staff, many with extended roles, using the latest equipment and prescribing top-quality digital hearing aids. The service continues to grow and innovate, which indeed resulted in a further award nomination in 2017.

### Education

The Isle of Man has no institutions offering audiology training programs. Potential students are required to attend a UK institution and follow a UK approved program of training,
There are three different entry levels into Audiology at the moment. (British Academy of Audiology, 2017)

#### Foundation degree / Diploma in Higher Education in Hearing Aid Audiology (undergraduate diploma)

This type of qualification involves working as a trainee while completing the course. Graduates are eligible to register to work as a hearing aid dispenser with the HCPC on completion. This course requires employment in the right healthcare context with access to patients or clients, as well as supervision from a registered audiologist or hearing aid dispenser.

#### BSc (Hons) Healthcare Science (Practitioner Training Program) (Audiology)

This course is offered at several universities in the UK. At the time of writing, these include:
* University of Southampton
* University of Swansea
* University of Manchester
* Aston University
* Middlesex University
* University of Leeds
* De Montfort University
* University of Sunderland
* Anglia Ruskin University

#### Postgraduate MSc Level

Pre-registration level.
At the time of writing, the courses below offer graduates from related honors degrees the opportunity to study Audiology.
* MSc Clinical Science (Practitioner Training Program)
* Aston University: MSc Clinical Science (Neurosensory Sciences)
* University of Birmingham: MSc Clinical Science (Blood Sciences)
* King’s College London: MSc Clinical Science (Medical Physics), MSc Clinical Science (Clinical Engineering)
* University of Liverpool: MSc Clinical Science (Medical Physics)
There are other MSc Audiology pre-registration options available as well at:
* Queen Margaret University
* University College London
* University of Manchester
* University of Southampton

### Audiology Practice: Public and Private

NHS audiology and hearing aids are provided free of charge to all residents. Services are paid for by taxation and National Insurance Contributions.
Adults can access services by general practitioner referral, referral from the Ear Nose and Throat Department and, subject to certain criteria, by self-referral. At no point in the treatment pathway does the service user pay for any NHS provision except for lost/misplaced hearing aids, for which there is a small charge.
The service provides the latest digital hearing aids from the current NHS portfolio of available hearing aids. The patient cannot choose type, design, color, etc.
Children are referred from the Newborn Hearing Screening Service, school screenings, the ENT Department, and general practitioners. Again, services are free, and children are issued hearing aids from the current NHS portfolio of pediatric digital hearing aids. Children are exempt from lost hearing aid charges. Children can choose colors for their hearing aids but again, do not choose design, model etc.
The main differences between the public and private sectors on the island are:
* Choice: In the private sector, the patient can choose from a range of hearing aids whereas in the NHS they cannot
* Waiting times: Patients visiting the private sector are typically seen and fitted more quickly than via the NHS.
The private sector is, however, notoriously expensive, with hearing aid costs running into thousands of Pounds; hence, the vast majority of hearing aid users on the island acquire their aids from the NHS as opposed to the private sector.

### Services Offered by Physicians
#### Otorhinolaryingologist

Otolaryngologists on the Isle of Man offer a wide selection of ear-related services. Services may include the diagnosis and management of acute and chronic pathologies, balance disorders, traumatic injuries, congenital malformations; and surgical management of pathologies and tumors.
They liaise closely with specialist centers in the UK, referring patients to these centers when more specialized treatment is required, such as cochlear implantation, BAHA surgery, and more specialized neuro-otology.

#### Pediatrician

The children’s audiology clinic is supported part time by a pediatrician who will deal with complex or special needs children requiring long-term audiological care, and they liaise closely with other specialties such as speech and language therapy, pediatric medicine, occupational therapy, and children’s hospitals based in the UK.

#### Audiological Services

Widely available
* Screening and diagnostic audiometry including full range of speech/Speech in noise tests
* Screening / diagnostic tympanometry
* Screening / diagnostic Stapedial reflexes
* Screening / Diagnostic ABR (Threshold and Neurological)
* TE and DP OAE
* Aural (re)habilitation / Digital hearing aids
* Cerumen Management, microsuction and foreign body removal
* Tinnitus and Hyperacusis assessment and counselling / Tinnitus retraining therapy
* Vestibular and balance assessment including Video Head Impulse Test
* Vestibular rehabilitation (In development)
* Ward and Domiciliary visits
* VRA/BOA/ Distraction and performance tests
* Hearing aid repair clinics
* Swim plug and noise protection Provision
* Grommet Review Clinics
* Direct and self-referrals
* Education / training in Audiology / Deaf Awareness

#### Not currently available (patients are referred to specialist centers in the UK)

* BAHA fitting or adjustment
* Cochlear implant fitting or adjustment

### Professionals

The table below shows the professionals who regularly interact with individuals with hearing loss. The ratios are estimates calculated based on the population of 84,497.
| Professionals | Approximate Number | Ratio to the Population |
| Audiologists/Scientists | 5 | 1:16,899 |
| Otolaryngologists | 2 | 1:42,248 |
| Nurse Practitioner | 1 | 1:84,497 |
| Speech-Language Therapists | 6 | 1:14,082 |
| Teachers of the Deaf | 5 | 1:16,899 |
| Hearing Aid Dispensers | 6 | 1:14,082 |
| Hear2Help Volunteers | 5 | 1:16,899 |

### Professional and Regulatory Bodies
#### Professional Organizations

* American Academy of Audiology
* British Academy of Audiology
* British Society of Audiology
* IDA Institute
The above organizations play a significant role on the island. Given our remote and isolated location, it is essential that audiologists are kept up-to-date on developments within the profession. Having access to the professional bodies' websites, Facebook, and other media allows us to remain informed and up-to-date on such developments.

#### Regulatory Bodies

* Health and Care Professions Council (HCPC)
* Academy of Health Care Science (AHCS)
* Registration Council for Clinical Physiologists (RCCP)
All audiologists in the Isle of Man have to be registered with at least one of the above regulatory bodies, maintain a CPD portfolio subject to the regulatory body's requirements, and abide by its Code of Conduct.

### Scope of Practice and Licensing

The table below is an accurate representation of what services audiologists can provide in relation to their levels of experience and qualification on the island. This largely mirrors the UK Audiology.
NHS clinical audiologists do not require a license to dispense hearing aids although they are expected to be registered with a regulatory body. The same applies to high street hearing aid dispensers.

# Audiology Charities

There are several philanthropic organizations to assist families and individuals with hearing loss. A few are listed below:
* Manx Deaf Society
* Manx Blind Welfare
* British Tinnitus Association
* Meniere’s Society
* Vestibular Disorders Association
* Action on Hearing Loss
* Veterans Agency / War Pensioners)
* National Deaf Children’s Society
* Hearing Link / Hearing Concern
* Cochlear Implant Users Association
* British Acoustic Neuroma Association
* Red Cross Crisis Befriending Team
* Age Concern

# Challenges, Opportunities and Notes

===Challenges === Currently, our main barrier is our aging population in comparison to our resources and facilities. More and more people are accessing audiology services, and it is predicted the service will be operating at capacity within the next few years without scope for further resources.
The service, where time permits, will take part in research. Since 2015, we have been actively involved in research with GOSHAWK, a company that has designed a solution to the difficulties faced by hearing-impaired people using mobile phones. Mobile phone signals are designed for people with normal hearing, and GOSHAWK, along with leading academics, have invented a platform that amplifies the incoming phone signal to a patient’s hearing thresholds. They chose the Isle of Man (and our service) to test this product due to its requirement for a 4G telecoms network, which at the time of testing, only the Isle of Man had a robust 4G network up and running.

# References

* British Academy of Audiology. (2017, 11 23). What is Audiology.
* Health, NHS England and Department of. (2015). Action Plan on Hearing Loss. London: NHS England.
* Isle of Man. (2018, March 16). In Wikipedia.
| | Contributor to the original text |
| Stephen D. Griffiths | Contributor to the original text |