Best practice for consultations with patients with additional speech and hearing needs

Hearing loss is a prevalent public health issue. The Royal College of Speech and Language Therapists (RCSLT) estimates that nearly 20% of the population experiences communication difficulties at some point in their lives^​1​. Data from the Royal National Institute for Deaf People (RNID), published in 2024, revealed that over 18 million adults in the UK are affected by hearing loss in some capacity — 1.2 million of which experience severe hearing loss and are unable to hear most conversational speech^​2​. Age is a significant factor in developing hearing loss, with 50% of those aged over 55 years and 80% of those aged over 70 years affected^​2​. 

If communication is not adapted for patients with additional speech and hearing needs, it can negatively affect their understanding of and involvement in their care^​3​.

Types of speech impairment, hearing loss and the impact on communication

Speech impairments range from fluency disorders (e.g. stuttering) to vocal disorders (e.g. laryngitis) and articulation disorders, which can affect communication in unique ways. For more information on the different types of speech impairment, see Table 1^​4–8​.

Patients with communication challenges related to speech are likely to benefit from assessment by a speech and language therapist. They can review the patient’s “current, and likely future, ability to communicate, including their ability to understand, express themselves, retain and recall information, and reason”^​9​.

Hearing loss can be categorised into conductive, sensorineural or mixed hearing loss^​10​. These types of hearing loss are usually linked to where in the hearing pathway there is damage, or an issue that is preventing sound from getting to the brain. Whether hearing loss is conductive or sensorineural, it can have wide-ranging impacts, such as struggling to hear conversations, misunderstanding what others say, difficulty to hear over the phone and fatigue^​11,12​. 

It is also important for pharmacists to recognise Deaf culture (Box 1) to ensure the delivery of effective patient care. Access to BSL interpreters is a requirement, and making sure information is relayed clearly and effectively will ultimately support better patient outcomes.

Standards and guidance

There is no single guideline for communicating with patients who have additional speech and hearing needs. The National Institute for Health and Care Excellence (NICE) provides general advice for ensuring a good experience for adult NHS users^​15​. However, the NHS^​16​ offers specific information on communication difficulties. Charities such as RNID^​17​ and professional bodies such as RCSLT^​3​ also provide practical information. The best source of guidance for an individual patient is the patient themselves and their care records, which should detail communication preferences^​3​.

Ethical and legal considerations

When having consultations with patients who have speech or hearing considerations, pharmacists must adhere to ethical and legal standards to ensure effective communication. The Equality Act 2010 mandates reasonable adjustments, such as sign language interpreters, written materials or assistive listening devices^​18​. This aligns with the Accessible Information Standard, which is a legal requirement for NHS providers to ensure patients receive information in understandable formats and necessary communication support^​19​. The Health and Social Care Act 2012 requires involvement of patients in care decisions, which is achievable only through effective communication^​20​. The General Pharmaceutical Council (GPhC) standards emphasise person-centred care and effective communication^​21​. 

Pharmacists must ensure that their communication methods are adapted to meet the needs of patients with speech and hearing concerns, which upholds the principles of person-centred care and professional integrity. Failure to do so can lead to feelings of isolation and mistrust, ultimately compromising patient care. Failure to comply can lead to isolation, mistrust and compromised care, with significant penalties for non-compliance.

Some patients with speech needs may also have cognitive difficulties, such as dementia, affecting their decision-making capacity^​9​. Others, such as those with motor neurone disease, may have decision-making capacity but struggle to communicate without support^​9​. Misinterpreting communication needs as a lack of capacity can lead to patients being wrongly labelled as incapable^​9​. Some patients may have a relative or other designated person with legal authority to make decisions for them via a lasting power of attorney^​22​. The power of attorney should only be used, however, when the patient is unable to make the decision. It should not be used to avoid adjusting communication methods to enable the patient to make their own decisions.

Best practice for communication in consultations

Patients have different needs, and many know what works best for them. Ask patients what will assist communication or, in hospital or care-home environments, check the patient notes for communication preferences^​15,17​. The basic principles of good communication can help in all interactions^​16,23​: 

• Using clear, simple and unambiguous language;
• Speaking slowly and clearly;
• Using body language and gestures to support verbal communication; however, be aware that these may not be understood by all;
• Giving the person time to respond and express their needs. 

If the speech difficulties are associated with autism, there can be some additional considerations, such as using more direct language and being mindful of social interaction preferences^​24​.

Where possible, reduce distractions and background noise to help focus communication. This could mean moving to a private area or turning off music in waiting rooms^{​15,17,25​}. Give your full attention to the patient, which can help you identify whether your communication is effective. In addition, ask questions to clarify understanding and consider alternate phrasing or wording if information is not being understood. 

For patients who can lip read, position yourself so that they can see your face clearly, speak normally and do not exaggerate lip movements^​17​. For telephone consultations, first check if the patient needs time to adjust their hearing aid or assistive devices, then speak clearly and do not cover your mouth^​17​. Depending on the environment and situation, reinforce verbal communication with written information, such as text on device screens, pen and paper or whiteboards^​17​. Some video conferencing systems have live captioning that can assist with remote communication.

How to support communication with those with additional speech and hearing needs

Total communication is a “process that ensures that all forms of verbal and non-verbal communication are recognised, valued and actively promoted within an individual’s environment”^​23​. Going beyond verbalisation, gesture, body language, signing and facial expression, total communication includes objects of reference, photographs, drawings, symbols, written words and technology^​23​. An overview of some methods is given below.

If a loop system is available for use in the clinical area, a sign should be displayed at the patient counter to indicate its availability, and staff should be trained on its use^​15,25​. Those with hearing aids can directly connect to a loop system via a setting on their hearing aid to amplify the sound from the loop microphone^​26​. Patients may benefit from being prompted about using this setting. Figure 1 shows a traditional loop system, but portable systems are also available.

Figure 1: A loop hearing system

Adapted from hearinglink.org

Personal listening devices amplify sound for the user and typically connect to a user’s hearing aid via neck loop, ear hooks or Bluetooth^​26​. A speech-to-text mobile phone application can assist when giving information and can allow the patient to keep a transcript to refer back to^​27​. 

Augmentative and alternative communication (AAC) devices can include anything from picture books to personalised technology and are used by patients with complex needs who struggle to communicate by speaking. The Picture Exchange Communication System uses pictures and symbols printed on cards or in a ‘communication book’ that is made personal to them, with items of relevance to them and their life, see Figure 2 ^​28​.

Figure 2: Example of a communication book

The Pharmaceutical Journal

Electronic AACs include apps and software on mobile phones, tablets and devices that give a voice output from pressing buttons or using eye tracking^​28​.

Patient representatives can provide valuable information on how a patient best communicates. If communication aids are unavailable, patients may consent to relatives assisting with information and decision-making, such as acting as sign-language interpreters or guides. 

Sign-language interpreters are available in inpatient settings to assist with communication. They are regulated by the National Registers of Communication Professionals working with Deaf and Deafblind People^​29​ or the Scottish Association of Sign Language Interpreters^​30​. Sign-language interpreters also hold enhanced disclosure certificates, adhere to their regulator’s code, respect patient confidentiality and remain impartial^​31​. Patients can book interpreters for appointments through services such as Action Deafness^​32​ or access on-demand services through Scope^​33​. Hospital trusts can also book sign-language interpreters for appointments, if given notice by patients. Community pharmacists could ask if the patient would find it helpful to contact an on-demand service prior to any consultations, if there are no arrangements for support from their local health authority.

Referral flags

Hearing difficulties can have reversible causes. NICE suggests that for adult patients either presenting for the first time with hearing difficulties or for whom there is a suspicion of hearing difficulties, impacted ear wax and acute infection should be excluded before the patient is referred for an audiological assessment^​25​. Urgent referral is advised for those with sudden or rapid onset of hearing loss^​25​ as follows:

• Refer immediately to an ear, nose and throat service or an emergency department if hearing loss developed suddenly over a period of three days or less within the past 30 days;
• Refer urgently to an ear, nose and throat or audiovestibular medicine service, which should be seen within two weeks, if hearing loss developed suddenly over a period of three days or less and occurred more than 30 days ago, or if the hearing loss worsened rapidly over a period of 4–90 days.

NICE guidance, published in 2018, gives further referral criteria for hearing loss that is associated with additional signs and symptoms (e.g. stroke symptoms; resistant infection associated with discharge in immunocompromised patients; unresolved or recurrent vertigo; persistent tinnitus that is unilateral, pulsatile, has significantly changed in nature or is causing distress; fluctuating hearing loss not associated with an upper respiratory tract infection)^​25​. Urgent referrals to these services can be made by a GP surgery or through NHS 111^​11​. 

Although high-street audiology services can assist in some assessment of hearing loss, they cannot always directly refer to the required service and findings need to be presented to a GP or 111 for a referral to be made^​34​. There is regional variation in the arrangements for direct referral to audiology services^​34​.

Conclusion

Pharmacists should adapt their communication styles to support patients with hearing or speech needs. This involves using various methods, such as writing, visual aids or assistive technology, tailored to each patient. Understanding the purpose behind the patient’s communication — whether seeking clarification, expressing concerns or discussing medication — is crucial. By allowing sufficient time and approaching interactions with patience and empathy, pharmacists can ensure patients feel heard and supported. Adapting communication strategies enhances patient experience, improves health outcomes, fosters trust and empowers individuals to manage their health.