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Speech Pathology Australia’s Submission to the

Productivity Commission

National Disability Insurance Scheme Costs: Issues Paper

31 March 2017

The Speech Pathology Association of Australia Limited ABN 17 008 393 440

Productivity Commission
GPO Box 1428
Barton ACT 2600

Dear Productivity Commission

Speech Pathology Australia welcomes the opportunity to provide comment to the Productivity Commission (the Commission) for the Inquiry into National Disability Insurance Scheme (NDIS) Costs.

Speech Pathology Australia is the national peak body for speech pathologists in Australia, representing more than 7500 members. Speech pathologists are university trained allied health professionals with expertise in the assessment and treatment of communication and swallowing disabilities. A significant proportion of speech pathologists have historically worked in the disability sector where they provide a unique set of skills and expertise to people with communication and swallowing disabilities.

Over the past four years, there has been a significant transition of the speech pathology workforce in the disability sector, from government or large non-government disability organisations to small scale/sole private practice. Whilst some speech pathologists continue to work within large disability organisations, most now work at least part of their time in private practice. Private speech pathologists usually also provide services to non-NDIS clients across health, education, aged care and fee-for-service arrangements. Thus, NDIS supports may be only one component of their business services.

The recent Intermediate Report of the Evaluation of the NDIS highlights the considerable unmet demand for speech pathology services within the NDIS and the challenges faced by small-scale private providers. “Persistent shortages are identified in speech pathology, occupational therapy and psychology”i.

As the peak body regulating and representing speech pathologists, we have drawn together an array of qualitative and quantitative evidence from our members working with NDIS Participants gathered over the past 24 months from all states and territories of Australia – including targeted surveys, national surveys of members, reports and focused workshops with speech pathologists in the various NDIS trial sites. We have not included in our submission information drawn from our Western Australian (WA) members given the terms of reference for the Inquiry specifically exclude WA.

It is noted that the Commission acknowledges that it is difficult to separate out transitional issues from more structural issues that could affect the financial viability of the NDIS. It is understood that the primary focus of the Inquiry is on the structural issues associated with the NDIS. Whilst we have provided evidence about these structural issues in our submission, it is critical to understand that the significant problems associated with the Trials and transition have impacted to such an extent on the speech pathology workforce that they have acted as a disincentive for speech pathologists to enter the NDIS market at least in the short to medium terms.

Speech pathologists in private practice are now extremely reluctant to register as NDIS providers lest it compromise the financial viability of their small private practices. This is at odds with the views of most speech pathologists who see the immense potential value the NDIS has for people with disability.

We hope that our advice and evidence offers the Commission an understanding of the challenges facing the speech pathology workforce within the NDIS. The experiences and advice of SPs working in the NDIS workforce has largely been overlooked to date by the National Disability Insurance Agency (NDIA) – we believe this has led to the current situation of an undersupply of speech pathology services and the prevailing reluctance of our members to enter the NDIS provider market.

We offer recommendations on how the speech pathology NDIS provider market might be promoted and supported to ensure the medium to long-term sustainability of this essential component of the provider market. As the peak body representing the speech pathology profession, we are eager to constructively engage with the NDIA and governments to support the long-term viability of the NDIS.

Yours faithfully

Gaenor Dixon, National President

Table of Contents

Speech Pathology Australia’s Submission to the Productivity Commission’s Inquiry into the NDIS Costs . 5

• About Speech Pathology Australia

• About communication and swallowing disability

• About Complex Communication Needs

• About NDIS Participants with communication disability

• About the Speech Pathology Workforce and the NDIS

• Scheme Costs

• Cost drivers

• Utilisation rates for plans

• Scheme Boundaries

• To what extent have the differences in eligibility criteria in the NDIS and what was proposed by the Productivity Commission affected participant numbers and/or costs in the NDIS?

• What impact will the ECEI approach have on the number of children entering the scheme and the long-term costs of the NDIS?

• Intersection with Mainstream Services

• Is the current split between services agreed to be provided by the NDIS and those provided by mainstream services efficient and sufficiently clear?

• Is there any evidence of cost-shifting, duplication of services or service gaps between the NDIS and mainstream services or scope creep in relation to services provided within the NDIS?

• Is the range and type of services proposed to be funded under the ILC program consistent with the goals of the program and the NDIS more generally?

• Planning Processes

• Is the planning process valid, cost effective, reliable, clear and accessible?

• Assessment Tools

• Support Packages

• To what extent does the NDIA’s budget-based approach to planning create clear and effective criteria for determining participant supports?

• Market Readiness

• What factors affect the supply and demand for disability care and support workers including allied health professionals?

• What scope is there to expand the disability care and support workforce by transitioning part-time or casual workers to full-time positions?

• What role might technological improvements play in making care provision by the workforce more efficient?

• What are the advantages and disadvantages of making greater use of skilled migration to meet workforce targets?

• Are prices set by the NDIA at an efficient level?

• Recommendations

• References cited in this submission

Speech Pathology Australia’s Submission to the Productivity Commission’s Inquiry into the NDIS Costs

Speech Pathology Australia welcomes the opportunity to provide comment to the Productivity Commission (the Commission) for the Inquiry into the National Disability Insurance Scheme (NDIS) Costs. We have structured our feedback in response to relevant key questions asked in the Issues Paper and we conclude with recommendations that we hope the Commission will consider useful for the next stage of the Inquiry. We preface our remarks with information on communication and swallowing disability and the role of speech pathologists in improving outcomes for people with disability.

About Speech Pathology Australia

Speech pathologists are the university trained allied health professionals who specialise in treating speech, language, communication and swallowing problems. Speech pathologists work across the life span with infants, children, adolescents, adults and the elderly with communication and swallowing problems.

Speech pathologists provide services in the acute care (hospital), sub-acute care, rehabilitation and primary care sector (including community health, general practice and mental health services) as well as within other sectors such as disability, residential and community based aged care, education, juvenile justice, prisons and community settings.

Speech pathologists work in both publicly and privately funded services. In recent years, there has been a significant shift in the location of service delivery from a previous majority government-employed to the private sector including private practice, not-for-profit and non-government organisations.

Speech pathologists undertake a four-year undergraduate degree or a two-year graduate entry Masters degree to be qualified as speech pathologists. To be eligible to graduate students must have achieved the minimum skills, knowledge base and professional standards described in the Competency Based Occupational Standards (CBOS) Entry Level (2011)ii.

There are no formally credentialed areas of specialty within the speech pathology profession in Australia. New graduate speech pathologists enter the workforce with a minimum level of skills that equip then to commence working with the full range of ages and speech pathology client groups. It is recognised within the profession, however, that there are a number of client groups (e.g., those with multiple disabilities, or clients with complex communication needs) and a number of speech pathology services (e.g., assessment and prescription of Augmentative and Alternative Communication (AAC) for clients with complex communication needs or mealtime assessment for clients with multiple disabilities) that require further skills and competencies than what is gained in entry-level training degrees.

Speech Pathology Australia is the national peak body for speech pathologists in Australia, representing more than 7500 members. Speech pathology is a self-regulated health profession through Certified Practising Speech Pathologist (CPSP) membership of Speech Pathology Australia. Speech pathologists are not required to also be registered through the National Registration and Accreditation Scheme.

To be eligible for CPSP membership of Speech Pathology Australia, a speech pathologist is required to demonstrate they have completed an approved university course, they have recency of practice and have undertaken a minimum level of professional development in the previous 12 months. New graduate speech pathologists who agree to meet specified requirements are afforded provisional CPSP status.

The CPSP credential is recognised as a requirement for approved provider status under a range of government funding programs including Medicare, all private health insurance providers, some Commonwealth aged care funding, Department of Veteran Affairs (DVA) funding, Betterstart for Children with Disability (BetterStart) and Helping Children with Autism (HCWA) programs. At present, the CPSP

credential is required by some states and territories as a requirement for NDIS provider registration (to be discussed at length later in this submission).

As the national body regulating the quality and safety of speech pathology practice in Australia, Speech Pathology Australia is also well placed to monitor and progress workforce developments and initiatives. Speech Pathology Australia accredits the 25 university entry-level training courses for speech pathologists in Australia, evaluates requests for recognition of overseas qualifications, administers the continuing professional development (CPD) program for the profession and provides mentoring and support programs to the significant cohort of new graduate/early career speech pathologists currently within the speech pathology workforce. The Association also manages the formal complaints process for the profession and can, if necessary can place sanctions on practice for any member who is demonstrated to contravene the profession’s Code of Ethics. In the absence of any current government investment in speech pathology workforce initiatives, Speech Pathology Australia is responsible for all large scale workforce initiatives for the profession.

About communication and swallowing disability

Some people have problems with their speech, language, communication and swallowing that are permanent and impact on their functioning in everyday life.

Difficulties in speech, language, fluency, voice, social communication and swallowing can occur in isolation or the person may have difficulties in more than one area. Communication and swallowing difficulties can arise from a range of conditions that may be present from birth (e.g. Down Syndrome or Autism Spectrum Disorder), emerge during early childhood (e.g., stuttering, severe speech sound disorder), or during adult years (e.g., traumatic brain injury, stroke and head/neck cancers, neurodegenerative disorders such as motor neurone disease) or be present in the elderly (e.g., dementia, Alzheimer’s disease, Parkinson’s disease).

Communication disorders encompass difficulties with speech (producing spoken language), understanding or using language (including oral language, reading, spelling and written expression), voice, fluency (stuttering), and pragmatics (the social use of language), or a combination of areas. There is very strong international and Australian evidence that communication disorders negatively affect an individual’s academic participation and achievement, employment opportunities, mental health, social participation, ability to develop relationships, and overall quality of life.

Swallowing disorders affect the ability to safely swallow food or liquids and can lead to medical complications including chest infections/pneumonia and choking. Swallowing difficulties impact on a person’s health and wellbeing and can lead to social isolation, poor nutrition and medical complications (including choking and death).

People with communication and swallowing disability span the entire age range and the nature of their difficulties impacts on most areas of life. These people frequently require interventions and supports from multiple areas of public service (including health, the disability and education sectors and mental health services). The clinical protocols for speech pathology treatment are evidence based and backed by strong multidisciplinary scientific evidence for efficacy. Clinical protocols for treatment (in terms of session duration, frequency of care, intensity etc.) differ depending on the clinical presentation and diagnosis – usually speech pathology care is aimed at maximising function for that person.

A communication disability can be mild, moderate or severe, and may be developmental in nature, acquired through disease or injury, or from an unknown origin. Often communication and swallowing disorders are invisible (even silent), especially to the untrained eye, as the person may have no obvious ‘outward’ physical signs of their disability. This results in poor understanding by the general community of the experiences of people with communication disability in Australia. This can significantly affect

individuals’ access and participation in the wider society, and have negative impacts on their social and emotional wellbeing, and quality of life outcomes.

Currently there is limited available data regarding the prevalence of communication and swallowing disorders within the Australian population. Conservative estimates indicate there is in excess of 1.1 million Australians who have a communication disorder and one million who have a swallowing disorder.

The most recent information from the Australian Bureau of Statistics 2015 Survey of Disability, Ageing and Carers (SDAC) indicates that 1.1 million Australians use equipment and/or aids to communicate (including 700,000 using hearing equipment/aids). This reflects about a quarter (25.9 per cent) of all people with disability. Of these, 235,800 people report to use either electronic or non-electronic communication aids for reading, writing and speaking (this figure does not include hearing aids).

There is an overlap of incidence between the different types of communication disorders and swallowing disorders, with some Australians experiencing both due to developmental, disease or injury processes (for example, individuals with Down Syndrome or cerebral palsy). It is also clear that these prevalence figures will likely increase exponentially as the population ages.

In recognition of the prevalence of communication and swallowing problems and in accessing speech pathology services in Australia, in 2014 the federal Senate Community Affairs References Committee held an inquiry into the prevalence of speech, language and communication disorders and speech pathology services in Australia. At the time of writing, the Australian Government’s response to the Senate Committee’s recommendations is still forthcoming.

About Complex Communication Needs

Many people with disability have Complex Communication Needs (CCN); these are defined as difficulties with understanding or the expression of communication, which occur as a result of, or in association with, other sensory, cognitive or physical impairments. Individuals with Complex Communication Needs may have little or no speech or have unintelligible speech. Many of these people benefit from the provision of additional or alternative methods of communication such as aids and devices.

Additional or alternative methods of communication, termed Augmentative and Alternative Communication (AAC) methods include symbol and text based boards, electronic tablets and Apps, and access supports such as mounting and switches.

Information from the ABS SDAC 2015 indicates that some 235,800 people with disability use either electronic or non-electronic communication aids for reading, writing and speaking (this figure does not include hearing aids).

Most people whose functional communication is compromised such that they would benefit from of Augmentative or Alternative Communication (AAC) will likely fit the eligibility criteria for the NDIS. Many, however, will not seek or require individualised funding across their lifetime. For many people, particularly those with acquired communication difficulties, it may be possible to provide them with a functional communication system which meets their

medium term and/or their longer term needs at one earlier point in time.

For people with CCN the need for specialist assessments and intervention by speech pathologists is crucial. Australian Institute of Health and Welfare data indicates that nine per cent of users of disability services have little, or no effective communication.iii

About NDIS Participants with communication disability

Publication of detailed data regarding the functional needs and supports/services accessed by NDIS Participants has not been publicly released to date – thus there is not quantifiable evidence as to the number of NDIS Participants who have communication or swallowing disability or who have access to speech pathology services as part of their NDIS Plan.

There is good quality information that would suggest that a large proportion of NDIS Participants will have communication disability. The most recent information from the Australian Bureau of Statistics 2015 Survey of Disability, Ageing and Carers (SDAC) indicates that 1.1 million Australians use equipment and/or aids to communicate (including 700,000 using hearing equipment/aids). This reflects about a quarter (25.9 per cent) of all people with disability. Information from the ABS SDAC 2015 indicates that some 235,800 people with disability use either electronic or non-electronic communication aids for reading, writing and speaking (this figure does not include hearing aids). Whilst this figure is unlikely to capture all people with communication disability who are eligible for the NDIS, it is probable that the majority of these people will be eligible for NDIS due to their complex communication needs.

“I have just started seeing a 19 year old man with autism and an intellectual disability. He is non-verbal and doesn’t appear to have any functional communication. During my second appointment yesterday, he was forming sentences on an AAC app and has a lot more to say than anyone knew! His mum was in tears at the possibility of him communicating with her. She was never able to afford speech therapy for him prior to the NDIS” – NSW speech pathologist

Concrete and comprehensive data regarding the total number of children with communication and/or feeding and/or swallowing difficulties is unavailable at present. It is estimated that there are approximately 250,000 – 300, 000 Australian children living with a disabilityiv. It is unclear how many of these children would be eligible for NDIS under the full scheme (post age seven) or through the Early Intervention stream. Detailed comment will be made later in this submission regarding the eligibility criteria for the early intervention stream of the NDIS.

The Intermediate Report of the Evaluation of the NDIS highlights two groups of NDIS Participants who are not experiencing improved outcomes. Firstly, people with disability who are ‘unable to effectively advocate for services on their own behalf, including people with psychosocial disability and/or those people who struggle to manage the new and sometimes complex NDIS processes’v. It is highly likely that Participants with communication disability are disproportionately included in this group of NDIS Participants who are unable to effectively advocate on their own behalf.

The second group of Participants which the NDIS Evaluation indicated are faring poorer within the NDIS are those facing difficulties accessing disability supports for which they have received funding – primarily due to a lack of local providers, lengthy waiting lists and lack of quality provision. It is the experience of Speech Pathology Australia that most members who are NDIS providers have lengthy waiting lists and in some cases, have effectively ‘closed their books’ as they are unable or reluctant to accommodate further NDIS Participants in their current case loads within private practice. There is also a scarcity of some specialised speech pathology expertise across the country (for example the management of complex

dysphagia, oral eating and drinking for young children with developmental disabilities and the provision of electronic and non-electronic aided communication devices for people with co-occurring physical disabilities).

The Intermediate Evaluation Report repeatedly acknowledges the unmet demand for allied health, including speech pathology services currently experienced within the NDIS. It is the view of Speech Pathology Australia that this second group of NDIS Participants who need (and have NDIS funding for), but are unable to access speech pathology services are likely to be facing poorer outcomes under NDIS .

“NDIS has been amazing for many of my clients. I have one particular boy with verbal dyspraxia and, initially, expressive language issues. Through the use of NDIS funds, he accessed twice weekly speech therapy for from age 3 - 4.5, then weekly therapy thereafter for two years. His speech is now completely clear, bar an occasional distorted /s/, and even more importantly, his literacy is completely on track in year 1. I see him for 3-monthly reviews, but will scale that back soon. Parents would never have been able to afford this amount of therapy without NDIS”

• SA speech pathologist

About the Speech Pathology Workforce and the NDIS

Information about the speech pathology workforce comes from a number of sources. In 2014, Health Workforce Australia (HWA) in collaboration with Speech Pathology Australia produced a publication on the speech pathology workforcevi. From this publication and analysis of Speech Pathology Australia membership statistics, the following can be said about the speech pathology workforce in Australia: Estimated to be approximately 9000 practitioners1

• Significant increase in the number of practitioners in the past five years (with the workforce skewed with a higher than expected proportion of new graduates and early career speech pathologists)
• Experiencing significant growth with an estimated 1300 new graduates entering the workforce from 2017 onward
• Female dominated
• Characterised by a career break (or slow down) during the child bearing years for practitioners
• Two thirds reside in major cities
• Australian born (only 0.2 per cent are Indigenous)
• Predominantly working part time hours (most commonly four days per week)
• Working at least part of the time within private practice

1 Membership of Speech Pathology Australia is voluntary (although there exists significant incentives for membership based on CPSP being a requirement for approved provider status for MBS and health insurance provision). Thus, there is an estimated 1500 practising speech pathologists who are not currently members of the Association – these are most likely employed within Departments of Education, within Health Departments (hospital based speech pathologists) and within large disability service provider organisations (although this is changing rapidly with the registration requirements for NDIS).

A snapshot of Australia’s speechies

[Infographic page showing statistics about speech pathologists in Australia]

Traditionally the majority of speech pathologists working within the disability sector have been employed within government disability services or not-for-profit disability providers. Historically there have been only a small number of speech pathologists offering private services to clients within the disability sector. These speech pathologists were usually senior clinicians who had obtained extensive experience within the public sector and who decided to offer private services. However, the introduction of the NDIS has changed the employment profile within the disability sector. These are in-line with other workforce trends that are encouraging speech pathologists to enter private practice (e.g. individualised funding of aged care services, MBS approved provider status, retraction of government funded services). In terms of the impact of the NDIS, changes to the speech pathology in disability workforce profile include:

• Knowledgeable and experienced speech pathologists who were previously working in not for profit and government provider organisations have transitioned into private practice or (to a lesser extent) into existing or new provider organisations.
• A significant number of existing private speech pathologists whose total client group may previously have included only a smaller proportion of children with disabilities (who were accessing Better Start and Helping Children with Autism {HCWA}) are now providing support to a greater number of children with disabilities, and this group is becoming a greater proportion of their total client group. The same pattern is occurring in practices that have previously had a focus on adult service provision.
• A significant number of experienced speech pathologists who were previously working in larger disability organisations have entered private practice (but not as NDIS providers) or have left the profession.
• Organisations which may have traditionally had a more specific focus (e.g. cerebral palsy, autism spectrum disorders) are now broadening their client group.

An analysis of Speech Pathology Australia membership data in March 2017 indicates a total of 6691 CPSP members, of which 1016 have indicated that they are currently working within the disability sector. This does not include speech pathologists in private practice who are potential NDIS providers but who at this point in time have not registered as NDIS providers. It also includes speech pathologists in WA.

Of the 1016 speech pathologists who currently report to work within the disability sector:

• 98 per cent are female
• Approximately two thirds work with all age ranges (children and adults) (73 per cent)
• Keeping in mind the NDIS roll out process, there is a significant maldistribution of speech pathologists across Australia working within disability/NDIS. 17.3 per cent are in South Australia (to be expected given the NDIS Trial cohort included children)
• 16.8 per cent of these speech pathologists are based in rural areas of the country, with an additional 0.5 per cent in remote areas.
• 60.6 per cent work in private practice with a further 27.4 per cent working in non-government organisations. Only 12 per cent of speech pathologists working in the disability sector report working in government services.
• Most speech pathologists working in disability/NDIS are doing so in small or solo private practices².

2 This is supported by the Intermediate Report on the Evaluation of the NDIS which states ‘Most new entrants were small or solo allied health practices’ (Mavromaras et al, 2016:29).

Scheme Costs

Speech Pathology Australia provides feedback to key consultation questions outlined in the Issues Paper in relation to the costs of the Scheme. Whist it is expected that the Commission will make conclusions regarding the long term sustainability of the Scheme in relation to the costs experienced to date, it is important not to lose sight of the benefits the Scheme will reap in terms of improved outcomes for people with disability. It may be too early in the roll out of the Scheme to be able to quantify the benefits and rewards associated with the NDIS for Participants, or to enumerate the value these outcomes will achieve in terms of increased education, employment and productivity gains.

“I have a 10 year old client with high functioning Autism Spectrum Disorder. His parents couldn’t afford regular speech therapy in 2016 but this year he has a definite block of 18 hours approved by NDIS. He is benefiting from consistency of service related to his social language skills. I am able to liaise with his carers and teachers regularly to ensure we are coordinating his support better.” Rural NSW speech pathologist

“I work in a disadvantaged public school. All my caseload are children who are now on NDIS packages, who did not know they were eligible, and most had not had any speech pathology support before.”

• VIC speech pathologist

Cost drivers

The Issues Paper identifies a range of factors that impact on the costs of the NDIS. The drivers identified in Figure Two in the issues paper are an appropriate representation of the key cost drivers for the Scheme.

What the Issues Paper does not canvass however are the factors/issues that place significant pressure on some of these drivers only in the early stages of the Scheme which in turn are increasing the Scheme costs. Some pressures will be related to the current time and context (e.g. specific to Trial sites) and may be alleviated once the Scheme matures. However, there are some pressures on cost drivers that will have an impact in the short to medium term and which will influence the Commission’s analysis of the sustainability of the NDIS in the longer term.

For example, the retreat of state funded services is increasing demand on those attempting to enter the Scheme as these people are faced with no other avenues of support outside of what might be offered through the NDIS. People with milder forms

“We have seen a girl with severe intellectual disability in foster care. Prior to accessing NDIS she had no speech therapy. She had no purposeful communication, no task focus, and no cause-effect understanding. With weekly therapy she started using PECS and later Proloquo2go (very basically) and school were very impressed with her change in behavior. She changed from completely solitary activities to seeking out interaction.” - SA speech pathologist

of disability who otherwise might have been serviced through state-funded or Information Linkages and Capacity Building (ILC) type supports are now approaching the NDIS for support. This may explain the statement in the Issues Paper that indicates that there is a larger number of people approaching the Scheme than would be expected for those with newly acquired conditions. With the retraction of state-funded services, prior to the full roll out of the NDIS and without ILC supports being funded and enacted, the current context of limited support outside the NDIS may explain the increase in numbers. It is possible that in the future when ILC and LAC supports are funded, enacted and wide-spread that these people with ‘milder’ forms of functional problems associated with their disability may have their needs met outside of individual funding through NDIS. Speech Pathology Australia recommends caution when presuming that the same numbers of people will be seeking to access the NDIS in the future as has been seen recently as these increased numbers might actually be a reflection of the upheaval experienced across the disability sector during the transition to the NDIS rather than a true reflection of ongoing demand for individual funding that will be experienced over the longer term of the Scheme.

In terms of the supply of service providers, in the case of speech pathology, there are significant competition from other sectors for speech pathology services that will have considerable impact (now and in the future) on the supply of a speech pathology workforce to the NDIS Provider market. The speech pathology workforce is spread across a number of sectors including health (hospitals and private practice in primary care), education (significant numbers employed by Departments of Education), Aged Care (often through sub-contracting of private practitioners) and less numbers in child and adolescent mental health and juvenile justice settings. In terms of private practice, speech pathology services can be purchased through a range of funding mechanisms including fee-for-service (both individual and contracts through organisation such as schools), private health insurance rebates, Medicare Benefits Scheme, accident insurance schemes (such as TAC and Worksafe) and Commonwealth Home Support Programme. Funding of speech pathology services through the NDIS needs to be appropriately remunerated and administratively ‘easy’ in order to secure a speech pathology workforce within the disability sector.

Exit rates from the Scheme, particularly in the case of children enrolled in the ECEI stream may depend on the quality and quantity of supports and the timing of those supports being provided to them during their NDIS eligibility. When considering this, a number of the drivers identified in the Issues Paper are inter-dependent.

It is recommended that the Commission also consider the temporal dimension of the Scheme – at least in the short to medium term in relation to the factors driving the costs of the Scheme. Issues associated with the transition to full scheme may be driving up costs in the initial stages, but once systems and procedures are put in place and working effectively, pressure on these costs might be alleviated. For example, workforce supply, amount of support needed by people following a period without or delay in accessing the supports which the evidence indicates would maximise impact of intervention.

Another driver of Scheme costs that is useful to consider is ‘cost-shifting’ from other sectors including health and education. There is considerable evidence of this occurring (to be discussed later in this submission) with the withdrawal of many previously state-funded services with a presumption that people will be provided with support through the NDIS. A recent example is the proposed restructure of the Child and Adolescent Mental Health Service in South Australia that presumes a reduction in demand for their services by children and adolescents that will be eligible for the NDIS. It is the view of Speech Pathology Australia that the restructure of this service to reduce operating costs from the SA Health budget shifts these costs to the NDIS and creates a significant risk that vulnerable children and adolescents will fall through the gaps. Similarly, there are reports of primary schools refocusing their allied health resources to children who are not eligible for the NDIS with a presumption that these children will be receiving what services they need through the NDIS, freeing up these school based services to focus on non-NDIS

eligible children. Arguably, the NDIS will now need to provide ‘more’ support through allied health to make up for what the child would have previously also accessed through their school.

Whilst it is recognised that the Commission needs to consider the costs of the Scheme in relation to the current bilateral funding agreements for the NDIS, it is important that the Commission consider savings achieved for all Governments in other portfolios due to the changing functional capacity of NDIS Participants (as identified as a driver of scheme costs) and increases social and economic participation of people with disability. These savings are likely to be greatest over a lifetime for children receiving NDIS services within the ECEI system.

Utilisation rates for plans

Publication of detailed data regarding the functional needs and supports/services accessed by NDIS Participants has not been publicly released to date – thus there is not quantifiable evidence as to the number of NDIS Participants who have communication or swallowing disability and who have speech pathology funded as part of their Plan and who are unable to access services. The Intermediate Report of the Evaluation of the NDIS highlights speech pathology as a key area of unmet demand within the NDIS. As such, it is presumed that significant numbers of NDIS participants have funding for speech pathology allocated within their Plans but have been unable to use this funding allocation.

Speech Pathology Australia members who are NDIS providers report that many have long waiting lists for their services by NDIS Participants or are restricting the percentage of their client base who are NDIS Participants (due to concerns regarding payment for their services) and are having to reduce the services provided as part of a service agreement because of capacity issues. There may be a number of reasons why Participants are not using their allocated funding for speech pathology services:

• They are not able to access existing speech pathology NDIS provider services (waiting lists etc)
• Insufficient speech pathology approved NDIS providers available (lack of market supply due to competition and range of other factors detailed in this submission)
• They are not able to access specialised speech pathology services if they have a complex need
• Physical access to speech pathology is problematic (e.g. funding of travel in Plans, lack of funding for tele-practice service delivery or rural location)

Concerningly, it has been reported to Speech Pathology Australia that in the Northern Territory (NT) Trial site, speech pathology was not listed as a support on Participants Plans due to the lack of available speech pathology services within the region. Whilst this is unable to be verified due to the limited data publicly released from the Barkley Trial site – Speech Pathology Australia has canvassed NT speech pathologists and has been unable to identify any who provided services to NDIS Trial participants. This suggests that at least in this Trial site, Plans were written in a way that focused on available supports – not on the needs of Participants to meet the goals they had identified for themselves. It is extremely unlikely that Participants in NT trial site did not need speech pathology services.

Speech Pathology Australia advises caution in interpreting data on utilisation rates of Plans in the early stage of the Scheme roll out – as this may reflect the immaturity of the Scheme and not a systemic problem.

Scheme Boundaries

To what extent have the differences in eligibility criteria in the NDIS and what was proposed by the Productivity Commission affected participant numbers and/or costs in the NDIS?

Speech Pathology Australia wishes to make comment on eligibility criteria in relation to two matters: the inclusion of learning and social interaction under the NDIS eligibility criteria, and the inclusion of developmental delay under the Early Childhood Early Intervention eligibility.

Inclusion of ‘learning or social interaction’ under NDIS eligibility

Activities of learning or social interaction are included in the eligibility criteria for the NDIS. It is unclear what type of Participant may be entering the scheme based on ‘learning or social interaction’ needs alone, who does not have needs in relation to the other eligibility criteria. For example, participants with communication impairments would likely also have significantly reduced functional capacity for social interaction and possibly for learning.

It is unclear if children (for example) with specific learning difficulties (such as Dyslexia) are entering the Scheme. These may be children whose ‘only’ disability relates to learning at this point in time. These children receive variable support through the education system and as such, exclusion from the NDIS with the presumption that they will be ‘looked after’ in the NDIS is not accurate.

Advice from Speech Pathology Australia members who are NDIS Providers is that they have not been providing services to children whose only disability relates to learning and literacy – thus, it is our conclusion that the increased numbers of people entering the Scheme is not due to the eligibility of people whose only functional disability relates to activities of learning and/or social interaction.

Inclusion of Developmental delay under the Early Intervention requirements

Concrete and comprehensive data regarding the total number of children with communication and/or feeding and/or swallowing difficulties is unavailable at present. It is estimated that there are approximately 250,000 – 300, 000 Australian children living with a disabilityvii. Many of these children will have communication, feeding and/or swallowing difficulties that require the support of a speech pathologist. Some children will have communication difficulties as their primary disability. Others will have communication and/or feeding and/or swallowing difficulties in addition to or as a result of a co-occurring intellectual, physical and/or sensory disability.

It is useful to clarify the terminology used to differentiate between different groupings of children with speech, language and communication difficulties/delays who may be eligible for the NDIS. It is important to understand the different terminology and ‘categories’ of children, particularly in relation to those that would and should be eligible under the ECEI stream of the NDIS and the longer term NDIS supports after age seven.

The overarching term used for children with specific functional needs in the domain of speech, language and communication is Speech, Language and Communication Needs (SLCN). The functional problems of children within this category can differ considerably. Some will relate to various components of speech,

some to language use and understanding3 and some to both. The presenting issues, appropriate interventions and prognosis for ongoing functional impacts is different for different sub-groupings of children with SLCN, which has implications for children within the sub-groupings in regards to access to the NDIS Early Intervention.

When considering children with communication needs that may require supports under the NDIS, it is useful to understand three terms: differentiating conditions, co-occurring conditions and developmental language disorder and/or developmental speech disorder.

Differentiating conditions are biomedical conditions in which speech and language disorder occurs as part of a more complex pattern of impairments. This may indicate a specific intervention pathway. Those children with a developmental speech delay or developmental language delay associated with a differentiating condition (such as cerebral palsy or Down Syndrome) are generally easily identified as appropriate for early intervention access to the NDIS and provision of individualised funding.

Co-occurring conditions (which may also be present in children with an associated differentiating condition) are impairments in cognitive, sensory-motor or behavioural domains that can co-occur with developmental language delay and may affect patterns of impairment and response to intervention, but whose causal relation to language problems is unclear. These include attentional problems (ADHD), motor problems (developmental co-ordination disorder or DCD), reading and spelling problems (developmental dyslexia), speech problems, and limitations of adaptive behaviour and/or behavioural and emotional disorders. In these children, their speech and language problem relates to other co-occurring conditions but the relationship is unclear or harder to predict in the scientific literature. Depending on their level of functional limitations, these children may be eligible for individualised support through the NDIS.

Developmental Language Disorder (DLD) is recent terminology, used to refer to cases of language disorder with no known differentiating condition. Similarly, Developmental Speech Disorder (DSD) can be used to refer to cases of speech disorder (i.e. where a child’s speech development is aberrant) Children in both of these groups may have a different aetiology for their disorder, and there may be different implications for prognosis and intervention. Despite having no outward physical sign of disability, their ability to communicate may be severely compromised. There are complexities in determining access for the NDIS for children with Developmental Language Disorder or Developmental Speech Disorder as it is difficult to reliably identify these children under the age of five years. These children may be determined to meet the access requirements for Early Intervention (under the Developmental Delay criteria) or, for older children, under the Disability requirements (under the eligibility criteria set out in ss21-25 of the NDIS Act that includes criteria of substantially reduced functional capacity to undertake activities of communication).

Access to the NDIS for children with Developmental Language or Speech delay or disorder without a differentiating condition (such as Cerebral Palsy or Down Syndrome) has been inconsistent and variable depending on the jurisdiction, and at the discretion of Planners.

In summary, many children experience a developmental speech, language or communication delay. Many will have a differentiating condition (such as cerebral palsy or intellectual impairment) and as such are more easily and reliably identified as appropriate participants of the NDIS. A small number will have a

3 The term ‘language disorder’ can be used for children who are likely to have language problems that endure into middle childhood and beyond, with a significant impact on everyday social interactions or educational progress. Research evidence indicates that predictors of poor prognosis vary with a child’s age, but in general, language problems that affect a range of skills are likely to persist. Prognosis is difficult to predict in children under three years of age but improves with children in older age groups. Research evidence indicates that language problems that are still evident at five years and over are likely to persist.

Developmental Speech or Language disorder i.e. a persistent speech or language disorder, in the absence of a differentiating condition.

It is difficult to reliably diagnose a developmental speech or language disorder until a child is five years of age (in the absence of a co-occurring disability). Children with a developmental speech or language delay will experience impacts on their functional communication (i.e. in everyday interactions with family, peers and other communication partners) and on their learning and longer-term social and emotional development.

Early intervention may reduce or even eliminate the functional impacts of the child’s delay or disorder – but it is difficult to identify for which children this may be the case. There is also evidence that even though a child may ‘catch up’ functionally, further speech, language and communication related issues can emerge as children develop further, and as the environmental demands change and increase.

This discussion is clearly pertinent to the deliberations of the Productivity Commission, in relation to its expanded eligibility criteria, concerns about sustainability, and the potential impacts of decisions on the ability for the NDIS to achieve its aims.

The introduction of the NDIS has led to a considerable disruption of the pre-existing service delivery for children with speech, language and communication difficulties. Even prior to the NDIS, access to services for children with communication disability has been variable, and inadequate, as evidence in the 2014 Federal Inquiry into the prevalence of different types of speech, language and communication disorders and speech pathology services in Australiaviii.

The NDIS has provided hope to families and speech pathologists alike, of the potential for children with communication disabilities including those children with Developmental Language Disorder (without a co-occurring disability/differentiating condition) to be able to access the early intervention supports that they need in order to ameliorate or eliminate the impacts of their disability.

Within the NDIS, one of the early intervention requirements for children with developmental delay is that a child’s delay ‘results in the need for a combination and sequence of special interdisciplinary or generic care, treatment or other services that are of extended duration and are individually planned and coordinated (section 9)’.

Speech Pathology Australia holds concerns, informed by experiences in the NDIS Trial and transition and the Early Childhood Early Intervention approach to date, that this requirement may be interpreted so as to exclude children with a developmental speech or language delay or disorder (in the absence of differentiating conditions) from accessing NDIS ECEI supports.

Speech pathologists have reported that NDIS Planners have told families that children are required to need support from more than one allied health practitioner (e.g. a speech pathologists and an occupational therapist) in order to be provided with access under the early intervention requirements. For some children, at particular points in their early childhood, early intervention supports they need might best be delivered by one particular allied health professional. In the case of children with developmental language disorder or delay (in the absence of a differentiating condition or co-occurring conditions) – this may be a speech pathologist.

Whether intentional or unintentional, an interpretation that these children are only eligible for NDIS ECEI if they require multidisciplinary supports – results in the exclusion of children who require specialised support from only one profession- would be a very unfortunate outcome.

These children are likely to:

• are likely to experience an exacerbation of the impacts on their functional communication and learning problems if denied adequate early intervention supports,

• will therefore be more likely to go on to meet the disability criteria for NDIS by the time they are aged seven (if they have not received adequate early intervention supports).
• May experience an increased range and severity of functional impacts at seven years of age and beyond, as a result of being denied access to the early intervention supports that could ameliorate or even prevent their development

Speech Pathology Australia recognises that in a number of jurisdictions, children with a Developmental Language or Speech Disorder or delay have not consistently been provided with supports through the disability sector and/or Early Childhood Intervention Services. This is believed to have resulted from a range of factors, including the difficulties in reliably predicting which young children with delay will go on to have a persistent Developmental Speech or Language Disorder, the stigmatisation historically associated with the label ‘disability’, the reluctance of some families to seek support from disability services, the lack of awareness and understanding of the impact of communication difficulties, and historical limitations around the conceptualisation of ‘disability’.

Children with Developmental Speech or Language Delay have often fallen into the void between sectors in terms of service provision, often as a result of ‘tightening’ of eligibility criteria as a response to funding pressures.

Speech Pathology Australia members have reported that some children with speech and language delays without differentiating conditions, have been provided with access to the NDIS, including individualised funding plans. No data is available on the numbers of children with these functional disabilities who have been approved entry to the NDIS, what has been included in their Plans or the utilisation of plans for this group. It is difficult, therefore, to determine what if any, pressure this group of children with disability may represent on the sustainability of the Scheme. It is the view of Speech Pathology Australia that it is unlikely that the inclusion of this group of children with this condition within NDIS Early Intervention is a significant contributing factor to the larger than expected numbers of children entering the system.

Whilst it is recognised that the Commission is tasked with examining the long term financial sustainability of the NDIS and the various demand drivers that will impact on this sustainability, Speech Pathology Australia would caution an analysis that concludes that total numbers in the early childhood intervention stream are larger than expected and thus, the eligibility for this part of the Scheme should be tightened.

An increase in the number of children accessing early intervention within the NDIS should be viewed as an opportunity rather than a risk to ensure that people with disability are provided with supports as early as possible in their lives. There is very strong evidence of the benefits of early intervention for children with disability, from many disciplines and from within Australian and overseas. If appropriate intervention is provided early, it will reduce reliance on the NDIS in the medium and longer term for many of these children. Efficiencies in other parts of the NDIS (e.g. planning processes) should be prioritised before further restrictions are made to how the NDIS supports young children with disability.

What impact will the ECEI approach have on the number of children entering the scheme and the long-term costs of the NDIS?

The current ECEI approach offered through the NDIS is problematic in a number of ways. The impacts of ECEI approach are less likely to be related to the number of children entering the stream (this is an eligibility issue) but will impact on the long term costs of supports for the children who are deemed eligible. There are a range of concerns that speech pathologists hold regarding the evidence base for the current ECEI approach and what aspects of this are currently funded through the NDIS. This will be discussed in detail later in relation to the impact this has on the supply of speech pathologists to the NDIS provider market.

Throughout the Trials and NDIS rollout, the NDIS has privileged the provision of ‘transdisciplinary’ practice for early childhood services. This ‘privileging’ included the labelling of the only support item under which early intervention allied health provision could be funded as ‘transdisciplinary support’. A lack of clarity from the NDIA about what was meant by ‘transdisciplinary support’ created confusion with Participants and providers. The information provided on the NDIS website about the use of transdisciplinary support was unclear and in some cases contradictory. Planners were unable to define what services and therapy could be accessed under ‘transdisciplinary support’. Equally concerning was the fact that even though allied health professionals (including speech pathologists were listed as appropriate to register for and provide this NDIS support, there was no consultation with the professional associations (including Speech Pathology Australia) about the evidence based for transdisciplinary practice within their clinical professions for young children. No consultation occurred with allied health profession representatives about how allied health service provision in early intervention would best be provided in order to be effective and efficient, how practitioners from the various clinical professions might work together to achieve outcomes for individual children or exactly what types of interventions and therapy could be claimed against this support item by NDIS providers.

Participants were not provided with any, or adequate support to understand the principles of ‘transdisciplinary’ practice as espoused by the Scheme– even when it became understood across the allied health professions that the term when used by the NDIA was supposed to encompass all of the best practice components of early intervention service provision.

Neither Planners, Participants nor providers were effectively supported to understand what ‘choice and control’ for participants actually meant when it was applied to the purchase of ‘transdisciplinary practice’ or how that might be ‘operationalised’ within the NDIS system. In the absence of widespread and effective opportunities to learn about circumstance and where they are provided with very limited options of NDIS providers that are registered to provide ‘transdisciplinary’ services - families have opted to use their funding to access the maximum number of individual, local (clinic based) allied health sessions that their funding would support, directly conflicting with best practice early intervention.

Evidence based early childhood intervention models would routinely include the following components – namely integration, interaction and communication between the various professionals providing therapy to the child. Evidence based and best practice components of early intervention have not been funded by the NDIS including the collaboration amongst ‘team’ members, the transfer of knowledge and skills within the team (including parents), the assessment and exploration of a child’s needs, the identification of priorities and planning for provision of a prioritised and coordinated series of interventions from a cohesive and cooperative team. The provision of services within a home environment or within the usual community spaces of the child (play grounds, kindergarten, play group etc) have been challenging due to issues around NDIS funding of travel by providers.

The Early Childhood Early Intervention funding rules for the NDIS also do not allow for family-focused therapy programs which have been demonstrated to be evidence based and effective. Some interventions recommended and provided by speech pathologists are group based and targeted at the ‘environmental’ level to meet the needs of a child. For example, interventions might be targeted at parents and other significant communication partners and supports in a child’s life to ensure that the ‘learnings’ from the therapy are reinforced and practiced within the family so that the child receives a large ‘dose’ of the support on a regular basis (more than can be provided within a time limited consultation session with a speech pathologists). These approaches to therapy are consistent with family centred and family focused, capacity building princples of best practice early intervention. Examples include the Hanen ‘It Takes Two to Talk’ and ‘More than Words’ programmes, or Key Word Sign one day workshops.

Taken together, aspects of the planning process, support items and pricing, Portal design issues, requirements around registration for providers, service agreements, and lack of funding for coordination and planning have all contributed to create a situation where significant barriers exist to the ability of the NDIS provider market to provide evidence based and efficient models of early childhood intervention. In order to reap the benefits of early intervention for individual NDIS Participants, and for the system overall to reduce the longer term costs of support for these children over their lifetime – significant changes need to be made to the ECEI approach so that it includes aspects known to be effective.

Intersection with Mainstream Services

Is the current split between services agreed to be provided by the NDIS and those provided by mainstream services efficient and sufficiently clear?

Speech Pathology Australia has members who work across multiple sectors including the NDIS, education, aged care and health. As such, speech pathologists are often in unique circumstances to experience the disconnect between NDIS and mainstream services – often for the same NDIS Participant. Whilst there are significant problems at this point in time in relation to the interface between education, health and the NDIS, with significant cost-shifting and gaps appearing in access to services – this may be a reflection of the point in time in which the Scheme is transitioning in the different states and territories of Australia. Whilst the disability sector is undergoing significant reform, so too are sectors that intersect with it and in response to it. Whilst it can be argued that time is needed to allow the reforms to ‘settle’ and new systems of services in health, education and disability to be established – for people with disability who need access to supports now – waiting is not an option. For an NDIS Participant who needs an assessment of their swallowing function so that it can be determined how they might eat and drink safely – they need this service immediately or they face the risk of choking, medical complications such as malnutrition or chest infections. It is unacceptable for this person to have to wait until it is determined if a health sector employed speech pathologist or a NDIS funded speech pathologists should conduct this assessment.

Clarifying the roles and responsibilities between education, health and the NDIS needs to be addressed by government as a matter of urgency.

Intersection with Education

Governments are yet to come to agreement to clarify the roles, responsibilities and service pathways between the NDIS and other sectors. For example, in the education system, issues can arise for individual students when they have multiple agencies providing services. There are students who will always straddle the intersectorial government jurisdictions (education departments, human services, community services, mental health, health, juvenile justice) and non-government organisations. Speech Pathology Australia has members who provide services under all these different government funding streams and are reporting considerable confusion over service delivery responsibilities. The risk is that each sector will assume needs are being managed by the other sector – to the detriment of the child or young person concerned.

This is of particular concern for children and young people who have specific language disorders or communication disabilities that

“I’m in NSW and have a family who wanted to use their NDIS funding to fund support workers as extra aide time in class. They were told this is an education expense. Another family were randomly given an additional chunk of money to pay for school transport. The family had previously been under the assumption that this was an expense covered by education.” NSW Speech pathologist

are ‘stand-alone’ conditions and are not associated with differentiating conditions (such as Cerebral Palsy or Down Syndrome). It is unclear if, and how, these children will be eligible for NDIS services. At present, there is variable (inconsistent) access for these children across Australia – an issue that has been raised consistently by Speech Pathology Australia with the NDIA. These communication disabilities have profound consequences for participation in activities such as learning and recreational activities, as well as impact on social interaction and behaviour. In the absence of the child receiving any early intervention services prior to schooling , the school will likely be required to make even more significant (and costly) adjustments for the student to access/participate in the curriculum.

There is also a presumption by the NDIS ‘system’ that the education sectors are able to effectively support students with disability. Recent federal and state based inquiries into educational supports for students with disability reflect considerable variation in their ability to do so across states and territories, across school systems (public, independent and Catholic) and for students with different types of disabilities4.

There is now widespread reports of schools across Australia restricting all access to NDIS providers to students during core learning times, school hours and in some cases on school premises. This barrier to the Participant accessing best practice support within an educational setting, or at worst not service at all, is concerning.

Schools are in the business of ‘educating’, and their priorities need to be to support access and participation in the learning environment for a student with disability. Individual schools, principals, teachers and speech pathologists are placed in positions where they need to make local, individual judgements about who is responsible for what type of support for a student. Clear guidance is needed from the Governments and the Departments of Education about the interface between the NDIS and the education system; where the provision of reasonable educational adjustments finish and where the provision of reasonable and necessary disability supports start.

“Under the NDIS, therapists are often in a school for 45-60 minutes, school staff do not understand your role, and may not want you to be providing support during the school day. Funding and time constraints means that there is little to no time available for consultation/collaboration with teachers (who have many different therapists coming into the school) and it is difficult to build relationships with schools” – NSW speech pathologist

“Literacy is a tricky area. A number of our NDIS Participants have very significant literacy delays e.g. still learning the alphabet in year 4 mainstream school. We know literacy skills are part of communication with long term benefits in terms of community participation, employment etc but often NDIS Planners will say the school should cover literacy. These kids are so far behind and need a more developmental approach to therapy than any school can provide.” SA Speech pathologist

4 For example see the Senate Inquiry into Current levels of access and attainment for students with disability in the school system, and the impact on students and families associated with inadequate levels of support in 2015, the South Australian 2015 Inquiry into Access to the Education System for Students with Disability and the currently underway inquiry in NSW 2017, inquiry into student with disability or special needs in New South Wales Schools.

Intersection with Health

Governments are yet to come to agreement to clarify the roles, responsibilities and service pathways between the NDIS and the health sector. Given speech pathologists often work across health and disability services, they are in a unique position to identify problems with the interface between health services and disability services for the NDIS, and contribute to the development of solutions (such as clinical pathways and processes to support continuity and consistency of care across health and disability).

The most problematic interface between mainstream health and NDIS services is related to the provision of speech pathology services relating to people with swallowing disability and the provision of meal time management supports. There seem to be a range of decisions being made by individual health services and also the NDIA around where the responsibility for service provision should sit based on simplistic assumptions about the health needs of people with disability.

For example, people with Down Syndrome often have problems associated with swallowing and eating and drinking. Often they require a diagnostic assessment of their swallow function (a videofluroscopy assessment that is usually performed in a hospital and is like a moving x-ray of how someone swallows). Speech pathologists are part of the health team in a hospital conducting this assessment. A speech pathologist working in the disability sector would usually be involved (or at least working in collaboration with the health team) to understand the technical restrictions on swallowing and how this will impact on how the person can eat and drink safely in their usual circumstances (at school or work) and what supports (such as modifications to the texture of foods and fluids, position of the head etc) they might need to do this safely. In this scenario, the health and disability team members work together to diagnose and understand the person’s clinical needs and their functional needs. It is not an ‘all or none’ scenario where one service is provided by health and one service is provided by the disability sector – both health and disability sectors have a role to play in contributing to the quality of life of that person and their participation outcomes in social, economic and educational life. The funding parameters of NDIS where only face-to-face time by speech pathologists with a Participant is funded create barriers to this kind of collaboration across health and disability. This scenario gets even more complicated if the mealtime management recommendations need to be enacted in a school based setting so that a child with dysphagia can attend school!

“NDIS eligible people are not ‘core business’ for community health any longer (as they are ‘able’ to access services with NDIS funding from private registered NDIS providers)…if there are services out there. In a rural community this is not the case. People with degenerative conditions like Motor Neurone Disease previously accessed multidisciplinary allied health team from community health but not if registered with NDIS they are supposed to access services from private providers. Again in rural community NDIS providers (even if they see adults) are sole traders and not part of an allied health multidisciplinary private company” – NSW speech pathologist

Speech Pathology Australia has had reports of hospitals now referring clients with disability (eligible for NDIS) to have videofluroscopy completed in private facilities using NDIS funding. Were the person not to have a disability (e.g. Down Syndrome) but to require a videoflurosopy for some other reason – this would be available through the hospital system in Australia.

Urgent clarity is needed between the NDIA and state and territory Health Ministers and their Departments about where the responsibilities lie for provision of health and disability services for people with disability.

Is there any evidence of cost-shifting, duplication of services or service gaps between the NDIS and mainstream services or scope creep in relation to services provided within the NDIS?

It is the view of Speech Pathology Australia, that there is evidence of cost-shifting (namely in health and education towards the NDIS) as described earlier in this submission. This cost-shifting may be a reflection of the considerable uncertainty that exists in terms of what supports for people with disability, and which people with disability the NDIS will cover. It is not clear if this cost-shifting is a system-wide and longer-term issue that will impact on the sustainability of the NDIS or if it is context and time sensitive.

The Intermediate Report of the Evaluation of the NDIS acknowledges the concerns in the sector about the impact the NDIS would have on people with disability not eligible for the NDIS. Some non-NDIS participants were reported to be receiving fewer services while others were falling through service gaps and getting no supports at allix.

It is of significant concern that service gaps have emerged during the Trial and transition to full scheme that have left particular groups of people with disability with no access to speech pathology services (and presumably other supports they require).

The most notable service gaps are appearing in relation to early childhood intervention supports as state-funded services offered through Community Health are retracted in anticipation that demand will be reduced as clients transition to become NDIS Participants and/or where Community Health allied health staff are directed to provide to NDIS participants on a fee for service basis. For example, in South Australia, the Early Childhood Intervention Services prior to the NDIS were limited (and significantly different in structure from those in VIC and NSW). Community health services in rural parts of SA are now being directed to prioritise NDIS participants aged 5–8 years of age (sometimes on a fee for service basis), younger children are now no longer being seen by Community Health. This means that these children, despite their problems are no longer able to see a practitioner to demonstrate ‘evidence of disability’ when requesting access to the NDIS. Families who are unable to afford private practice fees and can’t get in to see Community Health practitioners and are consequently left in limbo.

In the ACT, the system has evolved differently with the closure of Therapy ACT and the opening of government funded Children Development Service. Reports from speech pathologists in the ACT indicate that the CDS’s acts to triage young children into the NDIS as a priority, with minimal services remaining to provide to children who are not eligible for NDIS. Reports indicate that the CDS has not been adequately resourced to keep up with the significant demand for children not eligible for NDIS, and as such significant waiting times and restriction of service (a small number of consultations are offered only) are currently being experienced.

Other notable service gaps have emerged with the retraction of state-funded disability services particularly in NSW where the state government Ageing Disability and Home Care (ADHC) has been retracted significantly, it is difficult for the market to provide, and for Participants to access services which were previously provided by (ADHC) speech pathology in particular:

• Assessment, trial, prescription and intervention support for provision of electronic and non-electronic aided Augmentative and Alternative Communication
• Multi-disciplinary team based assessment of oral eating and drinking difficulties

• Referral to and support for instrumental assessment of swallowing by health sector, and where appropriate the provision of recommendations
• Person centred communication accessible negotiation around mealtime supports
• Information and training for support workers around specific and individualised mealtime interventions and strategies to support safe, enjoyable and effective mealtimes

Is the range and type of services proposed to be funded under the ILC program consistent with the goals of the program and the NDIS more generally?

The range and type of services proposed to be funded under the ILC program appears to be consistent with the goals of the NDIS. However, whether the services that are finally funded under ILC National Grants meet the needs of people with disability is unclear at this point in time (whist the competitive grant process is still underway).

What is of concern is the allocation of a minimal amount of funding to the ILC and LAC components of the NDIS. It is a widely reported view from the disability sector that there is a significant under-funding of the ILC in order to meet the needs of people with disability. Of particular concern is the significant component of this overall funding that has been allocated to LAC functions.

It is unclear (even in areas that are well advanced in their roll out of the NDIS), the parameters and value of the LAC functions to the overall Scheme. The LAC function is variable across Australia and it is unclear what skills, qualifications and experience that personnel who are employed as LACs are required to have.

*“In our region it is still in roll-out phase but the current service (state funded early childhood intervention) sends eligible families from a central waiting list which we then contact. Often these are

services. There may be a further financial imperative to do this if their operating budgets have been further retracted with an assumption of reduced demand due to transfer of demand to the NDIS.

It is of significant concern that conflicts of interest between organisations that are funded to provide LAC and are also NDIS providers themselves has not been acknowledged by the NDIA. This appears to be a systemic failure of the NDIS that organisations have been funded to provide LAC and service provision. Participants have reported to Speech Pathology Australia members that they have been told by LAC that they must receive all of their supports from a particular service, reduce the number of providers they are seeing or discontinue seeing their regular therapist (even though they are an NDIS provider) who in many cases has been providing a service to them over a number of years.

Planning Processes

The NDIS Planners are the ‘gatekeepers’ to supports for NDIS Participants. Whilst they are acknowledged as an important component of the overall NDIS system, insufficient recognition of the critical role and influence Planners have in the outcomes for NDIS Participants compromises the long term sustainably of the NDIS.

The Issues Paper argues that ‘Robust planning processes and assessment tools, and sufficiently skilled and impartial planners, are therefore important for the ongoing financial sustainability of the scheme’ (pg. 18). Unfortunately, it is the experience of Speech Pathology Australia members that the planning system currently used by the NDIA is exactly the opposite of what the Commission argues is needed.

The NDIS Planning process and the decisions made by the NDIS Planners themselves generally demonstrate a lack of understanding of the complexity of needs for individuals with disability and the complexity involved in developing an outcomes based plan for supports and services.

Significant improvements are needed to the planning process if the NDIS is to achieve improved outcomes for Participants in the longer term

Is the planning process valid, cost effective, reliable, clear and accessible?

Inconsistency in Decisions Regarding Eligibility

Feedback to Speech Pathology Australia from both speech pathologists working within the NDIS system and from individuals and their families with disability indicate that there is considerable inconsistency and uncertainty regarding eligibility for the NDIS – as determined by individual Planners. Repeated problems with access to the NDIS have been raised – whereby a Planner has determined that an individual is not eligible for NDIS, yet another person with the same condition and similar functional needs is determined by a different Planner to be eligible. This has been particularly problematic in the case of children in the Early Childhood Early Intervention stream of the NDIS (but not exclusive to this NDIS stream) where it is unclear if the functional problems experienced by the child will be permanent.

Even when provided with evidence from multidisciplinary practitioners (including speech pathologists) regarding the functional needs of the person (that is considered to demonstrate clear eligibility for NDIS) Planners as the “gate keepers” who determine eligibility make determinations that are often at odds with specialist advice.

Review and complaints processes for those deemed by a Planner to be ineligible are burdensome, not easily accessible and time consuming for individuals with disability and their families. It is anticipated that as the Scheme matures, if inconsistencies in eligibility determinations by Planners is not improved, that the number of eligibility reviews requested by people who have been deemed ineligible by NDIS will

increase exponentially. This will be further exacerbated if the ILC component of the NDIS is not sufficient to meet the needs of those with disability who are ineligible for individual packages.

It is the view of Speech Pathology Australia that the eligibility criteria set out in the NDIS Act are appropriate for the Scheme, however it is the interpretation of this eligibility by Planners that is inconsistent, variable and often suggests an insufficient knowledge of disability conditions and functional needs that pose the most significant risk for the NDIS to meet its goals.

Inconsistent and Poorly Informed Decisions regarding Plan Supports

Concerns are repeatedly raised with Speech Pathology Australia regarding the allocation of funds in NDIS Participant’s plans that appear to reflect a lack of understanding by the NDIS Planners of supports that are evidence-based to meet the outcomes identified by Participants. Allocation of supports in Plans is often inconsistent and unreliable.

Speech pathologists repeatedly report that they see Plans for NDIS Participants with similar functional needs that do not include key supports (that are reasonable and would be considered necessary by anyone familiar with specific disabilities), over-fund certain supports or significantly under-fund certain supports. Many examples have been provided where even the Participant does not understand what the supports funded in their Plans are intended to achieve or why they would wish to use them. Most recent examples include the significant (and disproportionate) allocation of funds for coordination.

“We saw a plan this week with just over $2000 for capacity building and $ 4200 for support coordination- doesn’t that seem out of whack or am I misunderstanding support coordination? Twice the amount than is allocated to access therapy and this family have services in place and don’t need support coordination? Seems unproductive and costly to me” – SA speech pathologist

Whilst it is acknowledged that the recent transition to full Scheme has placed enormous pressure on the Planning process, some of the efforts that have been made to streamline and speed up this process have come at the expense of personalisation of Plans to meet the needs of Participants.

The My First Plan process and use of benchmark packages are efforts to create standardisation of Plans – however there should not be a ‘one size fits all’ approach to disability support planning. These processes on their own are not problematic, but when coupled with other structural aspects of the NDIS – they mean that the planning process is inflexible and unable to be responsive to the individual needs of Participants.

“Core supports is another significant issue. Most of our families are primarily looking for therapy but keep being given significant core support budgets with smaller capacity building budgets by the Planner. We don’t have anyone providing core supports in our area. Families tell us they tell the NDIS they don’t want respite and yet still get thousands allocated in core supports” – rural NSW speech pathologist

Recent reports from ACT indicate that Planners are unable to make adjustments to NDIS Plans outside of a yearly review cycle. If an individual has a My First Plan, or even a Plan that largely met their needs, if circumstances change they are unable to make adjustments to their Plan to accommodate their changed needs. This is a significant problem in relation to young children whose functional needs may change rapidly (in the space of a year), for young people and adults who may be entering/leaving the workforce, anyone experiencing key life transitions (breakdown of a marriage where the partners was a key support, death of a family member who provided a caring function) or for any Participant with a progressive condition where their functional abilities may deteriorate unexpectedly. There needs to be the capacity within the NDIS Planning process for adjustments to be made to Plans in light of changing needs of NDIS Participants.

The recent introduction of telephone based discussions to establish My First Plans for NDIS Participants is considered to be a very poor choice of service delivery by the NDIA – and acts as a significant access barrier to the estimated quarter of a million NDIS Participants who report to require the use of aids to communicate.

Planners overriding clinical recommendations

Of significant concern to speech pathologists is the ability within the NDIS system for NDIS Planners to disregard and override clinical recommendations and decisions made by speech pathologists for individual NDIS Participants. Some examples reported to Speech Pathology Australia is Planners determining the number of speech pathology sessions that is far below/above that which the evidence recommends for clinical efficacy (and change in functional status). This is akin to a Planner deciding to only provide half a dose of antibiotic that a medical doctor has prescribed. Other examples include Planners asking for a literature review of the evidence base for a particular speech pathology intervention before approving it to be included in a Plan.

The most pressing issue in relation to Planners overriding clinical recommendations relates to the prescription of Augmentative and Alternative Communication (AAC) devices. Reports have been received of Planners determining at the outset a maximum amount that can be spent on a device for communication in a Plan (for example, at present in the ACT it appears to be $1000). This ‘cap’ is largely seen to reflect a presumption by Planners that any Participant with a communication need can have their needs met through the provision of an ‘ipad’ with Apps (equating to approximately $1000). The listing of an AAC device in a Participants Plan occurs during the Plan development stage and in isolation from any recommendations from experts in AAC provision and is not informed by expert advice. This ruling demonstrates a lack of understanding of the unique needs of people with disability, a lack of understanding of the various support options that should be available to that person and a lack of knowledge of the standard multi-step best practice procedure (which often involves the trailing of a number of devices) for choosing an AAC device.

When an individual finally does see a speech pathologist with expertise in AAC, the clinical recommendation may be that the person’s needs would be better met through another kind of AAC device. Some of these devices exceed the $1000 cap on Assistive Technology (AT) that has been listed in the Plan. In order to have the clinical recommendation for a different device accepted, there is a complex and time consuming review process that needs to be undertaken with no guarantee that the clinical recommendation of the speech pathologists will be accepted. This has been intensely frustrating for the individuals and their families, and the speech pathologists supporting them, who are prevented from accessing the device that would allow them to communicate most effectively. This is akin to providing someone with a walking stick when they need a wheelchair.

Ironically, without an effective communication device, these individual NDIS participants are least able to advocate for changes to the provision of AAC in their Plans without relying on family members or carers to do this on their behalf. It was unsurprising for speech pathologists working in the NDIS to learn that the Intermediate Report on the Evaluation on the NDIS found that the NDIS Participants who were more likely not to have their needs met, and who has the poorest levels of satisfaction with the NDIS – were those who were unable to advocate on their own behalf.

The recent introduction of NDIA Technical Advisors in September 2016 may be one way in which the system can be improved to ensure that Planners are not required to made decisions regarding high intensity/high costs supports without having the requisite knowledge to do so. However, at this point in

time, no information is available regarding the qualification, skills, expertise or even number of Technical Advisors that will be employed by the NDIA. It is unclear if NDIA Technical Advisors will be responsible for making these kinds of decisions, or if they will be appropriately resourced to make determinations on the sheer number of Participant Plans that may require technical expertise to determine what supports are appropriate. At this point in time (March 2017) the introduction of NDIA Technical Advisors appears to have made no difference to reports to Speech Pathology Australia of Planners over-riding clinical recommendations of speech pathologists or improving the inconsistency in planning decisions over the past six months.

Training and Qualifications of Planners

Information about the level of training and qualifications NDIS Planners are required to have prior to employment as Planners is not in the public domain. Whilst it is acknowledged that there are numerous individual Planners who are exceptional in their roles, we focus our comments in here on systemic issues associated with the planning process and workforce.

The myriad of problems reported relating to what supports are offered within NDIS Plans, inconsistency in eligibility approvals, planners overriding clinical recommendations etc all point towards a need to ensure that Planners are appropriately trained and skilled, with good understanding of disability and the varying needs of individuals and with excellent understanding of the range of supports that might be funded by NDIS (including what may be beneficial for that individual). It is the view of Speech Pathology Australia that Planners with these skill set are the exception rather than rule within the Planning workforce.

It is unclear what training and professional development the NDIS Planning workforce has been offered or required to undertake (either during induction or ongoing to support their roles). Speech Pathology Australia has offered to support training of planners but this offer has not been taken up by the NDIA.

It is hoped that as the Scheme matures, the Planning workforce might be under less workload pressures than has been the case during the Trial and transition stages and that these skills could be further developed in the workforce.

“The situation was that the mother of my client who is self-managing felt she could not use all of her funding and asked that part of the funding be put to resources. She was told there would be an additional form for her therapist to complete to do this. I completed the form but the application was rejected. They told my client that resources like these - games, computer software (to produce the same output as peers) and posters to help manage social responses as the arise with peers were not considered inclusive. They described inclusive resources as being like a child who sits on the side of the pool and cannot join in with his friends because the child requires a floatation device to be able to enter the pool. My client’s mum has now been provided with a support worker - she stated to me that this has just added more work for her as she has to come up with things for the support worker to do. Why is it that assessors always bring it back to a physical disability example? They really don’t get speech, language or social impairment at all!” – SA Speech pathologist

Accessibility of the Planning Process

Speech Pathology Australia is concerned that the NDIS Planning process is not communication accessible for people with disability.

Approximately one million Australians have disabilities that effect their ability to communicate. The most recent information from the Australian Bureau of Statistics 2015 Survey of Disability, Ageing and Carers (SDAC) indicates that 1.1 million Australians use equipment and/or aids to communicate (including 700,000 using hearing equipment/aids). Over a quarter of a million Australians with disability (278,000) report to need assistance with communication. The survey found that people with disability who need informal assistance and support (from family or carers) to participate in social and economic life needed it for communication (89.9 per cent) and mobility (88.7 per cent). For those people who needed formal supports (from organisations or government services), they were most likely to need it for health care (55.0 per cent), cognitive/emotional tasks (52.8 per cent) and communication (43.5 per cent).

Based on data from the ABS, it is likely that around half of the NDIS population require support to communicate. These Australians experience a range of barriers to participation in community life. For example, having questions addressed to their support worker rather than themselves, being treated and spoken to like a child despite having normal intellect, being unable to use public transport because they are unable to verbally convey their destination, or being unable to order what they wish at a cafe because the waiter is too busy (or embarrassed) to persist in trying to understand what they want. Of critical concern, people with communication disability face significant barriers to being able to report abuse, neglect or mistreatment, because they are not provided with the opportunity or the means to do so in a way that matches their communication abilities. These Australians require ‘communication access’ to participate in community and economic life. They require communication access to participate in the NDIS.

Communication access is a similar idea to providing ’kerb cuts’ for communication. Kerb cuts make it possible for people who are in wheelchairs to access their physical environment. Similarly, communication access involves the provision of environmental supports for people with communication disabilities to access their community and services. Communication access can be simply defined as being ‘when everyone can get their message across’. Communication occurs when people are respectful and responsive to individuals with communication difficulties, and when strategies and resources are used to support successful communication’x. Communication by definition involves at least two people. This means that those people who are within the NDIS interacting with a person with communication difficulties are a significant part of the environment which may require ‘modification’ to enable access.

Communication access does not require a lot of money to achieve, but relies on awareness and understanding of staff and a willingness to adjust their interactions in line with the communication needs of the person. For example, this may be having signage that is pictorial or uses simple language, speaking directly to the person with disability (rather than speaking to a carer), indicating to the person when they have not understood what they have said, providing information in multiple formats if necessary, pointing or using other gestures, reading out information to the person, giving people time to respond and repeating information if needed.

The concepts of communication access and participation are relatively new, and Australia is the home of some of the world leading activities in the area - this includes the development of a symbol to denote communication accessibility, similar to the familiar wheelchair and Hearing Impairment accessible symbols which are now common recognised.

Communication access is a vital pre-requisite for people with communication disability to participate in the NDIS planning process. The Intermediate Report of the Evaluation of the NDIS indicates that one of the groups of NDIS Participants who were not faring well in the NDIS are those that are unable to advocate on their own behalf. It is of concern that a presumption is made that these people with disability are ‘unable’ to advocate for themselves and make decisions about their goals and which supports they desire – when it may very well be the communication environment and verbally mediated system of NDIS planning that has prevented them being able to participate in this process.

At a minimum, the NDIS planning process needs to undertake an audit to determine how communication accessible the process is – and make changes to ensure that the ‘process’ of planning is not placing additional barriers on people with communication disability from interacting with the system.

Assessment Tools

The assessment tools used by the NDIA have not been made public. It is unclear then to organisations with expertise in the particular areas (for example communication needs) to determine if there is appropriate assessment of people communication needs. This combined with a lack of technical expertise in the NDIA adds to the concern amongst technical experts such as speech pathologists that the assessment tools have insufficient sensitivity or specificity to differentiate people who need the supports of the NDIS.

Support Packages

To what extent does the NDIA’s budget-based approach to planning create clear and effective criteria for determining participant supports?

Inconsistency in Plan Supports

Concerns are repeatedly raised with Speech Pathology Australia regarding the allocation of funds in NDIS Participant’s plans that appear to reflect a lack of understanding by the NDIS Planners of supports that are evidence-based to meet the outcomes identified by Participants. Allocation of supports in Plans is often inconsistent and unpredictable.

Speech pathologists repeatedly report that they see Plans for NDIS Participants with similar functional needs that do not include key supports (that are reasonable and would be considered necessary by anyone familiar with specific disabilities), over-fund certain supports or significantly under-fund certain supports. Many examples have been provided where even the Participant does not understand what the supports funded in their Plans are intended to achieve. Most recent examples include the allocation of significant amounts of coordination funding.

Whilst it is acknowledged that the recent transition to full Scheme has placed enormous pressure on the Planning process, some of the efforts that have been made to streamline and speed up this process have come at the expense of personalisation of Plans to meet the needs of Participants.

Evidence-based supports

Packages should include only evidence based therapy and supports and be developed in consultation with allied health peak professional bodies who can inform on evidence based best practice. Whilst there needs to be consideration of the budget/financial implications of the level of support in Plans – the budget/resource allocation needs to be made with an informed understanding of the evidence relating to specific supports. Planners are making decisions about ‘how much support’ for therapy is provided in NDIS Plans without advice from technical advisors/experts (including speech pathologists) about what would be needed in order for the person to achieve their goals. This has led to numerous examples where the number of speech pathology sessions listed in a Participants Plan is far above or below that which the evidence recommends for clinical efficacy (and change in functional status) for that person’s condition.

Allied health professional associations are responsible for quality and safety of their profession’s practice, and as such are not providers of services directly to the NDIS market. As such, Speech Pathology

Australia (and other Allied Health peaks) are well placed to advise the NDIA in relation to the evidence base for particular interventions and supports for the NDIS system.

Aids and Equipment

The NDIA needs to consider the approach to accessing AAC for NDIS Participants as fundamentally different from access to other items of equipment that Participants may need. The provision of an effective form of communication is intrinsic to the ability of a participant to develop and exercise their choice and control within the NDIS scheme. AAC is a critical tool to assist people to actually participate in NDIS.

Unlike other equipment that may require a relatively small investment of time to train in the operation of the equipment, the majority of AAC devices requires significant information, training and ongoing support for participants so that the Participant can develop their knowledge, skills and understanding of the operational as well as functional aspects of the technology. Learning how to adapt their use of the AAC device in a given communication context will also take time and support. For example, vocabulary selection is a key contributor to successful use of AAC, but requires specialist knowledge and needs to be tailored to what the participant is likely to need to ‘say’ in their usual environments and also in unfamiliar or community based environments. The prescription of, setting-up of and training for AAC devices cannot be met by a ‘one size fits all’ approach.

In the case of AAC devices, it is critical that participants have access to expert advice about the AAC methods that are likely to best suit their needs. Speech pathologists are the allied health practitioners who are able to provide this advice in order to support Participant decision making, including:

• Information about the wide range of AAC devices that might be suited to a participants’ needs in order to help narrow down the options
• The demonstration of the merit of particular AAC devices/methods in different communication contexts
• Advice on the adaptation of AAC devices for individual needs. For example, The inclusion or lack of a small feature (e.g. availability of an audible beep on switch activation, or ability to ‘add on’ speakers to increase volume etc), can make a significant difference to the appropriateness and functionality of an AAC device and will often only be identified as important by a knowledgeable and experienced advisor.
• Integrating AAC devices into the broader equipment needs for a participant. For example, in many cases a collaborative multi-professional team is required e.g. where an integrated system (combining all or some of AAC, Information and Communications Technology (ICT) access, environmental control and electric wheelchair or other electric wheeled mobility control options) is required and/or where complex alternative accessing (e.g. eye-gaze or switch based scanning) is needed.
• Providing advice on ‘value for money’ for devices depending on the needs of the individual

Current funding to support high quality evidence based AAC assessment, prescription and ongoing support by speech pathologists is problematic in NDIS Plans which lack an understanding of the approaches needed to choose a device that will provide the most effective mechanism for the Participant to communicate. It sometimes appears that “costly” AAC devices are seen as a luxury instead of the essential tools for supporting Participants to communicate and thus access and participate in life.

Alternative models of service delivery

Despite strong evidence of the clinical efficacy of speech pathology services provided through tele-practice, the NDIS does not currently have a consistent approach to the provision of funding for speech pathology services delivered through telepractice. Speech Pathology Australia is aware of a few individual case examples where NDIS Participants have been able to have telepractice services funded after

negotiation with the NDIA regarding their Plans. Access to funding of telepractice appears to occur only at an individual level with the NDIS, intermittently and variably.

Similarly, the way that NDIS has structured plans, the development of service agreements and the claiming process has created a barrier to the provision of some group-based supports and impacted negatively on the ability of speech pathologists to provide some evidence-based interventions. For example, the Hanen programmes It Takes Two to Talk and More Than Words are both evidence-based programmes which may be a part of speech pathology intervention for children with developmental speech and language delay, and austim spectrum disorder respectively. To be viable, these programmes need a cohort of at least eight parents of children who are able to commit to attend eight 2 ½ hour sessions across a 10 to 12 week period. Prior to the NDIS different providers were able to ‘share’ the process of provision of the Hanen programmes, and so more quickly and easily achieve a viable number of parents to be involved. The current plans, service agreement and claiming processes create barriers to providing these programmes. As a consequence, speech pathologists are tending to provide Hanen at Home programmes individually, which is more expensive and less effective than group delivery models. .

Another example is the provision of Key Word Signing (KWS) group workshops. KWS workshops are valuable for parents of children with communication difficulties. The introduction of the NDIS has meant that:

• KWS organisations in each State have needed to become a registered NDIS provider
• Attendance at a workshop has needed to be specifically included in a plan for prospective attendees
• The workshop providers need to get the names, dates of birth and NDIS number for all NDIS Participants prior to determining if it is viable to run a workshop in a particular location (due to numbers needed)
• To claim payment, the provider is required to create a service booking for each Participant, and then make a claim for payment against each Participant through the Portal.

In South Australia, issues with gaining NDIS registration (because of a requirement for all providers, who were providing a workshop to adults in a public group based setting, to provide evidence of their working with children clearance) has meant that KWS providers have waited over 12 months and are still unable to claim for payment for KWS Workshops.

These administrative barriers restrict the ability of the NDIS provider market to provide an evidence based intervention in an effective, efficient, high quality format – as had occurred within the previous disability systems across Australia.

Travel costs

The Intermediate Report of the Evaluation of the NDIS acknowledges that there are concerns in the sector regarding the funding of therapist travelxi. The NDIS decision to cap the funding each therapist could claim for travel has led to a range of access issues and administrative challenges for speech pathologists. It has led to reduced frequency of appointments for many rural and outer metropolitan Participants.

Funding rules and decisions relating to travel are emerging as a critical ‘pain point’ for speech pathology providers in the NDIS – with significant implications for the supply of speech pathology services to rural and remote areas. The allocation of travel costs does need to be balanced with the need for financial sustainability of the system but also needs to be considered in relation to the principles of choice and control upon which the NDIS is based. The way in which funding decisions regarding travel are impacting on speech pathology providers and Participants is complex and varied and needs immediate inquiry by

the NDIA to resolve issues and to develop consistent and practical solutions to determining travel allocations.

“I am in regional SA and my staff travel about 150km radius further out from our town. So far we have had to quote for travel under four different methodologies one of which I was told about by phone while traveling with nothing provided in writing. We have had to purchase cars and the NDIS are poor at processing and adding travel quotes to plans. We are currently owed over $11,000 in outstanding claims most related to unresolved travel quotes. We have been told by one office in the NDIS - you need to quote like this … and when we do the quotes they are rejected by another office. It is wasting so much admin time! I would estimate we spend 20 hours a week chasing up rejected claims and that is all time we cannot recover financially. We have an almost full time staff member primarily chasing up rejected claims. The NDIS also take weeks to reply to queries - other providers are making service bookings that take up our therapy time with their travel time that hasn’t been added to plans - so even for local participants without travel for us we are having to suspend services. The latest thing is assuming we are seeing a number of clients in a location and the NDIS only allocating a shared portion of travel - so we would have to make sure all kids were attending before we could make every trip which is just unworkable.” Rural SA speech pathologist

Market Readiness

It is encouraging to see a focus on the NDIS Provider Market in the Productivity Commission’s Issues Paper. To date, it is the experience of Speech Pathology Australia that the focus of the NDIS has primarily been on the Participant side of the Scheme with very little investment of focus on the Provider side – particularly in the case of allied health providers in the NDIS market.

There is a lack of data about speech pathology services funded through NDIS released by the NDIA. This would be welcomed as it would allow the sector to explore ways to address the significant workforce shortages for this small but critical component of the NDIS system. The Intermediate Report of the Evaluation of the NDIS indicates that speech pathology is a significant unmet demand in the NDIS.

In order to ensure a viable speech pathology provider market, significant and targeted efforts will be needed to encourage speech pathologists to remain in, and enter the market. We offer comment relating to the nature of the challenges experienced by the speech pathology workforce within the NDIS to date and how these are, and will impact on costs and delivery of services within the NDIS.

“The pros - more kids are getting services - that’s it, the cons - the admin requirements, the constant change, the poor or complete lack of communication and cover ups when things go wrong from their end (eg the endless comment that it was provider error when the portal didn’t work). We had three small private practices near us two years ago and they have passed their clients on to us when the owners have gone on maternity leave with one not returning, one possibly returning and one to make up their mind. I am pretty sure it’s the stress put on by NDIS that is causing them to not return - it is almost impossible to manage the admin load as a small practice”.

What factors affect the supply and demand for disability care and support workers including allied health professionals?

Speech Pathology Australia does not envisage a reduced demand for speech pathology services as the NDIS fully matures. As such, our response is focused on issues affecting the supply of speech pathology services to the NDIS provider market – given that this is already acknowledged to be an areas of service provision where there is an unmet demand.

The key factors affecting the supply of speech pathology services in the NDIS are:

1. Concern regarding the ability of the NDIA to pay for speech pathology services rendered
2. The registration process for speech pathologists
3. Prevailing attitude towards the NDIS by the speech pathology workforce
4. Lack of clinical governance arrangements within the sector
5. The training pipeline for speech pathologists and lack of systemic support for clinical placements
6. The lack of systemic support for the supply of speech pathologist services to rural and remote Participants
7. NDIS funding models that do not support best practice or evidence based therapy
8. Demand from other sectors for speech pathology services
9. Presumption by the NDIA that National Disability Services represents the speech pathology workforce

It is important to recognise that most of these factors influencing supply of speech pathology services to the NDIS market were identified a number of years ago. In fact, the Senate Community Affairs References Committee held an Inquiry into the prevalence of communication disorders and speech pathology services in 2013-2014 and recommended that:

Recommendation 5: The committee recommends that the federal Department of Health work with the National Disability Insurance Agency to develop a position paper on the likely impact of the National Disability Insurance Scheme (NDIS) on speech pathology services in Australia. The paper should consider:

• the possible impact of the NDIS on the demand for speech pathology services in Australia, and the likely drivers of this demand;
• the need for greater numbers of trained speech pathologists as a result of increased demand for speech pathologist services arising from the introduction of the NDIS;
• the need for the speech pathology profession to develop telehealth practices to cater for NDIS participants requiring speech pathology services; and
• concerns that the withdrawal of State funding for speech pathology services in anticipation of the NDIS may leave some people worse off if they are ineligible to become an NDIS participant.

It is disappointing and frustrating that three years since this recommendation was made, the Australian Government has not released a response to the Senate Inquiry. Without government support and NDIA collaboration, Speech Pathology Australia has had limited capacity to progress work on these important issues.

1. Concern regarding the ability of the NDIA to pay for speech pathology services rendered

The breakdown of the NDIS My Place Portal in June – September 2016 had a profound and negative impact on the existing speech pathology NDIS workforce and has discouraged the remainder of the speech pathology workforce from entering the NDIS provider market.

During the My Place Portal problems, speech pathologists were restricted from lodging claims for payment of services due to technical problems associated with the setup of their provider accounts or the setup of the participant’s accounts. For example, speech pathologists were listed as ‘social workers’ and therefore unable to claim for speech pathology services, Participant plans were not entered into the system or were inaccurate or lapsed, transdisciplinary plans (especially for young children) were unable to be claimed against by providers of different clinical disciplines (e.g a speech pathologist and an occupational therapist).

The impacts experienced by speech pathologists during the My Place Portal problems were reported to include:

• Not providing any NDIS funded services to NDIS participants
• Restricting service provision to only self-managed NDIS clients to avoid interacting with the NDIA
• Limiting service provision to only those Participants where a disruption in therapy would severely compromise clinical outcomes (e.g. newly diagnosed young children).
• Speech pathologists cancelling clinical sessions during business hours in order to receive 1:1 training by NDIS technical support to try to resolve issues. Advice outside of business hours was not possible in the early stages of the Portal problems.
• Business owners reduced clinical hours of staff, stepped staff down without pay and let go of speech pathology staff due to cash flow problems
• Mental health impacts due to the financial stress were reported to Speech Pathology Australia by some members
• Significant investment was made in additional administrative support to try to resolve the payment and technical issues. At one point, 67 speech pathologists reported to Speech Pathology Australia that in a one week period they had collectively spent an additional 604 hours in administrative time. At an average hourly rate of $143 per hour in private practice – this reflects an opportunity cost of $86,000 in one week alone that these speech pathology providers spent in trying to deal with these administrative issues rather than providing services.
• Significant financial distress for business owners. At least one sole speech pathology provider ceased operating entirely and others reported need to take out overdrafts/loans to cover business expenses.

At one point over a million dollars was owed to just 100 of our members. The problems disproportionately affected small scale allied health NDIS providers – predominantly speech pathologists and occupational

“As of today I have sent 29 e-mails and have been paid once since the start of June (I am an existing provider). Since last Wednesday I have sent 7 e-mails and spoken to one person in Melbourne and another in Brisbane from the NDIA. Since Monday I have had one person, from the Department of Human Services actually ringing me. I have had 2 separate hour long phone calls with her and despite her intensive assistance, my claims will still not go through the provider portal. I am going to a session at the NDIA to try and get this sorted tomorrow. So just this week it has taken up at least 6 hours of non-paid time with no payment. I do not have words to express my feelings over this level of incompetence. I am a speech pathologist not a spreadsheet analyser. I love working with the kids I see who are truly at risk and have very complex family lives. My problems are nothing to the children I see. They are the reason I persist – otherwise I would have stopped seeing them long ago:” – NDIS Speech pathologist provider during Portal problems in August 2016

therapists. Only after intervention by Assistant Minister Prentice were concerns regarding payment problems for speech pathologists addressed by the NDIA.

The Intermediate Report of the Evaluation of the NDIS states that ‘reports were also provided of allied health professionals disengaging from the Scheme due to issues with pricing and best practice”xii.

Reports from Speech Pathology Australia members who are NDIS providers indicates that some of those providers are restricting the proportion of their businesses that is funded via NDIS (in order to safeguard their financial viability in the case of further payment problems) rather than ceasing to provide NDIS funded services altogether.

“I am quite stressed about my financial situation. Normally I would find admitting this embarrassing but I am realizing that I am far from alone. For me personally I have had personal issues that make the experience with NDIS payments more traumatic (I’m sure I am not alone either), until recently and I was the sole income earner in my household. I have exhausted savings and had to draw out of my mortgage to cover my business expenses, including payments to contractors and tax. NDIS participants are not the sole income of the practice but make up a significant enough portion for the payment issues to have had an enormous impact.”- speech pathologist provider during Portal problems in August 2016

However, the largest and long term impact of the payment problems is on the remainder of the speech pathology workforce who are now reluctant to enter, or are delaying entering the NDIS provider market as they mistrust the ‘system’ to pay for their services. In a market economy, a fundamental principle of payment for services has been undermined. This is in contrast to other funding streams for private practice including the MBS, aged care funding, private health insurance and fee-for-service that have not experienced these type or scale of debtor issues. As such, significant and targeted efforts will be needed to encourage the remaining speech pathology workforce to enter the NDIS market.

2. The registration process for speech pathologists

The majority of private speech pathology practices are small or sole trader organisations, with limited infrastructure and resources. This is especially true for those newly established and/or newly providing supports to Participants in the NDIS. While it is important that there are safeguards and standards in place to ensure that services provided to people with disabilities are safe and of high quality, there is a concern of the impact of regulation on the small private speech pathology providers. To retain the capacity of Participants to choose their provider of speech pathology services, it is critical that whatever quality and safeguarding requirements are put in place do not restrict the entry of new speech pathology providers, and do not undermine the sustainability of these small private practices.

It is the view of Speech Pathology Australia that allied health providers (particularly those in the self-regulating professions), have endured the most significant impacts in the NDIS provider market due to inadequate, ill-informed and ill-advised decisions and poorly designed provider registration processes within the NDIS. The problems experienced with provider registration appear to stem from a lack of awareness (or prediction) by the NDIA of the extent to which private practice allied health providers would enter the NDIS provider market particularly as the providers of supports to children in early intervention.

From the outset, information about provider registration on the NDIS website has been incomplete and difficult to interpret for allied health private practitioners (and arguably, other potential providers). When States and Territories transitioned to be responsibility for ‘credentialing’ of NDIS providers registering in their jurisdiction, it became even more difficult for potential providers as they tried to match the supports that they wanted to register for, with the corresponding services as described in the quality and safeguarding frameworks for the individual States and Territories.

Many speech pathologists, all tertiary trained professionals whose work demands a high level of language decoding skills, despaired at being able to understand the requirements for provider registration as were outlined on the NDIS website.

States and Territories (and the NDIA) failed to recognise and discriminate between the levels of governance appropriate to ask of community based allied health practitioners (who were part of a self-regulating profession), and large early childhood intervention services /specialist disability services (often legacy providers). The same type and level of quality and safeguarding requirements were required from both, despite the significant differences in regulation already in place, and the different level of risk for participants of the supports being offered. The problems with registration were exacerbated, and solutions made more difficult to achieve, as a result of the ‘transdisciplinary support’ item being the only support item included on plans for children in early intervention that allied health providers were able to claim against. This meant that small, community based private practices were required to demonstrate that they met the Disability Standards in the same way and at the same level as large organisations which were, in fact, providing a ‘specialist disability service’ - simply because both were deemed to be providing the same ‘transdisciplinary’ NDIS support. Registration requirements were not risk adjusted, not tailored to the size of the organisation seeking registration and lacked a recognition (or acknowledgement) of additional safeguards already in place for some allied health professions.

Of note, registration requirements for allied health practitioners from professions currently regulated by government under the Australian Health Practitioner Regulation Agency (AHPRA) were different from the comparable professions who are recognised to self-regulate appropriately and do not require registration under APHRA. Registration with APHRA for Occupational Therapists in SA was accepted as the requirement for NDIS registration however CPCP membership of Speech Pathology Australia was not and speech pathologists were required to meet significant additional (and burdensome requirements). Certified Practising Speech Pathology (CPSP) membership is the equivalent to APRHA registration for speech pathologists and is recognised by Medicare, all Private Health Insurances, Department of Veteran Affairs, BetterStart for Children with Disability and Helping Children with Autism Package as the credential required to be eligible to provide services under these funding streams. This situation is still the case in South Australia.

The registration requirements differ in each jurisdiction, depending on which support items were being registered for by speech pathologists. The requirements have now also varied over time. South Australia, New South Wales and Victoria have presented the greatest difficulties for speech pathologists to register as NDIS providers. Speech Pathology Australia had advocated to Ministers for Disability in each of these States on behalf of members to try to streamline the registration processes.

The difficulties experienced by speech pathologists in registering as an NDIS Provider in VIC, SA and NSW have acted as a disincentive for the speech pathology workforce to enter the NDIS provider market. A detailed outline of the barriers experienced in the various jurisdictions is provided below.

In NSW, it became apparent that the difficulties and confusions with registering as a NDIS provider had arisen out of the lack of a shared understanding between the NSW Department of Families and Communities and the NDIA about what constituted ‘therapeutic supports’. There was a lack of shared understanding about whether ‘therapeutic supports’ could be offered as an independent NDIS support (for any Participant regardless of age) or if for children aged 0-7, therapy needed to be included as part of provision of supports in early childhood early intervention stream (and therefore must be included as part of the Early Childhood Supports cluster of supports). The interpretation of the definitions is important because it was the basis for decisions made about what types of NDIS supports speech pathologists could seek NDIS provider registration for in NSW.

The interpretation of the NSW requirements by the NDIA led to a situation where small sized speech pathology providers (solo or small group speech pathology practices) were required to undertake Third

Party Verification (TPV) of their compliance with the Disability Standards, as per the requirement for Early Childhood Intervention Services. This TPV required an independent audit of the practices systems and processes that is more appropriate for larger disability organisations than for single discipline small practices. Information from speech pathologists who were required in 2016 to undertake a TPV process was that the TPV was:

• Administratively burdensome and onerous for small private/solo practitioners
• Of significant direct cost (with estimates between $2000 and $4100 provided as examples of direct costs incurred) to meet registration
• Delays of between six and 18 months to be ‘verified’ were experienced/quoted to our members.
• TPV acted as a significant disincentive for speech pathologists to apply to be NDIS providers.

Only after advocacy by Speech Pathology Australia to the NSW Minister for Disability was this issue clarified and agreement made between the NSW DoFC and NDIA to exempt solo small allied health providers from TPV requirements as long as they hold CPSP membership of Speech Pathology Australia. This clarification still took months to confirm. During this time, speech pathologists did not register to become NDIS providers in NSW. Significant damage was done to the reputation of the NDIA amongst NSW speech pathologists as many considered the TPV requirement and months it took to receive clarification from the NDIA– to have been avoidable had there been appropriate consultation with allied health professional associations. A number of speech pathologists in NSW have advised Speech Pathology Australia that they will no longer be seeking to provide services to children under NDIS, despite having previously provided the same services under HCWA or BetterStart programs.

In SA. little progress has been made on streamlining the requirements for NDIS registration for speech pathologists in private practices. Again, requirements of the SA Government are that speech pathologists seeking registration as NDIS providers are required to undertaken a significantly onerous process. Allied health practitioners who are registered with APHRA are not required to undertake this process. Speech Pathology Australia has been in communication with staff of the Disability Ministry in SA for over 12 months attempting to find a solution to remove this barrier to registration for speech pathologists and to streamline the process – to no success. Over this 12 months, no progress on this issue has been evidenced within the Department and speech pathologists seeking to register as NDIS providers in SA are still required to undertaken a burdensome registration process (in lieu of demonstrating CPSP membership of SPA in the same way that registered allied health practitioners can demonstrate AHPRA registration). This is acting as a significant barrier to increasing the speech pathology workforce in SA (particularly those that would provide services to adults).

In Victoria, issues with provider registration emerged at the commencement of transition to full scheme, and are similar to those in NSW. Small allied health practices wishing to register to provide early childhood early intervention supports within the NDIS in community based settings are being required to undertake a self-assessment against the Disability Standard in the same way as is being required of specialist disability providers. The Victorian Government has acknowledged in writing to Speech Pathology Australia that it is inappropriate to expect the same degree and level of compliance with the Standards for small allied health practices and solo practitioners, but has not yet provided useful guidance or examples of what will be required to register as NDIS providers of ECEI supports. At this point in time, it appears that speech pathologists in Victoria will be require to undertake a TPV like audit process, carried out by organisations approved and endorsed by the Victorian State Government, and paid for by the provider. The experience of TPV in NSW acted as a barrier to NDIS registration for speech pathologists and is likely to further constrict the development of the speech pathology provider market within Victoria.

The impacts of the various barriers to NDIS registration for speech pathologists are varied. Widespread impacts reported to Speech Pathology Australia include:

• Costs of the registration process act as a significant disincentive to apply to be registered – particularly for solo, part time practitioners
• The continuity of existing therapeutic relationships between practitioners and children and their families is compromised when the verification/registration process is delayed. Families either have to seek out an alternative NDIS approved practitioner with which to continue therapy (if they can access one) or they are unable to use NDIS funds if they wish to continue to receive services from the speech pathologist they have been seeing prior to the introduction of the scheme.
• Increasingly families with children with NDIS plans are being ‘turned away’ by private practitioners who are awaiting the verification/registration process or who are not entering the Early Childhood Support NDIS provider market due to registration barriers.
• Some speech pathologists are reluctant to register at all to be an NDIS Provider – despite many of these practitioners being currently approved providers under the BetterStart and HCWA Commonwealth disability funding streams.

The recently released NDIS Quality and Safeguarding Framework offers hope of a reasonable and appropriate level of governance of speech pathology service provision within the NDIS, requiring Continuing Practising Speech Pathologist (CPSP) membership of Speech Pathology Australia, professional indemnity and public liability insurance and evidence of working with children and/or vulnerable persons checks. This appears to recognise the level of self-regulation of the speech pathology profession and the low level of risk around the services typically provided. However, even with this, the Quality and Safeguarding Framework, despite using a sole trader speech pathologist as an example of a provider who would have the requirements as described above, there still appears to be ambiguity about what may actually be required, in relation to the provision of Early Childhood Supports. These are included in the list of complex supports, and therefore requiring specific practice standard modules. There would appear to be a real risk that the same difficulties experienced by speech pathologists registering in the States and Territories could be repeated under the national framework.

Despite the problems being experienced in multiple states under jurisdictional registration requirements that have acted as significant barriers to the development of an NDIS speech pathology provider market – the NDIA and the relevant Government Departments have demonstrated little, if any, interest in engaging with Speech Pathology Australia to find solutions to these barriers that balance the needs for quality and safety safeguards and a need to ensure a viable speech pathology provider market.

3. Prevailing attitude towards the NDIS by the speech pathology workforce

As the representative and self-regulatory body for speech pathologists in Australia, Speech Pathology Australia has invested significant member resources in support for members working within the NDIS and in policy and advocacy relating to the NDIS. Speech Pathology Australia is fortunate to have members who by the nature of their training are ‘expert communicators’. As such, hundreds of members have made contact with Speech Pathology Australia over the past four years to detail their experiences of, concerns about and hopes for the NDIS. Members also avail themselves of various collegial networks and communication forums to share their experiences of working with the NDIA and with NDIS Participants.

Speech Pathology Australia is confident that the following statements accurately reflect the prevailing attitudes of speech pathologists to the NDIS (both those registered as providers and those that are potential providers). This prevailing attitude to the NDIS acts as a caution, if not an outright disincentive for speech pathologists to remain in, or enter the NDIS provider market.

Current prevailing attitude of speech pathologists to the NDIS is:

• The NDIS is a welcomed and transforming reform for the disability sector
• NDIS supports offer life-changing opportunities for Participants and will lead to improved outcomes
• The NDIS roll out has witnesses a substantial increase in demand for speech pathology services across the country for NDIS Participants in all age ranges
• The NDIS roll out has improved access to speech pathology services, particularly for some children in the ECEI stream
• NDIS processes are not communication accessible – and by design are not easy for a person with communication disability to engage with and use.
• The NDIA staff (and as evidenced by NDIS processes) demonstrate little understanding of and respect for speech pathology expertise and how practitioners help Participants achieve their goals. There has been very little interest shown by the NDIA in improving this knowledge of their staff about this support.
• The attitude of NDIA staff (and as evidenced by NDIA processes) presumes that speech pathologists as ‘providers’ only consider their finances first and foremost and not the needs of Participants.
• Administrative processes required by the NDIA for speech pathology providers are overly burdensome, require significant and ongoing financial investment and can compromise the financial viability of private practices (both small and large).
• Speech pathologists in private practice should consider the opportunity cost of providing services to an NDIS Participant (including unpaid administrative time) with providing services under other funding streams (including MBS, private health insurance and fee-for-service) to other clients.
• Private practitioners should be careful not to allow too high a proportion of their income to NDIS Participants, lest payment delays and problems compromise the financial viability of the practice.
• Current registration requirements for NDIS supports in some states and territories of Australia are overly burdensome and inequitable when compared to allied health professions regulated through AHPRA. Tertiary educated speech pathologists who by the nature of their training have university level skills and education in disability services feel affronted that some State/Territory Registration processes do not acknowledge outright this qualification in their registration processes.
• Current registration processes for some NDIS supports (including those under the ECIS stream) are not appropriate when applied to single-discipline therapy supports (such as a small private speech pathology practice).

4. Lack of clinical governance arrangements within the sector

As an allied health profession, speech pathology relies on systems and structures in place to ensure that care provided by practitioners is evidence based, safe and of high quality. Clinical governance is an overarching term encompassing a range of activities that ensure provision of safe, high quality clinical services. Activities which can be considered part of clinical governance frameworks include clinical supervision, development and support for clinical practice guidelines and standards, transfer of evidence into practice, training and professional development, support for research, quality auditing, facilitating innovative clinical interventions, collection of clinical data and outcome measures.

Prior to the NDIS, provider organisations in the disability sector were responsible for identifying areas that require a higher level of skill and experience than that possessed by a new graduate or early career speech pathologist. Examples include some organisations requiring speech pathologists to be credentialed for the prescription of AAC for clients or to conduct mealtime assessment for individuals with multiple disabilities. In some cases, larger provider organisations provided support for the development of these more advanced competencies not only for their own employees, but across the sector. Practitioners who were new to the disability sector were able to access support to develop their competencies from more senior and experienced speech pathologists through training, professional development and supervision, including in areas identified as advanced practice within a specific organisation and across the sector.

The introduction of the NDIS has negatively impacted on the availability of clinical governance systems in allied health service provision across the disability sector. Organisations which have previously offered these clinical governance activities (government and not for profit providers) are moving out of service provision. Existing provider organisations that prioritised provision of support for development of more advanced competencies have lost (or are at risk of losing) the funding to provide these types of activities. It is unlikely that these type of activities supporting clinical governance will meet the criteria for funding under the NDIS Information, Linkage and Capacity building supports.

The lack of clinical governance systems within the NDIS provider market means that the quality of service provision and outcomes for NDIS Participants will be compromised as implementation of the scheme progresses. Speech pathologists, like any other health professional, expect to work with the support of an established clinical governance system to ensure their practice remains safe and of high quality. The absence of clinical governance systems acts as a disincentive for practitioners to enter the NDIS provider market.

It is critical that this issue is acknowledged if the speech pathology provider market in the NDIS is to be retained or expanded. Options need to be explored and developed to ensure continued availability of the clinical governance structures and systems required to maintain provision of high quality speech pathology interventions for people with disabilities. Such a system is needed in order to support practitioners to identify and develop the more advanced competencies that they require, including in any areas identified by the sector as requiring more specialised skills or as advanced practice. This may require a cross-programme solution with the establishment of Chief Allied Health Officers in each discipline within the Department of Health or Social Services to address these issues across disability, health, aged care and education.

Speech Pathology Australia would welcome the opportunity to work with the NDIA to explore options to enable the establishment of a sustainable system to provide clinical governance for speech pathology service provision as part of the roll out of the NDIS.

5. The training pipeline for speech pathologists and lack of systemic support for clinical placements within the disability sector

There has been an increase in the numbers of undergraduate and graduate level training programs for speech pathology over the past decade. While this may be positive for the potential speech pathology workforce across Australia, it has created pressure for the provision of clinical education placements overall. At the same time, the introduction of the NDIS has led to a reduction in the number of clinical education placements in the government disability sector. There are a number of factors that have contributed to this, including:

• A shift of service provision from the government sector and large established NGOs to private practice, which does not have capacity or support for clinical education placements.

• The NDIS pricing and rules regarding funding of services has created barriers to the provision of clinical supervision for speech pathology students on placements with NDIS provider organisations (including private practice).
• Financial pressures associated with the changed funding model impact on the ability and willingness of organisations to support clinical educational placements for speech pathology students.

Speech Pathology Australia is aware of activities being undertaken within a number of the jurisdictions to try to address the demand for speech pathology clinical education placements – however these are ad hoc and usually within the health sector and not part of a broader NDIS workforce initiative. Support is needed at a national level, from the NDIA, to facilitate an efficient, cohesive and consistent approach to workforce planning for speech pathology (including clinical placements).

6. The lack of systemic support for the supply of speech pathologist services to rural and remote Participants

There is a long history of challenges with the provision of allied health supports in rural and remote areas. Like all health professions, there exists a maldistribution of speech pathologists across Australia with the vast majority residing in urban centres in the east coast states. The NDIS has only added to and exacerbated the challenges for supply of speech pathology to rural and remote Australians.

As well as the persistent and significant issues around recruitment and retention of speech pathologists to rural practice, the NDIS has created additional barriers to supply. For example, the shift to individualised funding through the NDIS has impacted on the availability of a ‘critical mass’ of consumers in rural centres as well as outlying and remote areas, for existing health and/or education sectors. The viability of private practice located within rural and remote areas that focuses solely on NDIS Participants is highly questionable – and as such, rural and remote speech pathologists need to offer services to a generalised case load (e.g. non-NDIS funded clients). In these cases, competition from other funding sources for their services as well as a range of current administrative rulings and practices within the NDIS (e.g. funding of travel) will act as a disincentive for rural and remote practitioners to enter the NDIS provider market.

The NDIS has also disrupted well-established and effective mechanisms of localised collaboration between allied health and disability service providers. These collaborations (both formal and informal) have in the past acted to allow for the provision of services to more sparsely populated areas where the community may have a broad spectrum of needs across health, education and disability. Examples include ‘hub and spoke’ models of service delivery, collaborative models of service provision (involving regular visits by specialist disability service providers), a negotiation with local providers about roles and responsibilities and consistent capacity building and transfer of knowledge and skills, some services provided in metropolitan, opportunities for ‘exchanges’, provision of training and coaching to local providers etc.

Employment conditions and contracts in public sector organisations in rural areas may create a barrier to entry to the NDIS provider market for rural practitioners. For example, the ability for allied health practitioners to work privately through the NDIS as well as being an employee of the health or education sectors within rural settings. A ‘critical mass’ of demand may not exist in many rural areas – either to accommodate a full time speech pathologist within the local health service, or within the Department of Education, or within private practice servicing NDIS Participants. A speech pathologist in a rural area may need to work across all these funding streams – however often contractual arrangements with Government health and education services will preclude also working in private practice.

Unlike medical and nursing health professions, speech pathology has not been provided with government support to incentivise rural practice.

7. The number and distribution of practitioners with specific skills specialisations

In some areas of clinical speech pathology focus and/or for some populations of NDIS Participants, there is a need for further development of specific and additional professional competencies in the speech pathology workforce. For example, specialised speech pathology skills and knowledge are needed to effectively work with children and adults with lifelong disabilities and complex dysphagia. As discussed previously, well-established (clinical governance) systems were in place in previous disability systems to support the the development of these additional competencies within practitioners. Similarly, systems were in place in the jurisdictions to identify people with disabilities who needed to access these services and referral and clinical pathways were established to enable appropriate and timely access to these specialised speech pathology services.

The ‘systems’ that encouraged and supported the supply of specialised speech pathology services to those people with disability who require them has been disrupted by the NDIS. There are currently no system-wide processes or structures supported by the NDIA to identify these issues and to support access to specialised speech pathology expertise.

Rulings regarding NDIS payment for travel by providers further restricts access to these specialised speech pathology services to NDIS Participants who need them. Defining strict limits for payment for provider travel in all Participants plans and not allowing flexibility in travel expenses for individual Participants means that Participants who required the services of a speech pathologists\ with specialised expertise may not be viable to purchase within the parameters of the funded plan if that practitioner is located a significant distance away from the Participant.

“My issue with rural services is that, as the only speech pathologist in my area I am getting referrals for much more complex children than I used to. I am having to quickly skill myself up in AAC that is more than an iPad and ProLoQuo2Go. Once upon a time I could have called on the assistance of an ADHC NSW therapist, but now they are my competition. Now I am trying to provide the service in consultation with suppliers who really want to sell you their product” — Rural NSW speech pathologist

Complaints around travel costs are seen by the NDIA to reflect an issue around the ‘business model’ determined by providers – with the implication that travel limit allowances should be sufficient to enable choice and control for Participants and that the provider market will adapt business practices in order to secure the purchase of their services by NDIS Participants. In the case of specialised services (and in the case of rural and remote participants) the lack of flexibility regarding payment for provider travel will facilitate a market failure in accessing specialised supports.

This lack of flexibility in payment for provider travel is creating a market context that leads to a lack of access for participants to services, a requirement on participants to travel to access providers (which may be contrary to evidence based practice for that particular person) or the provision of services which are outside of the personal/organisational scope of practice of the provider. All of these circumstances undermine the principals of ‘choice and control’ for NDIS Participants who require specialised speech pathology expertise.

It is the view of Speech Pathology Australia that a market approach to disability service provision will not provide the environment for which these specialised workforce will be retained or further developed. NDIS Participants will not have choice nor control over the speech pathology services they wish to purchase

with the NDIS funds if those services are not in existence within the accessible provider market. Specific, targeted workforce initiatives supported by the NDIA are needed to ensure that this component of the provider market of speech pathology services is available to meet the needs of NDIS Participants who require specialised supports.

8. NDIS funding models that do not support best practice or evidence based therapy

It is understood that the introduction of the NDIS is a transformational change to service provision for people with disabilities in Australia and that the concept of learning from the Trial sites in order to inform transition to full scheme was both appropriate and necessary. Unfortunately, some of the processes and practices that were part of the initial implementation of the NDIS Trials have in fact created barriers to the provision of efficient, effective, evidence based interventions. Speech Pathology Australia is concerned that these processes and systems will be retained in the longer-term design of the Scheme and will act as a disincentive to evidence based therapy practice and in doing so, will discourage speech pathologists from entering the NDIS provider market. This is particularly the case in relation to the ECEI Approach.

Speech pathologists are evidence based allied health practitioners and are concerned that the NDIS funding model actively discourages evidence-based speech pathology interventions.

Early Childhood Early Intervention

The assessment and identification of ‘speech, language and communication developmental delay’ in comparison to ‘developmentally based disability’ is both complex and multi-factorial. The existence of multidisciplinary health teams to assess and diagnose indicates that it requires specific clinical skills and knowledge in the right combination in a team in order to determine this. Speech pathologists are routinely part of the multidisciplinary team within the health sector that determine diagnosis and functional needs of young children. Speech pathologists are routinely part of the multidisciplinary teams that determine the best options for intervention and therapy for a young child and their family.

The implementation of the NDIS has resulted in a range of issues around the provision of early intervention speech pathology services. These issues are many, intersectorial, in constant flux as the disability sector evolves with the roll out of the NDIS ECEI stream and vary in complexity depending on the jurisdiction and interaction with existing mainstream services. While some key issues are outlined below, the service delivery environment and the NDIS provider market for early childhood intervention continue to be dynamic and unpredictable, with further and different issues arising as transition to full Scheme progresses.

There are a number of impacts on the ability of the market to provide EI supports which emerged out of the early implementation of the NDIS and which continue to be the case today. The sector, including allied health providers with experience in Early Intervention (and in addition to the Early Childhood Intervention Services in Victoria, NSW and QLD) need to be consulted if sustainable and effective solutions to these and similar issues are to be achieved. To date, consultation by the NDIA with these stakeholders has been inadequate.

One of the key issues that is impacting on effective early childhood intervention services through the NDIS is the characterisation and championing with NDIS funding of ‘transdisciplinary’ early childhood intervention supports. This has a range of implications for evidence based speech pathology services.

Throughout the Trials and NDIS rollout, the NDIS has privileged the provision of ‘transdisciplinary’ practice for early childhood services. This ‘privileging’ included the labelling of the only support item under which Early Intervention allied health provision could be funded as ‘transdisciplinary support’. A lack of clarity about what was meant by ‘transdisciplinary support’ created confusion with Participants and providers. The information provided on the NDIS website about the use of transdisciplinary support was unclear and in some cases contradictory. Planners were unable to define what services and therapy could be accessed under ‘transdisciplinary support’. Despite the fact that allied health professionals

(including speech pathologists) were listed as appropriate to register for and provide this NDIS support, there was no consultation with the professional associations (including Speech Pathology Australia) about the evidence based for transdisciplinary practice within their clinical professions for young children. No consultation occurred with allied health profession representatives about how allied health service provision in early intervention would best be provided in order to be effective and efficient, how practitioners from the various clinical professions might work together to achieve outcomes for individual children or exactly what types of interventions and therapy could be claimed against this support item by NDIS providers.

Rather than being understood as a model of service delivery by providers that the NDIA wanted to encourage and promote, ‘Transdisciplinary Practice’ simply became a budget line item in children’s Plans.

Participants were not provided with any, or adequate support to be aware of or understand the principles of ‘transdisciplinary’ practice as espoused by the Scheme– even when it became understood across the allied health professions that the term when used by the NDIA was supposed to encompass all of the best practice components of early intervention service provision.

Neither Panners, Participants nor providers were supported to understand what ‘choice and control’ for participants actually meant when it was applied to the purchase of ‘transdisciplinary practice’ or how that might be ‘operationalised’ within the NDIS system. This has led to parents opting to contract with one larger provider in order to access as many face to face sessions as possible with allied health providers from various professions when group or environmental approaches may have been best practice and led to better outcomes.

All allied health service provision for children under six had to be claimed against the one support item (budget line) within the child’s NDIS Plan. Typically, this has occurred without any remuneration available to support aspects of service delivery that are core tenets of best practice early childhood early intervention – namely integration, interaction and communication between the various professionals providing therapy to the child. Evidence based and best practice components of early intervention have not been funded including the collaboration amongst ‘team’ members, the transfer of knowledge and skills within the team (including parents), the assessment and exploration of a child’s needs, the identification of priorities and planning for provision of a prioritised and coordinated series of interventions from a cohesive and cooperative team.

Issues have arisen around funding for travel by therapists, which has led to pricing rules being put in place by the NDIA which mandated against what, in some cases is best practice intervention. Current NDIS rules regarding travel funding acts as a disincentive to best practice interventions for children including home based therapy, parent focused supports and interventions, therapies provided by a team of collaborative EI providers.

In the absence of an opportunity to learn about and understand what the evidence is of best practice early intervention for children, and in a circumstance where they are provided with very limited options of NDIS providers that are registered to provide ‘transdisciplinary’ services - families have opted to use their funding to access the maximum number of individual, local (clinic based) allied health sessions that their funding would support. A model of individual therapy options is not best practice early intervention.

The ECEI funding rules for the NDIS also do not allow for family-focused therapy programs which have been demonstrated to be evidence based and effective. Some interventions recommended and provided by speech pathologists are group based and targeted at the ‘environmental’ level to meet the needs of a child. For example, interventions might be targeted at parents and other significant communication partners and supports in a child’s life to ensure that the ‘learnings’ from the therapy are reinforced and practiced within the family so that the child receives a large ‘dose’ of the support on a regular basis (more than can be provided within a time limited consultation session with a speech pathologists). These

approaches to therapy are consistent with family centred and family focused, capacity building principles of best practice early intervention. Examples include the Hanen ‘It Takes Two to Talk’ and ‘More than Words’ programmes, or Key Word Sign one day workshops.

Taken together, aspects of the planning process, support items and pricing, Portal design issues, requirements around registration for providers, service agreements, and lack of funding for coordination and planning have all contributed to create a situation where there exists significant barriers to the ability of the NDIS provider market to provide evidence based and efficient models of early childhood intervention.

Speech pathologists have reported extreme frustration and professional dissatisfaction as they struggle to negotiate for evidence based therapy with the NDIA for individual children, or have been simply unable to provide the evidence based interventions that would more likely meet the needs/goals of the children>

This frustration stems from a professional assessment that these evidence based therapies should be aligned with the NDIS principles but are unable to be accessed by children and their families due to barriers inherent in the supports, pricing and operational aspects of the NDIS.

It is understood that the decisions about what is reasonable and necessary needs to sit within the NDIS system. It is problematic however, that supports which could be and are deemed ‘reasonable and necessary’ and which are based on national and international evidence of effectiveness and efficiency in the various allied health professions are difficult to provide because of the limitations of the operational processes and structures put in place by the NDIS.

9. Demand from other sectors for speech pathology services

Like many other allied health professionals, speech pathologists are employed across the aged care, health and education sectors as well as the disability sector. The opportunities for employment across the various sectors creates additional pressures for recruitment and retention of speech pathologists to the disability sector and NDIS provider market. Challenges in recruitment and retention and in meeting the demand for speech pathology services within the NDIS has been evidenced in the recent intermediate report of the evaluation of the NDIS and in the National Disability Services’ most recent ‘State of the Disability Sector Report 2016’.

10. Presumption by NDIA that National Disability Services represents the speech pathology workforce

To date, the NDIA has largely engaged with National Disability Services (NDS) as the peak body representing non-government NDIS providers. Very few speech pathologists (or other allied health practitioners) are members of NDS – which tends to represent larger disability provider organisations (which may employ some allied health practitioners as part of their workforce mix but whom predominantly employ generic disability support workers/carers).

It is unclear if any individual speech pathologists in private practice are members of NDS.

Attempts to engage with NDS in workforce initiatives by Speech Pathology Australia have been unsuccessful to date.

In terms of workforce initiatives for the speech pathology workforce in the NDIS, the particular workforce needs of the profession (clinical governance, clinical placements, redistribution, early career support, promotion of NDIS as a viable private practice option etc) are unlikely to meet the eligibility criteria for applications under the NDIS Workforce Innovation Fund for workforce initiatives – which is being administered by NDS. A bespoke solution to speech pathology workforce needs for this small but critical component of the NDIS provider market is needed.

It is the view of Speech Pathology Australia that if progress is to be made in relation to workforce planning and addressing the increasing demand on supply of speech pathologists and occupational therapists to the NDIS, then the NDIA need to work specifically with the allied health professional peak bodies (Speech Pathology Australia and Occupational Therapy Australia) who are responsible for workforce planning and initiatives for their professions.

What scope is there to expand the disability care and support workforce by transitioning part-time or casual workers to full-time positions?

In terms of the NDIS speech pathology provider workforce, a focus on transitioning the largely part time workforce to full time positions is unlikely to make a marked impact on the overall supply of speech pathologists to the NDIS market. As a female dominated workforce, speech pathologists tend to work less than full time hours (across the profession, not just within the disability sector). The demand for speech pathology services already exists within the NDIS (and is currently unmet demand), thus within private practice the environment already exists to facilitate increased working hours for speech pathologists.

There is the potential for changed service delivery models to alter the employment trends of speech pathologists within the NDIS provider market (e.g. service delivery occurring outside traditional business hours, telepractice etc) – however it is unlikely that this would make a significant difference to the overall supply of speech pathologists to the NDIS provider market.

Workforce supply initiatives for speech pathology within the NDIS should address first and foremost the following systemic and structural issues raised in this submission, namely:

• Concerns regarding ability of NDIA to pay for speech pathology services rendered
• The registration process for speech pathologists
• Prevailing attitude towards the NDIS by the speech pathology workforce
• Lack of clinical governance arrangements within the sector
• The training pipeline for speech pathologists and lack of systemic support for clinical placements within the disability sector
• The lack of systemic support for the supply of speech pathologist services to rural and remote Participants
• The number and distribution of practitioners with specific skills specialisations
• NDIS funding models that do not support best practice or evidence based therapy (e.g. home based or school based services)
• Demand from other sectors for speech pathology services

What role might technological improvements play in making care provision by the workforce more efficient?

There is very strong evidence of the clinical efficacy of speech pathology services provided through tele-practice – but currently the NDIS does not consistently provide funding for speech pathology services delivered through telepractice. Speech Pathology Australia is aware of a few individual case examples where NDIS Participants have been able to have telepractice services funded after negotiation with the NDIA regarding their Plans. Access to funding of telepractice appears to occur only at an individual level with the NDIS, intermittently and variably.

Telepractice offers NDIS Participants in rural and remote areas of Australia access to speech pathology services that otherwise may not be available to them (due to thin provider markets). There are a number of excellent examples of telepractice speech pathology services in existence within the education and health sectors across Australia that act to improve access to services for rural and remote Australians.

Access to telepractice for speech pathology within the NDIS is complicated further by the registration processes requiring providers to register in each state and territory in which they wish to offer services. Coupled with the significant barriers to registration existing for private practice speech pathologists – there is little incentive to adapt models of service delivery to include telepractice to improve access to services for NDIS Participants who might benefit from alternative models of service delivery.

Tele-practice would also improve access for any NDIS Participant who requires specialised speech pathology expertise (even if they reside in an urban centre with better access to generalised NDIS Provider speech pathologists). This is a similar model that is funded within the Medical Benefits Scheme to improve access to medical specialists for patients who do not have easy access to medical specialisations.

System-wide funding and structural supports for speech pathology services via telepractice within the NDIS is recommended and could offer a key solution to addressing some of the issues with the supply of speech pathology services to the NDIS provider market.

What are the advantages and disadvantages of making greater use of skilled migration to meet workforce targets?

Speech pathology has long been considered a profession in shortage, with inclusion on Department of Employment skills shortage lists since 2000. However, since 2012, the profession has been rated as having ‘no shortage’ due to the increased number of applicants for positions – the profession has been ‘flagged’ for review by the Department.

Speech Pathology Australia recognises that there has been a large increase in the training of speech pathology students in recent years, and hence there has been a significant increase in the number of applicants for available positions, largely involving new graduates. However, across all sectors that speech pathologists work within, there can still be considerable difficulties recruiting to more senior roles, academic posts, and those requiring more specialised skills and knowledge, with these positions not being suitable for new graduates or early career speech pathologists.

Speech Pathology Australia assesses applications for recognition of overseas qualifications for speech pathologists. There has been a small increase in the number of applications in 2016 and 2017 however these reflect practitioners who have been working in Australia for a number of years (in government employed positions) who have not become members of Speech Pathology Australia but who are now seeking membership (and recognition of their overseas qualifications) due to the Certified Practising Speech Pathology (CPSP) credential being mandated for most government funding of speech pathology private practice services.

It is unclear if making greater use of skilled migration would actually increase the supply of speech pathologists to the NDIS provider market in any marked way. It is possible that targeted migration initiatives might go some way to filling ‘gaps’ in the provider market – particularly in senior roles and those with areas of clinical specialty – however without a focus on addressing the barriers to the speech pathology workforce in the NDIS outlined in this submission, there is no guarantee that speech pathologists entering the Australian market would choose to work within the NDIS (in comparison to health or education sectors).

Are prices set by the NDIA at an efficient level?

Current pricing for speech pathology services is adequate and currently competitive with other sources of government remuneration for speech pathology therapy services (e.g. Medicare, Helping Children with Autism Package or BetterStart for Children with Disability). However, NDIS pricing for speech pathology services needs in the future to be indexed to inflation in order to remain competitive for speech pathology private practice.

In terms of retaining the existing, and increasing the supply of, speech pathologists to the NDIS provider market, pricing is just one component of the system that influences supply. Pricing and funding rules relating to the following needs to be considered carefully as these all impact on the financial viability of private practitioners providing services to NDIS Participants (as well as larger organisations who employ speech pathologists as part of the multidisciplinary workforce). Consideration needs to be given to:

• Rules regarding funding of travel associated with the provision of speech pathology services to NDIS Participants
• Funding of administrative tasks associated with NDIS provision (unpaid administration time associated with payment processing, report writing etc)
• Funding of non-face-to-face NDIS Participant tasks (e.g. liaison with families/carers, schools, other NDIS providers etc)
• Funding for speech pathology services focused on capacity building of families and carers of individual NDIS Participants
• Funding for the provision of speech pathology therapy provided via tele-practice models
• Differential remuneration for specialised speech pathology supports (those that require significant levels of further competency development to enable efficient, high quality support provision)
• Funding of services provided under the direct supervision of a speech pathologist (e.g. provided by a student on clinical placement or an Allied Health Assistant).

“The time required to negotiate with the school and to meet the communication needs of these clients from the context of being a private sole provider are extremely difficult. NDIS funding underestimates the time required to support school aged children with AAC needs.” – SA speech pathologist

“We all went into the caring professions because we care. We still need to be able to run our businesses at a profit - we cannot run at a loss so they need to work with businesses to see if the decisions they are handing down around travel and price structures (eg can’t charge for non-attendance) are workable for us.” – SA speech pathologist

Recommendations

It is requested that the Commission consider the following recommendations:

1. That the NDIA have improved mechanisms to engage with representatives of speech pathology and other allied health providers by:
   • Inviting Speech Pathology Australia, Occupational Therapy Australia and the Australian Psychological Association to join the NDIS CEOs Forum
   • Employing a Chief Allied Health Officer within the NDIA to liaise with the professional bodies on issues impacting on access, quality and safety of allied health services within the NDIA market.
   • Ensure that allied health peak organisations are included in all ‘provider market’ forums and discussions.
2. That the NDIA partner with Speech Pathology Australia to canvass strategies to improve the supply of speech pathologists to the NDIS provider market (for the short and longer term).
3. That the NDIA and relevant jurisdictions work with Speech Pathology Australia in the immediate future to streamline and fast track the registration processes for qualified speech pathologists to register as NDIS providers.
4. That the NDIA work with the allied health professional bodies to develop an Allied Health NDIS Workforce Strategy including:
   • Clinical governance arrangements
   • Clinical education/training placements
   • Mentoring and supervision systems for early career practitioners
   • Skill distribution and specialisation considerations
   • Use of support staff (Allied Health Assistants)
5. That the NDIA recognise the variability of supports required for children with differing communication needs, and seek advice from Speech Pathology Australia to develop processes to determine reference packages for children under the Early Childhood Early Intervention approach.
6. That the NDIA recognise the variability of supports required for people with complex communication needs requiring Augmentative and Alternative Communication (AAC) and seek advice from Speech Pathology Australia to develop processes to determine appropriate guidelines for the funding of AAC.
7. Clarification be provided urgently regarding the roles, responsibilities and service delivery parameters of State/Territory Departments of Education and the NDIS in supporting students with disability. For national consistency, this could best be achieved through the COAG Education Council.
8. Clarification be provided urgently regarding the roles, responsibilities and service delivery parameters of State/Territory Departments of Health and the NDIS is supporting people with health and disability needs. For national consistency, this could best be achieved through the COAG Health Council

9. That the NDIA convene a rural NDIS forum (including Speech Pathology Australia, other peak allied health professional bodies and the National Rural Health Alliance) to advise on issues relating to the support of NDIS services in rural and remote part of Australia. Urgent issues to be addressed include sustainable solutions to funding of travel, access to allied health with specialised skills and telepractice arrangements.
10. Systemic changes to the Planning process be put in place including:
    • Review processes for eligibility determinations to be streamlined and fast-tracked
    • Minimum standards relating to the qualifications, skills, experience and knowledge of Planners to be mandated (and monitored)
    • Induction and continuing professional development training of Planners on the roles of the allied health professions providing services within NDIS
    • Review processes for Plans to allow for mid-cycle reviews so that Plans can be amended in light of changes in functional needs or in response to key transition experiences in a Participants life.
    • Quality assurance systems be established (and reported on publicly) for the planning process
11. That the NDIA release detailed data regarding services and supports being funded in Plans to allow for more nuanced workforce planning activities to be undertaken for allied health services which are based on evidence of demand.
12. That the NDIA have ongoing and targeted monitoring of funding of key workforce components (including speech pathology services) to ensure they are remunerated on a comparative basis with other funding streams for these services. This will assist in developing and sustaining a speech pathology workforce within the NDIS.
13. That an audit be undertaken of the NDIS planning process to determine if it is communication accessible for people with communication disability.

If Speech Pathology Australia can assist the Productivity Commission in any other way or provide additional information please contact Dr Ronelle Hutchinson, Manager of Policy and Advocacy

References cited in this submission

i Mavromaras, K., Moskos, M., and Mahuteau, S. (2016) Evaluation of the NDIS, Intermediate Report, National Institute of Labour Studies, Flinders University. Adelaide. Pg 31. ii Speech Pathology Australia (2011) Competency-based Occupational Standards (CBOS). Melbourne Vic. iii Australian Institute of Health and Welfare (2015) Disability Services National Minimum Data Set (DS NMDS) collection, accessed 28 February 2017, http://www.aihw.gov.au/disability-data-cubes/ iv iv Australian Bureau of Statistics (2012) Australian Social Trends – Using Statistics to paint a picture of Australian Society v Mavromaras et al (2016): Pg. XI vi Health Workforce Australia 2014: Australia’s Health Workforce Series – Speech Pathologists in Focus vii Australian Bureau of Statistics (2012) Australian Social Trends – Using Statistics to paint a picture of Australian Society viii Senate Community Affairs References Committee (2014) Prevalence of different types of speech, language and communication disorders and speech pathology services in Australia. Parliament House. Canberra. ix Mavromaras et al (2016): Pg XVII x Communication Access Network 2014 Annual Report, SCOPE, Victoria. xi Mavromaras et al (2016): Pg. 28 xii Mavromaras et al (2016): Pg 29