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Speech Pathology Australia’s Submission to the
Productivity Commission
National Disability Insurance Scheme Costs: Position paper
12 July 2017
Productivity Commission GPO Box 1428 Barton ACT 2600
Dear Productivity Commission
Speech Pathology Australia welcomes the opportunity to provide further 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 7700 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”. 1 Indeed, speech pathologists in private practice are increasingly 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.
As the peak body representing the speech pathology profession, we are eager to constructively engage with the National Disability Insurance Agency and governments to support the long-term viability of the NDIS. We have structured our feedback in response to relevant information requests in the position paper. We preface our feedback with brief information on communication and swallowing disability and the role of speech pathologists in improving outcomes for people with disability. We hope the Commission finds our responses helpful.
Yours faithfully
Gaenor Dixon National President
1 Mavromaras, K., Moskos, M., and Mahuteau, S. (2016) Evaluation of the NDIS, Intermediate Report, National Institute of Labour Studies, Flinders University. Adelaide. Pg 31.
Speech Pathology Australia’s Submission to the Productivity Commission’s Inquiry into the NDIS Costs - request for further comment
Speech Pathology Australia welcomes the opportunity to provide further 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 requests for further comment in the Position paper (June 201) 7.
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 Pathology Australia is the national peak body for speech pathologists in Australia, representing more than 7700 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 funding, Betterstart for Children with Disability and Helping Children with Autism programs. At present, the CPSP credential is required by some states and territories as a requirement for NDIS provider registration.
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).
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.
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.
Speech Pathology Australia’s response to relevant Position paper information requests
For ease of reference, the following section uses titles and textual excerpts as per the position paper.
Scheme eligibility
INFORMATION REQUEST 3.1
The Commission is seeking feedback on the advantages and disadvantages of maintaining ‘List D — Permanent Impairment/Early Intervention, Under 7 years — No Further Assessment Required’ in the National Disability Insurance Agency’s operational guidelines on access. Feedback is sought on the extent to which the list:
- reduces the burden on families to demonstrate that their child will benefit from early intervention and/or provides certainty that support will be provided
- reduces the burden on the National Disability Insurance Agency of assessing whether children are eligible for early intervention support under the National Disability Insurance Scheme Act 2013 (Cwlth)
- may be contributing to supports being provided to children who are unlikely to benefit from such supports
- may be discouraging or inhibiting exit from the scheme
It is Speech Pathology Australia’s position that List D should be maintained, at least in the medium term.
Speech Pathology Australia acknowledges the risks as described; that families whose children have a diagnosis on the list may assume that their child requires the provision of individualised funding on a long term basis, but would advocate that removal of the list not be considered until and unless:
- the pathways, both in to the Early Intervention (EI) partners, and, if appropriate, out to ‘mainstream’ supports are clear, accessible and well understood by both families, providers, mainstream partners and the NDIA.
- the criteria/processes for determining access to the individual funded supports, or a ‘Plan’ versus the EI Partner ‘open gateway’, as well as the criteria for determining:
- whether, and why, a child will be provided with ‘short to medium term supports’
- what are the anticipated outcomes of provision of short to medium term supports
- which children will be recommended for provision of individualised funding plans are clear, transparent and consistently applied.
- There is improved availability and access to information for families about concepts and practices involved in best practice EI, including; developmental approaches, the important role families can play in facilitating their child’s developmental opportunities, an understanding of participation and how this interacts with functional skills etc.
- supports for families are being provided within the best practice EI principles, whether from mainstream services, or EI partners, or NDIS providers.
Speech Pathology Australia believes that the benefits to families and to the NDIS, resulting from the relative ease and certainty of access for children on the list outweighs the potential risks as described.
The maintenance of the list, at least in the medium term, is of particular value given:
- families, mainstream services, the community and EI providers are still developing an understanding of the role of the EI partner, and the short to medium term supports that the EI partner can provide
- the need and opportunity to learn more about the impacts of a service provision landscape which includes Early Childhood Early Intervention (ECEI) partners, along with a more mature and ‘settled’ ECEI provider market
- the need for the broader ECEI sector to develop a greater level of knowledge and certainty about the role of the mainstream in providing EI supports to children
- families often report feeling anxious as are still developing their own coping strategies as well as their understanding of many of the concepts of best practice in early intervention, including the critical role for families in facilitating their child’s development. Having a sense of certainty regarding access to the NDIS EI partner can significantly ameliorate families experiencing stress and uncertainty as to whether they will be able to access the supports they believe they need
- the current pressures on the EI partners and NDIS planners, which are contributing to inconsistencies in decisions, are unlikely to be addressed in the short to medium term, and therefore anything that can provide for a more streamlined and efficient approach to access should be maintained.
Speech Pathology Australia has concerns about some of the assumptions reflected in the Position paper in relation to access to funded supports (i.e. a Plan) through the scheme, which are also reflected in some of the processes, and appear to have the potential to direct children away from the scheme.
It is disappointing to see the same criteria for (and barriers to) access to supports from the EI partner and/or access to individualised funds within the NDIS, that existed in the majority of previous state and territory disability services. These include:
- the assumption that access to funded supports, and the level of funding provided, should be based on the ‘severity’ of the child’s needs as assessed by the PediCat. The PediCat is not a sensitive enough tool to consistently and specifically identify children with delayed or disordered speech, language and communication development. It effectively demonstrates a bias towards a requirement for delays/difficulties on more than one domain, and also tends to over identify children as having mild versus moderate needs. The level of supports provided should be based upon evidence and best practice requirements to ameliorate the impacts of a child’s impairment on their developmental opportunities, and the potential to support them to develop into individuals who are contributing to and participating in society.
- an apparent lack of acknowledgement that for some children, early intervention can prevent them experiencing limitations on their developmental opportunities, and potentially reduce or prevent them developing a greater delay and/or more significant activity limitations and participation barriers over the medium to long term. This is the case for children with hearing impairment, and for those children with receptive and expressive language difficulties.
- the requirement, effectively, that children demonstrate impairments in two or more domains. Access requirements for early intervention services through the NDIS, as stated in the NDIS Act, only require evidence of delay in one domain. Recent ‘interpretation’ by the NDIS of the requirement that children’s delay must ‘result 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’ (Part 4, section 9, (c)) 2 appears to be leading to a requirement that children have delays or difficulties in more than one domain. This in effect discriminates against children whose only functional impairment is of receptive and expressive language.
2 National Disability Insurance Scheme Act 2013, https://www.legislation.gov.au/Details/C2016C00934
Requiring children to develop and demonstrate more significant delays and/or to have to be demonstrating social/emotional impacts arising from their communication difficulties, before offering early intervention supports, which include direct interventions funded through a Plan, contradicts the insurance principles of the NDIS.
It is also problematic if the needs of children with disability are seen as a Health or Education department responsibility as they would in effect be denied access to supports until they reach school age, unless parents can pay out of pocket costs to access timely and adequate supports. As with many other ‘diagnoses’, children with speech, language and communication needs are a heterogeneous group and therefore, the type of supports which are appropriate can vary greatly dependent on the child’s age and specific needs and difficulties.
Speech Pathology Australia sees the implementation of the NDIS as an opportunity to consider the following recommendations made by the Senate Inquiry 3 regarding the prevalence of speech, language and communication disorders, speech pathology services and the potential impact of the NDIS.
Recommendation 3 5.89 The committee recommends that the federal Department of Health work with the most relevant stakeholders to make an assessment of the financial cost, timeframe and research benefits of a project that maps language support services across Australia against the Australian Early Development Index information about vulnerable communities.
5.90 Pending an assessment of this proposal, the committee recommends that the federal government consider funding a project along the lines proposed. The findings of this research should inform future policy decisions to fund public speech pathology services in Australia. The findings should also guide private practitioners as to those locations where their services are most likely to be needed.
Recommendation 4 5.93 The committee recommends that the federal government provide funding and/or support for an appropriate research institute to conduct a thorough and systematic audit of the adequacy, strengths and limitations of existing speech and language services for children in Australia. The audit should consult with children’s health and education providers, including but not limited to early childhood education and care centres, primary schools, secondary schools, speech and language therapists and special needs coordinators.
5.94 The committee recommends that this research proceed as soon as possible. The research would provide a foundation for the federal Department of Health to conduct its work into paediatric speech and language disorders.
Recommendation 5 6.22 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.
The position paper should be circulated to key stakeholders for consideration and comment and to assist in decision making.
3 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
Speech Pathology Australia would happily contribute to the development of assessments to facilitate identification of the type and level of need of children with speech, language and communication difficulties and to support consistency around the decision making of the EI partners and development of evidence based clinical pathways for children.
INFORMATION REQUEST 3.2
The Commission is seeking feedback on the benefits and risks of maintaining ‘List A — Conditions which are Likely to Meet the Disability Requirements in section 24 of the NDIS Act’. In particular:
- to what extent does List A reduce the burden for people with permanent and significant disability of entering the National Disability Insurance Scheme under the disability requirements?
- is there any evidence that people who do not meet the disability requirements are entering the scheme under List A?
Speech Pathology Australia would support the maintenance of List A with an understanding that it should not be seen as representing a complete and exhaustive list of conditions which may qualify a person as meeting the disability requirements, and that people should not be excluded from the NDIS simply because they do not have one of the diagnoses on the list.
Speech Pathology Australia is unaware of anyone entering the scheme who does not meet the disability requirements.
Scheme supports
INFORMATION REQUEST 4.1
Is the National Disability Insurance Scheme Act 2013 (Cwlth) sufficiently clear about how or whether the ‘reasonable and necessary’ criterion should be applied? Is there sufficient clarity around how the section 34(1) criteria relate to the consideration of what is reasonable and necessary?
Is better legislative direction about what is reasonable and necessary required? If so, what improvements should be made? What would be the implications of these changes for the financial sustainability of the scheme?
Speech Pathology Australia would not recommend further legislative direction regarding the ‘reasonable and necessary’ criterion and contends that it is unlikely that additional legislative direction would provide greater clarity or lead to greater consistency or equity of what is provided in plans. It is felt that the introduction of a range of strategies to scaffold and facilitate better informed and consistent plans would be more effective. For example:
- specialist ‘planner teams’ should be involved in the development of plans for groups of participants with more specialist and/or homogenous and predictable needs
- more robust systems for review and evaluation of plans, and the related decisions regarding ‘reasonable and necessary’ would be beneficial
In the case of provision of allied health supports, Speech Pathology Australia would recommend greater engagement with providers to help inform planning for the provision of supports, including the most effective models and the intensity of intervention. This is particularly important where the needs of the participant are complex and/or dynamic in nature (i.e. in degenerative neurological conditions, or in Early Interventions service delivery)
Additionally, it is recommended that the NDIS engage with providers and other experts to develop ‘reference packages’ and/or tools to help determine the appropriate type and ‘dosage’ of supports, for a range of participant groups such as children with complex communication needs and adults with severe and multiple disabilities.
INFORMATION REQUEST 4.2
Should the National Disability Insurance Agency have the ability to delegate plan approval functions to Local Area Coordinators? What are the costs, benefits and risks of doing so? How can these be managed?
While the involvement of Local Area Coordinators (LACs) in plan approval as a response to the underestimated number of potential participants is understandable, Speech Pathology Australia would reiterate our viewpoint that the role of the LAC versus Planner requires a different set of knowledge and skills, and therefore plan approval should only be delegated to LACs, where they have undertaken the necessary training and are provided operational supports for them to be able to perform the task. The most obvious cost therefore is related to capacity building.
Workforce readiness
INFORMATION REQUEST 7.1
What is the best way for governments and the National Disability Insurance Agency to work together to develop a holistic workforce strategy to meet the workforce needs of the National Disability Insurance Scheme?
Approaches to date have been inadequate, uncoordinated and piecemeal, therefore mechanisms need to be developed and implemented to:
- facilitate a coordinated and collaborative national approach which involves the federal, state and territory governments to develop strategies and resources to address the significant workforce shortages of allied health professionals with the skills, experience and supports required to work in the sector.
- involve the university sector
- involve the professional associations
- support the professionals who are already in the workforce as well as those at entry level
- support the appropriate and effective utilisation of allied health assistants, including allied health supports in plans, and pricing to ensure appropriate supervision by Allied Health Professionals.
Participant readiness
INFORMATION REQUEST 8.1
Is support coordination being appropriately targeted to meet the aims for which it was designed?
The inclusion of support coordination is relatively recent, therefore it is difficult to judge at this point to what extent it builds capacity in participants to negotiate the system and manage their own supports, or whether support coordination is only a short-term requirement.
The scope of the role of ‘support coordination’ isn’t clear and appears to still be emerging, however support coordination, done well and by people with the appropriate level of knowledge and skills, can be a very important part of supporting participants and their families, particularly when provided as part of early intervention. It is also an important component of service provision for participants or families who are experiencing disadvantage or have complex medical or social needs and are required to engage with multiple agencies.
It may be appropriate for providers of therapy services to also provide support coordination as they have the relationship and regular contact and communication with a participant and their family, however they need to be flexible and responsive to changing needs and priorities of participants as some participants may prefer and/or need to have a component of support coordination funded within their plans on an ongoing basis and or only periodically (e.g. in response to times of particular challenges to their capacity to manage their supports such as at transition points, during periods of ill health for the participant or their natural supports).
INFORMATION REQUEST 8.2
Is there scope for Disability Support Organisations and private intermediaries to play a greater role in supporting participants? If so, how? How would their role compare to Local Area Coordinators and other support coordinators?
More information and clarity is required about the perceived role for intermediaries, including the differences between and/or overlap with the roles of Local Area Coordinators and other support coordinators.
As an aside, Speech Pathology Australia would suggest using an alternative word to ‘intermediaries’ as this term has a different and specific usage in the justice sector.
Governance
INFORMATION REQUEST 9.1
The Commission is seeking feedback on the most effective way to operationalise slowing down the rollout of the National Disability Insurance Scheme in the event it is required. Possible options include:
- prioritising potential participants with more urgent and complex needs
- delaying the transition in some areas
- an across-the-board slowdown in the rate that participants are added to the scheme.
If the decision is made to slow down the rollout, Speech Pathology Australia would recommend prioritising the continued provision of:
- early childhood early intervention, and within that, access for children who are likely to go on to experience ‘costs’ and disadvantages, both personal and to their future participation and productivity, if not provided with timely and adequate early intervention, including provision of an NDIS plan.
- supports to participants with more urgent and complex needs
This could be combined with an overall slowdown in the rate that participants are added to the scheme and delaying transition in some areas.
Speech Pathology Australia’s overall perspective is that the risks to the long term operation and viability of the scheme outweigh the negative impacts of delayed entry to the scheme for potential participants and would suggest firstly increasing consultation with providers to develop solutions to the issues and manage the risks that are arising out of the current transition, and secondly increasing the upfront budget available to the NDIA and NDIS to develop and implement such solutions.
The Commission is also seeking feedback on the implications of slowing down the rollout.
A slowdown of the rollout will have a range of implications to both providers and participants. The capacity of ‘legacy’ providers to continue to provide services has been eroded as both organisations and individuals have made changes in anticipation of the NDIS rollout. This may add to the concerns and negative experiences of potential participants about any proposed changes to the rollout schedule, as well as leading to an exacerbation of needs amongst potential participants.
Funding arrangements
INFORMATION REQUEST 10.2
The Commission is seeking information on the best way to align the ability to control cost overruns with the liability to fund cost overruns. Possible options include:
- estimating the proportion of cost overruns that the Australian and State and Territory Governments are responsible for and allocating funding responsibility accordingly
- altering the governance arrangements of the National Disability Insurance Scheme to give the Australian Government greater authority to manage the risk of cost overruns, to better reflect their funding liability.
Of the two suggestions, Speech Pathology Australia would support the former over the latter. If the second option is implemented, Speech Pathology Australia would strongly recommend the development of linkages with a broader cross section of providers, including representatives of the significant number of private practice allied health providers, and the professional organisations. These representatives, professional organisations and providers who have experience in the sector, are in the best position to help identify the long term risks of overruns, contribute to the development of viable and effective strategies and solutions, and to support trials and pilots prior to larger scale implementation.
If Speech Pathology Australia can assist the Productivity Commission in any other way or provide additional information please contact Ms Cathy Olsson, National Advisor Disability on 03 9642 4899 or by emailing disability@speechpathologyaustralia.org.au.