Submission 19 — Speech Pathology Australia — Market Readiness | External submission

Level 1 / 114 William St T 61 3 9642 4899 office@speechpathologyaustralia.org.au Melbourne Victoria 3000 F 61 3 9642 4922 www.speechpathologyaustralia.org.au

Speech Pathology Australia’s Submission to the

Joint Standing Committee on the National Disability Insurance Scheme: Market Readiness for provision of services under the NDIS

22 February 2018

The Speech Pathology Association of Australia Limited

ABN 17 008 393 440

Hon Kevin Andrews MP Chair Joint Standing Committee on the National Disability Insurance Scheme PO Box 6100 Parliament House Canberra ACT 2600

Dear Mr Andrews

Speech Pathology Australia welcomes the opportunity to provide feedback to the Joint Standing Committee on the National Disability Insurance Scheme’s Inquiry into market readiness for provision of services under the NDIS. Speech Pathology Australia is the national peak body for speech pathologists in Australia, representing more than 8000 members. Speech pathologists are university trained allied health professionals with expertise in the assessment and treatment of communication and swallowing disabilities.

While the majority of speech pathologists see the immense potential of the NDIS for people with disability, many are reluctant to register as NDIS providers lest it compromises the financial viability of their small (often solo) private practices. This would directly affect the supply of speech pathology services, and could therefore potentially undermine the ability for individuals to exercise choice and control over their care. When market based principles are applied to the provision of services, such as health and disability, it is essential to also vigilantly monitor for market failure. When the level of demand is so low no profit can be made, which is often the case with very specialised services, government direct provision or subsidisation will be required to ensure the full range of services are available; failure to provide such services not only has potentially immediate high-risk consequences but also long term (and therefore more costly) impacts.

As the peak body regulating and representing speech pathologists, we have drawn together evidence and feedback from our members working with NDIS Participants from all states and territories and present this as case studies/scenarios to illustrate the key issues we feel relate to the Inquiry’s Terms of Reference. We preface this with background information about the role of speech pathologists in providing support for people with communication and swallowing disabilities.

As always, we would be keen to appear before the Committee, to bring together leaders in the speech pathology profession with expertise and ‘real life’ experiences of these issues to provide more detail regarding the particular problems we highlight in our submission and to discuss potential solutions.

In the meantime, if Speech Pathology Australia can assist in any other way or provide additional information please contact Ms Catherine Olsson, National Advisor Disability, on redacted

Yours faithfully

Gaenor Dixon

National President

Table of Contents

Introduction ………………………………………………………………………………………………………………………………… 4

About speech pathologists and Speech Pathology Australia ………………………………………………………… 4

About communication and swallowing disability ………………………………………………………………………….. 4

About NDIS Participants with communication disability ……………………………………………………………………. 5

Speech Pathology Australia’s specific comments relating to the Inquiry’s terms of reference ……………….. 6

a) The transition to a market based system for service providers ……………………………………………………… 6

b) Participant readiness to navigate new markets …………………………………………………………………………. 11

c) The development of the disability workforce to support the emerging market ……………………………….. 12

d) The impact of pricing on the development of the market ……………………………………………………………. 14

e) The role of the NDIA as a market steward ……………………………………………………………………………….. 15

f) Market intervention options to address thin markets, including in remote Indigenous communities …. 16

g) The provision of housing options for people with disability, with particular reference to the impact of Specialist Disability Accommodation (SDA) supports on the disability housing market ………………….. 17

h) The impact of the Quality and Safeguarding Framework on the development of the market …………… 17

i) Provider of last resort arrangements, including for crisis accommodation ……………………………………. 18

j) Any other related matters ………………………………………………………………………………………………………. 18

Recommendations …………………………………………………………………………………………………………………….. 19

References cited in this submission …………………………………………………………………………………………….. 20

Introduction

Speech Pathology Australia welcomes the opportunity to provide feedback to the Joint Standing Committee on the National Disability Insurance Scheme’s Inquiry into market readiness for provision of services under the NDIS. We have structured our feedback in response to the Terms of Reference and conclude with recommendations that we hope the Commission will find useful. We preface our comments with background information on communication and swallowing disability and the role of speech pathologists in improving outcomes for people with communication and swallowing disability.

About speech pathologists and 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 however, 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 8000 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 Australian Health Practitioner Regulation Agency (AHRPA).

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

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 and a reduced ability to safely and enjoyably participate in social, employment and education experience where consumption of food and liquid is needed. Swallowing problems are common in people with complex disability.

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.

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.

About NDIS Participants with communication disability

While detailed data 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 is not yet readily available, there is good quality information that would suggest that a large proportion of NDIS Participants have communication disability. For example, the most recent information from the Australian Bureau of Statistics, based on the 2015 Survey of Disability, Ageing and Carers (SDAC)i estimates 1.2 million Australians have some level of communication disability, ranging from those who function without difficulty in communicating every day but who use a communication aid, to those who cannot understand or be understood at all. The ‘majority (81.6% or 850,500) of Australians with communication disability (living in households) use aids or equipment to assist them with their disability. Almost two-thirds (63.6%) of people with communication disability had a hearing aid, while others used low technology reading or writing aids (4.4%), high technology reading or writing aids (4.3%) and low technology speaking aids (1.8%). Other forms of aids used include email or internet (6.2%), cochlear implants (1.1%) and high technology speaking aids (1.0%).’ It is probable that the majority of these people will be eligible for NDIS due to their complex communication needs. ‘There were 278,100 children with disability, of whom almost half (46.0% or 127,900 people) had some level of communication disability. The majority (86.5%) of these children had profound or severe communication disability.’ It is unclear how many of these children would be eligible for NDIS under the full scheme (post age seven) or through the Early Childhood Early Intervention (ECEI) stream.

It is likely that NDIS Participants with communication disability are disproportionately represented in the two groups, and not experiencing improved outcomes described in the Intermediate Report of the Evaluation of the NDIS. The first group being those 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’ii. The second group being those facing difficulties accessing disability supports for which they have received funding due to a lack of local providers, and lengthy waiting lists. Indeed the Intermediate Evaluation Report repeatedly acknowledged the unmet demand for allied health, including speech pathology services, currently experienced within the NDIS.

Speech Pathology Australia’s specific comments relating to the Inquiry’s terms of reference

Speech Pathology Australia expects demand for speech pathology services to increase 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 area of service provision where there is an unmet demand.

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

Concern regarding the administrative burden (time and cost) of the Scheme,
The registration process and third party verification,
The training pipeline for speech pathologists and lack of systemic support for clinical placements,
The lack of systemic support for the supply of speech pathologist services to rural and remote Participants e.g. telepractice,
NDIS funding models that do not support best practice or evidence based therapy,
Demand from other sectors for speech pathology services.

a) The transition to a market based system for service providers

The speech pathology NDIS provider market reflects a small but specialised disability service within the NDIS market. However, speech pathologists in private practice are being actively discouraged from being NDIS providers due to burdensome and costly administrative and regulatory processes, a lack of travel funding, and eligibility/access to service issues. Such barriers are impacting greatly on the transition to a market based system for speech pathology services. Indeed, we again highlight to the Committee the results of our member survey carried out in November 2017, which showed approximately 42 per cent of respondents stated that they have considered withdrawing from the NDIS at some point in the last 6 months.

Administrative burden and registration issues for speech pathologists

The majority of private speech pathology practices are small or sole trader organisations, with limited infrastructure and resources.

Our members have reported the increased administration burden of providing services through the NDIS (in comparison to other funding streams including Better Start for Children with Disability, Medicare, Department of Veteran Affairs and private health insurance). Many practices have resorted to employing additional administrative staff to work solely on NDIS administration processes in the transition. However, the additional excessive administrative burden cannot continue to be absorbed into the per hour NDIS fee for speech pathology services for many private practitioners. Speech Pathology Australia receives regular

communication from speech pathologists who are delaying entering the NDIS market, reducing the share of their practice case load of NDIS clients and/or restricting service to self managed clients to avoid the costs associated with excessive administrative burden. A recent survey of our members revealed that there is a high percentage of speech pathologists being impacted by the current administrative load of seeing clients under the NDIS. 57% of respondents who commented on this issue stated overwhelming administration pressures/difficulties that had caused them to consider de-registering. 68% discussed iceesues with the cost of operating under NDIS, both in terms of time and/or money.

With regard to registration, 49% of respondents who provided comments found it too complex/too hard. They frequently described the registration process as ‘onerous’, ‘confusing’ and with ‘conflicting information’. Several members commented that they had tried to register and then given up.

In line with the nationally consistent quality and safeguarding framework for the NDIS and per the bi- lateral agreements, each jurisdiction is currently managing a process of registering applicants to be NDIS providers. The current requirements for organisations to register for the different types of disability provider supports vary considerably across jurisdictions. Speech pathologists in Western Australia, Victoria and South Australia whose businesses are smaller single or multi-professional allied health practices are facing significant barriers to becoming registered as NDIS providers. We have received concerning feedback from many of our members seeking to be registered as NDIS providers in these states that they are being prevented from registering in a timely and efficient manner due to ‘new’ registration requirements that are administratively burdensome, and inappropriate when applied to private practitioners or single-therapy service providers. This registration process involves lengthy delays and significant direct cost for practitioners to meet the various requirements.

The impacts of the 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 provider market due to registration barriers. This is particularly the case in regards to registering for Early Childhood Supports.
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 Better Start and HCWA Commonwealth disability funding streams.

The provision of Early Childhood Supports (ECS) are also being impacted by the constraints around registration; for example, the requirement for ‘at least two years experience’ within Early Intervention and transdisciplinary practice as part of the jurisdictional requirements for several states in the Guide to Suitability.

At present there is no provision for a potential system of clinical supports and supervision which would be deemed suitable to support someone without the relevant experience, and mean that they are compliant with the guidelines. The result of this is a block to providers being able to bring new entry practitioners into some areas of service provision within the NDIS i.e. Early Childhood Supports, and enabling them to

gain the relevant experience in order to work within this sector. This is likely to prove a major obstacle to growing the workforce in this sector, which is one with particular growth and resulting demand.

Third Party Verification (TPV)

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 practice’s 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 ranging from $2000 and $7000) 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 an 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 the 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 Better Start programs.

In South Australia, 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 undertake 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 undertake 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 for those that would provide services to adults).

In Victoria, issues with provider registration emerged at the commencement of transition to full scheme, and were similar to those experienced in NSW. Allied health practices wishing to register to provide early childhood early intervention supports within the NDIS are being required to undertake a self-assessment against the Victorian Standards in the same way as is being required of specialist disability providers. Speech pathologists in Victoria will be required to undertake a TPV like audit process, carried out by organisations approved and endorsed by the Victorian State Government, but at the provider’s own cost.

The experience of TPV in NSW saw it act as a barrier to NDIS registration for speech pathologists and is likely to further constrain the development of the speech pathology provider market within Victoria. Currently we are hearing reports of speech pathologists de-registering, or ceasing to continue to provide services under ECS due to their feeling that the TPV process is too onerous and costly for the number of clients they currently see under this group. With the estimated average cost of TPV around $4500 it is not surprising that our members, especially sole providers are reluctant or refusing to register with the NDIS.

Members have expressed that:

“I deliberately have not registered for supports that require 3rd party verification, it is not worth it for a sole trader”

“We should have been automatically approved for early intervention due to previous approval with HCWA etc however after numerous applications back and forth, we have given up as the cost and time were too high to continue.”

Cost of travel

The Intermediate Report of the Evaluation of the NDIS acknowledges that there are concerns in the sector regarding the funding of therapist traveliii. The NDIA’s decision to cap the funding each therapist can claim for travel has led to a range of access issues and administrative challenges for speech pathologists. It has led to reduced frequency of services for many rural and outer metropolitan Participants, as Providers are faced with potentially travelling large distances (with lengthy times associated) unpaid. Equally, as travel costs are also taken from within Participant’s therapeutic budgets, these costs result in less therapy sessions overall.

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 needs to be balanced, ensuring the financial sustainability of the system while also considering the principles of choice and control upon which the NDIS is based. The way in which funding decisions regarding travel are impacting 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 funding. These solutions need to be developed in consultation with provider organisations to ensure any policy changes are actually ‘workable’ for providers. Speech Pathology Australia and other allied health peak professional bodies are not direct providers of service (and as such, have no direct financial interest in the changes) and can work with the NDIA to develop solutions to the current ‘travel cost’ crisis.

Eligibility/access to services issues

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 (ECEI) 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 are considered to demonstrate clear eligibility for NDIS) Planners, as the “gate keepers” who determine eligibility and make determinations, are often at odds with specialist advice.

One member recalled:

“We have had excruciating experiences with some planners trying to get assistive technology budgets approved for children who are non-verbal and who require a communication system to be put in place. In some cases we have spent 10 hours writing up letters/ reports of support after our initial, detailed and more than adequate support letters have been submitted and knocked back, up to 4 times!! This level of work is unsustainable and I don’t feel that planners have a realistic expectation of the time commitment or the demands they are placing on service providers.”

We are also hearing of examples where participants are being told that they are unable to have supports for both provision of assistive technology to support their communication (Augmentative and Alternative Communication Assistive Technology) and supports for provision of speech pathology interventions. It is difficult to understand the basis for these comments and decisions, as supports by speech pathologists for implementation of aided augmentative communication devices is a critical component in achieving functional communication access.

The ‘market’ of allied health professionals is particularly affected by uncertainty regarding which children will and won’t get access to NDIS plans/funding. This impacts on the demand (or lack of it) for their services, and therefore the value of or importance of expanding their businesses. This interacts with the variability in the interpretation of the Access Criteria, the role of the Early Intervention (EI) partners and the ‘short and medium’ term supports they offer.

There should be consistency of services offered, including a suite of evidence based, family focused, capacity building programmes which fit within the EI Best Practice guidelines. At the moment, what is and isn’t offered by the EI partners is variable which leaves providers in the market uncertain of what ‘offers’ they should have, which complement what is provided by the EI partner.

In order to ensure a viable speech pathology provider market, significant and targeted efforts are needed to remove current barriers and encourage speech pathologists to remain in, and enter the market. For example, it is essential for the NDIA to recognise the importance and value of solo/smaller private practices as part of the new provider group. Furthermore, the NDIA needs to consider how this group can be supported to provide more efficient, effective, high quality, evidence based supports. It is also imperative that the NDIA recognise important components of service provision (particularly for children) which may have specific elements, or require ongoing support beyond what is currently defined or included in individual NDIS plans. This includes but is not limited to: service planning, communication, coordination and collaboration of the multi-professional team who may be providing direct services and/or informing the provision of appropriate interventions by a ‘key worker’ interventionist.

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, and often suggests an insufficient knowledge of disability conditions and functional needs. The speed of the roll out of the Scheme has placed enormous pressure on the Planning process, with some of the efforts that have been made to streamline and speed up this process coming at the expense of plans meeting the needs of Participants.

One member has described a particularly distressing experience for the family of a Participant:

“Her package has been cut to 4 speech therapy reviews per year, in which I am supposed to fully review the functional gains made and then train the parents to run the speech program for the next quarter. My concern with this is that the NDIA is expecting lay individuals to do our job for us. I have attached a letter that this client’s mother wrote immediately after the appeals meeting – she told me that the whole NDIS process has brought back traumatic memories of her past marriage, in which she suffered severe psychological abuse by her husband. She told me that she feels like she is a victim again, with the NDIS holding all the power over her (including financial power to support her daughter) and that all the meetings are making her feel like she has to ‘grovel’ for money and support. She is a strong lady who is extremely distressed.”

b) Participant readiness to navigate new markets

It is difficult for Participants to navigate the private provider sector without help. Indeed, it is an enormous burden to ask that any one person, or even team of people, should have this knowledge across all of the different types of disabilities for all of the different age groups, and the different contexts in which they are living. Participants may not know what to ask for, where to look to get information to assist with their decision making process, or where to find providers of services once needs are established. Speech Pathology Australia’s website has a ‘Find a Speech Pathologist’ function, and the federal government has recently launched its online landing page for concerned individuals, parents, and carers to locate services and support for people with different types of speech, language and communication difficulties. However, prior to getting to the stage where they need to find a suitable service provider, Participants will require help to understand the intervention options available and how to ‘translate’ the evidence base (if any) for a range of supports/interventions that are on offer from allied health providers. Supporting Participants to understand these options and the evidence base would ideally be part of the role of Planners/Local Area Coordinators/EI partners.

Current supports provided however do not recognise the significant additional needs in relation to developing the capacity and competency of participants/families/natural supports (particularly for participants in early intervention – whether children or someone with a newly acquired disability). The assumption is that the ‘capacity building’ support (service coordination, support connection etc.) will only be needed for the short term, but for many families/participants these supports are needed over the long term, and/or at periodic intervals connected to intense periods of life transition (such as attending or leaving school). It is also assumed that this kind of capacity building can be, or is best provided by someone additional to or other than the direct provider, whereas the provision of these types of support may be most efficiently and effectively provided as part of the role of one or more of those providing allied health interventions. While this is particularly the case for children, the same principles may apply for adolescents and adults who are in the ‘early intervention’ stage, and for participants who may have complex clinical and/or social issues.

With regard to speech pathology services, our members have reported that Participants need a greater depth of information about the types of interventions that may be appropriate for them than what is currently available or provided within the planning process. Speech pathologists with considerable experience in the disability sector have identified that providing this information for people with disabilities, and their families regarding natural supports and paid supports has often been part of an extensive process, embedded within a trusting relationship. It is essential for participants to be supported to better understand the range of potential interventions that could address their needs, their benefits, and any risks (including risks if they are not implemented), so that participants are able to make informed decisions.

The provision of communication accessible information which provides the evidence base for different approaches will enable participants to truly exercise choice and control, and help them identify the provider best able to provide high quality interventions that are relevant for them. At a minimum, the NDIS planning process needs to ensure that the ‘process’ of planning is not placing additional barriers on people with communication disability from interacting with the system and ensure that service plans can be prepared using Easy English where appropriate.

In addition to providing clear and easy to access information, it is also necessary for the government or NDIA to ensure that gaps in service are being identified, and incentives, or alternative rectifying solutions, are put in place to fill these gaps in service.

For example, it was 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 and 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. Additionally it has been reported from another member that numerous Participants are approaching their Plan review, and have not actually spent any of their therapy budget due to a lack of available services in the area.

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 or specific area of need
Physical access to speech pathology is problematic (e.g. limited funding for travel in Plans, lack of funding for tele-practice service delivery or provision of services in rural locations)

c) The development of the disability workforce to support the

emerging market

In terms of the supply of speech pathology service providers, there is significant competition from other sectors 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 fewer 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 through contracts with organisations such as schools), private health insurance rebates, Medicare Benefits Scheme, accident insurance schemes (such as TAC and Worksafe), and the 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.

As a female-dominated workforce, speech pathologists tend to work part time hours (across the profession, not just within the disability sector). There is the potential for 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, and telepractice etc) but this will require the necessary changes to current reimbursement protocols.

Indeed, to increase the speech pathology workforce supply within the NDIS, initiatives are needed to first and foremost address the systemic and structural issues already raised in this submission to ensure that being an NDIS registered provider is financially viable for small and solo private practices. If the solo/smaller sized providers were lost to the market then this would result in the dominance of larger organisations and potential monopolies, which would be in direct conflict with the NDIS principle of Participant choice and control. Incentives are also required to ensure supply of services in areas that are geographically remote, with a currently sparse distribution of providers.

With regard to individuals requiring specialised supports and the level of expertise required by speech pathologists to provide it, it is the view of Speech Pathology Australia that a market approach to disability service provision will not provide the environment that will be required to retain or further develop such a specialised workforce. NDIS Participants will therefore not have choice nor control over the speech pathology services they wish to purchase with their 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.

Long-term initiatives would also need to focus on areas such as clinical education and training and work placements. The current lack of clinical education placements in disability provider services has been counter-productive in terms of supporting the development of the workforce to meet the emerging market. Such training and work placements are currently the responsibility of the jurisdictions, which has resulted in a number of universities having to ‘reinvent the wheel’ as there is no overarching monitoring process. A national approach would correct this wasteful duplication.

Finally, there are interim issues such as conflicts of interest that have occurred in instances when EI partners are also providing therapy services that will not continue after the transition period ends in July 2019. This could also affect the market, as there will be a resultant void of available services for this group of Participants, particularly taking in to account the effects of restrictions regarding the level of experience and resultant lack of new graduates or providers ability to gain experience within this area.

Speech Pathology Australia has noted a focus on the use of Allied Health Assistants as a potential solution to workforce shortages and areas of thin market. While the Association acknowledges that allied health assistants can significantly enhance the efficiency and efficacy of service provision in some areas of intervention, it is important to recognise that the role of allied health assistants is to provide delegated care, and that there are therefore issues about what it is appropriate to expect any individual allied health assistant to include as part of their personal scope of practice, and that there is always a requirement for active and dynamic support and supervision by an allied health professional.

d) The impact of pricing on the development of the market

Current pricing levels for speech pathology services are deemed competitive with other sources of government remuneration for speech pathology therapy services (e.g. Medicare, Helping Children with Autism Package or Better Start for Children with Disability). However, the current pricing for provision of group programmes, which are an appropriate, evidence-based intervention strategy (i.e. social skills groups, AAC groups, feeding groups) means it is virtually impossible to provide these programmes. In addition, with regard to 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 need 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). For example:

Rules regarding funding of travel associated with the provision of speech pathology services to NDIS Participants need to be reviewed, and strategies developed to make it viable for providers to deliver services in rural and remote areas.
Funding to address the administrative tasks associated with NDIS provision (currently unpaid administration time associated with payment processing, report writing etc) as well as trying to keep up to date with, and understand the impact of the currently ever-changing NDIS rules and processes. These additional administrative ‘costs’ for providers are creating a barrier to joining the NDIS market, in particular for the smaller practices and sole providers who find the extra cost and time burden unsustainable and financially unviable.
Funding of non-face-to-face NDIS Participant tasks (e.g. liaison with families/carers, schools, other NDIS providers, preparation of materials to provide to individuals to support their participation, such as ‘Visuals’, Situation Aided Language Stimulation communication boards, etc).
Funding for providers who continue to provide services to Participants whose plans have ended early, or wh are in between plans, or when their additional plan has not been forthcoming.
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 telepractice 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).

By way of some examples regarding impacts on businesses:

“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

“I have a current client and NDIS Participant who on their previous plan was arguing a shortfall in funds. NDIS told her to continue with therapy whilst a decision was pending regarding funds. Since this time, no decision was given to her and me despite many emails to the NDIS finance office as well as NDIS complaints department…I’m $300 out of pocket for services rendered in May and I know of two other service providers who are also out of pocket for this time period. In June the participant got a new plan and so I am still currently providing services under this new plan but continue to have no clear feedback from NDIS as to these outstanding claims.” NSW speech pathologist

The whole idea of ‘inclusive pricing’ for the provision of Early Childhood Supports/Therapeutic Supports has been problematic resulting in the risk of ‘cherry picking’, which in turn has led to problems with creating a viable business model for those allied health providers who are providing specialised/low incidence supports i.e. Augmentative and Alternative Communication Assistive Technology.

Members who are experienced in, and committed to, supporting people with disabilities are exhausted by trying to get clarity about the ‘rules’, getting a different response depending on who they speak to at Provider Support, being unable to contact anyone who is able to provide them with reliable information, and feeling that they are constantly having to grapple with decisions which create barriers to them being able to do what their professional skills and ethics say they should be, and carrying the anxiety that they may (unwittingly) not be following the ‘rules’.

One member described:

“Most difficulties are in the interim periods between plans. NDIS guarantees payments until new plan is established or funding is cancelled. But this doesn’t happen easily. I have spent over 20 hours on the phone, in emails etc claiming 10 hours of fees from one interim period for one child. Got paid in November for sessions dating back to May. When payment doesn’t happen it is a big problem when NDIS is about 80% of my income now. Biggest issues are with complete inability to talk to people to get help. Can’t talk to same person twice, can’t get same info twice, can’t get an answer in less than 23 days.”

Another member has stated (in relation to the many changes to the message regarding whether or not NDIS participants should be or can use Medicare or health benefit funds to ‘top up’ their NDIS funding) :

“I’m sorry how are we supposed to get this right when we can’t get the correct information. The NDIA is…killing small business 1 policy at a time”

As highlighted by the Productivity Commission report, at this point in time there is a conflict of interest for the NDIS to be setting/controlling pricing. Also, limiting payments to providers (per support item) as a strategy for managing costs of the scheme puts at risk the sustainability of providing high quality services, particularly to clients with complex needs and/or living in rural/remote areas, because providers are deciding against entering the market.

e) The role of the NDIA as a market steward

The NDIA has a significant role to play by:

Removing barriers such as the high administrative burden that is acting as a disincentive to speech pathologists entering the market,
Providing clear definitive instruction as to what will be funded for Participants (this is a particular issue for children who do not have a diagnosis on the NDIS eligibility lists i.e. solely speech and language issues),
Ensuring there is constant monitoring for gaps in service and thin markets and ensure that this is updated and communicated regularly to the provider market,
Supporting services such as telepractice for rural communities, and
Ensuring the complaints processes for those deemed by an NDIS Planner to be ineligible for the Scheme is easy and communication accessible and not time consuming for individuals with disability and/or their families.

f) Market intervention options to address thin markets, including in

remote Indigenous communities

Firstly, it essential to have in place mechanisms to identify and monitor thin markets, these are likely to not only be in geographically remote areas but also in the provision of very specialised, low incidence , and therefore uncommon, services. There are a number of interventions and direct supports that could potentially facilitate the NDIS provider market, but also, in order for those services not provided by the market to ensure a full range of culturally appropriate services are available, direct provision or subsidisation may be required.

Such supports and interventions include:

Support collaboration across sectors (health, education, disability) to provide a complete and well supported ‘team’ of providers.
Facilitate/support cultural sensitivity training, and ongoing peer support for allied health providers.
Work more collaboratively with the allied health provider market to explore what may (and may not) work in terms of the role of Allied Health Assistants acting as the direct provider of interventions in rural and remote (and peri-urban and urban) service delivery settings.
Undertake activities to promote/support telepractice. 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 is very strong evidence of the clinical efficacy of speech pathology services provided through telepracticeiv but currently the NDIS does not consistently provide funding for speech pathology services delivered in this way. 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.
Consider how to facilitate rural providers to act as ‘generalist specialists’ – including the need to be able to access and co-work with specialist providers, particularly to support participants with complex and/or low incidence needs. This could either be part of the ILC supports developed and funded in an ongoing manner, and/or reflected in the pricing of supports.
Reconsider rulings regarding NDIS payment for travel by providers. As it currently stands, it is restricting access to specialised speech pathology services to NDIS Participants who need them. By

defining strict limits for payment for provider travel in all Participants Plans, and not allowing flexibility in travel expenses for individual Participants, those who require the services of a speech pathologist with specialised expertise may not be able to purchase their services within the parameters of the funded plan if that practitioner is located a significant distance away from the Participant. In the case of specialised services (and in the case of rural and remote Participants) this lack of flexibility regarding payment for provider travel will lead to market failure in accessing specialised supports.

One member describes that:

“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

g) The provision of housing options for people with disability, with

particular reference to the impact of Specialist Disability Accommodation (SDA) supports on the disability housing market

No comment, as not within the scope of speech pathology practice.

h) The impact of the Quality and Safeguarding Framework on the

development of the market

The NDIS Quality and Safeguarding Framework should provide a reasonable and appropriate level of governance of speech pathology service provision within the NDIS, by 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 person 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, there still appears to be some ambiguity about what may actually be required in relation to the provision of Early Childhood Supports. 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, which would undoubtedly limit the entry of new speech pathologists in to the market.

Speech Pathology Australia would strongly recommend that clear and proportionate processes for registration to provide ECS and other interventions which are part of the scope of practice of speech pathologist be developed, informed by the Association and a clear and comprehensive understanding of the certification processes in place to gain CPSP status through Speech Pathology Australia.

i) Provider of last resort arrangements, including for crisis

accommodation

Last resort arrangements are another example of those services that are unlikely to be profitable and would probably lead to market failure, as the level of demand is too low to make a profit. However, last resort arrangements will need to be provided by a range of service providers to ensure people with very complex needs are supported, especially at times of crisis. The government will therefore have to provide, or subsidise, such services and supports if the market will not provide them.

Speech Pathology Australia recommends that consideration is given to the establishment of a ‘provider of last resort’ for provision of a ‘rapid response’ for NDIS participants who experience urgent and unanticipated need for timely provision of speech pathology supports for mealtimes for people with disability who have oral eating and drinking difficulties. This should be addressed urgently.

Clarifying the roles and responsibilities between sectors such as education, health and the NDIS needs to be addressed as a matter of urgency. This will help rectify a number of issues that have caused great concern, and often confusion, as to which sector is responsible for carrying out assessments, providing particular services, and/or funding these activities such as mealtime supports. To date, the NDIS decisions regarding what is and isn’t going to be funded in Plans is impacting upon the market. For example, supports for oral eating and drinking - businesses which are ‘specialists’ in this area are now uncertain about whether or not they will have a client base (or whether these supports will be shifted to Health to fund and provide). Speech Pathology Australia has received several reports of previous providers who have de-registered due to the level of restriction and lack of support for specialised services within Plans.

In addition, there is a need for clarity regarding the provision and funding of ‘infrastructure’ services such as those that underpin Augmentative and Alternative Communication Assistive Technology (AAC AT) services, i.e. the trialling and maintenance of equipment. These ‘extra’ but essential related services are unlikely to be effectively provided by the market. This could lead to Participants purchasing AAC AT that is not the best (or even at all) appropriate system for them.

Speech Pathology Australia would also draw the attention of the Inquiry to the provision of ILC services, as this requires investigation and subsequent improvement. There may be an area of the market for speech pathologists to enable better linkages with communication accessible supports, and the provision of services to aid current supports and businesses to be communication accessible for Participants with communication difficulties. Critically however, these supports would need to be provided at a systemic level and on an ongoing basis, which the present arrangements for ILC supports do not allow.

Recommendations

We request the Committee consider the following recommendations for the NDIA/NDIS:

Clarification be provided urgently regarding the exact roles, responsibilities and service delivery parameters of state/territory Departments of Education, Health and Disability Services.
Clarification be provided as to what will be funded in individual care plans – these instructions need to be clear and not open to interpretation which has led to confusion and inconsistencies about what can be claimed.
Decrease the costly (time and monetary) administrative burden on providers. This can be done by ensuring NDIS online systems and forms are clear, easy, and quick to use. In addition, reduce the amount of changes to rules and processes that have shown to be both time consuming and confusing.
Examine travel expenses/rulings and work with providers and peak bodies to determine consistent and practical solutions to facilitate access to services.
Carry out an audit of the NDIS planning and complaints process to determine if it is communication accessible for people with communication disability.
Provide system-wide funding and structural supports for services such as speech pathology to be delivered via telepractice within the NDIS. This could offer a key solution to addressing some of the issues with the supply of speech pathology services in rural and remote areas.
Ensure that registration requirements for provision of ECS and other interventions which are part of the scope of practice of speech pathologist are clear and proportionate, and informed by a clear and comprehensive understanding of the certification processes in place to gain CPSP status through Speech Pathology Australia.

If Speech Pathology Australia can assist in any other way or provide additional information please contact Ms Catherine Olsson, National Advisor Disability, on redacted

References cited in this submission

i Australian Bureau of Statistics (2107) Australians living with Communication Disability

http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/4430.0Main%20Features872015?opendocument&tabname=Summary&prodno=4430.0&issue=2015&num=&view=

ii Mavromaras, K., Moskos, M., and Mahuteau, S. (2016) Evaluation of the NDIS, Intermediate Report, National Institute of Labour Studies, Flinders University. Adelaide. Pg 11

iii Mavromaras, K., Moskos, M., and Mahuteau, S. (2016) Evaluation of the NDIS, Intermediate Report, National Institute of Labour Studies, Flinders University. Adelaide. Pg 28

iv See:

Keck, C. S., Doarn, C. R. (2014). Telehealth technology applications in speech-language pathology. Telemedicine Journal and e-Health, 20, 653–659. doi:10.1089/tmj.2013.0295.

Hill AJ, Breslin HM. Refining an Asynchronous Telerehabilitation Platform for Speech-Language Pathology: Engaging End-Users in the Process. Frontiers in Human Neuroscience. 2016;10:640. doi:10.3389/fnhum.2016.00640.

Theodoros D.G.(2014) Improving access to speech pathology services via telehealth: Submission to the National Inquiry into the prevalence of different types of speech, language, and communication disorders and speech pathology services in Australia. Brisbane (AU): University of Queensland; 2014. (Submission 234).