13 September 2019
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
Re: Joint Standing Committee Parliamentary Inquiry into NDIS Planning
Audiology Australia (AudA) is the peak body for the health profession of audiology, representing over 2,900 audiologists from across Australia. Audiologists work with clients of all ages, including National Disability Insurance Scheme (NDIS) participants to help them to preserve, manage and improve their hearing, their ability to process and understand sounds, and their balance.
We welcome the opportunity to make a submission to the Joint Standing Committee Inquiry into NDIS Planning.
Hearing services under the NDIS
The NDIS was established to allow people with disability to live “an ordinary life”: to fully realise their potential, to participate in and contribute to society, and to have a say in their own present and future – just as other Australians do. To support this, the NDIS’s objectives are:
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To support the independence and social and economic participation of people with disability
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To enable people with disability to exercise choice and control in the pursuit of their goals and the planning and delivery of their supports
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To maximise independent lifestyles and full inclusion in the community
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To facilitate greater community inclusion of people with disability. Currently, there are 10,957 people with a “hearing impairment” who are NDIS participants. This represents 4% of the total 286,015 NDIS participants (NDIA, 2019b).
There is limited data available on participant experiences within the NDIS. However, a survey conducted of NDIS participants who entered the scheme in 2016-17 and 2017-18 suggests positive outcomes for people with hearing impairments. For children from starting school to age 14, the survey highlighted that participants with a hearing impairment generally experience better outcomes than those with other disabilities. For participants aged 15 years and over, participants with a hearing impairment were more likely to be in a paid job, and more likely to be in open employment. They were also least likely to receive the Disability Support Pension, reflecting their high employment levels relative to other NDIS participants (NDIS, 2019a).
Audiology Australia Ltd Suite 101, 13 Cremorne Street, Cremorne, 3121I P: 03 9940 3900 E: info@audiology.asn.au W: www.audiology.asn.au
While AudA strongly supports the idea of the NDIS to improve the lives of Australians based on their individual needs and goals, there remain many challenges and issues for the delivery of high quality hearing services to NDIS participants, which are outlined further below.
Eligibility for NDIS
The National Disability Insurance Agency (NDIA) developed Operational Guidelines to set out the requirements to access the NDIS. In 2018, the NDIA clarified eligibility for access to the NDIS for individuals with hearing impairment, including to recognise the benefits of early intervention for participants under 25.
AudA supports a holistic assessment of the NDIS participant’s needs and goals in order to determine eligibility, rather than what is – in our view - restrictive, threshold-based criteria. A more holistic approach to a person’s NDIS eligibility not only ensures that all Australians receive the services they need but also encourages the spread of best practice approaches throughout the hearing services sector. At the same time, this will help to enable that service provision is more tightly matched to clients’ specific needs, thereby providing a more affordable and realistic option for government.
The need for the NDIA not to use the “hearing impairment” access criteria as an absolute threshold was highlighted in the recent Administrative Appeals Tribunal (AAT) case of Evans and NDIA [2019] AATA 754. In this case, Ms Evans had experienced hearing loss for a number of years and applied to be a NDIS participant. The NDIA decided that she did not meet the NDIS disability requirements set out in section 24 of the NDIS Act. At issue was whether Ms Evans had an impairment that resulted in substantially reduced functional capacity to communicate.
The NDIA argued that Ms Evans failed to meet the 65 decibel ‘threshold’ and therefore did not have an impairment that resulted in a substantially reduced functional capacity to communicate. Ms Evans gave evidence of how her hearing loss impacted her ability to hear in various conditions, including where there was background noise or where she was unable to lip-read.
The AAT decided that the NDIA could not apply its Operational Guidelines as a ‘threshold’ and, therefore, that it could not conclude that anyone whose hearing was reduced by less than 65 decibels did not have a substantially reduced capacity to communicate. Instead, the relevant question was whether Ms Evans’s hearing impairment resulted in a substantially reduced capacity to communicate, which required the AAT to look at her subjective evidence about how her hearing loss impacted on her ability to communicate. On that basis, the AAT determined that she satisfied the “hearing impairment” access criteria and was eligible to be a NDIS participant.
NDIS planning and funding for hearing participants
AudA members frequently report issues with NDIS planners such as significant variation in NDIS planners’ understanding of hearing and balance issues, how the NDIS eligibility criteria apply to people with hearing difficulties and planners questioning the basis of members’ clinical decisions about participants. In turn, this leads to confusion on the part of members about how best to advocate for their clients hearing health care needs.
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AudA members provided examples of funding discrepancies for participants with similar needs and goals, including:
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some participants obtained funding for higher technology hearing aids whereas others do not;
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some participants struggle to get funding for aural rehabilitation aimed at capacity building, while others do not; and
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some participants receive funding for higher-level technology to meet their needs while at work or university, while others do not.
AudA also is concerned that access to funding through the NDIS may be inconsistent within and across regions and also appears to be dependent on many factors that may not relate to individual participants’ needs and goals. These include:
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the level of advocacy families and individual NDIS participants can afford to invest time and money into;
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the NDIS planner’s knowledge of and attitudes towards hearing services; and
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location/jurisdiction. Audiologists have also reported that the level of funding some clients receive is not comparable
with the Department of Health’s Hearing Services Program Community Service Obligation (CSO)
scheme. We have received reports that clients have been told that they can receive more funding for a given device through the CSO scheme than through the NDIS. There is therefore an incentive to encourage clients to ‘shop around’. AudA considers that funding for specific devices should be based on individual goals and needs and should at least be comparable across all Government funded programs.
Further, we believe that the NDIS must fund the full range of required rehabilitation services for hearing loss. Although there is often a strong focus on hearing aids in the media, hearing aids alone are not sufficient for effective habilitation/rehabilitation for hearing loss and its consequences.
Audiologists are trained to offer a holistic rehabilitation plan that may also include: support and counselling (as needed) for the individual and family to improve ability to participate in activities that are meaningful to them; individual and group aural rehabilitation; behaviour change counselling; and devices as alternatives to or in addition to hearing aids such as telephone adapters, frequency modulation (FM) systems and streamers and television devices for hearing assistance.
In AudA’s view, it is only through such holistic rehabilitation that outcomes for participants with hearing impairment can be met across all of the domains in the NDIA’s outcomes framework – choice and control; daily living activities; relationships; home; health and wellbeing; lifelong learning; work; and social, community and civic participation.
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Transitional arrangements – issues for participants
An issue of major concern to AudA is the current transition of NDIS eligible clients from the Department of Health’s Hearing Services Program (HSP) as there is currently much uncertainty about how this will impact current and potential NDIS participants.
We note that the Roadmap highlighted the importance of having a “smooth transition for clients from the Hearing Services Program (HSP) to the NDIS, with a particular focus on vulnerable clients currently receiving services through the CSO component”.
However, we are concerned that there will be service gaps and inequity between the NDIS and the HSP during and following the transition period given the NDIS only accepts applications from people under the age of 65 and NDIS participants may be funded for a greater range of supports than HSP clients.
At the same time, while the NDIS may offer a greater range of funded supports, an adult applicant must have a high level of hearing impairment that results in their substantially reduced functional capacity to undertake activities such as communication or social interaction to become a NDIS participant. While the NDIS was never intended to cover all Australians with a hearing loss, we are concerned that this point is not well understood in the community and that there may still be people with hearing health care needs – especially those on low incomes - who will not have any ongoing access to government funded hearing services.
Another critical issue is whether hearing services for children will become contestable once the in kind arrangements cease as of 30 June 2020 or whether paediatric hearing services will remain with Hearing Australia as the sole provider. It is also not clear whether this change will just apply to children and young people or to all current and potential NDIA participants who are part of the CSO Scheme.
AudA supports the principles of choice and control and believes that they should be applied to the choice of audiologist in the same way as they are applied to the choice of any other health professional. On that basis, AudA supports the move to full contestability of hearing services for clients of all ages once the transitional arrangements come to end provided it is well managed and can be achieved with no disadvantage to the client.
However, we acknowledge that there are concerns around a potential reduction of quality of services if this occurs – especially for families of young children. We are also concerned that access to services for people in rural and remote areas may decrease if and when there is no longer an obligation for Hearing Australia to continue to deliver services under the CSO scheme.
The availability of audiologists and other health professionals is already limited in rural and remote areas (National Rural Health Alliance, 2019). This results in longer waiting times for participants as service demand exceeds the existing workforce and, in turn, severely impacts the ability of providers to deliver services funded by the NDIS. Or, in some instances, there is a total gap in service with no locally based service provider available, requiring participants to travel or to miss out altogether.
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One way to help address these issues could be through teleaudiology. Advances in technology provide new and exciting opportunities for the delivery of services, especially in remote areas where access to health care is limited and significant inequalities exist. AudA considers teleaudiology to be an appropriate model of service delivery for the audiology profession. It is already used in Australia by, for example: Hearing Australia for fitting hearing aids and The Shepherd Centre in assisting children develop their listening, spoken language and social skills.
If teleaudiology were funded under the NDIS, expected outcomes include increased and more timely access to audiological services for participants who are unable to access face-to-face services due to geographical, socioeconomic or physical reasons. We also note that teleaudiology was highlighted by the recent MBS Review Allied Health Reference Group and the Hearing Health Roadmap as playing an important role to improve access, momentum and quality of audiological services – especially to rural and remote areas.
In summary, there remains many unanswered questions about how hearing services for NDIS participants will work once the in-kind arrangements cease as of 30 June 2020. There is some urgency for these issues to be clarified, addressed and communicated to planners, providers and participants given that the legislation that transfers eligible people from the HSP to the NDIS comes into effect as of 1 October 2019 and the longer things remain unaddressed, the greater the uncertainty will grow. AudA seeks clarification on the following key questions for how hearing services will be delivered through the NDIS after 1 July 2020:
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What range of rehabilitation programs will be funded for both children and adults?
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What range of assistive technology will be funded?
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How NDIS participants will be able to identify practitioners with the competency to deliver services for people who have complex hearing rehabilitation needs?
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Whether hearing services for children and young adults (0-26 years) will become contestable once the in-kind arrangements cease as at 30 June 2020. What will be the arrangements for other participants in the CSO Program?
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How and when will clear information be provided to planners, providers and participants about options for accessing hearing services after the transition is complete in mid-2020?
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What mechanisms have or will be put in place to ensure that a person’s access to hearing services and a person’s hearing needs will continue to be met and funded from 1 July 2020 – especially for those who are part way through a hearing rehabilitation program?
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What will be the status of existing NDIS participants who also meet the HSP eligibility requirements?
Provider registration
In addition to concerns regarding the treatment and care of NDIS participants, AudA members have also raised concerns about provider registration for hearing services. Under current transitional arrangements, audiologists are able to register to provide services to NDIS participants in the following registration groups “Hearing Equipment” (Assistive Listening Devices), “Therapeutic Supports” and “Early Childhood Supports”.
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However, audiologists cannot currently register for the “Hearing Services” or “Specialised Hearing Services” categories as these categories are closed until the transitional arrangements for hearing services end as of 30 June 2020.
In the interim, audiologists who are registered with the Department of Health’s Hearing Services Voucher Program are able to provide voucher program services to eligible NDIS participants, which is considered to be equivalent to the “Hearing Services”; however, most audiologists cannot currently provide services in the category of “Specialised Hearing Services”. Under current “in kind” arrangements, this is currently restricted to hearing services provided by the statutory authority Hearing Australia through the Community Service Obligation program.
As of 1 July 2019, all NDIS service providers (except in WA) became subject to the quality and safety standards and registration requirements of the NDIS Quality and Safeguards Commission (the Commission).
This change affects audiologists who are registered or wish to register to provide services to NDIS
participants in Therapeutic Supports, Early Intervention Supports for Early Childhood and Hearing
Equipment (Assistive Listening Devices). They also affect audiologists who are supplying hearing services to NDIS participants through the HSP voucher scheme and wish to also offer services in Therapeutic Supports, Early Childhood Supports or Hearing Equipment.
The Commission registration process introduces new requirements and potential costs for providers. This new registration process requires providers to undertake an external audit, either for Verification if they are registered for supports that are deemed ‘low risk’ such as Therapeutic Supports and Hearing Equipment and are not operating within a company structure. The other option is Certification if they are registered for ‘high risk’ supports such as Early Childhood Supports or have an incorporated structure. If a Certification audit is required, providers are fully responsible for both the cost of audit, and the cost to fly and accommodate auditors if they do not have an audit office close to the provider.
It is not yet clear what level of audit the Commission will require of audiologists seeking to provide services in Hearing Services or Specialised Hearing Services categories. It is also unclear how “Specialist Hearing Services” will be defined and who will be eligible to provide those services. We note that audiologists registered with the HSP are already subject to an accreditation and audit regime via the Department of Health. However, hearing health care providers will have to meet an additional level of quality and safety accreditation given the Commission’s approach is that its requirements must be met despite any pre-existing regulatory systems and governance processes already in place to ensure the provision of ethical and evidence-based services by service providers.
While AudA supports accountability and transparency in the quality and competency standards for hearing service providers, we are concerned about members’ reports on the time and the cost of registration/accreditation and administrative requirements introduced by the NDIS. The onerous administration burden, unclaimable extra time required to support participants and the costs of registration/accreditation requirements are among the main disincentives reported by AudA members to register or re-register as a NDIS provider. In turn, this creates a barrier to entry into the marketplace for providers – especially smaller practices and solo providers - who find the extra
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cost and time burden unsustainable and financially unviable. This is regardless of whether the supports they are offering are low risk and/or they are currently seeing a relatively small number of agency-managed NDIS participants.
Given that there is already a lack of active providers in the NDIS space and it would be rare for an audiologist to only see NDIS clients exclusively, we are concerned that low numbers of registered providers will result in less choice and control for NDIS managed participants who will require these services now and in the future as the scheme expands over time.
We would welcome the opportunity to discuss this submission with the Committee further. I can be reached via Audiology Australia’s Advocacy and Policy Manager,
Yours sincerely
Dr Jessica Vitkovic
President
References
NDIA, ‘Improved support for hearing impaired’ 21 June 2018 < https://www.ndis.gov.au/news/521-improved-support hearing-impaired>
NDIA (2019a) NDIS Participant Outcomes: 30 June 2018
NDIA (2019b) COAG Disability Reform Council: Quarterly Report: 30 June 2019
National Rural Health Alliance (2019) Allied Health Workforce in Rural, Regional and Remote Australia: June 2019 https://www.ruralhealth.org.au/sites/default/files/publications/fact-sheet-allied-health.pdf.
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