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
Speech Pathology Australia’s submission to the
Joint Standing Committee on the National Disability Insurance Scheme
Inquiry: NDIS Quality & Safeguards Commission
31 July 2020
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 the operation of the NDIS Quality and Safeguards Commission (the Commission). As you are aware, Speech Pathology Australia is the national peak body for speech pathologists in Australia, representing more than 10,000 members. Speech pathologists are university-trained allied health professionals with expertise in the assessment, diagnosis and treatment of communication and swallowing difficulties.
We have structured our feedback in response to topics raised in the terms of reference that are relevant to speech pathologists providing services under the NDIS and make recommendations that we hope the Committee find useful. We preface these comments with brief background information about communication disability, swallowing difficulties and the role of speech pathologists. As always, we would be willing to appear before the Committee to provide more detail of the problems we highlight in our submission and to discuss potential solutions, as leaders in the speech pathology profession with expertise and ‘real life’ experience.
In the meantime, if Speech Pathology Australia can assist in any other way or provide additional information please contact Ms Amy Fitzpatrick, Senior Advisor Disability, on or by emailing
Yours sincerely
Tim Kittel
National President
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Table of Contents
Introduction ………………………………………………………………………………………………………………………………… 4 About Speech Pathology Australia ……………………………………………………………………………………………. 4 About communication disability and swallowing disorders ……………………………………………………………. 4 The role of speech pathologists ………………………………………………………………………………………………… 5
Speech Pathology Australia’s comments relating to relevant topics in the terms of reference: ……………… 6 Avoidable deaths …………………………………………………………………………………………………………………….. 6 Auditing …………………………………………………………………………………………………………………………………. 8 Limited Workforce …………………………………………………………………………………………………………………. 12 Restrictive practices ………………………………………………………………………………………………………………. 15 Poor Communication ……………………………………………………………………………………………………………… 16 Regulation of Professions ………………………………………………………………………………………………………. 17
Recommendations …………………………………………………………………………………………………………………….. 24
References ………………………………………………………………………………………………………………………………. 26
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Introduction
Speech Pathology Australia welcomes the opportunity to provide feedback to the Joint Standing
Committee on the National Disability Insurance Scheme’s Inquiry into the operation of the NDIS Quality and Safeguards Commission (the Commission). We have structured our feedback in response to the
topics within the terms of reference we believe are relevant to speech pathology and make
recommendations that we hope the Committee will find useful. We preface our comments with some brief background information on communication and swallowing disability and the role of speech pathologists.
About Speech Pathology Australia
Speech Pathology Australia is the national peak body for speech pathologists in Australia, representing over 10,000 members. Speech pathology is a self-regulated health profession through Certified Practising Speech Pathologist (CPSP) membership of Speech Pathology Australia.
The CPSP credential is recognised as a requirement for approved provider status under a range of government funding programs including the NDIS.
As the national body regulating the quality and safety of speech pathology practice in Australia, Speech Pathology Australia is also well placed to monitor and progress workforce developments and initiatives.
Speech Pathology Australia accredits the 26 university entry-level training courses for speech
pathologists in Australia, evaluates requests for recognition of overseas qualifications, administers the continuing professional development (CPD) program for the profession and provides mentoring and support programs to the significant cohort of new graduate/early career speech pathologists currently within the speech pathology workforce. The Association also manages the formal complaints process for the profession and can, if necessary, place sanctions on practice for any member who is demonstrated to contravene the Association’s Code of Ethics.
About communication disability and swallowing disorders
The Australian Bureau of Statistics’ 2015 Survey of Disability, Ageing and Carers (SDAC), estimated that 1.2 million Australians had 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.i
Some people have problems with their speech, language and communication that are permanent and impact on their functioning in everyday life.
Difficulties in speech, language, fluency, voice, and social communication can occur in isolation or the person may have difficulties in more than one area and can negatively affect an individual’s academic participation and achievement, employment opportunities, mental health, social participation, ability to develop relationships, and overall quality of life.
Communication disabilities can arise from a range of conditions that may be present from birth (e.g. Down Syndrome or Autism), 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). The prevalence and complexity of these disorders increase with age as both communication and swallowing functions are vulnerable to the natural ageing process; therefore, with an ageing population, prevalence and subsequent demand for supports will increase.
Some people with disability have complex communication needs (CCN), which are difficulties with
understanding or the expression of communication, associated with additional physical, cognitive or sensory impairments. Many people with CCN benefit from the provision of alternative or additional 4
methods of communication, including aided Augmentative and Alternative Communication (AAC) such as communication books, boards, speech generating devices and accessible technology for phone and internet-based communication.
Swallowing disorders affect the ability to safely swallow food or liquids and can lead to medical
complications and potentially death through choking, as well as a reduced ability to safely and enjoyably participate in social, employment and educational experiences where consumption of food and drink is needed. Swallowing problems are common in people with a complex disability such as cerebral palsy. For people with swallowing difficulties, supports may be required for the preparation and/or safe provision of meals to help to eat and drink effectively, safely, and as enjoyably as possible and ensure adequate nutrition. Too many people are still dying as a result of preventable swallowing disorders in Australia, at a young age.
The role of speech pathologists
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, disability and education sectors and mental health services). Speech pathologists, as experts in the assessment, diagnosis, and treatment of communication disorders are essential members of multi-disciplinary teams providing services to people with disability.
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. Speech pathologists use their diagnostic capacity to provide tailored and individually targeted intervention solutions to achieve functional outcomes. Some speech pathologists working in the disability sector focus their practice on the assessment and provision of communication aids for people with CCN. Speech pathologists working in this specific area of clinical focus typically develop their skills over many years working with people with CCN. This is also considered a specialised area of the NDIS workforce, called assistive technology, however under NDIS guidelines prescription of communication devices can be undertaken by a number of different allied health professionals, while we believe this is the role for an experienced speech pathologist.
Speech pathologists also provide valuable contributions to the assessment of decision-making capacity and the facilitation of supported decision making for people with communication support needs. This includes developing communication accessible health information and decision-making procedures and
protocols. In addition to identification of disease/disorder, assessment and intervention, speech
pathologists can also provide counselling/support to families and caregivers, education of other
professionals, case management, consultation, and advocacy. Communication partner training, including staff training, is considered an essential part of a speech pathologist’s work.
Speech pathologists have a pivotal role in the assessment and management of swallowing difficulties (dysphagia). Speech pathologists conduct assessments and diagnostic measures for dysphagia such as screening assessments, clinical and instrumental assessments (e.g. Videofluroscopic Swallow Studies), oral medication assessment, conduct oral trials to determine the most appropriate type of food or fluid for
the person to consume safely, and help the participant and their support networks decide on a
management plan, and consider compensatory measures or rehabilitation for their swallow.ii
With regards to dysphagia, all speech pathologists are trained to:
- determine the absence or presence of swallowing difficulty 5
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determine a participant or carer’s understanding and awareness of the feeding/swallowing difficulty
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describe a client’s feeding/swallowing abilities, including severity and level of impairment.
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determine the client’s nutritional and respiratory status, including ability to protect the airway.
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determine the ability to coordinate swallowing with respiration.
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determine the likelihood for safe oral intake
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prescribe the best consistencies of food or liquid to consume
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assess the best conditions for feeding/swallowing, such as positioning and alertness
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recommend alternative nutritional management if required.
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determine the need for further diagnostic studies.
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determine possible causes of dysphagia.
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plan treatment or compensatory strategies appropriate to the feeding/swallowing disorder. • determine requirement for referral to other health professionals, such as dietitians or
physiotherapists.
Speech Pathology Australia’s comments relating to relevant topics in the terms of reference:
Avoidable deaths
Oral eating and drinking difficulties are common in people with lifelong disability (e.g. Cerebral Palsy, or Down Syndrome) and can also occur as a result of acquired disabilities (such as Motor Neurone Disease or Stroke). Studies have shown about 15 per cent of people with lifelong disabilities require support to eat and drink and 8 per cent of people with lifelong disability known to disability services have dysphagia.iii It is difficult to get an accurate estimation of the numbers of people with disabilities who have oral eating and drinking difficulties, but it is likely that any numbers will be an underestimate, as these difficulties often go undetected and are under-reported. People with disability have an increased risk of choking and of receiving inadequate nutrition and hydration, particularly if they live out of the family home, and sadly, higher incidence of preventable death.
The NSW Ombudsman’s Report of Reviewable Deathsiv reports that ‘choking was a factor in the deaths of seven people in 2014-2015, and the deaths of four people in 2016-2017. This is a reduction on deaths from choking in the previous periods (10 deaths in 2012- 2013, and nine deaths in 2010-2011). All of the
11 people who died from choking in 2014-2017 lived in disability services, mainly group home
accommodation.’ Furthermore, investigations undertaken by the Disability Services Commissioner’s office into disability service provision to Victorians with disability who have died showed ‘in each of our first two years [2017-18 and 2018-19] conducting investigations into the deaths of people with disability, we received three cases where a person died by choking on food. In all six cases the person had a known swallowing issue, and in five cases the person had either a formal mealtime management plan or had received a swallowing assessment. In two cases, the person’s group home was aware of their mealtime support needs but failed to effectively communicate this to the day service attended by the person.’v
The fact many deaths of people with disability caused by aspiration pneumonia could have been prevented if the person had a mealtime support plan informed by speech pathologist assessment and, more importantly, if that mealtime support plan was consistently implemented,vi is not only distressing and
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frustrating for the members of our profession, but highlights the urgent need for accountability,
collaboration and change.
In conversations with our members regarding investigations into such deaths and near misses, feedback
from workers in group homes and in other professional settings, include the following statements:
“mealtime management plans are too long”, “we have never met the speech pathologist”, “we didn’t know where the plan was kept”, or “the person didn’t want that food”. This feedback reflects the lack of training, time and on-site support available for staff working day to day with people most at risk of sickness or death. Additionally, there seems to be a lack of accountability and learning from these investigations.
Speech Pathology Australia would like to see mealtime supports provided in a way that is accessible and based on informed choice and control for participants and their support networks. Speech Pathology Australia would also like to be notified when there are inconsistencies with the quality of mealtime management plans or services, so the most appropriate training and support can be given to members, as part of a coordinated response with the Commission.
People with disability who have oral eating and drinking difficulties, previously received speech pathology supports for mealtimes through state-funded disability services. With the implementation of the NDIS these clients (if under 65) transitioned to the NDIS and state-funded supports were ceased. Increasingly Speech Pathology Australia received feedback that at plan review for existing NDIS participants, and at plan development for new NDIS participants, funding for these supports for assessment and development of mealtime guidelines (for family and support workers providing assistance at mealtimes), and for products used in mealtime preparation such as fluid thickener were being rejected. Speech Pathology
Australia tirelessly advocated for mealtime supports to be included in NDIS plans, and this was
successfully resolved in 2019.
Despite this success, however, people with oral eating and drinking support needs are still not being provided with appropriate and high-quality supports for their eating and drinking. Speech pathologists are
key members of the multi-professional team (including dietitians, occupational therapists,
physiotherapists, support workers), who provide solutions to enable people with disabilities to participate safely in the functional activity of oral eating and drinking and thereby experience an enhanced quality of life. Speech pathologists develop guidelines for those providing direct support (family, unpaid and paid supports), including information and strategies with the aim to support enjoyment (e.g. food preferences, preferred mealtime companions), effectiveness (duration of meals, when and how to offer food, how a person may signal hunger, sensory preferences) as well as safety (food and fluid texture, positioning during and after meals, amount of food offered per spoonful, provision of sips between mouthfuls). However, this time is not adequately funded in NDIS plans, and participants often need to choose between basic and essential services such as physiotherapy to prevent muscle deterioration, or training for their workers to learn how to support them to eat.
Speech pathology support services and products which address functional impairments (which impact on participation in the activity of oral eating and drinking) and aim to improve functional capacity, and provide support to live an ordinary life, should be considered reasonable and necessary. Functional assessment of a person’s eating and drinking, development of recommendations and development of mealtime guidelines should be funded in NDIS participant plans to be delivered by a speech pathologist. Currently, the disability related health support items for dysphagia - particularly for mealtime management plans and oral eating and drinking care plans are able to be developed by a “NDIS-funded suitably qualified and competent clinician”. Speech Pathology Australia asserts that this item is able to be delivered by a speech pathologist only, and believes that this is essential for accountability in preventing near misses and deaths with regards to eating and drinking related incidents for people with disability.
To reduce the risk of choking and ensure adequate nutrition and hydration, input from speech
pathologists is essential to provide assessment, education and supports for participants to be able to have effective, enjoyable and safe mealtimes, and to provide training to staff so that they are confident
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and competent to provide supports to those individuals which balances dignity of risk and safety. In order to do this, face-to-face training and regular review is required. Speech Pathology Australia recommends that face-to-face training by a speech pathologist for all people with disability with diagnosed dysphagia is added as a separate line item in the participant’s plan.
There are some inconsistencies regarding service delivery in supported accommodation and dysphagia management that has been brought to the attention of Speech Pathology Australia by its members. While participants may choose to employ a speech pathologist to conduct a mealtime assessment, the
supported accommodation’s organisation/company may have a policy that limits the participant
implementing their choice and control. For example, one member writes:
“I developed a mealtime management plan for my client and we agreed to add bread when his family visited, if I trained them to supervise him, even though he wasn’t technically on that consistency for other meals. The home said he wasn’t allowed to do that, as that wasn’t in their policy, and it was too bad, as I didn’t work for them, I was contracted through the NDIS by the client. He was so upset, and they said his only choice was to sign a waiver saying they didn’t need to prepare modified meals anymore at all. It didn’t give either of us much choice and control, and made me really reluctant to work in this field anymore”
Similarly, many members report that some participants are choosing not to have mealtime assessments or treatment plans. This is of course their right, when they are given education about the potential impact of these choices on their health in an accessible and clear way. However, Speech Pathology Australia has identified this as an area of need for professional education, and therefore continues to publish position statements, offer communities of practice and advice for members. Participants need to have enough funding and flexibility in their plans to make informed choices about the assessments and treatments they want, rather than economising on services such as swallowing assessments that they do not realise to be basic and essential.
During 2019, representatives from Speech Pathology Australia participated in roundtable discussions on “Influencing future mealtime supports in disability services”, these meetings were convened by the Disability Services Commissioner to identify key issues and develop actions to ensure that people with disability who have swallowing difficulties receive appropriate assessments and mealtime supports.
Auditing
With the advent of the National Quality and Safeguarding Framework (NQSF) and registration and governance transitioning to the National Quality and Safeguarding Commission, there are now additional requirements for existing and potential providers. These requirements must be met regardless of pre existing regulatory systems and governance processes already in place to ensure the provision of ethical and evidence-based services by allied health providers, or if providers have already recently been audited as part of their state-based procedures.
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’, or for Certification if they are registered for ‘high risk’ supports. It should be noted that Early Childhood Supports (ECS), which allows providers to supply services to 0-7 year olds has been labelled as ‘high risk’, and that providers are fully responsible for both the cost of audit, and the cost of flights and accommodation for auditors if they do not have an audit office close by. This cost is substantial for the provider, both financially and in regard to time and productivity lost whilst several staff members are spending considerable hours preparing for the audit.
The majority of private speech pathology practices are small or sole trader organisations, with limited infrastructure and resources, and auditing, particularly under certification, is costly. These costs can be indirect (opportunity costs) due to the significant time required to complete the large amount of paperwork and preparation, as well as time spent during the actual auditing day when the business owner may not
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be able to see clients, and direct financial costs with Certification being reported by our members as between $7,000-$30,000 (exclusive of travel). One of the quotes for $10,000 was for a speech pathologist who had only four NDIS clients.
There does not appear to be a delineation between large companies who may have formerly been delivering Early Childhood Intervention Services (ECIS) under state block funding, and small private providers who are looking to provide therapy supports to children under 7 years of age. There have been mixed messages from the Commission around Certification. It has been said that it is only these larger organisations that would have the ECS supports allocated in plans, and that smaller allied health providers would be able to claim against the Therapeutic Supports item, including for children aged under seven. However, plans for children aged under 6 include only ECS support items. This demonstrates the lack of understanding of the sector, and implications of an additional and overly onerous registration process for providers who are already well regulated, either through AHPRA or as part of a self-regulating profession, as is the case with speech pathology.
Furthermore, registered providers in NSW and Victoria who may have already undergone an audit (at their own cost) to be able to deliver ECS as part of their state-based requirements are not having these audits recognised, and are still required to undergo this second audit, again at their own expense.
In light of this, many of our members are indicating that they are not re-registering, or dropping Early Childhood Supports from their registration, because of the requirement for Certification; both because of the cost of audit, and a sense that the compliance requirements are onerous and irrelevant or at least inappropriate for provision of therapeutic interventions by an already well-regulated profession. This reduction in registered providers is likely to contribute to creating a thin market for access to therapy services for agency-managed children under seven years old.
“Our profession is already regulated (Speech Pathology Australia standards & ethics) - NDIS seems to be applying a one size fits all to auditing, ironic that an organisation charged with individualised service provision has decided to impose this one size fits all structure to the array of people providing services to the NDIS - from the highly qualified professionals to untrained support workers” NSW Regional member
“Concerned about the cost for a solo practitioner with only 5 NDIS clients. Doesn’t seem worth it to me to continue being registered if the audit/registration process is so time consuming/costly. This would be a shame in a regional area where there are numerous SP’s like myself in the same position for the adult ABI population, it would probably wipe out the providers for that population in our area” VIC Regional member
“There is a huge financial and time burden to being an NDIS registered provider. Not only that but the NDIS now requires us to go through an expensive certification process which will likely cost us $10,000 to $15,000”. (Metro NSW member)
“the arduous process ahead for sole traders and small businesses (I employ one other SP currently) in getting all the paperwork sorted and costs involved for a service that I have been providing to the NDIS community since the start of the Barwon region trial. I have already completed a number of NDIS audits and now this. I am strongly considering not being a provider however I believe that the state government is relying on our community service nature as a caring profession to “just do it” for the good of all the families it will impact on already on our caseload.” (Rural VIC member)
It is unclear why the NDIA chose to identify the provision of allied health interventions to children aged under six as ECS, and therefore classify them under the high-risk category. While it does require the provision of family-centred services using strengths-based approaches and includes capacity building for communication partners and others, this is part of the provision of speech pathology services regardless of whether a child is over or under 7 years of age – and in fact, aside from the shift to person-centred rather than family-centred, it is the same for many adolescents and adults with disability.
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The standards for ECS also appear to have been developed by the Commission assuming that all ECS will be provided using a key worker model previously employed by Early Childhood Intervention Services in NSW and Victoria. Sole providers, and small businesses may not be able to adopt this model due to their structure, and concerns have been raised by our members who feel they may be penalised, even if they are acting according to the best practice guidelines, simply because they do not have a multi disciplinary team. Auditors need to be aware of these best practice guidelines, and not penalise the few providers willing to register for this group, simply because they are a smaller business.
Overall there is a lack of registered auditors, with only 15 companies servicing the whole of Australia. There are also not auditors present in every state and territory, and they often only have a metropolitan office, with reports from many rural and regional members that they as providers must cover not only the cost of audit, but the cost of travel, accommodation and food for auditors. This is particularly problematic when Certification apparently requires two auditors to undertake two on-site audits: one in the initial stages, and then a second ‘surveillance’ audit after 18 months. This has had a significant impact upon these member’s ability to afford to be audited, and has resulted in providers either only undertaking Verification, or not registering at all.
“[Cost] was the reason I chose to not register for ECEI. I’ll just see plan and self managed participants with that funding. I’m in regional Queensland and couldn’t afford to pay flights, meals, accommodation etc when I’m only just starting out.” (Rural Qld member)
“Our first quote was $20k - that’s before airfares and accommodation for 2 people.” (Rural Qld member)
“I am a trust but work on my own and only have 6 clients. I work remote. I have to pay for two auditors to come even though the second auditor will not have enough work to do!…I have only received 3 quotes back out of ?8 or ?10 two of these operate out of Melbourne and I would be paying for flights from Melbourne!!!! Ridiculous! One of my highest quotes would have set me back about 18000 over three years!!!! PWC have been the cheapest (approx 11000) over three years.” (Remote SA member)
Of those members who completed our NSQF survey in April 2019 and stated that they were currently unregistered, 23 per cent were formerly registered with the NDIS and when asked ‘why did you cease your registration?’ 88 per cent of this group said it was due to auditing cost; 70 per cent reported concerns about auditing requirements and almost 65 per cent said it was due to the administrative burden. Almost 53 per cent of those who were formerly registered said there was nothing that would make them decide to re-register.
“It is not viable for sole trader, part time practitioners to register. The time & workload for compliance is too much of a burden. Increasing the hourly rate for therapists does not address these problems. I will continue to only see self-managed or agent managed clients. Being in a regional area this means that many people miss out on help.” NSW Regional member
“Audits would cost more than my 1 or 2 direct NDIS clients would bring in, in terms of income. After 35 years in the profession servicing disability clients in specialised groups and diagnoses, there are too many problems for me to continue with registration and stay sane. Also, the NDIS requires further life insurances etc for each person registered to hold for continued registration. As a person with a disability I don’t qualify for income protection and life insurance due to possible pre-existing condition affecting all of
my medical circumstances so I also don't think I qualify any longer to be registered.” (Metro NSW
member)
“The total lack of recognition that as Speech Pathologists we have a national association, registered with health funds and Medicare and previously with FAHCSIA which have never scrutinised in such depth. Totally understand accountability but the amount of financial outlay to be NDIS registered along with the time doing so, makes it impossible for a small business to compete let alone provide more availability of services which was the philosophy of the NDIS initially.” (Metro NSW member)
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103 of the survey respondents who were registered providers responded to a question about whether they would re-register under the Quality and Safeguarding Commission. Thirteen percent of these 103 respondents said that they had decided not to re-register. 36 per cent indicated they had commenced formal re-registration, but felt they were unlikely to complete the process and a further 10 per cent indicated that they would have to drop some support groups from their registration. This represents a potential market loss of almost 60 percent. Of those who reported they would need to drop supports, 100 per cent identified this would be Early Childhood Supports.
“My favourite client group is in EI and if the costs are too high this means clients may no longer continue with me as a provider they may move to another practice that can afford to be certified. It’s upsetting as sole traders and businesses have worked hard to support these clients and some of us even put on extra staff to cope with the demands for us only to lose income and clients if not being certified. It means only big practices will thrive as they have the money backing them but not always the skills as people are hiring a lot of new graduates without supervision/mentoring and enough skills to assist them. There are so many good clinicians out there with great skills but will be lost as they decide not to reregister due to the cost and added workload.” NSW regional member
“I am highly experienced in the area of early intervention however bigger companies with younger and less experienced speech pathologist will be able to have access to this area, but I cannot afford the amount (and time) which it takes to go through the process.” NSW regional member
“I am concerned about being able to afford the cost of audit to remain registered under early childhood supports. Early intervention is my favoured area of practice and I have nearly 20 years’ experience
working in this area. Unfortunately, as a sole trader I don’t think I can afford to re-register for early
childhood supports, meaning I will no longer be able to see my ideal client caseload for those families that are NDIA managed.” NSW Metro member
This is of concern as there is already a lack of active providers who are registered to provide Early Childhood Supports, as seen in Table 1 below. The Association has grave concerns for market failure in the early childhood sector, where there will be a lack of providers, and therefore affect choice and control for families who are unable to self-manage. This will particularly affect the most vulnerable who may have disabilities themselves, are from CALD or low economic status backgrounds, or simply live in rural areas where their local provider is no longer able to provide services.
The potential to lose more than half the market of registered providers of speech pathology supports, or at least have these providers no longer provide early childhood supports, needs to be acknowledged and addressed. The auditing process, whilst suggested to be proportionate to the size of the provider’s business, appears far more related to the types of supports, and the provider’s geographical location. Without better regulation of auditors, control of their prices by the Commission, and reduction in the administrative burden placed upon providers that are already well regulated, there are significant risks for market failure with NDIS managed participants unable to access any registered providers of speech pathology supports.
The NQSF can 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 would be consistent with other government and private health funding schemes.
The classification of all Early Childhood Supports as high risk should be reviewed, as it is the position of the Association that these supports are not of higher risk than those provided to children (and adults) over the age of seven. It is short sighted to attribute it solely to a specific age group.
Additionally, a review of the costs of auditing should be undertaken to allow for regulation of the market and costs to providers, particularly in rural and remote areas. Rural and remote providers may need to
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receive financial subsidies, or have the additional fees associated with travel and accommodation of auditors to be waived or covered by the Commission. Alternatively, and in line with many services response to COVID-19, the auditing process itself could be reviewed to determine if an onsite audit is actually necessary, or if this could be completed remotely.
Limited Workforce
Rural and remote areas have thin markets for speech pathology, and this is also becoming an increasing issue in metropolitan areas including Sydney and Melbourne, the ACT and Tasmania. The Association has received numerous calls from participants and parents who have been unable to find a speech pathologist, even in metropolitan areas. We are also aware that some private providers in metropolitan locations closed their waiting lists for the remainder of 2020 in February.
Long waitlists to access providers are also commonplace for participants requiring particular expertise in specific areas such as those with specialist expertise in Augmentative and Alternative Communication (AAC), those providing direct mealtime supports and mealtime management planning advice, those able to work with participants with behaviours of concern, or with complex disability.
With the high cost of auditing, some providers are choosing to drop registration groups, particularly behaviour supports and early childhood, or to not re-register altogether. Table 1 shows the number of active providers compared to the number of active plans of that type, taken from the most recent COAG Disability Reform Council Quarterly Performance report. It should be noted that NDIS clients will make up only part of a speech pathologist’s case load/revenue stream, indeed it is rare for a speech pathologist to only see NDIS clients exclusively, further affecting the number of active providers. Low numbers of registered providers will obviously result in less choice and control for NDIS managed participants who require these services.
Table 1: Registered versus Active NDIS Providers
State Total # of Active ECS Total # of EI Active Total # of non
Registered providers in the plans Therapeutic EI plans
Providers last quarter supports
providers in the last quarter
NSW 7058 513 26451 1976 92813
VIC 4826 318 17572 1417 80969
QLD 4848 423 14115 1211 53572
WA 1241 95 2951 266 24326
SA 1716 178 10573 397 22554
TAS 996 49 1561 201 6782
ACT 975 42 2714 146 4778
NT 504 30 683 88 2441
Source: COAG Disability Reform Council Quarterly Performance Report – National 31 March 2020
The figures presented in Table 1, are particularly concerning when compared to figures from the same period last year as shown in Table 2.
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Table 2: Registered versus Active NDIS Providers 2019
State Total # of Active ECS Total # of EI Active Total # of non
Registered providers plans Therapeutic EI plans
Providers supports providers
NSW 8716 657 19136 2763 82827
VIC 6669 275 15068 1545 56702
QLD 5405 294 9728 959 36308
WA 1115 60 1456 171 12177
SA 4465 346 9921 524 17566
TAS 1459 33 1392 174 4922
ACT 1589 71 2949 210 4712
NT 783 16 650 52 1641
Source: COAG Disability Reform Council Quarterly Performance Report – National 31 March 2019
The total number of registered providers has dropped in every state except Western Australia, with South Australia now only having approximately a quarter of the registered providers available compared with a year ago. Additionally, the number of active providers of therapeutic supports (therapy supports for those over 7 years of age) and ECS (for children under 7) has drastically reduced in both New South Wales and South Australia following the introduction of the Commission, which we feel reflects an unwillingness amongst providers to re-register. There are also less registered providers of therapeutic supports in Victoria and the ACT, and a drop in ECS providers in the ACT.
Addressing thin markets
There are several challenges in attracting and retaining the speech pathologist workforce to provide services through the NDIS and these are even more pronounced for regional and remote communities. At the beginning of the roll-out of the NDIS, the administrative burden on providers, registration and third party verification requirements and delays to payment all had a very negative impact, as these caused extreme financial stress to some small and sole providers which in turn contributed to some providers de registering or deciding that providing services in the NDIS would not be financially viable for them at this point. While some of these initial issues have now been rectified or addressed to a certain extent, there are still areas where improvement is needed to ensure an adequate number of skilled and experienced providers are attracted to, and retained in, the NDIS workforce.
Firstly, it is essential that the Commission, in conjunction with the NDIA, has mechanisms in place 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, and therefore uncommon, services. The assumption that there will be providers accessible in all areas, or that telehealth can be used to provide services instead, is problematic in that many remote areas have poor internet connections, and also those providers who are available in the area may not be able - experienced or skilled - to provide the necessary services to meet all clients’ needs.
Secondly, the Commission should recognise the need for a range of incentives to ensure an adequate supply of services in areas with currently sparse distribution of providers and geographically remote. To increase the speech pathology workforce supply within the NDIS, initiatives are needed to, first and 13
foremost, address the systemic and structural issues to ensure that being an NDIS registered provider is financially viable for small and sole trader private practices. As a female-dominated workforce, speech pathologists tend to work part time hours (across the profession, not just within the disability sector), and be sole traders or small businesses. If the sole trader and smaller sized providers were lost to the market this would result in the dominance of larger organisations and potential monopolies, which would be in direct conflict with the NDIS principle of choice and control.
The Commission must urgently review the workforce data, particularly regarding registered providers, and look at incentivising re-registration, or at the very least removing the current significant barriers to auditing faced by providers, especially when attempting Certification.
Supporting supervision
In addition to addressing the issues with auditing identified above, consideration needs to be given to how providers can be supported to access the clinical supervision and supports they need, and to further develop their clinical competencies in specialised areas of service provision and/or needs which are of low incidence in the population, such as rare genetic conditions. Often, new graduates do not feel confident to take roles in rural and remote areas due to the lack of supervision available and the necessity to see participants with a wide range of communication and swallowing difficulties.
The Association supports the inclusion of supervision within the NDIS Code of Conduct; however, the Commission needs to consider how this will work in practice when the NDIA will not provide financial support for supervision, training or upskilling.
This is particularly relevant to complex interventions such as behavioural supports, or the provision of AAC supports, as we have seen the loss of pre-existing networks and community knowledge hubs
(particularly around complex disability and AAC provision) resulting in supports being siloed and
individual providers not having the support mechanisms they previously used. The reality is that in order to provide the most up to date and evidence-based supports, regular, ongoing professional development, clinical supervision and upskilling is necessary. Without being able to be adequately remunerated or maintain currency of knowledge and skills, providers will be unable to continue to provide services in these complex markets that are already thin due to their specificity.
“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
As discussed above, several members have expressed their apprehension that they, as small providers, are unable to financially sustain the costs of audit, which will further thin the market so that the only registered providers available for participants to choose from will be larger providers who may not always employ experienced staff. Furthermore, given the current lack of systemic support for upskilling of new graduates in disability specific areas there is a concern that workers within these larger organisations may not have the appropriate skills, and the organisation may not be incentivised to provide the necessary supervision and training.
“It appears to support the larger organisations that I thought the NDIS was trying not to limit services provision to. People with experience are pulling out of the options to provide services to the clients for which they have high expertise or to provide these but under their own business ability and those who can use self or plan management can access these but NDIS have ensured that direct clients WILL have limited access to service providers that have expertise.” NSW metro member
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“The financial and time burden will possibly make it impossible for small businesses who have specialist skills to comply, leaving the NDIS market to larger businesses. I am uncertain exactly what will be considered valid disability experience and who decides this.” QLD metro member
“Lack of information given to clients from NDIA regarding options for providers. With many small business not re-registering as providers there will be a lack of choice for clients to choose providers with potential waiting lists and inexperienced clinicians for a very complex caseload.” QLD metro member
It is the view of Speech Pathology Australia that a market approach to disability service provision will not provide the environment able to retain or further develop such a specialised workforce. NDIS participants will 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. 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 support the emerging market.
Restrictive practices
One of the main aims of the Commission is to monitor and ultimately reduce the use of restrictive practices. Restrictive practices such as seclusion are often used in disability settings in response to behaviours of concern. These practices are frequently implemented without any understanding or consideration of the underlying communication difficulties that may be contributing to the behaviours of concern which a person with disability may exhibit.
Being unable to understand and communicate effectively leads to increased frustration, anxiety and fear, which in turn leads to increased behaviours of concern. It is well understood that behaviours of concern frequently have a communicative function – people self-harm or harm others as a means of expressing their boredom, or frustration, or their dysregulation in the face of environmental stimuli. There is potential for behaviours of concern to lead educators, and support workers with inadequate training and support, to physically abuse people with disabilities, or use other restrictive behaviours such as exclusion – rather than recognising the reason and purpose of their behaviour and providing an appropriate response.
Despite the link between behaviour and communication, speech pathologists are not always consulted in
the development and implementation of behavioural support plans. There is also a lack of clarity
regarding what constitutes ‘behavioural supports’ and the experience and qualifications required to
provide them. Some of those providing ‘behavioural supports’ may also give advice regarding
communication with and for the participant without consultation, and this is reported to sometimes be at odds with what is being implemented by the speech pathologist.
Additionally, this is the only support item that has been mandated that providers must be registered for, and as it is a high-risk support this would result in a Certification audit and the completion of two extra registration modules. A small subset of speech pathologists indicated that this is an area where they have experience, and would previously have provided supports, however they have concerns that if they try to register for this group, and pay the audit costs, they may be denied registration because of their lack of competencies that are currently undefined by the Commission.
“It is a changing landscape. Unknowns are cost, ability for providers in QLD who were made redundant at the beginning of the year to learn business processes, learn NDIS and develop policies, procedures and compliance with the Quality and Safeguarding Commission as well as go through the process is a big ask for businesses that are not yet established. Also concerned about applying for Improved Relationships (my primary area of practice) due to lack of clarity of qualifications required (with SLP under other) and compliance with restrictive practice reporting from the commission which looks different from QLD legislative reporting. Both systems will remain in place placing risks on providers.” Qld metro member
Greater clarity around the boundaries of those providing behaviour supports, their required qualifications, and the need for liaison with a speech pathologist around communication is vital.
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Poor Communication
A consistent complaint regarding the NDIS has been the complexity of the scheme, and the NDIA’s poor communication with participants, providers, and the sector as a whole. Unfortunately, the Commission and their regulations for providers have also proven to be confusing, with a lack of clarification, and frequent changes. For example, the Commission changed their rules around reportable incidents, requiring registered providers to follow a different process that was time limited. This was not conveyed to providers, despite the Commission having the power to subsequently fine providers for not following these (potentially unknown) timelines, instead it was simply altered on their website, with no notification. This places an unreasonable onus upon providers to constantly monitor a large, unwieldy and complex website in case something is changed or updated. Whilst ‘provider alert’ emails have been used, these are infrequent; prior to the COVID-19 crisis this was only provided bi-monthly and did not include all of the changes that were made to various processes but were more general in nature.
The Commission website is difficult to use, with documents and pathways often altered or moved, making it challenging to find the documentation or item needed, and requiring constant re-learning. This is time
consuming and frustrating for providers as the website is the main source of information about
governance, and providers are expected to know and follow these rules. The website is also not accessible for consumers, creating barriers to people with disability or complex communication needs to make complaints or provide feedback easily.
The Commission portal that providers are required to utilise in order to renew their registration, or register for the first time, is also unwieldy and difficult to navigate. There are no explanatory documents, or task cards to explain where things are, or the process for using particular aspects of the portal. For example, the button that providers transitioning to come under the governance of the Commission must press to indicate they will re-register has changed location and its appearance several times. It is not intuitive as to where this button is, and no information is given as to where to find it. There have also been several ‘glitches’ whereby changes in legislation were not reflected in the portal systems, for instance there was one affecting the amount of modules that needed to be completed, causing further concern for providers. Currently after a provider indicates their intent to re-register they are given a further nine months to be audited, however this is not actually documented anywhere.
The Commission’s documents lack clarity and specificity, and legislation will often be changed with limited explanation or notice. This caused considerable difficulty and distress for providers in the rollout states of South Australia and New South Wales in a multitude of ways during the transition period. For example, in December 2019, without warning from the Commission, the auditing process was changed in a significant way to allow incorporated bodies to be audited against their registration groups rather than business structure, meaning that they could go down the verification pathway. Most providers in South Australia and New South Wales however, had already booked or completed their audit as per the previous arrangement; this short notice change unfairly disadvantaged them and forced them to go through the more arduous and expensive Certification process.
“We were over a barrel really. We had to jump because they were already booked to July and we need to
complete the process before the end of October. I truly believe that if disability services have been
devolved to the private sector with a regulatory body, that body should conduct and cover the cost of the audits. We don’t quite have two EFT staff yet we require two auditors.” (Rural NSW member)
There is also a lack of transparency regarding the complaints process, including the types and numbers of complaints, or the outcomes. This is concerning regarding the protection of people with disability, and governance of providers. It remains unclear whether providers who have been directly implicated in the abuse, neglect, and potentially death of people with disability have been appropriately managed and
disciplined. There is no clarity regarding communication between regulatory bodies, including peak
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bodies and the Commission, and whether there is an expectation or process for one system to inform the other of disciplinary action or warnings against a provider.
At present there is no engagement between the Commission and peak bodies at all, and therefore no way to provide feedback regarding issues experienced by providers, or to advocate on their behalf. This was further exacerbated by a general lack of stakeholder engagement, whereby providers were not able to call the Commission until it had officially rolled out in their state. Even with the majority of states and territories now officially under the governance of the Commission, there is seemingly no provider team to speak to about the many enquiries and concerns regarding the registration process. Instead Speech Pathology Australia receives these requests from its members directly and has invested significant
resources towards assisting speech pathologists to understand the guidelines and available
documentation to be able re-register if they choose.
One member reports:
“I had heard from Speech Pathology Australia that there was a glitch around the core module, and called the Commission to check on my registration, and that I didn’t have to do the whole thing. The first person I spoke to was lovely and said yes, there was a glitch and they were fixing it, and that we would be contacted. I didn’t hear anything for a while, so called a second time, this time I was put in to someone ‘higher up’ who very curtly told me that there was no glitch and that the Commission hadn’t changed the rules yet, and perhaps they wouldn’t and I would have to do the whole thing. So, which is it?” (Metro VIC member)
The Commission’s processes, rules, and internal structures should be made clear to providers, with greater transparency and communication around proposed changes, with time and opportunities given to provide feedback. A specific team or direct phone line for providers to call and receive advice regarding compliance or registration, with trained responders who know the latest rules, should also be established.
This phoneline or team should be open to providers across Australia, including Western Australia, despite it not officially being under the auspice of the Commission, as they have significant questions regarding the new process. Speech Pathology Australia was recently contacted by two members who had not yet come under the Commission, but had been told, by what they believed to be an auditing body, that they had, and they were required to complete several modules by the end of the month. This caused them significant stress as they were trying to manage their business during the COVID-19 pandemic. After lengthy discussion it was finally established that they were already registered in WA, therefore would be re-registering, and have time to do so. This significant stress could have been avoided, had they been able to discuss this with the Commission directly.
Regulation of Professions
At present, the Commission regulates all providers through the NDIS Code of Conduct and registered providers must also meet the NDIS Practice Standards. Whilst providers of therapy supports appear to be strictly regulated, there have been significant gaps identified in the Commission’s regulation of other professionals within the NDIS space.
Support workers and the impact of ableism
Whilst there appear to be minimum standards put forward by the Commission regarding care tasks such as providing enteral feeding supports, there are no standards for training regarding oral mealtimes, or communication access as a basic human right. There is an excellent set of modules as part of the ‘Quality, Safety and You’ mandatory training package, however whilst ableism is obliquely referred to within these modules, there is a lack of discussion of this directly, with some of the videos showing experiences of ableism not labelled as being inappropriate.
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Throughout Australian culture, including within the disability sector, ableism is a significant issue. Ableism can be defined as the discrimination or prejudice against people who have disabilities. It can take the form of ideas and assumptions, stereotypes, attitudes and practices, physical barriers in the environment, or oppression on a more systemic level. It is often unintentional, and most people are completely unaware of the impact of their words or actions.
Furthermore, there is widespread misunderstanding about the nature of communication disabilities and communication needs, a lack of knowledge about the range of supports, multi-modal communication options, including AAC, available to help people to communicate and participate to their full potential. It is also very common for able-bodied people to make assumptions which lead to discrimination against people with disabilities, particularly cognitive disabilities, resulting in reduced/inadequate supports being provided.
Even if people with severe to profound communication disability do not have the opportunity or capacity to learn to use representational systems using symbols or signs as part of their communication, most people with disability will, at the least, use some informal means of communication. People with disabilities may also understand more than they can demonstrate. People using informal means of communication are therefore more reliant on the people around them to optimise their communication opportunities and to interpret their facial expressions, body positioning, vocalisations and behaviours to indicate their wants, needs and preferences.
There are some basic guidelines which communication partners can adopt to make communication interactions with people with CCN more successful, but unfortunately there is very limited understanding and awareness of what these are or why they are important, therefore this is not usually included within
training for support workers. Therefore, people with CCN are denied access to communicative
participation within most settings, and may also not have access to safe, enjoyable mealtimes.
For an example of the lack of recognition of an individual’s right to communicate their preferences and appreciation of how they best communicate, we refer the Committee to the following witness testimony
from Ms Sam Peterson presented at the Royal Commission into Violence, Abuse, Neglect and
Exploitation of People with Disability’s Melbourne Public Hearing 10.09 AM, Friday, 6 December 2019 – Ms Peterson uses an augmentative and alternative communication device.vii
“The added avalanche of verbal words from support workers when they were supporting me was impossible to keep up with. They told me stuff when I was getting dressed and couldn’t respond as I
didn’t have my communication devices. I told them to stop it but they would forget. Some support
workers didn’t seek my input about what I needed and what I’m okay with. If I really wanted my speech device I could always get it but sometimes I risked them going away to work with someone else while I wrote. They could be gone for ages.
The result was that I was reluctant to assert my right to communicate. I had to choose between
communicating and getting dressed. When the support workers would dress me often they would have three people doing it at once. They would all ask me things at once and I couldn’t respond to all three of them without my speech device. They saw it as being efficient but I saw it as taking my say away.”
Disregarding Ms Peterson’s need to access her speech device and not respecting the time needed for her to communicate with them effectively, thereby restricting her ability to communicate her wishes and respond to their questions, highlights a lack of understanding by the support staff. We consider this an example of denying an individual’s basic human right to communicate and therefore constitutes a form of abuse; as Ms Peterson clearly states in her testimony “they saw it as efficient, but I saw it as taking my say away.” Support workers should receive training to assist them in understanding that this is not appropriate, and neglects the person with disability’s rights and autonomy.
People with disability are also often assumed to have a greater level of cognitive disability than they in fact do. In addition, people with communication disability face significant barriers to being able to report
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abuse, neglect or mistreatment, because they are not provided with the opportunity, time or the means to do so in a way that ‘fits’ with their communication abilities. Furthermore, people with cognitive disabilities face additional challenges to their ability to complain, as they often have a limited understanding of their rights, which increases their vulnerability.
The recent media reportingviii of the tragic death of a 54 year old Adelaide woman with cerebral palsy also indicates the potential impacts of poor regulation, and lack of training of support workers. She was reported to be malnourished, with difficulties feeding herself due to her cerebral palsy. It would appear that she was not given the opportunity or means to communicate about her care to anyone outside of the team providing that care. This situation can arise when the person with a disability is in effect totally isolated, and there is not a range of people interacting with or seeing them, except those providing care, who may also be the ones committing the acts of neglect or abuse.
This speaks to a common medicalisation of care of people with disability with high support needs, whereby they may have support workers to see to their physical needs, but they are not necessarily afforded the same opportunities to socialise, or leave their homes in a way that would be typical for those without a disability. This also reflects an attitude that has been reported by speech pathologists, that communication and social interactions are seen as secondary to the rhythm of care, less important than physical care tasks, and in some cases, seen as pointless by support workers.
A speech pathologist gave this example “I attended first aid training at his house, only to find him sitting with no communication device available to him. The moment I had a chance, I went and hooked up his device and put the mount on his wheelchair, only to turn around and see that the screen had been closed again. Not hindered by this, I opened it again and was then told by one of the staff (who closed it again), that “sorry…I really don’t think he is interested in neuroswitch today, he would much rather just watch
what we are doing”… It’s a very old and common story with communication devices and I think the
biggest reason they end up unused in the cupboard, is that they are not too much work for the person who needs it, but in fact a hindrance for the carers!” (Metro WA member)
These issues are frequently exacerbated by a high turnover of support staff and carers within disability support organisations where there is perhaps no one point of contact or responsible person identified. This makes maintaining supports so that all workers have been appropriately trained, residents’ mealtime and communication needs are being met, and recommendations from speech pathologists are being followed, difficult. For example:
“There are three siblings who are in long-term foster care. Rather than having a foster carer they are supervised by an agency. The agency provides a house for the children to live in and rosters carers to be there for the children. The carers come and go depending upon their shifts. I am finding the carers uninterested and at times they appear to dislike the children. One time they failed to attend and when I rang the head carer he said “I’m not working today”. As a therapist I am struggling to get follow through as the carers change every time.” (Rural NSW member)
Support workers and other staff supporting people with disability require training regarding ableism, different forms of communication, how to enable communication access for people with CCN and how to
provide safe, effective and enjoyable mealtimes. This training would ideally be provided by the
Commission, in consultation with the speech pathology sector and Speech Pathology Australia, and should be considered mandatory for support workers, similar to the current ‘Quality, Safety and You’ modules. There is currently no discussion of supporting communication and those with CCN within the modules, despite numerous examples of the use of AAC. We feel this is a missed opportunity, and one that should be ameliorated by the Commission.
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Plan Managers
Plan managers must be registered providers, yet there is a lack of regulation from the Commission regarding their conduct. There have been frequent reports by Speech Pathology Australia members of plan managers refusing to pay invoices because they have misunderstood the NDIS rules, particularly around travel. Plan managers have also been noted to deny payments because they do not feel the item is reasonable and necessary, despite their nonclinical role, where they should not be making judgements about items approved within the plan.
Our members have reported:
“We refused to work with clients from a particularly bad PM. When clients started feeding this back to them a senior manager from the company called and tried to bully me.” (Metro VIC member)
“We have $15000 in outstanding invoices - mostly from plan managers.” (Metro NSW member)
“Why does it take a Plan Manager 2 months and 4 reminder invoices to tell me that they can’t / won’t pay me and that the reason is ’confidential in nature.’” (Rural NSW member)
“We are having plan managers demand certain info on the invoice which we know to be redundant but they refuse to pay unless we meet their idiosyncratic interpretation of what’s needed. None have been able to show us documentation to back up their demands. Huge time wasters. I’d love to see NDIA spell out clearly how these plan managers are to operate.” (Metro NSW member)
Participants are poorly informed about their rights regarding plan managers and have reportedly been told that they are not allowed to change plan management companies, or that their therapist cannot charge at a particular rate. For example:
“If a plan manager is particularly bad another option is to negotiate with families that rather than cease service, they can pay you up front and then have the PM reimburse them. We had to do this for a particular company once who owed us thousands. It was certainly not ideal for the families, but they understood the need and preferred that option to ceasing service. Most of them then changed plan managers. The PM tried to tell families that they weren’t allowed to do this, but crumbled when the clients stood firm.” (Metro VIC member)
I’ve had a parent who was told they could only spend $170 per session for Speech Pathology as the NDIS won’t cover the gap. I told her the hourly cap was $193.99 and my fees are less anyway, and it shouldn’t affect me as I’m not ndis registered. This particular plan manager [has] asked me to drop my fees before.” (Metro NSW member)
Additionally, there have been numerous examples recently where plan managers have informed participants that they are able to purchase a piece of equipment, despite this not being clinically recommended by the speech pathologist, and not fitting within the NDIS rules around low cost, low risk assistive technology. This puts the speech pathologist in a difficult position, whereby they feel pressured by the family to provide a support letter because the plan manager has told them to, causing unnecessary stress for the therapist, and strain on their relationship with the client when they are unable to provide this due to the NDIS rules.
“I had a family requesting 1 [iPad] each for twins. I said one would allow both to access Tx as they have separate 1:1 sessions. Then they contacted me saying the fund manager said it was OK and could I send the specifics of which iPads they could get.” (Rural QLD member)
Currently the Commission do not accept such complaints about plan managers, and there is nowhere for providers or families to provide this type of feedback. The Association receives requests from providers, often weekly, for support and advocacy regarding plan managers where they may not have been paid for lengthy periods beyond the payment terms (sometimes up to several months), payments have been denied, or plan managers have made inappropriate clinical judgements or requests.
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There should be minimum training provided for plan managers, in addition to a financial Code of Conduct, and regular auditing of their services. The Commission should also be accepting and following up on feedback and complaints regarding plan managers provided by both therapists and families.
Support Co-ordinators
As with plan managers, support co-ordinators are frequently registered providers who are not subject to the same regulation as other providers by the Commission. Our members have reported that support co
ordinators have disagreed with clinical decisions and advice, actively undermined therapy
recommendations, and frequently suggested that therapists change their fees, be paid in a different way or under a line item that they are not able to access. For example:
“A support coordinator didn’t want us to charge travel because apparently other therapists didn’t charge travel which is their choice.” (Metro VIC member)
“I have a minimally conscious client in an aged care facility whose support coordinator is refusing to allow me to work on swallowing and oral hygiene. I’m very concerned for my client’s safety.” (Metro VIC member)
“I have received a rather interesting email from a support coordinator from one of my long term clients. She has requested me to begin claiming my sessions under ‘Individual Social Skills Development’ (line
item 11_024_0117_7_3) 'so there is enough funds for him to access OT supports'. As I am only
registered for therapeutic supports and EI…I am unable to do so due to not being registered for any items that fall in the improved relationships section.” (Rural NSW member)
Similar to plan managers, support co-ordinators often appear not to be aware of the NDIS rules and have been reported to promise participants equipment without consulting with the speech pathologist as to whether it is appropriate, or allowed by the NDIA.
“I have a parent (self-managing) who says she has spoken with her NDIS co-ordinator re: funding a colour printer and ink to print therapy materials for telehealth. She’s asked me to write a letter of support. From my understanding of the guidelines though, NDIA will not fund ‘additional hardware’, which would include a printer. I’ve communicated this to the parent but she says that she would like to try to claim for it, seeing that the SC has apparently OKed it. She’s already bought the printer and is hoping for/expecting reimbursement.”(Metro VIC member)
“II have had requests for the top model iPad and stylus… they’d already bought them and just wanted a letter… it was a really tough position.” (Metro SA member)
There have also been reports of support co-ordinators trying to solicit additional funds from providers for referrals, despite this directly contravening NDIA rules:
“I had a recruiter try to get me to link in with their support coordination service. They were wanting to take a 60% cut!” (Rural VIC member)
“They wanted to charge a fee to us as a percentage for referrals and told me that’s fine because we pay it, not the participant… One woman hung up as soon as we said we don’t pay a percentage at all and another tell me it’s totally normal to ask for a percentage and that’s how they earn their money.” (Rural NSW member)
Support co-ordinators should at a minimum be held to the same standards as providers of therapy supports, with a process to direct complaints and provide feedback to the Commission.
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Auditors
Auditors are not NDIS registered providers, instead they work within particular guidelines (the Approved Quality Auditors Guidelines 2018) and must undergo a type of audit process themselves in order to be approved. Subsequent to becoming an approved auditor, there does not appear to be any further regulation of auditors by the Commission.
As discussed above, there is wide variation between the charges of different auditors, but there have also been reports of variability in regard to their expectations of the audits themselves. One of the more common examples of this inconsistency is what types of NDIS clients are counted when a provider is audited. Some auditors have said that all types of NDIS participants, regardless of how they are managed count as NDIS clients, others state that only agency and plan managed do, and some say that it is only NDIA managed that are relevant. Whilst this may seem inconsequential, it is the number of these clients that determines how many files the auditors will request to see, and indeed the scale of the audit as a whole, with less than 25 NDIS clients being the apparent limit for a smaller audit, and anything beyond that increasing the cost of audit significantly.
Additionally, Speech Pathology Australia members have reported that auditors have insisted on having two auditors conduct the audit, at considerable additional cost when travel was also factored in, as this was the Commission’s rule, when in fact there is no such documented rule. There have also been concerns raised regarding exorbitant costs being charged (‘price gouging’) and quotes not always being honoured. The following member quotes are from within the last year:
“When the bill came, it has gone up over $1000, as they added in travel. This was never mentioned in the quote, and part of the cost was for food, this was after we purchased their meals and drinks…it is a rout, and I will be looking for a new auditor. On site for 2 days, everything was fine. The report back to us was minimal and nearly $10,000?” (Outer metro SA member)
“I will warn you that I had a colleague in SA who chose based on price and when the bill after the audit came in it was TWICE the amount quoted. The agency claimed that their quote was merely an estimate and they were not legally obligated to honour it.” (Metro NSW member)
Again, there is no feedback process, or avenue for providers to complain to the Commission regarding this behaviour. Auditors appear to be able to charge whatever they wish, with no regulation, or further
investigation, questioning, or review. This has left providers feeling further disillusioned with the
registration process, particularly when they themselves will be subjected to regulated pricing that is capped by the NDIA.
“There are no price limits on auditors, however our services are price limited - this does not allow us to increase prices to cover the cost of auditing. The prices charged by auditors seems to vary hugely and for regional and rural businesses we will also have the extra impost of travel and accommodation costs for auditors if none are available in our local area…” (Regional NSW member)
“I have twenty years of experience as a speech pathologist, and had been a Certified Practising Member for many years, and had to prove with the support of National Office that I didn’t have to meet the standards required for someone returning from maternity leave, that the auditor had mistakenly copied and pasted from the website. This was despite my pages of evidence and documentation. In the end I gave in and did what she asked anyway as I was close to the deadline, and paid for the privilege”. (Rural QLD member)
“There have been significant hold ups on the commission’s end, and then SIGNIFICANT hold ups with my auditor to complete a verification (desktop) audit. I contacted the commission, and their only response was that I am the one responsible for liaising with the (commission approved) auditor. I had to contact the commission and liaise with them in relation to educating my auditor about the process for the audit initially. The auditor has been terrible in updating and communicating with me. There is no process within
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the commission to monitor or provide feedback (or complain) regarding the auditing process.” (Metro NSW member)
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Recommendations
In summary, Speech Pathology Australia recommends the following:
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In conjunction with the NDIA, the Commission to collect workforce data to assist with workforce planning by identifying gaps in service in geographical areas as well as specialised services.
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The Commission to develop a notification system with Speech Pathology Australia for preventable deaths and near misses related to dysphagia to ensure timely and coordinated intervention occurs.
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Mandatory training (as part of registration) for all disability workers/carers working with people with mealtime supports needs.
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Any staff involved in eating or drinking/dysphagia related near misses are subsequently trained by a speech pathologist in mealtime management and supervised during mealtimes for competency for the following 6 months if returning to work.
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Clear recognition that people with disability who are at risk of choking or aspiration due to swallowing difficulties require specific support through clearly documented mealtime plans, that are easy for a wide range of people to understand. These plans should be written and regularly reviewed by a speech pathologist with extensive experience in this area.
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Speech Pathology Australia to be directly involved with any grant projects funded by the Commission that are aimed at preventing deaths and near misses for people with disability who also have swallowing disability to ensure a coordinated approach.
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Disability-related health support funding for dysphagia particularly ‘oral eating and drinking care plans’ and ‘mealtime management plans’ in participants’ NDIS plans are specified for speech
pathologists only, not as “NDIS-funded suitably qualified and competent clinicians”.
• The Commission work with other peak bodies and organisations working in supported
accommodation to ensure that training in mealtime management is consistent and reviewed regularly by speech pathologists contracted by the Commission onsite.
- More providers are encouraged to become NDIS registered providers through: o Large scale review of audit costs, with an aim to provide regulation of these costs and discounts for people in rural and remote areas who already have significant additional costs associated with the audit process.
o Changing the classification of registration groups, so that Early Childhood Supports, in particular, is no longer classified “high risk”.
o Improving the workforce skills and capabilities so they can meet the needs of the sector by ensuring providers have appropriate supports e.g. supervision, work shadowing, upskilling and that the providers can charge appropriately for this.
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The Commission to work with the NDIA to facilitate mentoring and supervision schemes for early career practitioners in order to attract more providers to both the disability sector, and to increase the number of providers working in rural and remote areas.
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Clarity to be provided around what constitutes ‘behaviour supports’; who is qualified to provide them, and the role and importance of communication and therefore speech pathology supports in managing behaviours of concern.
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Population-wide initiatives are required to improve attitudes and raise awareness of communication and swallowing disability to ensure people’s rights are understood and respected to create a more inclusive society with participation for all.
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Sector-wide initiatives are also required for support worker training to ensure a better understanding of the needs of people with communication and/or swallowing disability and the supports that are available, as well as potential causes for behaviours of concern and appropriate responses.
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Include mandatory modules on communication access, including informed choice and control for people with complex communication needs and dysphagia in the ‘NDIS Worker Orientation Module’ package, including communicating with people with intellectual disability, and using communication devices.
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All services and information from the Commission needs to be communication accessible, including the Commission website - communication access is a vital pre-requisite for people with
communication disability to participate in community life.
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The Commission must ensure an accessible and responsive complaints process - support is required for people with communication disability to help them fully participate in any complaints process, and for them to feel that they can raise concerns without fear of retribution or being labelled as ‘difficult.’ This can be done through the development of clear information and pathways about how to complain, in accessible formats and/or via disability liaison advocates.
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The Commission to facilitate access to resources and training for people with disabilities around the concepts, vocabulary and processes which are part of providing feedback and complaints. Currently, there are limited programs and resources available regarding preventing abuse and neglect that are specific to people with disabilities. Providing education and resources in the form of social stories, and relevant vocabulary around feedback and what would constitute abuse for clients will also enable them to make complaints and report abuse.
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Training regarding NDIS rules to be provided to plan managers and support co-ordinators, and greater regulation, governance and monitoring by the Commission regarding their practice.
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The scope of the Commission regarding complaints to be extended beyond just therapists to other types of registered providers such as plan managers and support co-ordinators.
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A clear complaints and feedback process to be developed with regards to approved auditors, with associated governance by the Commission.
• Greater transparency on behalf of the Commission regarding their requirements, with rules
concerning governance and compliance to be clearly documented, including timelines.
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The Commission to actively engage with stakeholders, and peak bodies. A specific team or phoneline to be established for providers to call to seek advice regarding registration or governance issues that is open to all providers in Australia.
Once again thank you for the opportunity to provide feedback on this important issue. If Speech
Pathology Australia can assist in any other way or provide additional information please contact Ms Amy Fitzpatrick, Senior Advisor Disability, by emailing or by phone on
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References
i Australian Bureau of Statistics (2017) 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 Guidance – swallowing difficulties.UK Government https://www.gov.uk/government/publications/reasonable adjustments-for-people-with-learning-disabilities/swallowing-difficulties-dysphagia
iii Guidance – swallowing difficulties.UK Government https://www.gov.uk/government/publications/reasonable adjustments-for-people-with-learning-disabilities/swallowing-difficulties-dysphagia
iv Ombudsman of New South Wales (2018) Report of Reviewable Deaths in 2014 and 2015 & 2016 and 2017: Deaths of people with disability in residential care. https://www.ombo.nsw.gov.au/__data/assets/pdf_file/0006/58389/Report-of-Reviewable-Deaths-in-2014-2017.pdf
v Disability Services Commissioner: A review of disability service provision to people who have died 2018–19 https://www.odsc.vic.gov.au/wp-content/uploads/02_DSC-2019-DeathR-4-October-2019.pdf
vi Salomon, C., Trollor, J. (2019), Findings: Scoping review of causes and contributors to deaths of people with disability in Australia, Sydney, University of New South Wales.
vii Royal Commission Into Violence, Abuse, Neglect And Exploitation of People With Disability, witness testimony on page 43. https://disability.royalcommission.gov.au/hearings/Documents/transcripts/transcript-6-december-2019.pdf
viii For example see: https://www.abc.net.au/news/2020-05-15/police-investigate-death-of-chairbound-woman-in-adelaide/12253326
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