Submission 33 — Speech Pathology Australia — Provision of services under the NDIS Early Childhood Early Intervention Approach | External submission

Level 1 / 114 William St T 61 3 9642 4899 office@speechpathologyaustralia.org.au

Melbourne Victoria 3000    F  61 3 9642 4922    www.speechpathologyaustralia.org.au

Speech Pathology Australia’s Submission to the

JOINT STANDING COMMITTEE ON THE

NATIONAL DISABILITY INSURANCE SCHEME

Provision of services under the

NDIS Early Childhood Early Intervention Approach

10 August 2017

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 comment to the Joint Standing Committee on the National Disability Insurance Scheme’s Inquiry into Provision of services under the NDIS Early Childhood Early Intervention (ECEI) Approach.

Speech Pathology Australia is the national peak body for speech pathologists in Australia, representing more than 8000 members. Speech pathologists are university trained allied health professionals with expertise in the assessment and treatment of communication and swallowing disabilities. A significant proportion of speech pathologists have historically worked in the disability sector where they provide a unique set of skills and expertise to people with communication and swallowing disabilities. Frequently speech pathologists focus their practice on children (paediatric practice) or adults and the elderly (adult practice).

Most paediatric speech pathologists working with children (either those with developmental delays or problems) and with those with diagnosed permanent disability, now do so within private practice. Many are/or were previously Providers of services through the Helping Children with Autism and BetterStart for Children with Disability programs.

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

Speech Pathology Australia holds significant concerns about the ECEI approach as it is currently being implemented through the NDIS. Whilst our members report that the ECEI approach has improved access to therapy and supports for many children, there is general confusion and lack of transparency about what the ECEI approach is and what families and providers can expect from it.

In preparing our response to your Committee’s inquiry, we have drawn together evidence from our leaders in paediatric speech pathology and from members working ‘at the ground level’ with NDIS Participants in all states and territories of Australia. We conclude with a set of recommendations that we think would address many of the problems that are currently being experienced by providers and families engaging with the NDIS ECEI approach.

We would welcome the opportunity to have representatives from our profession appear before you to give evidence at a Committee hearing in coming months.

Yours faithfully

Gaenor Dixon

National President

Speech Pathology Australia’s Submission to the Joint Standing Committee on the National Disability

Insurance Scheme - Provision of services under the NDIS Early Childhood Early Intervention Approach ………………………………………………………………………………………………………………………………. 4

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

About children requiring speech pathology early intervention ……………………………………………………….. 5

About speech pathologists and early childhood early intervention services …………………………………….. 6

Speech Pathology Australia’s specific comments relating to the Inquiry’s terms of reference ……………….. 8

The eligibility criteria for determining access to the ECEI pathway ………………………………………………… 8

The inclusion of developmental delay under the Early Intervention requirements ………………………. 8

The population of children who may be eligible for the ECEI Pathway ……………………………………… 10

The interpretation of the eligibility criteria for the ECEI Pathway …………………………………………….. 13

The service needs of NDIS participants receiving support under the ECEI …………………………………… 16

The timeframe in receiving services under the ECEI pathway …………………………………………………….. 18

The evidence of the effectiveness of the ECEI Approach …………………………………………………………… 19

The robustness of the data required to identify and deliver services to participants under the ECEI … 21

The adequacy of information for potential ECEI participants and other stakeholders ……………………… 21

The accessibility of the ECEI Approach, including in rural and remote areas ………………………………… 21

Access to specialised services ……………………………………………………………………………………………… 21

Travel rulings …………………………………………………………………………………………………………………….. 22

The principle of choice of ECEI providers …………………………………………………………………………………. 23

Other related matters …………………………………………………………………………………………………………….. 24

Unmet demand for speech pathology services in the ECEI ……………………………………………………… 24

Service ‘gaps’ for children deemed ineligible/waiting for ECEI …………………………………………………. 27

Recommendations …………………………………………………………………………………………………………………….. 29

References cited in this submission …………………………………………………………………………………………….. 31

Speech Pathology Australia’s Submission to the Joint Standing

Committee on the National Disability Insurance Scheme - Provision of

services under the NDIS Early Childhood Early Intervention Approach

Speech Pathology Australia welcomes the opportunity to provide comment to the Joint Standing Committee on the National Disability Insurance Scheme’s Inquiry into the Provision of services under the NDIS Early Childhood Early Intervention Approach. We have structured our feedback in response to relevant aspects of the Inquiry’s terms of reference and conclude with recommendations that we hope the Committee will find useful. We preface our remarks with information on communication and swallowing disability and the role of speech pathologists in improving outcomes for children with speech, language, communication and swallowing disability.

About speech pathologists and Speech Pathology Australia

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

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

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

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

There are no formally credentialed areas of specialty within the speech pathology profession in Australia. New graduate speech pathologists enter the workforce with a minimum level of skills that equip them to commence working with the full range of ages and speech pathology client groups. Many practitioners tend to focus their practice on infants and children (paediatric speech pathology) or adults and the elderly (adult speech pathology practice) or in different areas of clinical practice.

It is recognised within the profession, however, that there are a number of client groups (e.g., those with multiple disabilities, or clients with complex communication needs) and a number of speech pathology clinical areas (e.g., assessment and prescription of Augmentative and Alternative Communication (AAC) for clients with complex communication needs or mealtime assessment for clients with multiple disabilities) that require further skills and competencies than what is gained in entry-level training degrees.

Speech Pathology Australia is the national peak body for speech pathologists in Australia, representing more than 8000 members. Speech pathology is a self-regulated health profession through Certified Practising Speech Pathologist (CPSP) membership of Speech Pathology Australia. Speech pathologists are not required to also be registered with the Australian Health Practitioners Regulation Agency (AHRPA).

The CPSP credential is required to be an approved provider under a range of government funding programs including Medicare, all private health insurance providers, some Commonwealth aged care

funding, Department of Veteran Affairs (DVA) funding, Betterstart for Children with Disability (BetterStart) and Helping Children with Autism (HCWA) programs.

The NDIS Quality and Safeguarding Framework requires that providers of speech pathology services funded through the NDIS are required to be CPSP members of Speech Pathology Australia.

About children requiring speech pathology early intervention

Some children have problems with their speech, language, communication and oral eating and drinking that are permanent and impact on their functioning in everyday life.

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

Oral eating and drinking difficulties affect the ability to take and retain in the mouth, move around, chew and safely and adequately swallow food or liquids. As well as affecting nutrition, enjoyment, efficiency and effectiveness of food and fluid intake, it can lead to medical complications including chest infections/pneumonia and choking. Oral eating and drinking difficulties can affect a person’s health, wellbeing and social and community participation and can lead to social isolation and reduced participation in educational and economic activities.

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

Communication and/or oral eating and drinking difficulties can:

 occur due to premature birth, and/or

 arise from a range of genetic and congenital conditions present from birth (e.g. cleft palate, Foetal Alcohol Spectrum Disorder, Down syndrome, fragile X syndrome, Autism Spectrum Disorders, cerebral palsy, hearing impairment, blindness, deafblindness), and/or

 emerge during childhood (e.g., speech and/or language delay/disorders, Autism Spectrum Disorders, stuttering), or

 be acquired during childhood (e.g., as a result of a traumatic brain injury or cancer).

Difficulties in speech, language, stuttering/fluency, voice, social communication and oral eating and drinking difficulties can occur in isolation or the child may have difficulties in more than one area. For example, a child with cerebral palsy leading to mild physical and cognitive impairment may have difficulties producing speech to meet all of their needs, as well as facing challenges understanding language, along with difficulties with their ability to chew food adequately, and to swallow it safely and efficiently.

Children can have a range of profiles, and experience differing levels of impact of their difficulties in the different areas. For example a child may have a severe speech sound disorder and severe expressive language delay, but have age appropriate receptive language skills. The functional impact of a child’s communication difficulties may not be captured by providing a severity descriptor. It is also often difficult

to say what level of delay a child is experiencing compared to their peers of the same age, because the level of difficulty and age equivalency of their skills may vary across the different areas in which they are experiencing difficulty.

Many children with disability have complex communication needs (CCN). CCN are defined as difficulties with understanding, or the expression of, communication that occur because of, or in association with, other sensory, cognitive or physical impairments. Children with CCN have speech that is inadequate to meet their varied communication requirements in an intelligible, specific, efficient, independent and socially valued manner, in order to understand and/or be understood. Many of these children will benefit from additional (augmentative) or entirely different (alternative) means of communication, also termed Augmentative and Alternative Communication (AAC) methods.

AAC may encompass anything from a simple picture symbol choice board through to a complex electronic speech-generating device. Speech pathologists frequently use AAC methods when working with children with communication difficulties (even children with mild to moderate communication difficulties may be supported at some stage by the use of AAC methods). All AAC methods need to be tailored to the specific needs of the individual. The tailoring to the needs of individuals is managed by a speech pathologist in collaboration with the family and other communication partners who are supporting children. Tailoring may involve setting up non-electronic or electronic aids, training the individual and family/carers in the use of the aid in different communicative contexts and then ongoing review to ensure that use of the device continues to meet the needs of the individual. Families and others may also be supported to learn about and use unaided AAC, such as Key Word Signing. Most children requiring AAC will be eligible for funding support from the NDIS when it is fully rolled out.

Most children with communication, and/or feeding and/or swallowing difficulties will require support from a speech pathologist.

About speech pathologists and early childhood early intervention services

Speech pathologists are university trained allied health professionals who have specialised training in assessing and managing speech, language, social communication, feeding and/or swallowing difficulties.

Speech pathologists provide services to young children and their families in a range of settings including public and private hospitals, community health, early intervention and specialist services and programs, child care and education settings, disability services and private practice. In providing these services, the speech pathologist performs the following primary functions:

 prevention

 screening, evaluation, and assessment

 planning, implementing, and monitoring intervention

 consultation with and education for team members, including families and other professionals

 service coordination

 transition planning

 advocacy

 advancing the knowledge base in early intervention.

The aims of early childhood speech pathology intervention are to meet the child’s additional needs and to promote their optimal development, wellbeing and community participation. A range of professionals may be involved in early childhood intervention (e.g., audiologists, psychologists, occupational therapists, physiotherapists, paediatricians, special education consultants, family support workers, inclusion support

workers and speech pathologists). Best practice early intervention speech pathology incorporates the following core principles:iv  Services are family centred and culturally and linguistically responsive.  Services are developmentally supportive and promote children’s participation in their natural environments.  Services are comprehensive, coordinated, and team based.  Services are based on the highest quality evidence that is available.

The speech pathologist is uniquely qualified, within the early intervention team, to help a family enhance the communication of their child. Young children typically learn speech, language and communication over many years, and starting from birth, within interactions with their parents and other important developmental partners, in familiar natural everyday routines and activities. Children who have a speech, language or communication difficulty may experience changes to their interactions with developmental partners which can ultimately lead to reduced opportunities for, and expectations about their communicative development.

Speech pathologists providing early intervention services may provide child or parent group, consultant or coaching models and/or direct one to one. Each of these models is legitimate and appropriate as part of evidence based early intervention. Which model is used should be determined based on achieving the best outcomes for the child and family. The decision may be influenced by the disability the child is presenting with (including the complexity of the disability), the family preferences and the service provision context. In early intervention service provision, speech pathologists are an important member of the collaborative team providing supports to children and their families and carers, including acting as the primary coach or working in a more consultative and collaborative role within the team and with other agencies and professionals.

Providing information to parents and other caregivers that promotes their ability to implement strategies that enhance communication development during every day routines, leads to the creation of increased learning and participation opportunities for the child. Speech pathologists may provide this information with formal group based information and training programmes, or as part of individual service delivery. Coaching approaches may be used within the provision of group or individual services delivery. In an indirect, or consultancy model, the speech pathologist works with parents and other professionals to help them to include language stimulation within other activities that are part of the child’s everyday program. The consulting speech pathologist can provide information and support to the parent and/or professional regarding the rationale and methods for providing indirect language stimulation, during a range of activities and routines. The speech pathologist will continue to consult directly with the family and professional to monitor progress, and participate in development or revision of intervention plans. The indirect consultant role, while flexible to meet the child and family needs, is ongoing to ensure progress and appropriate implementation of the chosen strategies.

The evidence indicates that some interventions for children under seven years of age are best provided using direct one to one intervention with a speech pathologist, particularly where intervention aims to develop specific skills, which can then be supported to generalise into use outside of the one to one context. Examples where this may be appropriate include, for example, when supporting a child to experience and practice a specific movement of the articulators, or learning of how to operate a communication device within a specific communication context etc. This one on one direct support may also be needed where there is dynamic learning and change occurring which require specific and detailed responses from the clinician to support the development of the correct skills, and to prevent the rehearsal of incorrect learning.

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

The eligibility criteria for determining access to the ECEI pathway

Concrete and comprehensive data regarding the total number of children with communication and/or feeding and/or swallowing difficulties is unavailable at present. It is estimated that there are approximately 250,000 – 300,000 Australian children living with a disabilityv. Many of these children will have communication, feeding and/or swallowing difficulties that require the support of a speech pathologist. Some children will have communication difficulties as their primary disability. Others will have communication and/or feeding and/or swallowing difficulties in addition to or as a result of a co-occurring intellectual, physical and/or sensory disability. There will also be a large population of children who have a developmental delay (which may or may not lead to permanent disability) who may also fall under eligibility for the ECEI NDIS pathway. Robust national data on this population of children is unavailable however the most recent (2015) data from the Australian Early Development Census indicates that 11.1 per cent of children are developmentally vulnerable, at school entry, on two or more domains. vi

The inclusion of developmental delay under the Early Intervention requirements

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

The overarching term used for children with specific functional needs in the domain of speech, language and communication is Speech, Language and Communication Needs (SLCN). The functional problems of children within this category can differ considerably. Some will relate to various components of speech, some to language use and understanding1 and some to both. The presenting issues, appropriate interventions and prognosis for ongoing functional impacts is different for different sub-groupings of children with SLCN, which has implications for children within the sub-groupings in regards to access to the NDIS ECEI.

Developmental Language

When considering children with developmental language difficulties that may require supports under the NDIS, it is useful to understand three terms: ‘differentiating conditions’, ‘co-occurring conditions’ and ‘developmental language disorder’. vii

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

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

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

Developmental Language Disorder (DLD) is recent terminology, used to refer to cases of language disorder with no known differentiating condition.

Developmental Speech

Unfortunately, there is no similar agreed terminology when talking about children’s developmental speech difficulties. Children may show patterns of errors in their speech. These might be patterns that are observed in typically developing younger children (delays), or unusual or atypical patterns or non developmental patterns (disorders). The majority of children with developmental speech difficulties have no identifiable cause for their problems. However, speech difficulties can be associated with other conditions such as cleft palate, cerebral palsy and global developmental delay. Some children may have motor speech disorders (dysarthria, and childhood apraxia of speech). Children who are slow to talk and/or whose speech is difficult to understand when they are younger, may go on to developing typical speech by 5-6 years of age, or may have difficulties which persist into later childhood and beyond.

Children typically vary in their speech development. Younger children produce speech which is different to adult speech but which may be within the normal range, depending on their age and which sounds they are having problems with.

There are some analogies with the terminology used with Language Disorder.

Some children may have speech difficulties with a differentiating condition, such as Cerebral Palsy or Down Syndrome. Where this is the case, it is more likely that the child will have a motor speech disorder, but they can also experience any of the other developmental speech difficulties. There may sometimes be co-occuring conditions associated with developmental speech difficulties, including minimal motor difficulties, but the incidence of this is much lower than is the case for language delay or disorder. Some children may have motor speech difficulties (childhood apraxia of speech) in the absence of any co occurring or differentiating condition.

Children with Speech or Language disorder, without co-occurring or associated difficulties

Determining the type of difficulty and therefore the implications for prognosis and interventions for children with communication delays (whether of speech and/or of language) is a complex clinical process.

There is a small group of children whose communication difficulties occur in the absence of any differentiating or co-occurring condition, but will persist and be of such significance as to impact on their functional abilities up to and beyond seven years of age. This will create barriers to their medium to long term development and participation. Part of the complexity is that it will often take time before it is possible to know whether a child will be one of this small group whose difficulties will lead to continuing and significant impact on their functioning. While these difficulties can affect children’s communicative functioning across all of the environments, and their ability to connect and form relationships they may not experience functional impacts in any other developmental domain (i.e. mobility, fine motor, emotional etc).

These children may be determined to meet the access requirements for Early Intervention (under the Developmental Delay criteria) or, for older children, under the Disability requirements (under the eligibility criteria set out in ss21-25 of the NDIS Act that includes criteria of substantially reduced functional capacity to undertake activities of communication).

Access to NDIS – including individualised funding

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

Children with a developmental speech or language difficulty will experience impacts on their functional communication (i.e. in everyday interactions with family, peers and other communication partners) and on their learning and longer-term social and emotional development. Early intervention for children with a developmental delay may reduce or even eliminate the functional impacts of the child’s delay.

A small number will have a Developmental Language Disorder or a developmental speech disorder which will persist beyond seven years of age, and which occurs in the absence of a differentiating and/or co occurring condition.

It can be difficult to reliably diagnose a developmental speech or language difficulty as a disorder (versus a delay) until a child is five years of age or later (in the absence of a co-occurring disability).

There is also evidence that even though a child may ‘catch up’ functionally in the ages up to five or six, further speech, language and communication related issues can emerge as children develop further, and as the environmental demands change and increase.

Given these different, but difficult to differentially diagnose, groupings of children with developmental speech and language difficulties, the ECEI pathway is likely to include children with developmental speech, language and communication problems that are permanent and children who are experiencing a delay (where their functional problems may be resolved with appropriate and timely early intervention). It may be difficult or impossible to determine if a child’s issues are going to resolve, or persist and lead to ongoing and significant functional limitations and barriers to participation, before the age of seven, when early intervention access to the NDIS ceases.

The eligibility criteria for NDIS ECEI includes both disability and delay – however in young children, this distinction is often unable to be determined until later in childhood. Similarly, a lack of intervention at the clinically appropriate point in time in a young child’s life for a ‘delay’ may lead to permanent disability.

Issues with the knowledge base about disability of NDIS Planners is acknowledged in the recent report by the Productivity Commission’s Inquiry into the NDIS Costs. It is of serious concern that Planners with limited understanding of early intervention needs are making decisions regarding eligibility and entry into ECEI, and to access to individualised funding through a NDIS plan, in the absence of clear advice, pathways and evidence base for what is accepted as a very complex area even for those with expert skills in assessment.

The population of children who may be eligible for the ECEI Pathway

Detailed evidence of the significant and persistent barriers to access to speech pathology early intervention services for children was detailed through the Senate Community Affairs References Committee in 2014 into the prevalence of speech, language and communication disorders and speech pathology services in Australiaviii. The Senate Committee was presented with compelling evidence that indicated a patchwork, inconsistent and inadequate ‘system’ of early intervention speech pathology services across Australia with significant evidence of unmet demand. The Committee made a number of

bipartisan recommendations relating to quantifying and addressing unmet demand for early intervention speech pathology services for young children in Australia (repeated in Box 1). At the time of writing, the Australian Government’s response to the Senate Committee’s recommendations is still forthcoming.

Children entering the NDIS ECEI stream who require speech pathology early intervention are doing so from a context of inadequate services – where demand is currently not quantified and where even the population of children with these needs is unknown. Given this, it is unsurprising to Speech Pathology Australia that larger than expected numbers of children are seeking to enter the NDIS than was originally ‘modelled’.

Speech pathologists providing supports under the NDIS report that they are seeing an increase in access to timely and appropriate speech pathology services under the NDIS. This includes an increase in the number of children with speech and language delay or disorder, in the absence of any differentiating (i.e. ASD, or Cerebral Palsy, or Down Syndrome) or co-occurring condition. Many of these children would not previously have had access to any funded supports or therapy. There are a range of reasons for this including inadequacy of state funded early intervention services, significant waiting times and financial barriers to accessing private practice services.

In the earlier years of the scheme, this cohort of children were reported to be accessing individualised funding, however increasingly Speech Pathology Australia members are reporting that under the ECEI approach, these children are being triaged ‘out’ of the scheme.

The introduction of the NDIS has led to a considerable disruption of the pre-existing service delivery for children with speech, language and communication difficulties. With the retraction of state government funded early intervention services, there are limited (if any) alternative low cost or no cost early intervention services for young children who are deemed ineligible for NDIS ECEI but whom still have therapy needs. It is unclear where and how these children will access the early intervention supports they need.

Box 1: Relevant Recommendations from the Senate Community Affairs

References Committee Inquiry into the Prevalence of different types of speech, language and communication disorders and speech pathology services in Australia 2014

Recommendation 3 The committee recommends that the federal Department of Health work with the most relevant stakeholders to make an assessment of the financial cost, timeframe and research benefits of a project that maps language support services across Australia against the Australian Early Development Index information about vulnerable communities.

Pending an assessment of this proposal, the committee recommends that the federal government consider funding a project along the lines proposed. The findings of this research should inform future policy decisions to fund public speech pathology services in Australia. The findings should also guide private practitioners as to those locations where their services are most likely to be needed.

Recommendation 4 The committee recommends that the federal government provide funding and/or support for an appropriate research institute to conduct a thorough and systematic audit of the adequacy, strengths and limitations of existing speech and language services for children in Australia. The audit should consult with children’s health and education providers, including but not limited to early childhood education and care centres, primary schools, secondary schools, speech and language therapists and special needs coordinators.

The committee recommends that this research proceed as soon as possible. The research would provide a foundation for the federal Department of Health to conduct its work into paediatric speech and language disorders.

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

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

The position paper should be circulated to key stakeholders for consideration and comment and to assist in decision making.

The interpretation of the eligibility criteria for the ECEI Pathway

There are some overarching concerns around access to the ECEI Pathway. These are additional to the ‘consistently inconsistent’ practices and decisions of Planners:

 It is unclear whether the Access criteria for early intervention as documented on the NDIS website are in fact criteria for access to NDIS plans and/or the criteria for access to the EI Partner

 The initial concept of the ECEI approach was to provide an open gateway for any child who was identified as having a developmental delay. This does not appear to be what is occurring, with Speech Pathology Australia members reporting that some families have been told that their child was not eligible for support through the EI Partner, despite the fact that their child has been identified as having a developmental delay. This illustrates the confusion regarding the Access criteria.

 There is no transparency around which children will be provided with short (or medium) term supports through the ECEI approach, for what purpose, with what anticipated outcome, and how that will be measured.

 It is unclear what is the criteria for access to Plans. There is a concerning lack of transparency about the processes that are used to decide whether a child will or will not receive a Plan.

 It is unclear what the training and competencies are of Planners in using the Pedi-cat tool (and if this tool is appropriate or sensitive enough).

 It is unclear (although suspected) that the Access Criteria being used has reverted to a ‘deficit’ based access model. For example, where thresholds of ‘high’ and ‘low’ level of function, burden of care or years of delay, number of domains demonstrating delay are being used as criteria to support plans and supports. This is rather than focusing on access where early intervention is likely to maximise function and reduce longer term access to the NDIS. Such a deficit-based approach is in direct contradiction to an insurance model with a focus on functional outcomes. This is not a contemporary approach to disability.

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

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

Review and complaints processes for families with a child deemed by a Planner to be ineligible are burdensome, not easily accessible and time consuming for families. It is anticipated that as the Scheme matures, if inconsistencies in eligibility determinations by Planners is not improved, that the number of eligibility reviews requested by families with children who have been deemed ineligible by NDIS will increase exponentially. This will be further exacerbated if the Information Linkages and Capacity Building (ILC) component of the NDIS is not sufficient to meet the needs of children with disability who are ineligible for individual packages.

It is the view of Speech Pathology Australia that the eligibility criteria set out in the NDIS Act are appropriate for the Scheme, however it is the interpretation of this eligibility by Planners that is

inconsistent, variable and often suggests an insufficient knowledge of disability conditions and functional needs that pose the most significant risk for the NDIS to meet its goals.

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

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

These children may be determined to meet the access requirements for Early Intervention (under the Developmental Delay criteria) or, for older children, under the Disability requirements (under the eligibility criteria set out in ss21-25 of the NDIS Act) that includes criteria of substantially reduced functional capacity to undertake activities of communication. In some areas of the country, children are granted entry to ECEI on this basis.

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

Speech Pathology Australia holds concerns, informed by experiences in the NDIS Trial and transition and the ECEI approach to date, that this requirement is interpreted by some Planners in a way that excludes children with a developmental speech or language delay or disorder (in the absence of differentiating conditions) from accessing NDIS ECEI supports.

Speech pathologists have reported that NDIS Planners have told families that children are required to need support from more than one allied health practitioner (e.g. a speech pathologists and an occupational therapist) in order to be provided with access under the ECEI requirements. For some children, at particular points in their early development the supports they need might best be delivered by one particular allied health professional. In the case of children with Developmental Language Disorder or delay (in the absence of a differentiating condition or co-occurring conditions) – this may be a speech pathologist. The fact that only one allied health provider is required does not preclude the intervention from being in line with best practice principles of early intervention i.e. family centred, capacity building, functional/participation focussed, strengths focussed etc.

The criteria is being interpreted as: even if a child has a substantially reduced functional capacity to undertake activities of communication they must also require early intervention from more than one allied health therapy discipline. This interpretation acts to exclude children who require therapy from only one type of therapy discipline. This interpretation is not based on the functional needs of a child but on technical interpretation of criteria by Planners in the absence of clinical advice.

There are young children whose communication is severely compromised and who will go on to have lifelong communication disability, who at this point in their development may require therapy only from a speech pathologist, but who are being excluded from the NDIS ECEI because they do not also need another type of therapy.

Any interpretation that these children are only eligible for NDIS ECEI if they require multidisciplinary supports – resulting in the exclusion of children who require specialised support from only one profession

would be a very unfortunate outcome. It is the view of Speech Pathology Australia that this situation would be at odds with the principles of the NDIS.

These children are likely to:

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

 go on to meet the disability criteria for NDIS by the time they are aged seven (if they have not received adequate early intervention supports) as the access criteria for people over seven years of age is likely to be inclusive of these children i.e. that they demonstrate substantially reduced functional ability in communication)

 develop or demonstrate increased levels of mental health and behavioural problems, which are commonly recognised as associated with untreated communication disability

 experience an increased range and severity of functional impacts at seven years of age and beyond, as a result of being denied access to the early intervention supports that could ameliorate or even prevent their development

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

Speech Pathology Australia members have reported that some children with speech and language delays without differentiating conditions, have been provided with access to the NDIS, including individualised funding plans. No data is available on the numbers of children with these functional disabilities who have been approved entry to the NDIS, what has been included in their Plans or the utilisation of plans for this group. It is difficult, therefore, to determine what if any, pressure this group of children with disability may represent on the sustainability of the Scheme.

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

SA speech pathologist Eligibility issues for NDIS ECEI for children with speech, language and communication problems include:

 Widespread confusion by families and speech pathologists regarding the eligibility criteria

 Widespread inconsistency in interpretation of the eligibility criteria by Planners – leading to reported inconsistency in the types of children, diagnoses and functional problems entering the

Scheme

 Interpretation of the eligibility criteria by Planners that a child MUST have therapy needs from more than one allied health profession and/or in one functional area, acts to restrict access to

ECEI for children who have Developmental Language Disorder (and who may have permanent and high functional needs in the domain of communication).

 Eligibility has increased access to support for many children – many of whom had no, or extremely limited access to therapy supports prior to the roll out of the NDIS.

 It is unclear what ‘eligible’ means in the context of the ECEI short term supports pathway. Practitioners report confusion over what children who are ‘eligible’ for are actually able to obtain in terms of supports and services if they are ‘eligible’ but are not ‘eligible’ for an individualised funding package.

 The distinction between developmental delay and disability in early childhood is clinically complex and not straightforward even for clinicians. The ECEI criteria and its application and interpretation by Planners does not reflect this complexity and requires more sophisticated understanding of early childhood delay and disability than currently exists by those making eligibility decisions. There are opportunities to ‘tighten’ the criteria to ensure the ‘right’ children are entering the different steams (individual plan vs short term supports) but this needs to be developed in collaboration with the peak clinical professions (including Speech Pathology Australia) that can draw on the clinical evidence base. There has been no consultation with the professions with expertise in issues of early childhood development and delay. Speech Pathology Australia could provide significant assistance to the NDIA to assist in clarifying what ‘types’ of children and functional problems would benefit from what type of service and support through the ECEI.

The service needs of NDIS participants receiving support under the ECEI

The nature of developmental disability and delay in young children means that children will have different needs, and different needs at different times in their early childhood. This adds a level of complexity to planning of supports that is unique to ECEI Participants as compared with NDIS Participants in older cohorts. The early childhood period is recognised as a critical window of opportunity to maximise the developmental and longer terms gains that can be made by appropriate intervention. Given this, it is even more critically important that the NDIS ECEI processes for planning are adaptable, flexible and responsive to individual needs in a timely way, than for older NDIS Participants. For example, waiting six months for supports or a plan review will have a disproportionate impact on the outcomes for a child of four than for an adult of 35.

The support needs of children in the ECEI will also be different based on whether the child has a developmental delay or functional needs that are more likely to lead to a permanent disability. The two streams (shorter term ECEI and longer term Plan) are appropriate – but ONLY if applied appropriately and shorter term ECEI supports are evidence based. Decisions regarding entry into the two streams needs to be made by informed and knowledgeable Planners who are able to draw on clinical expertise and evidence base. Furthermore, decisions regarding what supports are appropriate for a child and their family under the two streams needs to be based on the evidence of what supports are effective for particular functional problems. This is not currently the case.

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

Speech pathologists repeatedly report that “We saw a plan this week with just over $2000 for they see Plans for children with similar capacity building and $4200 for support functional needs that do not include key coordination - doesn’t that seem out of whack or supports (that are reasonable and would be am I misunderstanding support coordination? considered necessary by anyone familiar Twice the amount than is allocated to access therapy and this family have services in place and16 don’t need support coordination? Seems unproductive and costly to me” – SA speech pathologist

with specific disabilities), over-fund certain supports or significantly under-fund certain supports. Many examples have been provided where even the families do not understand what the supports funded in their Plans are intended to achieve or why they would wish to use them. Most recent examples include the significant (and disproportionate) allocation of funds for coordination.

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

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

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

“AAC issues are a big problem - one example I had is a child who waited one year for a high tech communication device to be approved – the NDIS looks at cheaper devices such as iPads without understanding the variability in disability and people’s needs – they are using a one size fits all approach and this did not ‘fit’ with what this child needed” - – speech pathologist July 2017

other Allied Health peak organisations) are well placed to advise the NDIA in relation to the evidence base for particular interventions and supports for the NDIS ECEI system.

Another concerning trend which has emerged recently is the ‘adjustment’ of the funding available in plans by the NDIS. This suggests that the NDIS assumes that service provision will occur consistently across the life of a Plan from all providers, and reducing the next Plan by the proportion of the total funding if it hasn’t been used across a period of time. While it is understandable that the NDIS does not wish to see funds sitting in plans unused, this approach fails to recognise that:

 a range of issues may legitimately and appropriately lead to an ‘uneven’ spend across the life of a plan. For example, funding to support a trial and then introduction of an AAC device may sit unused in a plan while waiting to access a device for trial from a supplier, and may even need to go across into the following years plan.

 this is likely to lead to the perverse outcome of families feeling anxious about funding not being available in their plans to enable them to meet future/unpredicted needs and

 families directing/pressuring providers to deliver interventions in ways that are contrary to best practice and evidence based practice.

The timeframe in receiving services under the ECEI pathway

Speech Pathology Australia members report inconsistency in waiting times for families receiving support under the ECEI pathway. In many areas, it appears that the ECEI pathway is working effectively and children are accessing services in a timely manner. There are areas of unmet demand for speech pathology services (recognised by the Intermediate Evaluation of the NDIS report) and this is likely to increase given the reluctance of speech pathologists to enter the NDIS market and the barriers in place in some states for registration to provide NDIS ECEI supports (to be discussed in detail later).

However, there are particular concerns in areas of the country where the Early Childhood Partner is also a provider of services. This is particularly the case in the Hunter Region of NSW. Reports from private practice speech pathologists are that children who are eligible for ECEI are being delayed in having planning meetings, having plans approved and accessing therapy services.

In some instances where the Early Childhood Partners is also a provider of therapy services, reports from Speech Pathology Australia members are that children are on ‘wait lists’ for therapy. If this waiting is to access the ‘short to medium’ term supports from the EI partner, it once again points to the need for the EI Partner to be clear about the purpose of the interventions and the outcomes that they are hoping to achieve. If the supports that families are waiting for are simply an alternative to those which had already been provided by the private practitioner, and they are only going to be provided short term, it would be important to consider whether there are alternate ways of funding these services, which don’t lead to an interruption of the therapeutic relationship.

The other, and more concerning potential, is that families who have been provided with an individualised funding Plan are waiting to access therapy supports from the EI provider, without having been provided with information about the alternatives and/or having experienced any kind of undue and inappropriate influence to stay with the EI provider, rather than being referred out to another NDIS provider who may have capacity to initiate therapy.

In Tasmania, there is an agreement between the Tasmanian Government and the NDIS that St Giles will continue to provide ‘in kind’ services for this service to be the Early Childhood Partner. It is unclear the parameters of this short term EI support (how much, for how long, for what type of problems).

In South Australia, there are reports that there are significant delays in children who are in EI getting NDIS plans approved. These children meet the access requirements and may have had planning meetings but there are delays in having the plan ‘approved’ and/or put on to the Portal. “From our experience, the time frames in receiving services under the ECEI pathway It is of significant concern that the bilateral agreement are very long. We had one client wait a year between the Commonwealth and the South Australian from applying to ECEI to receiving their governments indicates that the number of estimated NDIS plan. In that time, they did not receive existing and new participants to the scheme aged any therapy via ECEI and instead continued under 18 years of age, per quarter in 2018, is 282 . to pay privately. Clients are getting This would appear to be a significant under estimation confused and mislead as they are being of the likely demand, and would predictably lead to told they have been approved for ECEI but failure of timely access to supports. the terminology is confused as they are Speech Pathology Australia has had members report saying they have been approved for a plan. that approval of children’s plans is being delayed in SA Parents think they have been approved for until a ‘place’ opens up in the NDIS. Essentially, ECEI an NDIS plan when in fact they have just been approved for ECEI and it is not clearis acting as a ‘capped’ program. These families are in what services they will actually receive”a ‘holding pattern’ until their Plans are approved and it – speech pathologist July 2017

2 https://www.coag.gov.au/sites/default/files/communique/NDIS_SA.PDF

is unclear if children are receiving any therapy or supports whilst they wait.

Time spent waiting ‘in the system’ for a young child with disability without receiving early intervention therapy represents the closing of the window of opportunity to maximise children’s longer term outcomes through the provision of appropriate and timely early childhood early intervention. This is at odds with tenets of and the evidence base for early intervention and to the insurance approach upon which the NDIS is based. The evidence of the effectiveness of the ECEI Approach

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

Throughout the Trials and NDIS rollout, the NDIS has The evidence for early intervention is privileged the provision of ‘transdisciplinary’ practice strong in speech, language, literacy, for early childhood services. This ‘privileging’ included and for associated biomedical all supports for children under seven, under the diagnosis such as Autism Spectrum ‘Trans-disciplinary supports’ items. . It seems that the Disorder. The ECEI approach seems to aim of these decisions were to attempt to drive disregard this evidence and instead is a practice/service delivery to fit within a certain model. system of putting children on waitlists While it is admirable and appropriate to try to put in with no communication about how and place strategies and mechanisms that support the what they should be accessing. The provision of best practice, this (amongst other ECEI approach is failing the children in decisions) had perverse outcomes. A lack of NSW as they are missing out on vital understanding and clarity within and from the NDIA early intervention which evidence about what was meant by ‘transdisciplinary support’ clearly states is the best approach. created confusion with Participants and providers. The Connecting children to the community information provided on the NDIS website about the when they have a language, speech use of transdisciplinary support was unclear and in and or social communication disorder is some cases contradictory. Planners were unable to not efficient as these children need define what services and therapy could be provided explicit teaching and instruction to under ‘transdisciplinary support’. Initially the improve their skills. information to providers was very clear; they could – speech pathologist July 2017 only claim for time spent face to face with the client. This implied to families that ‘more (face to face, one on one) therapy is better’, and that time spent planning for services, or providing information, or facilitating coordination in the immediate as well as extended teams was not valuable or valued. The continuing confusion about whether and what travel could be claimed prompted a shift back to centre based allied health appointments. Clinicians who continued to provide flexible, home and community based services to families were financially disadvantaged. Children and families with more complex allied health support needs, who may particularly benefit from a coordinated, collaborative, team based approach to service provision represented a risk, for providers, of getting reduced, and in some cases, no remuneration for significant time and effort. Providers who have offered a service with a specific and more specialised focus risk became unviable, with families being pushed back to ‘local’ services. The structure of the pricing and supports meant that provision of evidence based group programmes to build parent capacity to support their child was difficult to set up and financially risky, to the point of being unviable.

Equally concerning was the fact that even though allied health professionals (including speech pathologists) were listed as appropriate to register for and provide this NDIS support, there was no consultation with the professional associations (including Speech Pathology Australia) about the evidence base for transdisciplinary practice within their clinical professions for young children. No consultation

occurred with allied health profession representatives about how allied health service provision in early intervention would best be provided in order to be effective and efficient, how practitioners from the various clinical professions might work together to achieve outcomes for individual children or exactly what types of interventions and therapy could be claimed against this support item by NDIS providers.

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

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

Taken together, aspects of the planning process, support items and pricing, Portal design issues, requirements around registration for providers, service agreements, and lack of funding for coordination and planning have all contributed to create a situation where significant barriers exist to the ability of the NDIS provider market to provide evidence based and efficient models of early childhood intervention. In order to reap the benefits of early intervention for individual NDIS Participants, and for the system overall to reduce the longer term costs of support for these children over their lifetime – significant changes need to be made to the ECEI approach so that inefficiencies, and outcomes which are contrary to best practice don’t result from the structure and functioning of the approach.

Speech Pathology Australia is concerned that the NDIS and governments are seeking to further tighten the eligibility for the ECEI stream of the NDIS. An increase in the number of young children accessing early intervention within the NDIS should be viewed as an opportunity rather than a risk to ensure that people with disability are provided with supports as early as possible in their lives. There is very strong evidence of the benefits of early intervention for children with disability, from many disciplines and from within Australian and overseas. If appropriate intervention is provided early, it will reduce reliance on the NDIS in the medium and longer term for many of these children. Efficiencies in other parts of the NDIS (e.g. planning processes) should be prioritised before further restrictions are made to how the NDIS supports young children with disability. It would also be of value to consult with the professional organisations to consider how to design a more cohesive system which would lead to the provision of efficient, effective services of the right kind, at the right time (in their development) and by the right person, for all children who are eligible under the current access criteria.

The robustness of the data required to identify and deliver services to participants under the ECEI

Exit rates from the Scheme, particularly in the case of children enrolled in the ECEI stream may depend on the quality and quantity of supports and the timing of those supports being provided to them during their NDIS eligibility. The NDIA publishes very little data (with very limited granularity) regarding the provision of supports for children in the Scheme. In terms of expected exit rates from the ECEI stream, it is difficult to understand how the projections for exits were calculated. There is no sophisticated analysis that is publicly available that examines the types of children (functional problems and diagnoses) and then the evidence of the type and duration of supports needed to produce specific outcomes (including leaving the Scheme). The lack of analytics is a serious problem for an insurance based scheme. The NDIA has not sought advice from the professional bodies regarding the evidence base for services of particular type, what is effective, what is appropriate and the ‘amount’ of therapy the evidence indicates is needed to garner the type of outcomes that could see a child ‘exit’ the NDIS at age seven.

Speech Pathology Australia supports the recent Productivity Commission’s recommendations on improved data reporting and analysis for the NDIS. Recording and reporting on the outcomes and demonstrating the evidence of effectiveness of the ECEI may take some years. The ECEI NDIS should undergo a separate formal independent evaluation.

The adequacy of information for potential ECEI participants and other stakeholders “We’ve only had two clients so far Speech Pathology Australia refers the Committee to the come through with a new NDIS submission made by Children and Young People with plan from the ECEI pathway. In Disability Australia for comment regarding first hand both cases we’ve had access to experiences of families receiving information regarding even less information than ECEI for their children. previous pathways (direct from From a provider perspective, many Speech Pathology NDIS). One family has a child that Australia members report doing considerable Participant has complex needs, the family are capacity building activities (without payment) with families bilingual and he has not yet been that are transitioning to the NDIS to help explain the diagnosed. There is no additional ‘system’ and to teach the family how to interact and supports in his plan for a support advocate for what they wish for their client. These coordinator or any respite as they practitioners usually have a ‘trusted’ therapeutic weren’t made aware they could ask for that, despite going throughrelationship already established with the family and are the ECEI pathway”.able to tailor information about the ECEI and NDIS to the – speech pathologist July 2017needs of the family.

The accessibility of the ECEI Approach, including in rural and remote areas

Access to specialised services Service for EI is non-existent in Some children with disability require specialised services Newcastle. We have reached our to meet their needs. These services may not be easily ‘cap’ for early intervention participants and they are now on aaccessible, even for urban based families, and maybe wait list for any type of service. Theparticularly challenging to access for rural and remote need for service continues tofamilies. remain high, complex and crucial In some areas of clinical speech pathology focus and/or for change. for some populations of NDIS Participants, there is a –speech pathologist July 2017 need for further development of specific and additional

professional competencies in the speech pathology workforce. For example, specialised speech pathology skills and knowledge are needed to effectively work with children and adults with lifelong disabilities and complex “My issue with rural services is that, as the only dysphagia. Well-established (clinical speech pathologist in my area I am getting governance) systems were in place in referrals for much more complex children than I previous disability systems to support the used to. I am having to quickly skill myself up in development of these additional AAC that is more than an iPad and ProLoQuo2Go. competencies within practitioners. Similarly, Once upon a time I could have called on the systems were in place in the jurisdictions to assistance of an ADHC NSW therapist, but now identify children with disabilities who needed they are my competition. Now I am trying to to access these services and referral and provide the service in consultation with suppliers clinical pathways were established to enable who really want to sell you their product” – Rural appropriate and timely access to these NSW speech pathologist specialised speech pathology services.

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

Travel rulings

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

“Accessibility to any form of service in rural and remote areas is already limited. Lack of funding or clear direction has made access to services even more difficult. There are very few (if any) ECEI providers in some rural areas including Southern NSW. Appropriate specialist supports are not able to be accessed and emergency funding or plans have not been provided for children with significant needs (e.g. intensive PT/OT/SP required for children with a new diagnosis/Cerebral Palsy etc.). Support is limited and families appear to struggle to understand and engage due to lack of clarity.” –speech pathologist July 2017

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

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

It is the view of Speech Pathology Australia that a market approach to disability service provision will not provide the environment for which these specialised workforce will be retained or further developed. Families with a child with disability 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. Specific, targeted workforce initiatives supported by the NDIA are needed to ensure that this component of the provider market of speech pathology services is available to meet the needs of children who require specialised supports through the ECEI pathway.

The principle of choice of ECEI providers

The continued provision of ‘in kind’ services by ‘legacy’ providers who have had block grant funding is creating significant disruption to the development of the NDIS market, including the ECEI NDIS provider market.

For example, it has been reported to Speech Pathology Australia that in Tasmania, families have been told that they can either access ‘all the services they need’ if they go across with their plans (which do not have any specific level of funding identified ) to receive their services from the ‘in kind’ provider (St Giles) – or they will only be provided with 10 sessions of one hour, to access other registered NDIS providers. This must surely be creating concern and uncertainty for St Giles, as they are required to take on children with a broad range of needs which may sit outside of their organisational scope. Parents at the same time are being provided with unrealistic expectations about the level of services that may be provided by St Giles. There is also the risk that smaller private providers, who have set up to enter the market as an NDIS provider in Tasmania will simply not survive the period of transition. Solutions to this problem can e developed, with some consultation with providers and a greater focus on potentially negative unanticipated consequences of decision, which will enable legacy services to transition, without undermining the development of tenuous providers in a thin market. The undermining of a private practice market acts to restrict the choice and control families of young children have in engaging with the NDIS.

Considerable concerns exist due to perceived conflict of interest/privileging which is occurring as a result of the Early Childhood Partner also being a provider of supports in Participant Plans. Members in private practice in these areas report having their referrals ‘dry up’ and families being placed on wait lists at the Early Childhood Partner provider. It is possible that these wait lists may be for access to ‘short to medium’ term supports – but regardless, they are leading to an interruption in the provision of services. This acts to restrict the choice and control families of young children have in engaging with the NDIS.

Participants were not provided with any, or adequate support to understand the principles of ‘transdisciplinary’ practice as espoused by the Scheme ECEI approach– even when it became understood across the allied health professions that the term when used by the NDIA was supposed to encompass all of the best practice components of early intervention service provision. Families have not been provided with adequate information to make informed decisions about if what is offered as ‘transdisciplinary practice’ is evidence based and/or likely to meet their child’s needs.

Neither Planners, Participants nor providers were effectively supported to understand what ‘choice and control’ for participants actually meant when it was applied to the purchase of ‘transdisciplinary supports’ or how that might be ‘operationalised’ within the NDIS system. There is a lack of resources or systems that support Participants to learn about early childhood intervention. In the absence of widespread and effective opportunities to learn what they should expect and look for in an early intervention provider; the value and importance of planning, coordination and collaboration within a transdisciplinary team; the concept of capacity building supports, where they are supported to develop the knowledge and skills to support their child’s development. This, along with the ways that supports have been structured, has created a situation where families have opted to use their funding to access the maximum number of individual, face to face allied health sessions that their funding would support. This may be at odds with the evidence base for what would be most effective for their child at this point in their child’s development.

Additionally, the attempt to ‘engineer’ service provision by restricting the ability for families to choose to pay a provider to travel to them, has driven services back to being ‘clinic based’ rather than being provided in the community. It has also meant that it is difficult for families to access more ‘specialised’ service providers, who may be fewer in number and therefore less ‘local’ to participants. All of these changes, driven by the structure and pricing of NDIS supports, are in direct conflict with best practice early intervention, and the concept of choice and control with families.

There is no choice with ECIA intervention as described above. We no longer receive NDIS plans for children under 6 for speech pathology intervention and our current clients who attended our speech clinic privately cannot return with their funding for intervention. It’s horrible and unethical. Where is the choice and control for these individuals and families?

Other related matters

Unmet demand for speech pathology services in the ECEI

Most paediatric speech pathologists working with children, with either developmental delays or diagnosed permanent disability, now do so within private practice. Many are/or were previously Providers of services through the Helping Children with Autism and BetterStart for Children with Disability programs. Many were also providers of services funded through state/territory government funded community health services or non-government organisations. As the disability sector is evolving in response to the roll out of the NDIS, more and more practitioners are needing to enter the private practice market. This market has a range of competing funding sources including MBS, private health insurance and significantly, fee for service.

Two specific issues are restricting the increase in the speech pathology NDIS provider market adding pressure to unmet demand for speech pathology through the ECEI:

Concerns regarding direct and indirect costs of NDIS service provision. This is due to Portal breakdown, inconsistency of advice and decisions, constant changes in NDIS processes leading to reversals of decisions, issues with ‘quarantining’ of funds via service bookings for agreed service delivery.
Significant barriers to NDIS provider registration to deliver ECEI supports in some states and territories

Costs of NDIS service provision for speech pathologists

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

The Intermediate Report of the Evaluation of the NDIS states that “reports were also provided of allied health professionals disengaging from the Scheme due to issues with pricing and best practice”x. Reports from Speech Pathology Australia members who are NDIS providers indicates that some of those providers are restricting the proportion of their businesses that is funded via NDIS (in order to safeguard their financial viability in the eventof further payment problems) rather than ceasing to provide NDIS funded services altogether.

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

NDIS provider registration for ECEI supports

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

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

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

States and Territories (and the NDIA) failed to recognise and discriminate between the levels of governance appropriate to ask of community based allied health practitioners (who were part of a self regulating profession), and large early childhood intervention services /specialist disability services (often legacy providers). The same type and level of quality and safeguarding requirements were required from both, despite the significant differences in regulation already in place, and the different level of risk for participants of the supports being offered. The problems with registration were exacerbated, and solutions made more difficult to achieve, as a result of the ‘transdisciplinary support’ item being the only support item included on plans for children in early intervention that allied health providers were able to claim against. This meant that small, community based private practices were required to demonstrate that they met the Disability Standards in the same way and at the same level as large organisations which were, in fact, providing a ‘specialist disability service’ - simply because both were deemed to be providing the same ‘transdisciplinary’ NDIS support. Registration requirements were not risk adjusted, nor tailored to the size of the organisation seeking registration and also lacked a recognition (or acknowledgement) of additional safeguards already in place for some allied health professions.

Of note, registration requirements for allied health practitioners from professions currently regulated by government under the Australian Health Practitioner Regulation Agency (AHPRA) were different to those required from the comparable professions who are recognised to self-regulate appropriately and do not require registration under APHRA. For example, registration with APHRA for Occupational Therapists in SA was accepted as the requirement for NDIS registration however CPSP membership of Speech

Pathology Australia was not and speech pathologists were required to meet significant additional (and burdensome requirements). Certified Practising Speech Pathology (CPSP) membership is the equivalent to APRHA registration for speech pathologists and is recognised by Medicare, all Private Health

Insurances, Department of Veteran Affairs, BetterStart for Children with Disability and Helping Children

with Autism Package as the credential required to be eligible to provide services under these funding streams.

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

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

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

The interpretation of the NSW requirements by the NDIA led to a situation where small sized speech pathology providers (solo or small group speech pathology practices) were required to undertake Third Party Verification (TPV) of their compliance with the Disability Standards, as per the requirement for Early Childhood Intervention Services. This TPV required an independent audit of the practices systems and processes that is more appropriate for larger disability organisations than for single discipline small practices. Only after advocacy by Speech Pathology Australia to the NSW Minister for Disability was this issue clarified and agreement made between the NSW DoFC and NDIA to exempt solo small allied health providers from TPV requirements as long as they hold CPSP membership of Speech Pathology Australia. This clarification took months to confirm. During this time, speech pathologists did not register to become NDIS providers in NSW. Significant damage was done to the reputation of the NDIS amongst NSW speech pathologists as many considered the TPV requirement and the time it took to receive clarification from the NDIA to have been avoidable had there been appropriate consultation with allied health professional associations. A number of speech pathologists in NSW have advised Speech Pathology Australia that they will no longer be seeking to provide services to children under NDIS, despite having previously provided the same services under HCWA or BetterStart programs.

In South Australia, little progress has been made on streamlining the requirements for NDIS ECEI registration for speech pathologists in private practices. Again, requirements of the SA Government are that speech pathologists seeking registration as NDIS ECEI providers undertake a significantly onerous process. Allied health practitioners who are registered with APHRA are not required to undertake this process. Speech Pathology Australia has been in dialogue with staff of the Disability Ministry in SA for over 12 months attempting to find a solution to remove this barrier to registration for speech pathologists and to streamline the process. Though there has not yet been any official notification, it is the understanding of Speech Pathology Australia that a more ‘streamlined’ process has been put in place – but this is only available to sole trader private practitioners – to no success. Over this 12 months, no progress on this issue has been evidenced within the Department and speech pathologists seeking to register as NDIS ECEI providers in SA are still required to undertaken a burdensome registration process.

This is situation is acting as a significant barrier to increasing the speech pathology ECEI workforce in SA.

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

The recently released NDIS Quality and Safeguarding Framework offers hope of a reasonable and appropriate level of governance of speech pathology service provision within the NDIS, requiring

Continuing Practising Speech Pathologist (CPSP) membership of Speech Pathology Australia,

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

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

Unmet need for speech pathology ECEI services is anticipated to increase unless these issues with provider registration are addressed.

Service ‘gaps’ for children deemed ineligible/waiting for ECEI

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

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

“Our area in Southern NSW was due to transition to NDIS from July

There is only one local ECEI provider and they are now withdrawing services from this area. The other two ECEI providers have very minimal/no presence in this area. There are no 0-6 year olds that have plans at this stage (July 2017) that I am aware of. With no funding and no services these children are missing out on important early intervention services including much needed therapy.”

Recommendations

It is requested that the Committee consider the following recommendations:

That the recommendations previously made by the Senate Community Affairs References Committee in 2014 into the prevalence of speech, language and communication disorders and speech pathology services in Australia be adopted. These related to:

 a thorough and systematic audit of the adequacy, strengths and limitations of existing speech and language services for children in Australia

 position paper on the likely impact of the National Disability Insurance Scheme (NDIS) on speech pathology services in Australia.

That the NDIA identify, record and publish detailed data regarding the types of children (functional problems and diagnoses) and type and duration of supports provided through the ECEI stream.
An independent and formal evaluation be conducted on the ECEI approach. This should be separate from the overall Evaluation of the NDIS.
That the NDIA have improved mechanisms to engage with representatives of speech pathology and other allied health providers by:

 Inviting Speech Pathology Australia, Occupational Therapy Australia and the Australian

Psychological Association to join the NDIS CEOs Forum

 Employing a Chief Allied Health Officer within the NDIA to liaise with the professional bodies on issues impacting on access, quality and safety of allied health services within the NDIA ECEI market.

 Ensure that allied health peak organisations are included in all ‘provider market’ forums and discussions.

 Ensuring that relevant allied health peak organisations are consulted on design features of the ECEI approach.

That the NDIA partner with Speech Pathology Australia to canvass strategies to improve the supply of speech pathologists to the NDIS ECEI provider market (for the short and longer term).
That the NDIA and relevant jurisdictions work with Speech Pathology Australia in the immediate future to streamline and fast track the registration processes for qualified speech pathologists to register as NDIS providers.
That the NDIA recognise the variability of supports required for children with differing communication needs, and seek advice from Speech Pathology Australia to develop processes to determine access, reference packages and recommended clinical pathways for children under the Early Childhood Early Intervention approach.
That the NDIA recognise the variability of supports required for children with complex communication needs requiring Augmentative and Alternative Communication (AAC) and seek advice from Speech Pathology Australia to develop processes to determine appropriate guidelines for the funding and provision of AAC Assistive Technology.
That the NDIA put in place processes to expedite planning and review timeframes for children under the age of six years – in recognition that delays in process are likely to have a disproportionate impact on longer term outcomes for young children. Changes to processes need

to identify Key Performance Indicators of maximum time periods for auctioning referrals, planning meetings, plan approvals and access to supports and services.

Clarification be provided urgently regarding the roles, responsibilities and service delivery parameters of State/Territory Departments of Education and the NDIS in supporting young children with disability through early childhood education and initial schooling transition. For national consistency, this could best be achieved through the COAG Education Council.
Clarification be provided urgently regarding the roles, responsibilities and service delivery parameters of State/Territory Departments of Health and the NDIS is supporting children with health and disability needs. For national consistency, this could best be achieved through the

COAG Health Council

That the NDIA convene a rural NDIS forum (including Speech Pathology Australia, other peak allied health professional bodies and the National Rural Health Alliance) to advise on issues relating to the support of NDIS ECEI services in rural and remote part of Australia. Urgent issues to be addressed include sustainable solutions to funding of travel, access to allied health with specialised skills and telepractice arrangements.
Systemic changes to the ECEI Planning process be put in place including:  Review processes for eligibility determinations to be streamlined and fast-tracked

 Minimum standards relating to the qualifications, skills, experience and knowledge of Planners to be mandated (and monitored)

 Induction and continuing professional development training of Planners on the roles of the allied health professions providing services to young children within NDIS

 Review processes for Plans to allow for mid-cycle reviews so that Plans can be amended in light of changes in functional needs or in response to key transition experiences in a child’s life.

 Quality assurance systems be established (and reported on publicly) for the planning process

That the NDIA release detailed data regarding services and supports being funded in ECEI Plans to allow for more nuanced workforce planning activities to be undertaken for allied health services which are based on evidence of demand.

References cited in this submission

i Mavromaras, K., Moskos, M., and Mahuteau, S. (2016) Evaluation of the NDIS, Intermediate Report, National Institute of Labour Studies, Flinders University. Adelaide. Pg 31.

ii Speech Pathology Australia (2011) Competency-based Occupational Standards (CBOS). Melbourne

Vic.

iii Australian Bureau of Statistics (2012) Australian Social Trends – Using Statistics to paint a picture of

Australian Society Sourced from

http://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/526C1495B6F4B7D2CA257A380016CBA4/$File/41020_ASTJune2012.pdf2July2015

iv American Speech-Language-Hearing Association. (2008). Roles and responsibilities of speech language pathologists in early intervention: technical report [Technical Report]. Sourced from www.asha.org/policy 2 July 2015

v Australian Bureau of Statistics (2012) Australian Social Trends – Using Statistics to paint a picture of

Australian Society

vi Australian Early Development Census 2015 https://www.aedc.gov.au/data/data-explorer

vii Bishop et al (2017) CATALISE: a multinational and multidisciplinary Delphi consensus study of problems with language development. Phase 2. Terminology, PeerJ Preprints https://doi.org/10.7287/peerj.preprints.2484v2

viii Senate Community Affairs References Committee (2014) Prevalence of different types of speech, language and communication disorders and speech pathology services in Australia. Parliament House. Canberra.

ix Mavromaras, K., Moskos, M., and Mahuteau, S. (2016) Evaluation of the NDIS, Intermediate Report, National Institute of Labour Studies, Flinders University. Adelaide. Pg 31.

x Mavromaras et al (2016): Pg 29