Submission 14 — Independent Audiologists Autralia Inc — The provision of hearing services under the National Disability Insurance Scheme (NDIS)

The Committee Secretariat

Joint Standing Committee on the National Disability Insurance Scheme

PO Box 6100

Parliament House

Canberra ACT 2600

27 January 2017

Dear Committee Secretary

Joint Standing Committee on the NDIS – Hearing Services

Thank you for the opportunity to provide comment on the points of reference for the above named

committee.

Independent Audiologists Australia Inc (IAA) is a not for profit incorporated association that

promotes and supports clinical practices owned by audiologists. IAA members all hold university

qualifications in audiology and have a financial interest in an audiology related business that is at

least 50 % owned by audiologists.

Currently, 190 sites across Australia are operated by IAA members under the following funding

arrangements:  Office of Hearing Services (OHS) as contracted service providers as part of the voucher

scheme for pensioners and as qualified practitioners (audiologists)  Medicare as service providers (allied healthcare)  WorkCover / WorkSafe programmes  Private patients funded (sometimes partially) by private health funds  NDIS providers under the NDIS scheme or as part of their contract as service providers with

OHS.

P.O Box 164 Turramurra NSW 2074 The mission of Independent Audiologists Australia is to T: 0424 720 915 promote and support clinical practices owned by audiologists. E: exec@independentaudiologists.net.au

IAA members provide audiological services for Australians of all ages (newborn to the elderly) and

their families, who live with the consequences of auditory (hearing) and vestibular (balance)

disorders. This submission to the Joint Standing Committee on the NDIS incorporates the

experience of members of IAA in delivering individualised supports that include counselling,

therapy, environmental adaptations and the use of assistive technologies. We welcome the

initiative of the Joint Standing Committee to canvass opinion on the integration of hearing services

into the NDIS. We acknowledge that the NDIS represents a major change in funding models and

we look forward to ongoing engagement with the NDIS to ensure a system that provides optimal

opportunities for all Australians.

A high level summary of the main points associated with each of the terms of reference for this

enquiry is provided first (Part I) followed by a detailed explanation (Part II).

Part I Summary of main points related to the terms of reference

a) the eligibility criteria for determining access to, and service needs of, deaf and hearing impaired people under the NDIS;

Functional ability, not a measure of impairment should determine eligibility for the NDIS

b) delays in receiving services, with particular emphasis on early intervention services; Ethical practitioners will ensure no delay in providing services to NDIS participants at the same

time ensuring that adequate time is provided to make informed decisions about long term

supports. Regulated national practice standards will need to ensure acceptable maximum waiting

times for all consultations, including those funded by the NDIS.

c) the adequacy of funding for hearing services under the NDIS; OHS funding adopted as an interim measure does not cover the full range of supports required by

NDIS participants with auditory related conditions. Hourly rates for professional services are

needed to supplement the OHS voucher scheme. Details are provided in the explanation that

follows later in this submission.

d) the accessibility of hearing services, including in rural and remote areas; Distance and mobility may serve as challenges to selecting a provider of choice.

Telehealth makes service delivery possible by distance and so is a valuable model of intervention,

in particular for those with restricted mobility or living at a distance from a major centre.

Telehealth, being part of all modern healthcare and rehabilitation systems, is an option for NDIS

participants that should be encouraged where it is necessary. Most practices will have the

technology available to offer telehealth, but will carry out face to face evaluations first to determine

what aspects of long term care and support can be offered remotely. The cost of visiting remote

sites or offering home visits should be incorporated into hourly rates charged for professional fees.

e) the principle of choice of hearing service provider; Choice of provider is a key principle of the NDIS and is a principle of the OHS voucher scheme.

To date, choice of provider has not been an option for Australians under the age of 26 years

receiving public funding for hearing devices and related services as all funding for that purpose

was allocated to Australian Hearing. Australian Hearing was self-regulating in that it created

positions for specialist audiologists and developed in-house policies. As no mandatory registration

process for university qualified audiologists or TAFE trained audiometrists exists in Australia, NDIS

planners need to ensure that participants are informed about the education and training levels of

different types of providers to ensure that participants requiring specialist services are directed to

practitioners who are qualified and positioned to offer the most suitable services tailored to

individual needs. Regulation of the profession ought to ensure mandatory referral between

professionals when needed.

f) the liaison with key stakeholders in the design of NDIS hearing services, particularly in the development of reference packages;

Clarity in the process for providers/practitioners to register with the NDIA is urgently needed.

Services that are provided by audiologists that are not included in the Office of Hearing Services

voucher scheme must be incorporated into the scheme. Consistency and clarity in information

provided by the NDIA to both audiologists and NDIS participants is called for.

g) investment in research and innovation in hearing services; Publicly funded research conducted through universities, the National Acoustics Laboratories

(NAL) and other institutions in Australia as well as international research findings serve as the

evidence base from which professionals develop clinic policies. All professionals currently access

the results of research conducted in Australia and elsewhere through publications, conferences

and seminars. Investment in research is essential to building the profession of audiology and is in

the interests of all Australians.

h)    any other related matters.     As below

Part II Explanation

The impact of auditory disorders on an individual’s participation in society and that of their family,

communication partners, colleagues and associates is easily underestimated because hearing

devices are advertised in ways that suggest that auditory conditions can be solved by technology.

In fact, conditions managed by audiologists usually require long term support that adapts to

changing needs over the lifespan [1]. Hearing loss, if not adequately supported, can lead to social

isolation which is directly associated with depression, anxiety and stress [2]. In children, auditory

disorders can impact on the acquisition of language which may have consequences for learning

and literacy [3]. Auditory and vestibular conditions are not uniform, and can range from the loss of

ability to hear some sounds to an ability to hear but not recognise or understand sounds, to being

intolerant of either sounds that occur in the environment or an internally generated sound (ie

tinnitus). As hearing disorders affect communication, partners, families, colleagues and carers are

typically the first to experience the effects of an unmanaged condition, meaning that

comprehensive rehabilitation of auditory disorders is, of necessity, family or community centred

and extends well beyond the individual [4].

Hearing thresholds (the decibel value of the softest individual tones just heard) are commonly used

to quantify impairment [5], but hearing thresholds or averages are a poor indicator of the needs of

any individual with an auditory or related problem [6]. Average hearing threshold level might

provide information about degree of hearing loss, but quantifying impairment can be misleading as

some averaging thresholds can mask difficulties experienced in everyday life. Audiometric

quantification in the form of hearing thresholds provides no information about available personal,

family or community resources or supports, the environment in which the individual communicates,

or their communication abilities – all of which are determiners of the impact of any auditory

disorder (regardless of degree of impairment). Little direct relationship exists between auditory

impairment and the impact of that impairment on participation, therefore, eligibility for NDIS funding

ought to be determined by the needs of each individual and an age-appropriate evaluation of

function. Some auditory conditions do not lend themselves to an audiometric quantification (such

as auditory processing disorders, balance disorders or tinnitus). If a quantified impairment-based

cut-off point were to be adopted, some Australians with milder impairments could be excluded from

NDIS funding, in spite of suffering significant disadvantages, which seems inconsistent with the

principles of the scheme.

The NDIS has adopted the OHS voucher scheme for participants, in what is understood to be an

interim measure. The OHS voucher scheme is designed as a hearing device distribution service

for pensioners with relatively simple audiological needs. Therapy is funded to a very limited way in

the voucher scheme – either as an alternative to device fitting or as a follow on to device fitting for

those who opt for fully subsidised devices. Extensive rehabilitation and therapy is not provided for

in the OHS voucher scheme funding model. OHS places restrictions on the number, purpose and

timing of funded consultations. The NDIS will be meeting the needs of those with a wide range of

auditory and related conditions with many alternative support options. For instance, children or

adults who are unable to work or study without support due to developmental or acquired auditory

processing disorders; those requiring support to cope with daily activities whilst suffering from

severe debilitating tinnitus; or those unable to participate in social life because of misophonia

require tailored supports from their audiologist involving regular consultations, home or school

visits, environmental adjustments, individual and group counselling.

Early information sessions offered to the profession about the NDIS referred to some conditions

that are treated by audiologists as falling under a banner of disability, not hearing services (Office

of Hearing Services Transition Workshops 2015). Dividing up hearing services from other services

that audiologists offer has proved to be very confusing.

Since the OHS scheme was adopted by the NDIS as a transitional measure, the process of

registering as a service provider has become even more confusing. Hearing services under the

NDIS have come to refer to the OHS voucher scheme. Providers contracted to OHS and qualified

practitioners working with OHS voucher holders are not required to register as providers with the

NDIS. Further, as is shown in the example below, audiologists are being advised that they may

not register with the NDIS if they are already OHS providers. Yet, as mentioned above, not all

supports offered by audiologists are covered by the OHS scheme.

NDIS participants who have developed their own plans have been advised by the NDIS that they

do not require an OHS voucher. In the absence of NDIS items for audiologic rehabilitation,

audiologists have been providing quotations for hearing devices bundled together with the cost of

associated rehabilitation. As can be seen, the NDIS has not provided a consistent message as to

whether NDIS participants have to receive an OHS voucher. They are advising participants that

self-managed plans do not involve OHS. Audiologists are being advised that that they do not need

to register as providers under the NDIS because they are already OHS providers.

One IAA member, for example, received the following message from the NDIS, which is at odds

with the provision of services to NDIS participants outside of the OHS voucher scheme:

“I have gone into your application this afternoon to confirm the status of your registration groups that you have requested. I can confirm these are under assessment by our team, namely Lisa, and this is why you were contacted. At this stage you are not yet approved for these supports.

Further I can see that you have only submitted applications for Hearing Services and Specialised Hearing Services. Can you confirm this? If this is the case then we will be unable to process and approve your registration at this time.

As per the guidance in the NDIA Guide to Suitability, we currently are not accepting providers for the above two registration groups. The reason for this is that these registration groups are currently not in use with participants and their NDIS plans.

Governments have agreed that aspects of the Commonwealth Hearing Services Program for people under 65 years are transitioning to the NDIS. However, for the period of transition, all NDIS funded hearing services are being provided through the Hearing Services Program. Providers who are registered with the Office of Hearing Services are not required to individually register with the NDIS during transition. As arrangements for full scheme are agreed and implemented, providers will be updated by the Office of Hearing Services and NDIA.

If you are already registered per the above with the Hearing Services Program you do not need to register with us currently. “

The OHS scheme does not provide for comprehensive services, yet the message sent out to

audiologists (as shown in the example above) is that only services and devices funded by OHS (in

its voucher scheme for pensioners) will be funded by the NDIS in the transition phase. It seems

that at least in some locations, NDIS participants are being told that they can self-manage hearing

related services outside of the OHS scheme. Clarity is required both for interim and long term

arrangements. We want to make very clear to the inquiry that funded audiology services need to

extend beyond device distribution that is funded by the OHS voucher scheme. Auditory training,

classroom support, counselling and communication training are reasonable and necessary

audiological supports [7] that should not be excluded from the NDIS simply because they are not

specifically funded by the OHS voucher scheme. We urge the NDIS to include the full range of

supports that might be offered by audiologists in the scheme. We strongly urge an unbundled

approach to recognise the role of supplementary intervention separately to device supply.

Using the OHS voucher scheme for NDIS participants has meant that some audiologists who

specialise in paediatric or other specialist services ideally positioned to support NDIS participants

have had to apply for OHS contracts in order to provide services under the NDIS.

Yet, in some places at least, NDIS participants are receiving services that are provided outside of

the OHS scheme. Clarity as to what audiologists need to do to register as providers of

audiological services outside of those funded by OHS is required.

In Australia, audiology training is offered at a postgraduate level (Masters Degrees) level in

diagnostic and rehabilitative audiological services related to hearing and balance for all ages and

types of conditions. Audiometry training is offered at TAFE to diploma level in conducting basic

hearing assessments for adults and fitting hearing aids to adults without complex needs.

Audiologists and audiometrists are employed by clinic chains some of which are tied to

multinational companies and hearing device manufacturers, government agencies, Ear Nose and

Throat specialist owned clinics or businesses owned by those with no training or links to the field.

Additionally, both audiologists and audiometrists operate independent clinics in Australia. OHS

contracts to “hearing service providers” who are business owners, not practitioners. In many

cases, the provider contracted to OHS is a large multinational company.

The OHS voucher scheme does not differentiate between university qualified audiologists and

TAFE qualified audiometrists in the way that rehabilitative services and device supply are funded,

even though the range of services that each profession can offer is different. These professions

have no external regulation, nor any mandatory registration. No protection of title for audiology or

audiometry exists. Recent efforts commissioned by OHS to identify scope of practice for

audiologists and audiometrists resulted in a self- assessment tool that is acknowledged by its

authors to be unenforceable (see here). Clinic accreditation is expected to be introduced, to

regulate the national practice standards. IAA contributed to an expert reference group that

established standards of practice and can testify that in spite of extensive discussions on this topic,

the standards obscure differences between differently qualified practitioners and provide little

guidance to the public to know when to consult an audiologist or when consulting an audiometrist

would be sufficient. Given that choice of provider is a core principle of the NDIS, planners ought to

be familiar with the training undertaken by audiologists and audiometrists and encourage NDIS

participants to make informed choices, taking the qualifications of their practitioner into account.

Useful professional boundaries between the professions of audiometry, audiology and

otolaryngology have been developed by IAA in conjunction with Assoc Prof Wayne Wilson

(University of Queensland) and can be found here.

Choice of provider is complex for those new to needing audiological services. Choice of provider

may be confused with choice of hearing device, which in Australia, is also tied to the choice of

funding model. Providers under the OHS voucher scheme need not be practitioners. Many OHS

providers are multinational companies who are closely associated with hearing device

manufacturers. Device manufacturers operate closely to control the industry, not only through

business associations with retail outlets for their products, but also with one another [8].

Clinics with close ties to the hearing device industry may primarily supply devices from the

particular manufacturer that they are associated with. Some providers bundle hearing device

costs with assessment and rehabilitation whereas other unbundle their professional fees, making

comparison on the cost of services and devices across providers almost impossible [9]. Many

employers, including Australian Hearing, pay commissions on device sales and set targets for the

sale of hearing devices [10]. All of the above many not be immediately obvious to anyone seeking

a provider, but might impact on the rehabilitation options that are offered.

Many Australians requiring hearing related services might find themselves having to decide on a

service provider at very short notice. Many will be guided by their general practitioners [11], some

of whom enter into prearranged contracts to direct their patients to particular providers [see for

example 12]. Prearranged referral arrangements may not take individual needs into account as

not all providers have the resources to cater to all types of disorders.

Proposed privatization of Australian Hearing and shifts of funding to the NDIS means that all

Australians (including parents of children newly diagnosed with deafness) are likely to soon be

able to choose their own providers for publicly funded services and devices. Without regulation of

the professions of audiology and audiometry through a mandatory registration process, the public

(including referring general practitioners) have no way to assess if a provider is qualified to meet

their needs. Arrangements between referrers and businesses (including the government agency

Australian Hearing) cannot be a guarantee that individual needs can be met in all cases.

To explain to the public the difference between the hearing device industry and the profession of

audiology, IAA, along with colleagues in New Zealand, developed the Wellington Declaration

(here) which provides an aspirational guide to future developments of the profession and its

relationship to industry. The principles of the Wellington Declaration ought to be understood by all

NDIS participants so that choice of provider is informed.

Early intervention can prevent unwanted sequelae of auditory conditions that might turn out to be

costly and complex to support. Early intervention services need to include time to explore long

term options and allow for life changing decisions (such as deciding on implantable devices and

Auslan–English bilingual language acquisition) to be made in an unhurried manner, allowing for

informed decision-making. The NDIA should ensure that all those with newly acquired or newly

diagnosed conditions are given the opportunity to fully investigate all available alternatives.

All ethical audiology practices will prioritise service delivery for children and those newly

diagnosed. Members of IAA are signatories to a code of ethics that calls for ensuring that the

healthcare of all seeking assistance is the priority (see here). Business owners who contract as

service providers to OHS are not required to have professional skills. Consequently, there is a

concern that businesses owned by those who are not practitioners may not recognise the

importance of prioritising services for children because they may not fully understand, for

example, the implications of deafness for language acquisition or the impact that balance disorders

may have on the life of an individual and their family members.

An additional group of people who may have difficulty choosing providers are those who are

unable to regularly travel to their preferred service provider. Telehealth makes service delivery

possible by distance and so is a valuable model of intervention, in particular for those with

restricted mobility or living at a distance from a major centre. Telehealth, being part of all modern

healthcare and rehabilitation systems, is an option for NDIS participants that should be

encouraged where it is necessary. Most practices will have the technology available to offer

telehealth, but will carry out face to face evaluations first to determine what aspects of long term

care and support can be offered remotely. The cost of visiting remote sites or offering home visits

should be incorporated into hourly rates charged for professional fees.

Investment in research and innovation in the audiology field has a long tradition in Australia, with

public funding supporting the National Acoustics Laboratories (NAL) and the Hearing CRC.

Research by NAL is sometimes mistakenly understood to guide government owned services only,

as suggested by Australian Hearing in their advertising to the Royal Australian College of General

Practitioners that “We are uniquely supported in Australia by our research division, the world

renowned National Acoustic Laboratories (NAL)” [13]. Describing themselves as uniquely

supported suggests, not only to general practitioners, but to parents and other advocacy groups

that Australian Hearing has an advantage over other clinics because of research backing from

NAL.

Australian Hearing competes with the private sector to provide services under the OHS voucher

scheme and the NDIS, with further changes to the scope of Australian Hearing already under

discussion. Promoting the agency as uniquely positioned to be guided by NAL is inaccurate and

could be considered anticompetitive.

In fact, all practitioners and providers have access to international and Australian research findings

which are published in international journals and presented at local and international conferences.

Peer reviewed published research is the basis for all evidence–based professional practice

guidelines followed by audiologists. IAA, as a privately funded not-for profit incorporated

association, demonstrates its commitment to translating research into clinical practice through its

Excellence in Education programme, which provides in depth examinations of topics of clinical

relevance and makes all resources available to all members.

In summary, IAA welcomes the opportunity for audiologists to provide services to the Australian

public under the NDIA. The new system presents the opportunity to address inequities and

misunderstandings in relation to service delivery. Thank you for the opportunity to present the

concerns and experiences of IAA members to your inquiry. We trust that this submission will serve

to inform and guide the committee of key areas needing attention as the NDIS progresses.

We look forward to working together with the NDIA to achieve optimal outcomes for the one in six

Australians whose daily lives are impacted by auditory or related conditions.

Myriam Westcott               Grant Collins                   Louise Collingridge

IAA President                IAA Vice President            IAA Executive Officer

Deborah Pallett                    Tricia Sharples                Mel Gray-Thompson

IAA Treasurer                IAA Secretary                IAA Executive

Sharyn Lim                      Philippa Long                Jane MacDonald

IAA Executive                IAA Executive                IAA Executive

Elaine Melville Nolene Nielson

IAA Executive IAA Executive

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