Speech and Hearing Clinic
Faculty of Human Sciences
Ground Floor, Australian Hearing Hub
16 University Avenue
Macquarie University
NSW 2109 Australia
T: +61 (2) 9850 2900 F: +61 (2) 9850 1470
mq.edu.au
ABN 90 952 801 237
CRICOS Provider No 00002J
Joint Standing Committee on the
National Disability Insurance Scheme
PO Box 6100
Parliament House
Canberra ACT 2600
January 2017
Macquarie University Speech and Hearing Clinic
Submission to the Inquiry into the provision of hearing services under the
National Disability Insurance Scheme (NDIS)
CLINIC BACKGROUND
The Macquarie University Speech and Hearing Clinic provides best practice audiology services to the community, including services delivered to clients eligible for Commonwealth subsidies via the Office of Hearing Services (OHS) voucher scheme. We view hearing impairment as more than a loss of auditory acuity because our experience shows us that for nearly all affected individuals, the consequences in regards to communication, relationships, participation and access far outweigh the sensory loss.
Although we fit hearing aids, we do so with a significant amount of audiological counselling and communication training. Individual clients are asked to specify communication goals, and we tailor this holistic rehabilitative approach towards achieving these goals. Our most recent satisfaction survey showed over 90% of 48 respondents who were fitted with hearing aids at our clinic in the second half of 2015 report using their hearing aids 4 hours or more per day, and 73% used their devices more than 8 hours per day. In the same survey, 100% of respondents reported an improvement in their quality of life through hearing aid use, and we believe this is because the hearing aid itself is offered as part of a broader intervention that address relevant psychosocial factors, not solely as a means to an end. This approach differs from the standard clinical approach in Australia, where hearing aids are often recommended as a “solution” for hearing loss, despite the lack of any independent evidence that shows them to be effective in dealing with the complex issues caused by hearing impairment. Historically, services are funded in a large part by hearing aid profits, which may explain this focus.
Our clinic also sees a large number of children for diagnostic audiological services, some who are eligible for the National Disability Insurance Scheme (NDIS). We have framed our response to reflect the areas where we have clinical expertise, that is, diagnostic audiology for adults and children, and audiological rehabilitation for adults.
EXECUTIVE SUMMARY
Every person with a hearing impairment will require a different set of supports and resources to help reduce the impact of their sensory loss on their function. We propose a program that can account for this individual variation, while maintaining consistent measures of eligibility, equitable funding rules, and standardised measurement and reporting of outcomes. Specifically we recommend that:
Eligibility for the NDIS should be assessed with a combination of results from a comprehensive audiological test battery, as well as standardised measures of function, ability, participation, and individual context.
A funding model emphasises proper assessment and holistic rehabilitation over device fitting is required. In particular, the level of influence exerted by commercial interests in clinical decision-making must be controlled.
Only clinics and clinicians that demonstrate sufficient qualifications and experience, and that also disclose any real or perceived conflicts of interest, should be able to deliver services under the NDIS. Recipients of NDIS funding should be free to choose from any service provider who meets these standards.
The funding of paediatric habilitation services should be limited to clinics and clinicians who can demonstrate adherence to strict regulations.
A working group be established to aid in the development of hearing services via the NDIS, as well as a strategy for communicating information to funding recipients and service providers.
Standardised outcome measures are used, to simplify and objectify the challenging task of assessing program impact.
RESPONSE TO TERMS OF REFERENCE
- a) the eligibility criteria for determining access to, and service needs of, deaf and hearing impaired people under the NDIS;
Hearing impairment is often referred to as a “hidden handicap”, which is an apt description given the mismatch between the immense scale of the problem compared to relatively low engagement in the community with Audiological services. It is an often quoted fact that 1 in 6 Australians has some form of hearing loss, rising to 1 in 3 by the age of 65 (Access Economics, 2006). Access to funding for hearing aids and rehabilitation services has recently focussed on a determination based largely on the audiometric threshold (Office of Hearing Services, 2015). We feel this is an inadequate measure, as the degree of loss measured by an audiogram is not a good indicator of the level of impact the hearing impairment has on an individual. We believe that eligibility for the NDIS should be based on level of impact, including an assessment of the activity and participation restrictions arising from the loss of hearing, as well as the individual and contextual factors that enhance or inhibit an individual’s ability to overcome these restrictions. The World Health Organisation (WHO) have developed a framework for this type of assessment, the International Classification of Functioning (ICF) (Granberg et al, 2014). Completing the ICF with a client would provide a much stronger indicator of the functional impact of hearing loss than an audiogram alone, and we believe the two should be considered together when assessing a person’s eligibility for the NDIS.
This is an area where considerable experience is required, and where careful consideration needs to be given to the management of commercial conflicts of interest. That is, the assessment of a person’s eligibility should not be solely the domain of an assessor who does not have a deep understanding of the functional impact of disability and hearing impairment, nor should it be undertaken by a clinic or clinician who stands to benefit financially via the provision of services or a hearing device. Our clinical team is firmly of the belief that self-regulation in the OHS scheme does not provide the best value for money for government-subsidised services. We view the rollout of the NDIS as an opportunity to improve the assessment of eligibility by incorporating a consideration of the impact of the disability on the individual.
b) delays in receiving services, with particular emphasis on early intervention services;
We agree with the principle that early intervention will provide a child with the best chance of achieving their potential. We feel that this issue is best addressed by the families of children identified as having a permanent hearing loss through newborn hearing screening, and our colleagues who specialise in that field.
c) the adequacy of funding for hearing services under the NDIS; We are of the opinion that the funding model for NDIS participants should not be linked in any way to that used under the current OHS voucher scheme. Under the OHS funding model, an initial assessment, with a repeat every three years, is funded. In some cases, particularly with children or adults with a known progressive hearing loss, more regular assessment may be required, and adequate funds to cover the required amount of monitoring should be allocated.
Under the OHS funding model, if a client is eligible for, and requires, hearing aids then these devices are funded to a minimal amount which covers the cost of basic technology
but generally not other useful technologies (be they more advanced hearing aids, or another assistive devices). Clients who wish to trial other technologies are required to top-up, that is, make an out-of-pocket contribution to cover additional costs. We acknowledge this is not an enquiry into the OHS funding model, however we are concerned that this model could be used as a template for NDIS funded services. The reality is that in many commercial clinics there is an emphasis on encouraging clients to top-up. In a recent survey by Audiology Australia, nearly half of the 1221 respondents indicated they had received an incentive directly linked to the sale of hearing devices as part of their salary packages (Audiology Australia, 2016). We are not opposed to the top-up concept per se, however, we feel it does introduce ethical considerations, which can be bypassed by a more appropriate funding model.
The model we suggest to cover the costs associated with hearing aids is based on the worker’s compensation model used in New South Wales (State Insurance Regulatory Authority, 2016). Under this model the eligible client is able to obtain any hearing aid up to a specified wholesale cost. The insurer pays the wholesale amount, and a flat fitting fee is then payable to the clinic, irrespective of the initial cost of the device. This would negate the commercial incentive to recommend devices with a significant out of pocket cost to NDIS participants, while still allowing limits to be set on the costs of devices. A similar model could be employed for all assistive listening technologies, not just hearing aids.
Based on the initial assessment of eligibility that we have proposed (a combination of audiological assessment and a description of an individual’s current functioning), planners will be able to determine a reasonable number of review, counselling or follow up sessions per year. By considering these three factors (likely number of assessments per year, costs of technology required, and number of reviews required per year) it should be possible to plan suitable levels of funding for all recipients of NDIS funding.
d) the accessibility of hearing services, including in rural and remote areas; We operate almost exclusively in the Sydney Metropolitan area. We believe other parties, specifically NDIS participants in rural and remote areas, as well as service providers in these areas, would be better placed to comment.
e) the principle of choice of hearing service provider; We agree with the view that individuals have a right to make choices in regards to their own care, as stated in the principles underpinning the NDIS (Australian Law Reform Commission, 2014):
People with disability have the same right as other members of Australian society to be able to determine their own best interests, including the right to exercise choice and control, and to engage as equal partners in decisions that will affect their lives, to the full extent of their capacity.
It is critical that people be given all the information required to make informed choices. To us this would include clinicians having to disclose their qualifications, experience, and any potential or perceived benefit they may receive from making a particular recommendation to a client. It is also important that all Australians, including people with disability, be provided with access to information relevant to any recommendations made to them before deciding a course of action. For example, a person requiring hearing aids should be aware that many of the claims made in regards
to hearing aids are substantiated only by research carried out or funded by the manufacturers of those devices.
Once clinics or clinicians can show they are suitably qualified in audiological case management, have suitable experience in the field and freely disclose any personal gain they derive from their recommendations, then they should be registered as providers. NDIS participants will be able to choose providers with confidence that these core criteria are met. We would recommend that the delivery of services to NDIS participants be limited to Audiologists registered with Audiology Australia or an equivalent professional body.
We note that special care should be taken in the registration of providers seeking to deliver services to children. Best practice protocols in assessment and re/habilitation for children with hearing loss differ to those used with adults. We would urge the committee to consult with families and current service providers who could potentially be affected by a change to current funding arrangements. While the principle of choice is important, ensuring that services are delivered by clinicians with expertise in paediatric audiology is critical for children with hearing impairment.
f) the liaison with key stakeholders in the design of NDIS hearing services, particularly in the development of reference packages;
Our clients who have become eligible for the NDIS have been frustrated by conflicting information regarding their eligibility to receive services at a clinic like ours, which is currently in the process of registering as an NDIS provider. This has been particularly confusing for clients who are also eligible for OHS funding. Plain language communication about client rights and the differences between funding sources should be reviewed regularly to reflect current understanding. There is, anecdotally at least, a certain level of frustration amongst audiologists as well, who have been accustomed to different funding models in the past and are now struggling to make sense of another set of rules and protocols.
We recommend a working group be established, with representation from hearing impaired people who are eligible for the NDIS, community groups with a focus on deafness or hearing impairment, audiologists via Audiology Australia, health economists and government. This group could offer advice on both the design of the program, as well as the best way to communicate changes to the program as they occur.
g) investment in research and innovation in hearing services; As service providers, we feel it is important to understand the overall benefits of any program, especially when the taxpayer funds it. We recommend that measures of achieved outcomes be standardised across the program, so that data from a range of different service providers can be captured and collated. We believe this will simplify the process of validating the success of the program, and enable research on a large scale into benefits derived by recipients of funding, as well as areas for further improvement.
REFERENCES
Access Economics. (2006). Listen Hear – The economic impact and cost of hearing loss in Australia
Audiology Australia. (2016). Audiology Now, 63, p. 10
Australian Law Reform Commission. (2014). The National Disability Insurance
Scheme: Objects and principles. Retrieved from https://www.alrc.gov.au/publications/objects-and-principles
Granberg, S., Swanepoel, D.W., Englund, U., Moller, C., & Danermark, B. (2014). The ICF core sets for hearing loss project: International expert survey on functioning and disability of adults with hearing loss using the international classification of functioning, disability and health (ICF). International Journal of Audiology, 53, 8, pp 497-506.
Office of Hearing Services. (2015). Minimum Hearing Loss Threshold. Retrieved from
State Insurance Regulatory Authority. (2016). Workers Compensation (Hearing Aid
Fees) Order 2017. Retrieved from http://www.sira.nsw.gov.au/__data/assets/pdf_file/0003/112863/Hearing-aid_Fees-Order-2017.pdf