A Submission to the Joint Standing Committee on the NDIS – Hearing
Services
The Provision of Hearing
Services under the NDIS
January 2017
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Introduction
Services for Australian Rural and Remote Allied Heath (SARRAH) welcomes the opportunity to submit comments and recommendations to the inquiry into the provision of hearing services under the National Disability Insurance Scheme (NDIS), Joint Standing Committee on the NDIS Hearing Services. SARRAH is a nationally recognised as a peak body representing rural and remote allied health professionals working in public service and private practice. SARRAH’s representation comes from a range of allied health disciplines including but not limited to: aboriginal health workers, audiology, dietetics, occupational therapy, optometry, oral health, pharmacy, physiotherapy, podiatry, psychology, social work and speech pathology. These allied health professionals provide a range of services to people who live in rural and remote communities. They are critical in supporting people with disability to access education, to develop skills of daily living, and to participate meaningfully in all aspects of community life. The allied health professional, particularly in rural and remote areas, is well versed in transdisciplinary practice and supporting people with disability in an holistic and collaborative fashion, especially in providing services for people with hearing loss/impairment. The shortages in the allied health workforce in rural and remote areas is a well-known issue and is a contributing factor to the poorer outcomes for people with hearing loss/impairment in those communities. SARRAH maintains that every Australian should have access to equitable access to the NDIS, including hearing services, wherever they live. Allied health professionals are essential to the provision of hearing services across the continuum of screening, assessment, habilitation, rehabilitation, and community education. The following submission aims to address the points of reference of the Joint Standing Committee inquiry whilst highlighting the necessity for allied health services, in the broader provision of hearing services, to be provided in rural and remote communities.
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A – The eligibility criteria for determining access to, and service needs of, deaf and hearing impaired people under the NDIS.
People who wish to access the NDIS must meet eligibility criteria from List D – Permanent Impairment/Early intervention, under 7 years – no further assessment required. People with hearing loss/impairment will typically access the NDIS through section 4 of List D: “Conditions resulting in Sensory and/or Speech impairment”, by satisfying one or both of the criteria below: o Deaf/blindness confirmed by ophthalmologist and audiologist and assessed as resulting in permanent and severe to total impairment of visual function and hearing o Deafness/hearing loss – a 45 decibels or greater hearing impairment in the better ear, based on a 4 frequency pure tone average (using 500, 1000, 2000 and 4000Hz). (Access to the NDIS. n.d.). The criterion of hearing loss greater than 45 decibels is equal to a moderate hearing loss/impairment, and Australian Hearing states: Conversational speech will be hard to hear, more so when background noise is present, such as when the television or radio is turned up. A hearing device will assist most hearing difficulties if speech discrimination is good and background noise low. (Degrees of hearing loss. 2013, September 27) From that definition, it can be gathered that a moderate hearing loss has a significant and often permanent impact on the quality of life of an individual. Where hearing loss is not permanent and a child is still acquiring language, the effects of hearing loss on communication skills can seriously hinder language development. The effects of hearing loss on speech and language development should be noted and services should be made available to people in rural and remote areas to mitigate the effects of hearing loss. In some cases, hearing loss/impairment may form part of a broader constellation of signs or symptoms that may satisfy criteria in another section of List D. The NDIA has given children with mild hearing loss access to the NDIS in an attempt to prevent permanent effects of hearing loss/impairment in those children. Critical service needs for people with hearing loss/impairment include habilitative and rehabilitative support services, and not merely diagnostic/monitoring services. Although GP/audiometrist support for medical issues relating to hearing loss is often present in rural and remote areas, there is often little therapeutic support for people to develop their communication skills once any medical/surgical issue is resolved.
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Long-term effects of hearing loss include reduced socialisation, poor language skills, higher likelihood of mental illness, and higher likelihood of incarceration. (Vostanis et. al, 1997) NDIS services include access to audiology and speech pathology in order to augment communication skills of people with hearing loss/impairment but workforce shortages in rural and remote areas mean that those services aren’t always available there.
Recommendations: Ensuring that rural and remote residents have access to hearing services that extend beyond hearing screening and monitoring, to include habilitative and rehabilitative services. Funding for training for clinicians and associated workers (e.g. aboriginal health workers, therapy support workers) in identifying people in need of hearing services and specific interventions related to hearing loss – e.g. auditory rehab, Auslan, key word sign. Funding for teletherapy services and fly-in fly-out services to augment existing local services. Funding for generalist rural and remote clinicians to access supervision or expert support in cases where clinical specialist advice is indicated.
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B – Delays in receiving services, with particular emphasis on early intervention services.
SARRAH members submitted comments relating to delays in receiving services in various locations throughout Australia. The comments are included below:
Across Australia: Newer graduated Speech Pathologists do not have undergraduate training in audiometry, such as pure tone testing, tympanometry and using an otoscope. In the past, speech pathologists have provided some screening to rural communities but this is no longer core business. There is very little community health promotion about hearing health and the relationship between hearing and communication development.
In Victoria: The cost of a hearing assessment is more than many families are able to pay. Locally, community members can have a hearing test for between $40 and $80. If parents are not aware of the effects of hearing loss, they are unlikely to pay this. The waiting list to have grommets inserted is very lengthy – more than 6 months (some parents have been told over 12 months). Most children fall further behind in speech and language development during this time.
In South Australia: Hearing services are not provided by Country Health SA (the provider of the majority of public allied health services). Also services do not cover all areas of country South Australia. Services are provided by private audiologists where there is market demand (usually focused on hearing aides for the elderly), and by not for profit organisations (e.g. Novita Children’s Services), but it is fair to say coverage is patchy.
Riverland Mallee Coorong Region, South Australia: Waiting times for a paediatric assessment can be significant as the only services available are visiting services.
Eyre and Far North and Flinders and Upper North Regions, South Australia: There is a visiting service from Adelaide twice yearly for children, but it is difficult to get an appointment so families often travel to Adelaide as an alternative.
Private audiology services in the region tend to work mostly with adults and
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with hearing aid fitting.
Patient transport assistance to Adelaide is not always available so many families cannot afford to get to Adelaide for ENT and audiology services.
South East Region, South Australia: Australian Hearing charge for all assessments for children, but if a client requires hearing aids, then the assessment will often not be billed.
There are many private services across the region, with most offering free assessments to adults.
Some children who are participants in the NDIS are accessing services through visiting audiologists and telehealth.
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C – The adequacy of funding for hearing services under the NDIS.
At this stage there are some inconsistencies in funding levels. NDIS planners are continuing to refine levels of financial support for people with similar needs. The needs of people in rural and remote Australia are different from the needs of people in metropolitan areas. Increased travel allowances, support for co-workers (e.g. allied health assistants) to deliver hearing services, and teletherapy services, will improve the ability of rural and remote residents accessing relevant supports. (Fulcher et. al, 2015)
Recommendations: Increasing travel allowances for people in rural and remote areas. Funding (or greater financial incentives) for positions for clinicians to provide habilitative and rehabilitative hearing services in rural and remote areas (therapy support workers, audiologists, and speech pathologists). Funding for communities to improve access to therapy support workers and internet/computers so that NDIS participants can access alternative service delivery methods like teletherapy or augment FIFO services with a therapy support worker.
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D – The accessibility of hearing services, including in rural and remote areas.
Many people with hearing impairment currently access services through the Community Service Obligation (CSO) Program. In rural and remote areas of Australia, hearing services are often limited to the registered CSO provider. The service providers anticipate they will continue to provide the same services beyond 2018 when the CSO services for NDIS-eligible consumers is absorbed into the NDIS. The CSO providers most often provide their services on a fly-in fly-out basis. This can be a useful model for rural workforce solutions but can mean sporadic and intermittent services which do not meet the needs of the client. A small number of clinicians are required to service a large area and a large number of clients, which often limits services to screening, prevention, and monitoring, without habilitative and rehabilitative services. Workforce shortages and difficulty in the recruitment and retention of professionals (including those working in hearing support) affects the amount of services that can be provided in rural and remote areas. (Dew et. al, 2012) Many areas are serviced by audiometrists (hearing technicians) alone. Audiometrists are not generally trained interventionists, so they are able to monitor and refer, but not able to provide habilitative or rehabilitative services. Because this is the only model of support to which many rural and remote consumers have been exposed, they are not aware that additional services or service models are available to them. When developing and NDIS plan, a consumer may not mention that they require additional audiology or speech pathology services, because they are not aware that those services exist.
Recommendations: Supporting the development of teletherapy services to link rural and remote clients and local service providers with specialist hearing services in metropolitan or regional centres. Supporting fly-in fly-out services of specialist speech therapy providers to augment rural and remote service delivery. Supporting co-workers to provide more local knowledge and therapeutic support to families in rural and remote areas. Providing education to NDIS consumers and providers about the services that they can access, include those outside of typical face-to-face one-on one therapy sessions.
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E – The principle of choice of hearing service provider.
The NDIS aims to give choice and control to consumers in accessing supports for everyday life. Consumers should be able to choose between different services so that they can access a service that fits best with their priorities. A variety of hearing service providers are available in metropolitan centres. Because of small populations in rural and remote areas, there is not always a service available, or there may be only one service. In that case NDIS participants must choose whether they would like to use that service or no service. (Dew, A. et. al, 2012; Skinner M. & Rosenberg M., 2006) A monopoly in the market can create a less person-centred service and a more one-size-fits-all model. Communities where services have not been available for extended periods of time sometimes normalise the lack of services, and seek less support. Solutions to market gaps or monopolies must be sought in areas currently serviced by the NDIS, and during the transition to the NDIS for those areas not yet covered by the Scheme. Many services (especially tertiary referral services such as the Royal Institute for Deaf and Blind Children) are beginning to offer teletherapy to people in rural and remote areas. (RIDBC Teleschool, n.d.) An evidence base is being developed by researchers to investigate the effectiveness of teletherapy and other service delivery models that may be able to provide more choice to NDIS participants in accessing hearing services. (Wakerman et. al, 2008) Training local health professionals in specialist skills could help to provide more person-centred and timely services to people in rural and remote areas. For example, co-workers such as aboriginal health workers and allied health assistants should be supported to gain skills in administering auditory-verbal therapies so that they can provide services to people in their communities in the immediate absence of a therapist. (Johnson, 2016)
Recommendations: Supporting different organisations to develop teletherapy services and incentivise the provision of hearing services through teletherapy to rural and remote NDIS participants.
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F – The liaison with key stakeholders in the design of NDIS hearing services, particularly in the development of reference packages.
Consumers and/or consumer groups must drive the development of reference packages. The NDIA has: established an Early Childhood Intervention (hearing loss) expert advisory group to inform the development of evidence based guidelines for hearing loss, early intervention and an appropriate hearing services model. (The Hearing Services Program and the
National Disability Insurance Scheme, 2015 June 17)
The project was run by Early Childhood Intervention Australia (ECIA) and consisted of parent/carer representatives, service providers, academics, state/territory government representatives, professional representatives, rural and remote representatives, culturally and linguistically diverse representatives, and an aboriginal and Torres Strait Islander representative. As yet, little information has been widely available regarding the work that the expert reference group developed. In developing reference packages, the NDIA should continue to seek advice from families and individual NDIS participants from rural and remote areas. Unfortunately the rural and remote representatives on the ECIA expert advisory group included service providers but no NDIS participants. The parent/carer representative group included just one parent of a child with a disability. Whilst the expertise of the other representatives was no doubt valuable, it is crucial that there is direct and proportional representation from parents/carers/families/individuals. One of the most common ways that families learn about hearing services, gain an understanding how systems work, and find out what is available in their area, is by communicating with other parents. It is important that the NDIA takes the opportunity to communicate ideas to parents/participants through their reference packages in language that is accessible and meaningful to other parents. This can be achieved through inviting the contributions of parents or children with disability to the reference packages.
Recommendations: Increasing the involvement of NDIS participants and rural and remote people in the development of reference packages for hearing services.
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G – Investment in research and innovation in hearing services.
Teletherapy services are being provided by the Royal Institute for Deaf and Blind Children (RIDBC) to some regional areas. The Shepherd Centre offers teleintervention services across rural and remote Australia, using auditory-verbal therapy to encourage development of speaking, listening, and social skills. Royal Far West is developing its capacity to deliver telehealth speech pathology services that include habilitative hearing services. Research into hearing and the NDIS is not prolific. One reason for this may be that much of the audiology research is happening within the context of “health” rather than “disability” so it is difficult to ascertain the effectiveness of audiology services within the NDIS.
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H – Other related matters.
Australia needs a model of hearing services for rural and remote people with disabilities that includes local hearing health care professionals, working with co-workers or assistants at the local community level. This arrangement also needs to link into specialist hearing services in metropolitan or large regional centres. Funding is required to promote the development of such a model, including sympathetic modifications to the MBS system, and support for the provision of telehealth communication capacity. Consequently, anyone with a clinical need for amplification or other hearing services should be eligible to access those services.
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References
1 Access to the NDIS. (n.d.). Retrieved from https://www.ndis.gov.au/operational-guideline/access/list-d.html. 2 Degrees of hearing loss. (2013, September 27). Retrieved from (https://www.hearing.com.au/degrees-hearing-loss/. 3 Dew, A., Bulkeley, K., Veitch, C., Bundy, A., Gallego, G., Lincoln, M., Brentnall, J. & Griffiths, S. (2012). Addressing the barriers to accessing therapy services in rural and remote areas. Disability and Rehabilitation, Early Online, 1-8. 4 Fulcher, A., Purcell, A., Baker, E. & Munro, N. (2015). Factors influencing speech and language outcomes of children with early identified severe/ profound hearing loss: Clinician-identified facilitators and barriers. International Journal of Speech-Language Pathology, 17(3), 325-333. 5 Johnson, E. (2016, October 5). Australian Government Australian Institute of Family Studies, Child Family Community Australia. Retrieved from https://aifs.gov.au/cfca/2016/10/05/victims circumstance-disability-services-rural-and-remote-areas. 6 RIDBC Teleschool. (n.d.) Retrieved from http://www.ridbc.org.au/teleschool. 7 Skinner M. & Rosenberg M. (2006) Managing competition in the countryside: non-profit and for-profit perceptions of long-term care in rural Ontario. Social Science & Medicine 63, 2864–2876.
8 The Hearing Services Program and the National Disability Insurance
Scheme. (2015, June 17). Retrieved from http://hearingservices.gov.au/wps/wcm/connect/hso/56f9bd0f 8dc3-4a95-bad8 a7e72950d195/The+hearing+services+program+and+NDIS+sche me+fact+sheet.pdf?MOD=AJPERES. 9 Vostanis, P., Hayes, M., Du Feu, M. & Warren, J. (1997). Detection of behavioural and emotional problems in deaf children and adolescents: comparison of two rating scales. Child: Care, Health and Development, 23(3), 233-246. 10 Wakerman, J., Humphreys, J., Wells, R., Kuipers, P, Entwistle, P. & Jones, J. (2008). Primary health care delivery models in rural and remote Australia – a systematic review. BMC Health Services Research, 8, 276.
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