Submission to the inquiry into the Provision of Hearing Services under the
National Disability Insurance Scheme (NDIS)
Joint Standing Committee on the NDIS – Hearing Services
January 2017
Deafness Forum of Australia submission to the inquiry into the
Provision of Hearing Services under the National Disability Insurance
Scheme (NDIS)
Contents
Terms of Reference …………………………………………………………………………………………………………………….. 2
Deafness Forum of Australia ………………………………………………………………………………………………………… 3
Executive Summary – Recommendations ……………………………………………………………………………………… 4
Response to Inquiry Terms of Reference ………………………………………………………………………………………. 7
a) The eligibility criteria for determining access to, and service needs of, deaf and hearing impaired people under the NDIS ………………………………………………………………………………………………………………… 7
b) Delays in receiving services, with particular emphasis on early intervention services ………………… 9 c) The adequacy of funding for hearing services under the NDIS ……………………………………………….. 13 d) The accessibility of hearing services, including in rural and remote areas ……………………………….. 15 e) The principle of choice of hearing service provider ……………………………………………………………….. 18 f) The liaison with key stakeholders in the design of NDIS hearing services, particularly in the development of reference packages …………………………………………………………………………………………… 23
g) Investment in research and innovation in hearing services ……………………………………………………. 24 h) Any other related matters ………………………………………………………………………………………………….. 25
APPENDIX A – ELIGIBILITY CRITERIA FOR THE AUSTRALIAN GOVERNMENT HEARING SERVICES
PROGRAM ………………………………………………………………………………………………………………………………… 27
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Joint Standing Committee on the NDIS – Hearing Services
Terms of Reference
- That the joint committee inquire into and report on the provision of hearing services under the National Disability Insurance Scheme (NDIS), with particular reference to:
a. the eligibility criteria for determining access to, and service needs of, deaf and hearing impaired people under the NDIS;
b. delays in receiving services, with particular emphasis on early intervention services;
c. the adequacy of funding for hearing services under the NDIS; d. the accessibility of hearing services, including in rural and remote areas; e. the principle of choice of hearing service provider; f. the liaison with key stakeholders in the design of NDIS hearing services, particularly in the development of reference packages;
g. investment in research and innovation in hearing services; and h. any other related matters. 2. That the committee reports by 23 March. 2
Deafness Forum of Australia
Deafness Forum is the peak, national not for profit organisation that represents the one in six Australians who have a hearing impairment, a chronic disorder of the ear, are Deaf or deafblind, and the families who support them.
Deafness Forum’s objective is to provide timely and realistic advice to government on strategic public policy development and practice reform.
Hearing impairment or deafness is a grossly underestimated public health problem in Australia, causing significant productivity loss to the“ nation.
In addition, there must be a new focus on the prevention of avoidable hearing loss acquired from poor occupational health practices and other exposures to noise.
There is a real need for national advocacy.
It is Deafness Forum’s role to provide informed and realistic advice to the Australian Government and the Opposition, to inform public policy to benefit the one in six Australians it represents. ”
Hon John Howard OM AC, 25th Prime Minister of Australia, patron of
Deafness Forum of Australia
Deafness Forum of Australia thanks the Committee for the opportunity to comment on the Terms of Reference for this Inquiry.
Endorsed by Australian Federation of Disability Organisations
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Executive Summary – Recommendations
a) The eligibility criteria for determining access to, and service needs of, deaf and hearing impaired people under the NDIS
i. That clearer guidelines be provided to NDIS staff to ensure a more consistent approach is taken to assessing whether a person with hearing loss meets the access requirements for the NDIS. ii. These guidelines should be made public. iii. The guidelines should not be based solely on an average hearing threshold level. iv. That information be made available as soon as possible regarding the eligibility criteria for the NDIS for people requiring hearing services.
v. The development of this criteria should include consultation with consumers. vi. That information be made available as soon as possible regarding the eligibility criteria that will apply to the Australian Government Hearing Services Program following the roll out of the NDIS. vii. The development of this criteria should include consultation with consumers viii. That people with hearing loss receive an appropriate level of support to meet their needs regardless of whether they qualify for the NDIS or the Australian Government Hearing Services Program.
b) Delays in receiving services, with particular emphasis on early intervention services i. That under the NDIS, the care pathway for children with hearing loss supports a seamless and streamlined approach from diagnosis to audiological service provision and early intervention service provision and minimise the risk of loss to follow‐up. ii. That the NDIS pathway for adults between diagnosis and intervention, support timely access to services. iii. That the NDIS plan approval process be streamlined in a way that doesn’t compromise the process, to remove current delays in having funding approved for families to access early intervention services. iv. Once hearing services transition to the NDIS in 2019, families should continue to have access to unbiased advice about the range of hearing services providers and early intervention providers. The NDIS needs to provide adequate funding to an independent service to fulfil that role.
c) The adequacy of funding for hearing services under the NDIS i. That there be no reduction in services or technology with the transition of hearing services from the Australian Government Hearing Services Program to the NDIS. ii. If the level of funding and the services that are included in an individual’s NDIS Plan are solely based on the individual’s ability to articulate their needs, then the process requires safeguards to ensure people who are not able to advocate well for themselves are not disadvantaged.
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d) The accessibility of hearing services, including in rural and remote areas i. That the NDIA closely monitor service availability to ensure there is no loss of coverage with the transition of hearing services from the Australian Government Hearing Services Program to the NDIS so that hearing services continue to be available in locations where people can access them. ii. That interpreter services be funded under the NDIS when needed for people from culturally and linguistically diverse backgrounds. iii. That Auslan interpreting is automatically allocated to all Deaf people who use Auslan to access services, medical appointments and NDIS meetings. iv. That the appeal process for disputing what is in the NDIS funding packages, especially for Auslan interpreting, should be reduced from three months to a maximum of four weeks.
e) The principle of choice of hearing service provider i. There needs to be a system in place so that consumers or their carers can easily identify providers with the appropriate facilities, and with the staff with the required skills to deliver services to people with more complex hearing rehabilitation needs. ii. Due to the complexity of the work, hearing rehabilitation services should only be provided by qualified audiologists with training in working with children and with adults with complex hearing rehabilitation needs. iii. With the transition of the Community Service Obligations Program to the NDIS and the introduction of contestability, the NDIA needs to ensure that the Program does not become so fragmented that it is impossible for clinicians to maintain their skill level. iv. Once the Community Service Obligations Program has transitioned to the NDIS, if Australian Hearing does not retain a role of independent adviser, then other organisations need to be funded to take on this role so that hearing impaired adults and the families of children with hearing loss can know that the advice they are receiving is completely impartial.
v. Due to the small population of Deaf and hearing impaired children, it is recommended that a single provider be nominated as the sole provider of services to infants and children.
f) The liaison with key stakeholders in the design of NDIS hearing services, particularly in the development of reference packages
i. That the NDIS continue to work with stakeholders on the early intervention reference packages. ii. That the NDIA engage with stakeholders, particularly those with lived experiences of hearing loss, regarding the development of reference packages for adults with hearing loss and for people with multiple disabilities including hearing loss. iii. That there be continued involvement of consumer groups whenever participants are affected by changes to legislation, policies or procedures with respect to hearing services.
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g) Investment in research and innovation in hearing services i. That research into hearing loss continues to be supported with appropriate funding levels.
h) Any other related matters i. That the National Quality and Safeguarding Framework will ensure that hearing services and early intervention providers are using the latest evidence‐based practice recommendations and that services are delivered by staff with the appropriate qualifications and expertise. The framework should also ensure that client outcomes are regularly monitored so that there is evidence to demonstrate that NDIS funding is being used effectively and participants are achieving the best possible outcomes. ii. That the demographic report on children fitted with devices continues to be published annually and that data collection be enhanced with the transition of services from the Australian Government Hearing Services Program to the NDIS. iii. That assistive hearing technology supply arrangements under the NDIS and the Australian Government Hearing Services Program continue to ensure high quality products with appropriate features are available to clients and that the Government continues to achieve the best value for money in the device supply arrangements. iv. That the decision on the choice of device is based on clinical need and not influenced by the payment of financial or other incentives to hearing services providers/practitioners by the manufacturer.
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Response to Inquiry Terms of Reference
a) The eligibility criteria for determining access to, and service needs of, deaf and hearing impaired people under the NDIS
At the time of writing there has been no formal announcement of specific eligibility criteria for determining access to the NDIS for people with hearing loss, so it is assumed that the existing access requirements apply. Reports from consumers indicate there has not been a consistent approach to providing access to the NDIS for people with hearing loss across Australia, so some clearer guidelines are needed for those who currently assess eligibility.
Some consumers and clinicians have been advised that eligibility for the NDIS is dependent on the person’s average hearing threshold level. Eligibility for the NDIS should not be based on hearing threshold levels alone. This measure does not provide any information on the impact of the hearing loss on a person’s ability to undertake activities, or participate in employment or socially. An average hearing threshold level can be misleading if viewed in isolation especially if the person has other disabilities. When a person has their hearing assessed the determination of a hearing threshold level is only one component of the assessment process. Audiological assessment includes a broad range of information gathering including, a discussion of the impact of the hearing loss on the person’s functioning, a discussion of the individual’s needs and goals, as well as a diagnostic hearing assessment to determine the degree and type of hearing loss.
Deafness Forum of Australia supports the holistic approach taken by the NDIS to determine eligibility which is based on the WHO International Classification of Functioning, Disability and Health; and would be concerned if this was reduced to an average hearing threshold level for people with hearing loss.
If there is going to be specific eligibility criteria applied for people with hearing loss to qualify for the NDIS, then it is important this information is be made available as soon as possible. The lack of information is a key concern to Deaf and hard of hearing people and their families who are needing to make decisions particularly relating to device choice without knowing whether they will be supported into the future through government funded programs.
There have been assurances given by Government that everyone who is currently receiving services through the Australian Government Hearing Services Program will continue to receive services either through the NDIS or the Hearing Services Program. However it is still not clear what happens for people who are not yet in the Hearing Services Program. It may be that new eligibility criteria will be applied to the Hearing Services Program once the NDIS becomes fully operational in 2019.
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The Australian Government Hearing Services Program/NDIS Transition Plan1 has two work
packages that relate to eligibility for both Programs. Deafness Forum of Australia is very willing to contribute to the development of these work packages.
If both the NDIS and the Australian Government Hearing Services Program are going to continue to provide services to people with hearing impairment there is a risk that it could create a two tiered system, as the NDIS is able to meet a broader range of needs than the Hearing Services Program. It will be important to ensure that the individual receives the level of support they need regardless of which Program they qualify for.
RECOMMENDATIONS
i. That clearer guidelines be provided to NDIS staff to ensure a more consistent approach is taken to assessing whether a person with hearing loss meets the access requirements for the NDIS ii. These guidelines should be made public iii. The guidelines should not be based solely on an average hearing threshold level iv. That information be made available as soon as possible regarding the eligibility criteria for the NDIS for people requiring hearing services
v. The development of this criteria should include consultation with consumers vi. That information be made available as soon as possible regarding the eligibility criteria that will apply to the Australian Government Hearing Services Program following the roll out of the NDIS vii. The development of this criteria should include consultation with consumers viii. That people with hearing loss receive an appropriate level of support to meet their needs regardless of whether they qualify for the NDIS or the Australian Government
Hearing Services Program
1
http://www.hearingservices.gov.au/wps/portal/hso/site/about/national%20disability%20insurance%20scheme/nd is_transition_plan
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b) Delays in receiving services, with particular emphasis on early intervention services
Hearing services – children
Currently the provision of hearing services for children, even those who qualify for the NDIS, is managed through the Community Service Obligation Program component of the Australian Government Hearing Services Program. This arrangement offers a very streamlined process for the child and their family to access hearing services in a very timely way. The main reason the referral system works seamlessly is that there is one hearing services provider that delivers hearing services to children ‐ the government provider, Australian Hearing. All referral agencies are aware that Australian Hearing is the sole provider of services for children and most have a good working relationship with the local Australian Hearing centre so that referrals can be made easily.
For infants diagnosed with hearing loss through newborn hearing screening programs, the hospital audiologist who diagnoses the hearing loss contacts Australian Hearing directly and arranges an appointment often while the family is still with the hospital audiologist. Australian Hearing offers priority appointments for infants diagnosed with hearing loss so the family would be offered an appointment within a few weeks. This arrangement helps to eliminate the loss to follow‐up that might occur if the family is provided with a list of service provider options and left to organise the next appointment themselves. Because access to the Hearing Services Program for children is based on age, there is no formal eligibility check required which eliminates the potential for any delays created by the need to check eligibility.
For children diagnosed with hearing loss outside of the newborn period, again the referral agency can contact Australian Hearing directly, or advise the family of the contact details of their nearest Australian Hearing clinic. Australian Hearing would prioritise these children so they are seen quickly. Usually the diagnostic audiologist would seek permission from the family to send their results directly to Australian Hearing.
Once services transition from the Australian Government Hearing Services Program to the NDIS in 2019, there is a significant risk of delays occurring as there will be a need for:
Eligibility to be checked. This is not currently necessary so this introduces an additional step which takes time It is not yet known whether the NDIS and the Hearing Services Program will both be offering support to children with hearing loss depending on the degree of disability. If that was to be the case then there will need to be a system for informing families of the different programs and service provider options. If both programs were to fund hearing services, then it introduces a risk for the child to fall through the gap between diagnosis and audiological and education intervention services unless there is a system to monitor the progression of families from diagnosis to intervention.
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If the family qualifies for services under the NDIS, they need to meet with a planner, develop a plan, and have the NDIS plan for their child approved before they can access their preferred provider. Some families are reporting that this can take more than eight weeks. This step doesn’t currently exist. Under the Hearing Services Program the child goes immediately from diagnosis to an appointment with Australian Hearing to discuss hearing rehabilitation options and other early intervention service options such as educational programs or speech pathology services.
There needs to be a streamlined care pathway developed for children who qualify for the NDIS to remove these potential areas of delay. The pathway needs to replicate the existing streamlined approach which also provides safeguards to prevent loss to follow‐up.
If the Hearing Services Program is still going to offer hearing services to children who do not qualify for the NDIS, it is not yet clear how this will be provided or funded. Currently, Australian Hearing is the sole provider of services under the Community Service Obligations Program and receives a fixed allocation to deliver services to children and other groups identified as Community Service Obligations. The allocation covers the cost of service delivery only, so there is no profit in the allocation. If Australian Hearing exceeds the allocation it does not receive any additional funding from the Commonwealth Department of Health. It has to absorb the additional cost. It is not yet clear whether the arrangement of a Community Service Obligations Program delivered by a sole provider will continue after 2019 or whether the Department of Health will allow other providers to deliver services to vulnerable client groups who do not meet access criteria for the NDIS and continue to receive services under the Hearing Services Program eg., people over 65 years with complex hearing rehabilitation needs.
Hearing services – adults
Adults with hearing loss also need access to timely services. The current NDIS access pathway has many more gateways for the person to negotiate prior to accessing the supports they need compared with existing arrangements. With the NDIS, the person needs to have access approved, organise meetings with an NDIS Planner, develop their plan, and have the plan approved before they start their hearing rehabilitation program. Under the Australian Government Hearing Services Voucher Program, eligibility can be verified online in most cases through Centrelink or the Department of Veterans Affairs. The only other gateway is medical certification that there are no contra‐indications to a device fitting. For private clients there are no gateways at all. With the NDIS, there are examples of adults experiencing significant delays in having access approved and then waiting some time to see a planner. These examples were of people who had been accessing hearing services as private clients. While those delays are not impacting on them receiving rehabilitation services, it does mean that they continue to pay for their hearing services. Remaining as a private client, particularly if the person is on a low income, could be preventing them from achieving the best outcome if they cannot afford to pay for the items that would contribute to improvements, whereas if they could access the NDIS they may be able to have these services or assistive technology funded under their plan. It is imperative that people with significant hearing impairment have a seamless and timely
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pathway between diagnosis and intervention as any delays could result in increased stress levels and other health related issues and poorer outcomes in the longer term.
Early intervention services
Currently there are significant delays in having eligibility for the NDIS assessed and plans approved. This is leaving families and early intervention providers with difficult choices. Providers cannot be paid retrospectively. The early intervention service cannot deliver services before an NDIS plan has been approved and expect to receive payment for the services provided. Therefore the early intervention service is left in the difficult position of having to provide services to families without receiving payment for these services, or asking the families to wait until their eligibility is assessed and their plans approved before they can access their preferred provider. Time is of the essence in the delivery of early intervention services, so it is not a good option for families to be delaying early intervention programs while they are waiting for approval to proceed. The only other option for families is to access State government funded early intervention services which are not NDIS funded, which in effect eliminates the choice of early intervention provider.
There needs to be a more streamlined approach so that it matches existing arrangements. Currently, when the child is referred from the diagnostic service to Australian Hearing the paediatric audiologist at Australian Hearing talks to the families about the range of early intervention services, provides written information on the services and will arrange, or encourage the family to arrange an appointment with the various services before they make a decision. There is no delay for eligibility checks or plan approvals. Because the family has ongoing appointments at Australian Hearing the paediatric audiologist has regular opportunities to check that the family is accessing early intervention services.
Most families who have a child diagnosed with a hearing loss will not know of the range of early intervention agencies and the various programs that are available for children with hearing loss. The current system of having Australian Hearing provide unbiased information on the program options and range of service providers gives the families time to evaluate the various services to see which one suits their needs. Under the NDIS, the audiological service provision and the early intervention services could be within the one organisation which has the potential to limit choice. It will be important to maintain a system where families can receive independent advice so they can make an informed decision on where they want to access the various services their child may need. If Australian Hearing is not going to have ongoing responsibility for the provision of independent advice to families, then other organisations need to receive appropriate funding to fulfil that role.
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RECOMMENDATIONS
i. That under the NDIS, the care pathway for children with hearing loss supports a seamless and streamlined approach from diagnosis to audiological service provision and early intervention service provision and minimise the risk of loss to follow‐up ii. That the NDIS pathway for adults between diagnosis and intervention support timely access to services iii. That the NDIS plan approval process be streamlined in a way that doesn’t compromise the process, to remove current delays in having funding approved for families to access early intervention services iv. Once hearing services transition to the NDIS in 2019, families should continue to have access to unbiased advice about the range of hearing services providers and early intervention providers. The NDIS needs to provide adequate funding to an independent service to fulfil that role
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c) The adequacy of funding for hearing services under the NDIS Audiological services
Currently, children who qualify for services under the NDIS continue to receive their audiological services from Australian Hearing under the Community Service Obligations
Program of the Australian Government Hearing Services Program. Australian Hearing receives a
fixed allocation to deliver these services.
Adults who have hearing services approved within their NDIS plan are currently referred to the Australian Government Hearing Services Program. If the client elects to receive services under the Voucher Program component of the Australian Government Hearing Services Program they then have a choice of hearing services provider and the provider receives the standard fee that applies to clients receiving services under the Voucher Program. If the client elects to receive services under the Community Service Obligations component of the Australian Government Hearing Services Program they are seen by Australian Hearing under the fixed allocation that Australian Hearing receives to deliver the Community Service Obligations Program. If children or adults who are covered under the NDIS have needs that are beyond the scope of the Australian Government Hearing Services Program these requirements may be funded under their NDIS plans.
As the NDIS is using the existing funding arrangements of the Australian Government Hearing Services Program during the transition period, the adequacy of funding for hearing services under the NDIS has not yet been fully tested.
It is clear that the cost of delivering services to client groups currently funded under the Community Service Obligations arrangements will increase under the NDIS. This is due in part to the scope of the NDIS being broader than the Hearing Services Program. However it also relates to the different funding models being used by the two Programs. Under the Community Service Obligations funding arrangements, Australian Hearing receives a fixed allocation to cover the cost of delivering services to all of the eligible client groups. There is no profit margin in the funding allocation and Australian Hearing has to absorb any additional costs if it exceeds its allocation. As a large entity, Australian Hearing uses its economies of scale to find efficiencies and access high quality products as the best possible price. The NDIS provides funding to the participant to access the supports they need. The cost of a device to an individual is likely to be much higher than the cost to a large organisation with a supply contract where price can be negotiated based on volume purchases. It will be essential to ensure that there is no reduction in service levels or technology with the transition of services from the Community Service Obligations Program to the NDIS.
With the transition of services from the Hearing Services Program to the NDIS there is a risk that some services could be lost. For example, Australian Hearing audiologists provide support to schools with hearing impaired children. With the introduction of contestability, there would be multiple providers visiting schools and advising teachers. This could lead to conflicting
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advice being given and will also be more time consuming for teachers to have to repeatedly take time out of the classroom to speak with individual providers. Moving to having multiple providers may see the school visiting system fail if it becomes unworkable. It is important that these services continue as they support the best outcomes for the child.
With the way that the NDIS planning process is structured there is risk that participants may not receive adequate funding. The NDIS planning process is very focused on outcomes and goals and requires the participant, or their family and carers, to have a full understanding of their disability and its implications and to be able to articulate these needs to the Planner. Parents of children newly diagnosed with hearing loss are often still coming to terms with the diagnosis and are unlikely to have the knowledge to be able to list the types of supports their child will need. If their child has additional disabilities (30‐40% of children with hearing loss will have an additional disability2) it can take several months or years to get a clear understanding of the level of the disability. The ability of the participant to articulate their needs and goals will influence the level of funding that they receive. NDIS participants at trial sites have indicated that you need to have a clear vision of what outcome you want and be quite assertive during the planning interview. This will place a number of participants at a disadvantage if they are not able to clearly outline their needs or they do not have an advocate to help them with the process. It will be particularly difficult for people who are working through an interpreter. There need to be safeguards in place to ensure that the level of funding is appropriate for the participant’s needs. The process should not depend solely on the individual’s ability to articulate a detailed list of their requirements, particularly if they are not in a position to know what they should ask for even as a minimum. There could be some minimum funding packages that are automatically included in a participant’s plan once they are deemed to be reasonable and necessary. For example, NDIS participants who use Auslan interpreting services could automatically receive a standard level of funding and have the ability to provide evidence for higher levels of funding if needed. Currently, the provision of interpreting services seems to vary widely.
RECOMMENDATIONS
I. That there be no reduction in services or technology with the transition of hearing services from the Australian Government Hearing Services Program to the NDIS II. If the level of funding and the services that are included in an individual’s NDIS Plan are based entirely on the individual’s ability to articulate their needs, then the process requires safeguards to ensure people who are not able to advocate well for themselves are not disadvantaged
2 http://www.deafeducation.vic.edu.au/Documents/Resources/FactSheets/ChildrenAddDis.pdf
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d) The accessibility of hearing services, including in rural and remote areas Rural and remote areas
Current hearing services are reasonably accessible for people who qualify for the Australian Government Hearing Services Program. There are approximately 270 hearing services providers in all areas of Australia that are registered under the Voucher Program to deliver services to adults with non‐complex hearing rehabilitation needs. The Community Service Obligations component of the Hearing Services Program ensures a broad coverage through the service network available through Australian Hearing. The Community Service Obligations Program also funds an outreach program for eligible Aboriginal and Torres Strait Islanders to provide services in locations where people can easily access them. This service is provided by Australian Hearing as the sole provider of services under the Community Service Obligations Program and takes Australian Hearing audiologists to remote areas of Australia. Other eligible clients are also seen through this network of outreach locations (with the permission of the Aboriginal and Torres Strait Islander community). As many of the locations where Community Service Obligations client groups access services would generally not have the volume of clients to make a service commercially viable, there is a risk that access to services will become more limited under the NDIS. This situation will be exacerbated with the introduction of contestability for service provision to vulnerable client groups. Even in urban and rural areas the number of children requiring services is fairly small so again in a competitive market there may not be the volume of clients to make it viable for providers to staff these locations with audiologists with the expertise needed to deliver services to client groups with more complex hearing rehabilitation needs.
The availability of services will need to be monitored in a proactive way by the NDIA, as a situation of only acting once there is market failure would be hugely detrimental to the individual. It is encouraging to see that under the NDIS Market Approach3 the NDIA will play a role as “Market Steward” to monitor thin markets or market failure and take appropriate action. This is a responsibility that initially focusses on the transition to the full rollout of the NDIS in 2019‐2020. As hearing services will not transition to the NDIS until 2019 it will be essential for the NDIA to continue to monitor that there are sufficient providers with the appropriate skills to deliver services beyond the transition period.
Interpreter services
There is a risk of reduced accessibility to services for people from culturally and linguistically diverse backgrounds under the NDIS. Currently, under the Community Service Obligations Program Australian Hearing covers the cost of interpreters for people who need them. This arrangement does not apply under the Voucher component of the Hearing Services Program. It is not year clear whether interpreter services for hearing services appointments will be funded under the NDIS. If interpreter services are not funded it may prevent people who do not speak
3 https://www.ndis.gov.au/medias/documents/hcc/h3f/8799397412894/NDIS‐Market‐Approach‐PDF‐2.58MB‐.pdf
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English from accessing services, or it could lead to poorer services if the family is expected to provide their own interpreter as it is not appropriate to use a person who is not a qualified interpreter for allied health appointments. The cost of interpreter services is significant and providers could not afford to absorb these costs.
Auslan and Medical interpreters
The Deaf Society is concerned by the variation it has observed in NSW and ACT in allocated hours and funding for medical interpreting for NDIS participants. It noted that in some cases there was no provision for medical interpreting in the package even though the clients provided information/evidence of previous medical appointments and hours of medical interpreting. The Deaf Society has provided the following case studies:
In one area, every eligible Deaf person had received a minimum of 25 hours of medical interpreting per annum. If a client was able to provide evidence that they have a significant number of medical appointments in previous years, their approved funding in the package reflected it. A Deaf person who had a meeting with Local Area Coordinator received 40 hours of medical interpreting as a result of providing evidence that they required medical treatment every two weeks with appointments longer than one hour in duration. Some participants did not receive any funding for medical interpreting services and were told that their other approved hours for interpreting needed to be accessed in the event that medical interpreting was required.
The Deaf Society asserts that some participants are worse off than before they entered the Scheme because of inconsistency in assessment and allocation of funding. It noted that the process for disputing funding takes up to three months and this has created higher level of stress for participants as they are heavily reliant on access to information especially for their medical appointments.
RECOMMENDATIONS
i. That the NDIA closely monitors service availability to ensure there is no loss of coverage with the transition of hearing services from the Australian Government Hearing Services Program to the NDIS so that hearing services continue to be available in locations where people can access them. ii. That interpreter services be funded under the NDIS when needed for people from culturally and linguistically diverse backgrounds. iii. That Auslan interpreting is automatically allocated to all Deaf people who use Auslan to access services, medical appointments and NDIS meetings.
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iv. That the appeal process for disputing what is in the NDIS funding packages, especially for Auslan interpreting, should be reduced from three months to a maximum of four weeks.
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e) The principle of choice of hearing service provider
Choice
Deafness Forum of Australia has consulted with families on this issue. The results indicate that while parents understand the potential benefit of having a choice of provider, they believe it is far more important to preserve the existing benefits available through having the Government Provider as the sole provider of services to children and their families. Issues relating to expertise, unbiased information and advice, and trust were more valued by families than having a choice of provider. Families believe this will ensure the best outcome for their child. There is also concern that families who are very vulnerable at the time their child is diagnosed with hearing loss, and know very little about hearing impairment, are not in a position to make an informed choice about different providers. The current arrangements provide a safety net for children and their families to ensure that the child’s outcomes are not compromised and also ensure that families receive unbiased information on the range of services available.
The Deafness Forum consultation highlighted that many families do not support contestability in the delivery of services to Deaf and hearing impaired children. Similar views were shared by families at the public consultations that were organised by the Departments of Health and Social Security in 2015 to discuss issues relating to the transition of services from the Hearing Services Program to the NDIS.
For adults with significant hearing impairment, many are excluded from accessing the high level expertise available at Australian Hearing as they are not eligible for services under the
Australian Government Hearing Services Community Service Obligations Program and
Australian Hearing is not able to provide services to private clients. Eligibility under the NDIS will allow these individuals the choice of accessing hearing services from Australian Hearing’s specialist audiologists for the first time, however clients who do not qualify for government funded programs will still not be able to access services at Australian Hearing unless there are changes to the legislation.
Availability of expertise and specialised facilities
Another area of risk is that there is no information on the ability or interest of providers other than Australian Hearing to deliver hearing services to children, or to adults with more complex hearing rehabilitation needs. Information that was made public from the scoping study into the potential ownership options for Australian Hearing showed that there was a broad coverage of service providers to address the needs of hearing impaired adults with non‐complex hearing rehabilitation needs. Based on questions asked at the consultation it appears that the scoping study team did not investigate the potential coverage for the Community Service Obligations Program clients specifically, however this cannot be verified as the results of the scoping study were not published. It cannot be assumed that all hearing services providers will broaden their service offer to include clients with more complex hearing rehabilitation needs, so the coverage
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may become patchy particularly if Australian Hearing withdraws from any of their existing locations.
Australian Hearing has been the sole provider of services to children with hearing impairment for 70 years. There has been no reason for the private sector to develop skills and expertise or establish specialised facilities to deliver hearing rehabilitation services to this client group. It is a well‐defined market that will not experience growth with the introduction of the NDIS as all children in Australia with hearing loss can already access government funded hearing services. New providers entering the market to deliver hearing services to children will be competing for the 20,000 children and young adults aged under 21 years with hearing loss who currently receive services from Australian Hearing.
As Australian Hearing currently has responsibility as the sole provider of services to children with hearing impairment, it has established services in locations which improve access for clients but which may not be particularly profitable if viewed from a commercial perspective. Once services become contestable there is no longer an obligation for Australian Hearing to continue to deliver services to children at the number of locations where services are currently operating. Given the small number of children with hearing impairment it may not be financially viable to try to compete for such a small clientele. Children under 3 years and those with multiple disabilities require specialised facilities and high level expertise to deliver assessment services. According to the 2015 demographic report from Australian Hearing on the number of children fitted with devices4, there were 1,489 children fitted with devices aged under 3 years across Australia. It is difficult for one provider to maintain the equipment and staffing necessary to deliver services to this age cohort. It will be even more difficult in a contestable environment to justify continuing with this high cost service delivery on a commercial basis for such a small population. So while the claim is made that people will have a choice of provider in the future, there is no evidence that this will be the case. Indeed it may be that the introduction of contestability could create market failure. The NDIA will need to monitor this situation very closely to ensure that doesn’t happen. Under the NDIS Market Approach the NDIA as Market Steward will play an important role in ensuring that consumers continue to have access to the expertise needed in the places where they are needed.
Impartial advice
The introduction of contestability is likely to lead to the establishment of “one stop shops” where families can move from diagnosis to audiological intervention, speech pathology services and an early intervention program all at the one location. This arrangement can have advantages in that all of the information on the child is in the one location allowing ease of co‐ ordination between the different services. However there can be disadvantages with this arrangement as it could limit access to independent advice, it could limit choice for families or make it difficult for families to access different services from different providers. Families are
4 https://www.hearing.com.au/wp‐content/uploads/2016/12/2015‐Demographics‐of‐aided‐young‐Australians‐ under‐26‐years‐of‐age‐at‐31‐Dec‐2015.pdf
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very vulnerable at the time of diagnosis. They need unbiased advice and time to make an informed choice. With a one stop shop there is a risk that the family will not have access to information on the full range of providers and the different program options for their child. There needs to be appropriate funding provided for other organisations to take on the role of independent adviser so that families can know that the advice they are receiving is completely impartial.
Expertise
There are also issues around identifying audiologists with the appropriate expertise to deliver services to children and other vulnerable groups with complex hearing rehabilitation needs.
Audiology is a self‐regulating profession. There are several professional associations that represent audiologists and audiometrists, but there is no peak registration board or authority that has overarching responsibility for the profession of audiology. This is an area of risk for consumers who will have no objective way of knowing whether the audiologist has the expertise to deal with more complex areas of audiology such as working with hearing impaired infants.
The assessment of expertise to deliver services to vulnerable client groups will be challenging as there are no formal qualifications in the fields of paediatric audiology or working with adults with complex rehabilitation needs that would allow clinicians to objectively demonstrate that they have the necessary competencies to deliver services to these client groups.
Currently, services to clients in the Community Service Obligations Program are provided by experienced audiologists who have also received in‐house training at Australian Hearing in working with clients with complex needs and their families. Australian Hearing has developed training courses and mentoring programs for audiologists working with vulnerable client groups, and has a clinical support network for these audiologists. It is crucial that formal learning and development programs with independent competency assessments be established before moving the Community Service Obligations Program to a contestable arrangement.
Research indicates the expertise of the service provider has a significant impact on client outcomes. Consumers need certainty that they are accessing services from a clinician with the appropriate skills. If new service delivery arrangements are introduced, consideration needs to be given to the mechanism that would be used for clinicians to attain the competencies needed to deliver services to vulnerable clients in the future, and for consumers to be able to recognise that practitioners have the skill level required to provide these services.
Due to the complexity of the work, hearing services for children and adults with complex hearing rehabilitation needs should only be provided by qualified Audiologists with training in these specialised fields.
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Minimum Caseload Requirements
Once a professional has attained a certain skill, they need to apply these skills in the clinic on a regular basis in order to maintain their level of competency. This is easy to achieve in the Voucher Program as there are over 600,000 clients who access services from approximately 2,100 Hearing Services Practitioners (audiologists and audiometrists) across Australia.
The client groups within the Community Service Obligations Program are much smaller. There are approximately 20,000 children and young adults fitted with devices, and 20,000 adults with complex hearing rehabilitation needs receiving services from Australian Hearing. In the case of hearing aid fitting for children, there are only 2,800 children fitted with devices for the first time each year. Breaking that down further, there are approximately 300 infants under 12 months of age fitted for the first time annually. If these client groups were to receive services from a large number of Practitioners in the future, it would be difficult for a Practitioner to maintain their skill level if they were to only see a small number of children or adults each year or every few years. There is research evidence from the USA that demonstrates that a significant number of hearing impaired children were not fitted optimally when they were seen by a clinician who did not see children regularly.
When considering the service delivery arrangements for Community Service Obligations Program client groups, it is important to ensure that the Program does not become so fragmented that it is impossible for clinicians to maintain their skill level. Due to the small population of Deaf and hearing impaired children, it is recommended that a single provider be nominated as the sole provider of services to infants and children.
The situation would be different for adults who may be in a better position to make an informed choice regarding the qualifications, expertise and quality framework offered by various providers. However there still needs to be safeguards in place for more vulnerable clients who may have multiple disabilities, and may be relying on other people who may have no experience in the management of hearing loss to make these decisions for them. There needs to be a system in place so that consumers or their carers can easily identify providers with the appropriate facilities and with the staff with the required skills to deliver services to people with more complex hearing rehabilitation needs.
RECOMMENDATIONS
i. There needs to be a system in place so that consumers or their carers can easily identify providers with the appropriate facilities and with the staff with the required skills to deliver services to people with more complex hearing rehabilitation needs. ii. Due to the complexity of the work, hearing rehabilitation services should only be provided by qualified audiologists with training in working with children and with adults with complex hearing rehabilitation needs.
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iii. With the transition of the Community Service Obligations Program to the NDIS and the introduction of contestability, the NDIA needs to ensure that the Program does not become so fragmented that it is impossible for clinicians to maintain their skill level. iv. Once the Community Service Obligations Program has transitioned to the NDIS, if Australian Hearing does not retain a role of independent adviser, then other organisations need to be funded to take on this role so that hearing impaired adults and the families of children with hearing loss can know that the advice they are receiving is completely impartial.
v. Due to the small population of Deaf and hearing impaired children, it is recommended that a single provider be nominated as the sole provider of services to infants and children.
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f) The liaison with key stakeholders in the design of NDIS hearing services, particularly in the development of reference packages
The NDIA has organised an early intervention expert reference group that includes parent groups, early intervention agencies, and researchers to provide information on the early intervention packages that children with hearing loss are likely to need.
There has been no other contact with Deafness Forum of Australia regarding the development of NDIS hearing services for other age groups or for people with multiple disabilities including hearing loss.
RECOMMENDATIONS
i. That the NDIA continue to work with stakeholders on the early intervention reference packages. ii. That the NDIA engage with stakeholders, particularly those with lived experiences of hearing loss, regarding the development of reference packages for adults with hearing loss, and for people with multiple disabilities including hearing loss. iii. That there be continued involvement of consumer groups whenever participants are affected by changes to legislation, policies or procedures with respect to hearing services.
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g) Investment in research and innovation in hearing services There are several institutions in Australia that undertake hearing research including the HEARing CRC, the National Acoustic Laboratories, universities, Menzies School of Health Research, Ear Science Institute Australia, to name just a few. Deafness Forum of Australia strongly supports the provision of appropriate funding to allow these facilities to continue with their research as it ultimately improves the lives of Deaf and hard of hearing people.
It is important to ensure that independent research continues particularly in relation to technology. When device manufacturers release new devices or new features within a device, there may not be any independent research to support the improvements claimed in the sales information. There is a risk that clinicians could recommend the fitting of a high cost device, or clients may request a device, on the basis of the data provided by the manufacturer and in the absence of other independent research to support the recommendation. In order for the NDIS to make a decision as to whether to support the additional cost there needs to be independent research available to help them make an informed decision.
There is also a need for more research into improved rehabilitation programs, strategies and technology beyond the fitting of hearing aids and cochlear implants, to give the clinician a broader range of supports to help the hearing impaired person achieve the best outcomes.
RECOMMENDATION
i. That research into hearing loss continues to be supported with appropriate funding levels.
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h) Any other related matters Quality framework
The National Quality and Safeguarding Framework that the NDIA adopts will be an essential component of the NDIS. In particular, the monitoring of client outcomes under the Outcomes Framework will be important to ensure that NDIS funding is being used effectively and participants are achieving the best possible outcomes. It is essential that the measurement of outcomes be timely, and be sufficiently sensitive to highlight when alternative intervention strategies need to be considered. Time lost in going down the wrong pathway or receiving inappropriate services cannot be regained, so it is important that individuals are not left to fail before action is taken to modify their programs or organise a change of provider.
The quality framework will also need to ensure that hearing services providers and early intervention providers are implementing evidence‐based practice and that providers are using appropriately skilled staff to deliver services.
Data collection As the sole provider of hearing services to children for the past 70 years, Australian Hearing has been in a unique position to publish a demographic report on children fitted with devices in Australia. It is essential that this data continue to be collected and published. There is scope for the information that is collected to be improved. The roll out of the NDIS and the planned changes to the Australian Government Hearing Services Program provide an opportunity for this to occur and to broaden the publication of information to adults with hearing loss.
Assistive Hearing Technology
Currently, the Australian Government Hearing Services Voucher Program has a list of approved devices that meet particular criteria that have been chosen based on research evidence. Australian Hearing continually monitors the device market and the research evidence to ensure that features that result in clinical benefit are made available to the Community Service Obligations Program clients in a timely way.
With the introduction of competition under the NDIS, Australian Hearing will no longer have overall responsibility for monitoring developments in the device market and evaluating their benefit for vulnerable client groups so the NDIA will need find another mechanism to fulfil that role. Australian Hearing is able to ensure value for money to Government through its volume‐ based purchasing arrangements. It is essential that under the NDIS there are systems in place to ensure that clients are still being provided with devices that provide the features needed to meet their clinical needs, and that these devices are upgraded when there are new features or devices available that would result in improved clinical outcomes. It will be important to monitor that the devices are fit for purpose and the decision on the device is based on clinical
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need and not influenced by the payment of financial or other incentives to hearing services providers/practitioners by the manufacturer.
It will be important to ensure that the device supply arrangements under the NDIS and the Australian Government Hearing Services Program continue to ensure high quality products with appropriate features are available to clients; and that Government achieves the best value for money in the supply arrangements.
RECOMMENDATIONS
i. That the National Quality and Safeguarding Framework will ensure that hearing services and early intervention providers are using the latest evidence‐based practice recommendations and that services are delivered by staff with the appropriate qualifications and expertise. The framework should also ensure that client outcomes are regularly monitored so that there is evidence to demonstrate that NDIS funding is being used effectively and participants are achieving the best possible outcomes. ii. That the demographic report on children fitted with devices continues to be published annually and that data collection be enhanced with the transition of services from the Australian Government Hearing Services Program to the NDIS. iii. That assistive hearing technology supply arrangements under the NDIS and the Australian Government Hearing Services Program continue to ensure high quality products with appropriate features are available to clients and that the Government continues to achieve the best value for money in the device supply arrangements. iv. That the decision on the choice of device is based on clinical need and not influenced by the payment of financial or other incentives to hearing services providers/practitioners by the manufacturer.
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APPENDIX A – ELIGIBILITY CRITERIA FOR THE AUSTRALIAN GOVERNMENT
HEARING SERVICES PROGRAM5
Eligibility to the program is set out in legislation.
Voucher component of the program You are eligible for the voucher component of the program if you are an Australian citizen or permanent resident 21 years or older and you are
a Pensioner Concession Card holder a Department of Veterans’ Affairs Gold Card holder a Department of Veterans’ Affairs White Card holder issued for specific conditions that include hearing loss receiving Sickness Allowance from Centrelink a dependent of a person in one of the above categories a member of the Australian Defence Force1 referred by the Disability Employment Services (Disability Management Services) Program or a National Disability Insurance Scheme (NDIS) participant with hearing needs, referred by a planner
from the National Disability Insurance Agency
Please note that a Seniors Health Card does not provide eligibility for the program.
Voucher services are provided by a network of hearing services providers throughout Australia.
Community Service Obligations (CSO) component of the program You are eligible to receive hearing services through the CSO component (specialist hearing services) of the program if you are an Australian citizen or permanent resident and you are
people from the above eligibility groups who have complex hearing or communications needs or live in remote areas or any Aboriginal person and/or Torres Strait Islander person who is over 50 years of age or is a participant in the Community Development Programme (formerly known as the Remote Jobs and Communities Program (RJCP) and the Community Development Employment Projects (CDEP) program). or a person who was a CDEP program participant on or after 30 June 2013; has since ceased participating in the program; and was receiving hearing services from Australian Hearing prior to ceasing participation any person under 21 years of age who is an Australian citizen or is a permanent resident or is a young NDIS participant
Australian Hearing is the sole provider of CSO services.
5 http://hearingservices.gov.au/wps/portal/hso/site/eligibility/programhelp/eligibility
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