Senate Select Committee on Health

Transcription

1 Level 2 / Bank Place T office@speechpathologyaustralia.org.au Melbourne Victoria 3000 F Speech Pathology Australia s Submission to the Senate Select Committee on Health 19 September 2014 The Speech Pathology Association of Australia Limited ABN

2 Table of Contents Introduction... 3 About Australians with Communication and Swallowing Disorders... 3 About Speech Pathologists and Speech Pathology Australia... 4 An Underwhelming Policy Response... 5 Impact of Reduced Commonwealth Funding for Hospital and Other Health Services Impact of Additional Costs on Access to Affordable Health Care and Sustainability of Medicare... 8 Impact of Reduced Commonwealth Funding for Health Promotion, Prevention and Early Intervention.. 10 Interaction between Elements of the Health System Improvements in the Provision of Health Services Integration and Coordination of Medicare Services Health Workforce Planning Recommendations Appendix A Page 2 of 22

3 Speech Pathology Australia s Submission to the Senate Select Committee on Health Introduction Speech Pathology Australia (SPA) is the national peak body for speech pathologists in Australia, representing more than 6000 members. Speech pathologists are the allied health practitioners who specialise in treating communication and swallowing (dysphagia) difficulties. There are an estimated 1.1 million Australians who have a communication disorder and one million Australians who suffer from swallowing difficulties. Communication skills underpin the key indicators of successful modern day society, including the achievement of literacy and numeracy, educational attainment, employment, and civic participation. The impacts of communication disorders are far reaching and debilitating, resulting in poor educational outcomes, reduced employment opportunities and an increased likelihood of social, emotional and mental health issues. Likewise swallowing is a critical bodily function and swallowing complications (dysphagia) can lead to malnutrition, respiratory problems and in some circumstances - death. Speech Pathology Australia welcomes the opportunity to provide comment on the current health policy, administration and expenditure climate in Australia as investigated by the Select Committee on Health. Comment is provided in relation to the terms of reference for the inquiry as they relates to Australians with communication and swallowing disorders and speech pathology services in Australia. Our submission concludes with recommendations that we believe are achievable, would improve the effectiveness of the health system in Australia and would improve health, development and wellbeing outcomes for people with communication and swallowing conditions. About Australians with Communication and Swallowing Disorders Difficulties in speech, language, fluency, voice, social communication and swallowing can occur in isolation or the person may have difficulties in more than one area. For example a patient following a stroke may have speech (expressive and receptive), language and swallowing difficulties. Communication and swallowing difficulties can arise from a range of conditions and may be present from birth (e.g., cleft palate, Down Syndrome or Autism Spectrum Disorder), emerge during early childhood (e.g., stuttering, severe speech sound disorder or literacy learning difficulties), or during adult years (e.g., traumatic brain injury, stroke and head/neck cancers) or be present in the elderly (e.g., dementia, Alzheimer s disease, Parkinson s disease). Communication disorders encompass difficulties with speech (producing spoken language), understanding or using language, voice, fluency (stuttering), and pragmatics (the social use of language), or a combination of areas. Swallowing disorders affect the ability to safely swallow food or liquids and can lead to medical complications including chest infections/pneumonia. Swallowing difficulties impact on a person s health and well-being and often lead to poor nutrition, health complications and social isolation. Costs associated with untreated communication problems is self-evident within the health system in terms of preventable re-hospitalisations or escalation of medical ill-health from primary care to tertiary care sectors. However, costs also extend far beyond the health system and includes limitations to participation in the wider society including education and employment, and in negative impacts on social and emotional wellbeing (including a high co-morbidity with mental illness). Failure to adequately remediate communication problems in early childhood adds to the support costs required throughout schooling. It also has implications for future employment, with associated costs likely in welfare payments. Page 3 of 22

4 Untreated swallowing disorders give rise to increased costs in terms of length of hospital stay and people with undiagnosed difficulties are frequently referred to other health practitioners often for expensive and invasive investigations when a speech pathologist could readily manage the problem. Australians with communication and swallowing difficulties span the entire age range and the nature of their difficulties impacts on most areas of life. These people frequently require health interventions/support that span multiple areas of the health system (including general practice care, acute and sub-acute), community health and mental health. Currently there is limited available data regarding the prevalence of communication and swallowing disorders within the Australian population. Conservative estimates indicate there is in excess of 1.1 million Australians who have a communication disorder and one million who have a swallowing disorder. This is comparable with the number of people with Diabetes and three times the number of those with Dementia. There is an overlap of incidence between communication and swallowing disorders, with some Australians experiencing both due to developmental, disease or injury processes which affect both (for example progressive neurological conditions such as Parkinson s Disease). There is also evidence that some specific groups of Australians - for example, Australians of Aboriginal or Torres Strait Islander descent, and people who are socio-economically disadvantaged or are in rural and remote areas of Australia are over-represented in prevalence estimates. The social gradient seen in other health outcomes is clearly evident in available information about communication and swallowing disorders. It is also clear that these prevalence figures will likely increase exponentially as the population ages. About Speech Pathologists and Speech Pathology Australia Speech pathologists are the university trained allied health professionals who specialise in treating speech, language, communication and swallowing problems. Speech pathologists work with infants, children, adolescents, adults and the elderly with communication and swallowing problems. Speech pathologists undertake a four year undergraduate degree or a two-year graduate entry Masters degree to be qualified as speech pathologists. Speech pathologists provide health services in the acute care (hospitals), sub-acute care, rehabilitation and primary care sector (including community health and general practice) as well as within other sectors such as disability, residential and community based aged care, education, juvenile justice and community settings. We work across public and privately funded services. In recent years, there has been a significant shift in the location of service delivery from previously majority government funded positions to the private sector. In 2011, Australian Bureau of Statistics data indicate that 57.1 per cent of speech pathologists are now working in private practice 1. This is supported by more recent information from Speech Pathology Australia s membership demographics indicating a further retraction of the public funded speech pathology workforce. Speech Pathology Australia is the peak professional body representing speech pathologists in Australia dating back to At present, Speech Pathology Australia provides professional support services to in excess of 6200 speech pathologists in Australia. This is estimated to cover per cent of all practising speech pathologists in Australia. Speech Pathology Australia is governed by a Board of Directors at the national level with branch committees operating at state and territory levels. In addition, there are a range of special interest groups (member communities) supported by the Association in relation to specific areas of practice or clinical interests. To date speech pathologists are not an included profession in the National Registration and Accreditation Scheme (NRAS). In the absence of national registration, Speech Pathology Australia maintains robust self-regulation of its members and alongside certain other non-registered allied health associates has progressed work in establishing the National Alliance of Self-Regulating Health 1 Health Workforce Australia (2014) Australia s Health Workforce Series: Speech Pathologists In Focus. July. HWA Page 4 of 22

5 Professions (NASRHP) to facilitate the development of a National Framework for Self-Regulation for Health Professionals. Where possible, this national framework mirrors that required by NRAS in relation to monitoring and systematic self-regulation mechanisms for quality and safety in the delivery of health care by these professions. This framework augments the existing operations of the Association in relation to developing and maintaining the clinical, educational and ethical standards that promote high quality and safe speech pathology care. The Certified Practicing Speech Pathology (CPSP) program is the foundation of speech pathology as a self-regulated health profession. The CPSP credential is recognised by funding programs such as Medicare, the Department of Veteran Affairs and private health funds so that patients can access rebates for payments for evidenced based speech pathology services. An Underwhelming Policy Response for Australians Suffering Communication and Swallowing Problems Communication and swallowing disorders are largely invisible, poorly understood by the general community and are rarely addressed in public policy. Communication impairment is largely a silent disability in Australia with an associated underwhelming policy response at state and federal levels and across all the portfolios of health, aging, disability and education where there is responsibilities for service provision to people with communication or swallowing difficulties. Very recently, the plight of Australians with communication and swallowing difficulties and access to speech pathology services has achieved national focus with a federal inquiry by the Senate Community Affairs References Committee into the prevalence of speech, language and communication disorders and speech pathology services in Australia. The final (and bipartisan) report from the Committee recommended a range of improvements that should be made to improve the health and wellbeing outcomes for Australians with communication and swallowing difficulties. A full list of the Committee s recommendations is provided in Appendix A with an abridged version of the recommendations below. The senate committee s recommendations direct the federal Department of Health to work with state and territory governments and other stakeholders to progress work on fundamental building blocks to support speech pathology services to Australians across the health, disability, education, aged care and juvenile justice systems in Australia. Recommendations included: 1. Work to be undertaken to improve the availability of national data about current and future needs for speech pathology services. 2. The current service delivery model for speech pathology services in aged care residential homes is reconsidered as part of the federal government s ongoing aged care reforms. 3. Mapping of language support services across Australia against the Australian Early Development Index information about vulnerable children. 4. An immediate audit of the current speech pathology services for children in Australia 5. The impact of the National Disability Insurance Scheme on the demand and supply of speech pathology services is investigated. 6. A strategy be developed to broaden the opportunities for speech pathology students to undertake clinical placements that satisfy the competency based occupational standards. 7. An investigation into the geographical and demographic clustering of speech pathology services in Australia with a focus on new graduate positions and opportunities. 8. A position on the most effective models of speech pathology services in: a. Early childhood intervention services b. The educational system c. The justice system d. The health system e. The residential aged care environment. 9. A study of the costs and benefits of public funding of speech pathology positions and various service delivery models on individuals, the speech pathology profession and the Australian community. 10. Government at all levels work to develop policies that acknowledge and recognise the need to increase access to speech pathology services for people with speech and language disorders. Page 5 of 22

6 Speech Pathology Australia believes it is critical for the Australian government to respond positively to the Senate Committee s recommendations and to direct the Department of Health to progress this work plan. Improvements in the health and wellbeing of Australians with communication and swallowing disorders are unlikely to be achieved without the concerted effort of government. Impact of Reduced Commonwealth Funding for Hospital and Other Health Services provided by State and Territory Governments. Before providing comment on the impact of reduced Commonwealth funding for hospital and other services that are administered by the different jurisdictions, it is useful to provide an overview of the current funding system for speech pathology services for Australians with communication and swallowing problems. Public sector speech pathology services: Access to publicly funded support for communication and swallowing problems is highly variable in Australia and by and large, inadequate to meet the needs of Australians with communication and swallowing problems. The aforementioned Senate Inquiry gathered evidence that the demand for public funded speech pathology services exceeds supply of those services. Whilst some publicly funded speech pathology services exist across some segments of the health, rehabilitation, disability and aged care sectors access to these services varies considerably across State and Territories, vary in relation to diagnoses and conditions and is particularly problematic to access for Australians in rural and remote locations. Speech pathology patients often have extremely limited access to publicly funded speech pathology services. This limited access is usually due to long waiting lists for services, limited number of funded sessions that is based on rationalisation of resources rather than evidence based protocols for treatment or because of restrictive eligibility that limits access to a very limited number of people of the absolute highest of need categories. Access barriers are compounded for migrant, indigenous, and socioeconomically disadvantaged Australians. In some cases, services are not available at all or are extremely limited within the publicly funded system. For example, families are unable to access publicly funded services within the community for swallowing disorders in babies; speech and communication disorders for the majority of school aged children in New South Wales and Western Australia; and many adults cannot access public services particularly those with voice disorders or who stutter. Evidence provided to the aforementioned senate inquiry indicated that unless these families and individuals can pay for services within the private sector, they forego treatment for these conditions. Private Sector Speech Pathology Services The lack of adequately publicly funded speech pathology services means that families and individuals with communication and swallowing disorders either forego treatment altogether or seek treatment through the private speech pathology sector. Private services are an essential and valuable segment of the speech pathology profession. Private practitioners provide consumers with increased choice and control. In contrast to public services, they may offer evening and weekend sessions, thus providing greater flexibility for working clients or families, are not restricted to a set number of sessions and can routinely provide individual services. There may be no waiting period or a short waiting period to access private services. Private practitioners currently make up 50 per cent of the practising membership of Speech Pathology Australia. Feedback from members indicates that many private practitioners work part time and operate sole practices or small group practices. The number of members working privately has risen steadily over the past 10 years with a sharp rise in numbers in the past three years. Page 6 of 22

7 Some patients are eligible to access a partial rebate through private health insurance or specialty funding streams (such as Medicare Chronic Disease items, Better Start for Children with Disability or the Helping Children with Autism initiatives) for private speech pathology services. However, most patients incur full (or near to full) out of pocket costs of accessing private speech pathology services. The Effect of Reduced Commonwealth Funding on State/Territory Provided Speech Pathology Services Reduced or stalled (not indexed) Commonwealth funding for hospital and other health services has a number of significant effects on the entire health system not just the acute sector that appears to bear the most pressure from reduced funding availability. Examples here are provided in terms of Speech Pathology Australia members reports as of September 2014 to the current pressures for services for patients with communication and swallowing difficulties. Increased pressure on moving patients through Emergency Departments (ED) and reduced bed days available in acute wards has put increased pressure on sub-acute and in particular Geriatric Evaluation and Management (GEM) services. Speech Pathology Australia members working in the hospital sector indicate that clinical decision making that is expedited within the ED in order to increase flow of patients impacts on a patient s capacity to access the required and appropriate health care services (including speech pathology services) throughout their care process. For example, patients being transferred from the acute services to sub-acute services due to needing to increase capacity in the acute sector can occur PRIOR to the patient being able to participate in rehabilitation or other services. In these cases, the patient stays in the sub-acute setting for a period of time prior to them being well enough to actually participate in therapy or treatment yet their bed day count begins as soon as they are transferred. Speech pathologists report seeing patients who on the basis of decisions made in the acute setting, are moved on to geriatric services too early and then despite improving medically are then unable to be transitioned into rehabilitation. The system is structured to allow for patients to transition from rehabilitation services to GEM, but not from GEM to rehabilitation. This push to expedite transition from patients out of hospital has begun to restrict the scope of practice for speech pathologists working in the hospital setting. The priority of care is placed on swallowing assessment and management (due to the immediate safety concerns and hospital protocols), at the expense of treatment to improve or retain communication skills. Whilst this has effects for the individual patient in that they do not receive the evidence based speech pathology care that could improve/retain their communication skills it also acts to de-skill speech pathologists working in the hospital setting. Reducing the role of speech pathologists in these settings to swallowing care only, limits the opportunities to practice in the area of Adult Language or Aphasia. It is anticipated that over time, data/evidence will be generated that shows an increased shift towards private speech pathology services in lieu of services that have previously been provided in the state/territory funded hospital system. This data is not currently available although this anticipated trend is consistent with reports from Speech Pathology Australia members. Given the significant shortage of public speech pathology services, and increased pressure on these due to reduced/stalled Commonwealth funding to the hospital sectors the only avenue left for patients will be the private sector. The private speech pathology sector is not equipped at present to provide specialised and invasive diagnostic and management procedures that are currently available in hospital settings (for example for dysphagia, tracheostomy management, laryngectomy (prosthesis) care). These services are best provided within a health care setting that is best equipped to medically respond to adverse events. Whilst some patients may be able to access the private speech pathology sector, and avail themselves of the (minimal) rebates available through private health funds or some Medicare programs there will be a significant portion of patients who are unable to pay for these services and who will languish on public funded waiting lists. This is of particular concern for aged patients and those who have suffered a stroke but have been discharged into the community yet still require speech pathology services. Page 7 of 22

8 Impact of Additional Costs on Access to Affordable Health Care and Sustainability of Medicare Patients requiring speech pathology services face additional costs to accessing this care in a number of areas. For most Australians, we content that additional costs impose a barrier to accessing effective and timely health care. Publicly funded services co payments Where publicly funded speech pathology services do exist in Australia our members report that a policy of co-payment is increasingly being requested and the co-payment amount being requested is increasing. We have reports that requested co-payment (whilst a small part of the total cost of the treatment) is between $20 and $60. It appears that most public funded services would waive fees if a patient demonstrated that they couldn t afford it. Co-payment fees for publicly funded speech pathology services appear to vary from service to service and across jurisdictions. Whilst there is no data available about the charging of co-payments for publicly funded speech pathology services, Speech Pathology Australia is concerned that these services are not being resourced appropriately to actually be delivered. The short-fall in funding is being requested of patients those most in need of the services and most likely to be unable to meet this additional cost (given they are eligible for public funded services in the first place). The concept of co-payments for previously no-fee patient services (such as Medicare bulk billed services and for treatment for ambulatory care sensitive conditions in Emergency Departments) flagged in the report of the National Commission of Audit is of concern to Speech Pathology Australia. Whilst commentary has related to medical services, we are concerned this will be extended to allied health services previously publicly funded. This type of co-payment system is already occurring informally (as discussed) for groups of patients who are least likely to be able to afford any out of pocket costs. Speech Pathology Australia does not support any form of General Practitioners (GP) co payment to access general practice services. General Practitioners act as the gatekeepers to the health care system in Australia, and placing additional financial barriers to accessing their care (and their referral processes) will act as a disincentive to seek health care. Patients with communication and swallowing difficulties face significant barriers as it is (including communicative barriers) to accessing health care without further economic disincentives to access primary health care. Private sector speech pathology services The setting of private fees for speech pathology services is not regulated (consistent with Australian Competition and Consumer Commission guidelines), and Speech Pathology Australia members report wide variation depending on the expertise or specialised nature of the treatment and the experience of the practitioner. Generally, fees range from $140 to $180 per hour of treatment. Fees for diagnostic/initial assessments, which often require up to three hour long assessment sessions and report writing, can range between $500-$800. Some consumers have access to private health fund rebates if they hold eligible extras health insurance. However consumers report to our members an increasing gap in the rebate compared to the fee paid. Some report that rebates from their funds have seen little increase over the past 10 years. Many private health funds also cap the amount that can be claimed in any 12 month period or per family member. Many families report reaching that rebate ceiling after only a small number of sessions and then revert to being out of pocket for full fees. For those few clients who are able to access government funding through Medicare, the cap on the number of sessions means that this is not sufficient for effective treatment. This is particularly so for the Chronic Disease Management program (CDMP) which is capped at five sessions of all allied health treatment per calendar year. The rebate is currently $52.95 for each 20 minute speech pathology session. The scheduled fee for a 20 minute session is currently listed as $62.25, with the rebate calculated at 85 per cent of this fee. The speech pathologist may recommend a longer session and Page 8 of 22

9 charge accordingly. Most speech pathology sessions using evidence based interventions would be considerably longer than a 20 minute consultation, but there is no allowance through this rebate program for an extended consultation. There will almost always be a gap fee the amount between what the speech pathologist charges and the rebate. The patient is unable to claim a Medicare rebate and a private health insurance rebate for the same service. Those who do have access to Medicare rebates find that these rebates are capped and only cover a small portion of their out of pocket costs. There are a number of efficiencies to be gained with changes to the way the CDMP operates with recommendations provided below. The nature of complex communication difficulties is such that people have long term needs. These needs will often change during a person s lifespan, and therefore people may require treatment over a protracted period or require episodes of intervention at specific transition points in their lives. The total out of pocket costs for patients with complex ongoing speech pathology needs can equate to thousands of dollars per year over a number of years. Equipment costs Patients also bear out of pocket costs for equipment and resources prescribed by a speech pathologist. Patients report that financial considerations do influence whether they purchase much needed equipment or replace equipment as frequently as clinically required. Individuals with complex communication needs may have little or no speech, or unintelligible speech which often requires alternative methods of communication. People who require augmentative and alternative communication (ACC) methods may experience a range of different conditions including (but not limited to) Autism Spectrum Disorder, cerebral palsy, down syndrome, intellectual disability, stroke, traumatic brain injuries, progressive neurological diseases (such as Motor Neuron Disease). Individuals can be prescribed AAC aids and devices some of which are of minimal cost and low tech including communication books and boards but others are high tech and include electronic communication aids and tablets and come at significant expense. In addition to the AAC aids/devices, specialised training by a speech pathologist in the use of those aids is required. At times additional mounting or other adaptations are needed to ensure the device is secured to wheelchairs etc. in a useable way at additional cost. The ability of patients to access funding for ACC devices is variable across Australia with some access to state based equipment funding programs available. However there are also individuals requiring ACC devices for conditions (such as severe verbal dyspraxia) where they are not eligible for any funding support for ACC devices. At this point in time, it is unclear how much, and under which circumstances, AAC devices will be covered under the National Disability Insurance Scheme (NDIS). It is of significant concern to Speech Pathology Australia that some Australians bear significant out of pocket costs for equipment that provides them with a basic opportunity to communicate with others or are required to sustain their current health status. Of particular note is the plight of layrngectomee patients who have lifelong equipment needs. About 4,000 people in Australia (70% men and 30% women) are diagnosed with a type of head and neck cancer each year. Common treatments for head and neck cancers include one or more of a combination of surgery, radiotherapy and chemotherapy. Surgery often leads to a significantly altered physical appearance (e.g., patients who have their larynx removed have a tracheastoma a permanent breathing hole in their neck). The funding these patients currently receive only covers a fraction of their annual costs leaving some patients hundreds of dollars out of pocket each year. This is particularly concerning because 98% percent of this population are pensioners with reduced financial means to purchase expensive equipment. For example, in order to communicate, laryngectomee patients required silicone voice prostheses which cost approximately $370 each and have a life-span of 6 months. They will also require tracheastoma valves, covers etc. The current average annual equipment rebate (there is variability across states) available to laryngectomees patients is around $450. Speech Pathology Australia believes laryngectomees patients (particularly pensioners) should have their total costs covered for this essential equipment. Page 9 of 22

10 Impact of Reduced Commonwealth Funding for Health Promotion, Prevention and Early Intervention Much of the work of speech pathologists is centred on early intervention services intervening early in a child s life when it becomes apparent that their communication is not developing along typical lines, or intervention at an early stage in the progress of a disease or condition (such as stroke or progressive neurological diseases). Speech Pathology Australia is concerned about any reduction in funding or support for health promotion, illness prevention and early intervention most directly for people with communication disorders who could benefit from speech pathology services. However, we are also concerned about reported cost savings in the closure of the Australian National Preventive Health Taskforce as a signal to change or reduce focus on preventative work around things like tobacco control or obesity prevention. These risk factors lead to conditions such as stroke conditions which often results in communication and swallowing difficulties and the involvement of speech pathologists. Speech Pathology Australia would like to draw the Committee s attention to conclusions drawn by the Senate s Community Affairs References Committee in their inquiry into the prevalence of communication disorders the Committee reports in the committee s view, the key message that the federal government must convey is the significant benefits to both the individual and society from a strategy that prioritises early intervention of speech and language disorders 2. Furthermore, the Committee concluded that their inquiry highlights the costs to the individual and to society from delays in intervention and failure to treat conditions and emphasises the significant personal benefit from access to timely, professional speech pathology services. 3 Speech Pathology Australia advocates for increased funding for health promotion, illness prevention and early intervention with a view to reduce future health costs associated with preventable morbidity and mortality. It is critical that this funding focus be considered in light of an ageing Australian population. There is a concern that with reduced Commonwealth funding for health promotion, illness prevention and early intervention that these activities will move into non-health sectors. Recent proposals for health checks in supermarkets or in workplace settings are examples of transitions of health care from health care settings into non-traditional settings. Whilst Speech Pathology Australia is not in principal opposed to health promotion and illness prevention activities occurring in other sectors, we are concerned that there be appropriate clinical supports and governance in these initiatives. Speech pathologists as health care practitioners who routinely work in non-health settings (such as in schools or juvenile justice settings) have experience providing health care in contexts where health care is not the priority business. It is of concern that health promotion and illness prevention activities in our society may move into commercial non-health settings in lieu of appropriate public health funding in the health sector. Interaction between Elements of the Health System Speech pathologists offer a relatively unique perspective on the opportunities and challenges of providing health care across multiple elements of the health system and in providing health services between the health system and other sectors. Significant improvements could be made in the interaction between the health sector and the aged care sector and between the health and disability sectors for patients with communication and swallowing difficulties. 2 The Senate Community Affairs References Committee: Final Report Prevalence of Different Types of Speech, Language and Communication Disorders and Speech Pathology Services in Australia. September 2014 p Ibid. Page 10 of 22

11 Health and Aged Care While communication disorders affect people across the lifespan, the prevalence and complexity of these disorders increase with age and communication and swallowing are both vulnerable to natural ageing processes. There is of course the added possibility of disease or disorder in older Australians, and many common conditions including stroke, dementia and Parkinson s disease have a high prevalence of communication and swallowing disorders. The communication disorders associated with ageing vary significantly in type and severity and may be characterised by a stable, recovering, or degenerative course. Speech pathologists are an essential part of the team when it comes to care for older Australians. Speech pathology services cross health (e.g. acute, sub-acute, rehabilitation, community) and aged care sectors for this population, and can include identification of disease/disorder, assessment, intervention, counselling/support of families and caregivers, education of other professionals, case management, consultation, and advocacy. Furthermore, speech pathologists have an important role to play in promoting healthy ageing and minimizing the social, emotional and economic costs associated with communication disability and swallowing disorders. Untreated swallowing problems in older Australians can lead to preventable hospitalisation expenses. People who have poor swallowing ability (dysphagia) can be at serious risk of aspiration pneumonia. Pneumonia is a common cause of death from nosocomial infection in the elderly. Bacteria from dental plaque are carried in the saliva and aspirated into the lower respiratory tract leading to infection and, at times, death. In addition, dehydration and malnutrition are both life threatening conditions in elderly people, and both may be caused or exacerbated by dysphagia. These hospitalisation costs can be attributed to a complex interplay of complex medical symptoms and conditions. Speech pathologists assess and manage dysphagia and are, therefore, also involved in education and training regarding comprehensive health care in these patients. There is also evidence of psychological consequences of communication and swallowing difficulties in older Australians, including embarrassment and social withdrawal which can impact on mental wellbeing. Patients report depression and anxiety or panic related to eating, and rate these psychological consequences as the most important negative outcomes of dysphagia. Communication is fundamental to healthy ageing. The World Health Organisation (WHO) policy framework on Active Ageing emphasises the need for older people to realise their potential for physical, social, and mental wellbeing throughout the life course and to participate in society according to their needs, desires and capacities 4. Autonomy and independence are crucial to underpin Active Ageing, according to WHO. Rehabilitative services and long term management options are often missing for older Australians. Services need to be available which reflect a chronic disease management approach, as opposed to only acute and short-term rehabilitation services. With a medical model focus on the restoration of function, older people are at risk of being judged as having no rehab goals. They may be sent to a nursing home straight from an acute service with no rehabilitation in between or without coordinated discharge processes. With no speech pathologist waiting for them in the residential aged care facility, their ability to eat and especially to communicate goes unassisted. For people who experience an acute event such as a stroke, or who experience deterioration in their communication or swallowing due to disease or ageing, there are few supports available in the community, once discharged from hospital. A small number of schemes may support access via private therapists, depending on the condition and other personal factors. For example, some people may access ongoing support via the Department of Veterans Affairs and others may be eligible for up to five sessions of intervention under the Chronic Disease Management program, via their GP. The latter is only available if the condition is considered both chronic and complex, and there is a need for support from more than one specialist (e.g., physiotherapy and speech pathology) - thus, the five sessions are likely to be shared between specialist appointments. In some areas of Australia, there may be outpatient services available through local hospitals. We are unable to comment on the extent or location of these. 4 World Health Organisation (2002). Active Ageing: A policy framework. Retrieved February, 2014, from p. 12. Page 11 of 22

12 Anecdotal feedback indicates that it is very difficult for older Australians and their families to navigate the system and to access appropriate speech pathology services in a timely manner. Private speech pathology services are unlikely to provide a solution to access to speech pathology services for older Australians with communication or swallowing difficulties at the present time. Speech Pathology Australia member statistics show that only around 38 per cent of therapists who work in private practice work with adult clients, and only 18 per cent see people aged over 65 years. Thus even if people can afford private therapy, are aware of, and wish to access supports, older Australians and their families may be unable to find a speech pathologist who is able to help them. There is no systematic information available regarding access to speech pathology services in residential care facilities for older Australians. Members of Speech Pathology Australia consistently report that speech pathologists are rarely directly employed by aged care service providers as staff. Rather, the majority of residential aged care facilities contract private speech pathology services for assessment and/or management advice for specific residents. This service delivery model represents a significant challenge to best-practice care, which requires a coordinated interprofessional team working together to meet an individual resident s complex care needs. Furthermore, private speech pathologists working in the aged care sector consistently report that referrals for communication assessment or management are rarely received. This is despite the high prevalence of communication disorders for this population, and recognition by nursing and care staff that participation and social interaction are vital. This issue relates to the current Aged Care Funding Instrument that does not adequately assess communication or acknowledge the profound impact that communication and sensory impairments have on the total care needs of residents. Even though untreated communication difficulties increase the time, complexity and burden of care there is inadequate provision of funding or resources for aged care staff to identify or meet residents communication abilities or needs. This fails to comply with Aged Care Accreditation Standards (e.g. Standard 2.6 Residents are referred to appropriate health specialists in accordance with the resident s needs and preferences) and best-practice guidelines. Furthermore, this means that a large number of older Australians with a range of medical conditions (i.e. stroke, dementia, Parkinson s disease) are denied access to an effective mode of communication and provision of best-practice health care that is tailored to meet their specific communication needs. Considerable and significant improvements need to be made to how the health system and aged care sector interact to support older Australians with communication or swallowing needs. In recognition of this need, the aforementioned senate inquiry recommended that the federal government investigate current service delivery model of speech pathology health care in aged care residential services in terms of the capacity of nursing staff to screen for communication and swallowing difficulties, the number of speech pathologists employed and contacted and based on this investigation to form a view of whether these practices are compliant with aged care Accreditation Standards. It is the view of Speech Pathology Australia that current service delivery models for health care provided by speech pathologists in aged care do not meet Aged Care Accreditation Standards but more importantly, do not meet the health care needs of older Australians. The interaction between the health care system and the aged care system does little to provide continuity of care for patients and at times can act to prevent residents in aged care from accessing appropriate and timely health care. Health and Disability The interaction between the health and disability sectors is similarly problematic for Australians with communication and swallowing difficulties and for the speech pathologists who provide health care to these patients. Speech Pathology Australia supports the ethos and the successful implementation of the NDIS. The NDIS will provide lifelong support for Australians with disabilities many of whom have communication and/or swallowing disorders and who have had limited or no access to services in the past. It is particularly heartening to see that children with a specific speech and/or language impairment of unknown origin being included in the NDIS. These children can now access the reasonable and necessary supports to enable them to achieve improved social, emotional, educational and vocational Page 12 of 22

13 outcomes. Not only will this improve their quality of life and their ability to participate in everyday activities, it will also have a flow on impact on Australian productivity and competitiveness. However, there are still significant concerns as to whether the NDIS will provide increased support or whether essential services (including health services), expertise and social capital, which have often been established and maintained over many years in existing services, will be lost leading to a reduction in the choice of support options for NDIS participants. There is also uncertainty around the pathways for this client group with respect to accessing services through the health system as opposed to funding being available under NDIS. Recent reports from members indicate worrying precedents including instances where families were told that their child was not eligible for the NDIS for provision of speech pathology interventions because their underlying diagnosis is seen as a medical condition (e.g., a child with a Cleft Palate). It is essential that clear referral and management pathways are identified and that specialist skills of speech pathologists or other health practitioners working with those with people with disabilities is available. There is considerable opportunity for the interaction between the health and disability systems to improve with the continued roll out of the NDIS. For speech pathologists and the Australians with communication and swallowing difficulties who would benefit from their care, this has been acknowledged by the Senate Community References Committee with a recommendation that the Federal Department of Health develop a joint paper with the National Disability Insurance Agency scoping the impact of the NDIS on speech pathology service provision. Improvements in the Provision of Health Services (including indigenous health and rural health) Significant improvements could be made in the provision of health services (including speech pathology services) to indigenous Australians and to those living in rural and remote areas of the country. Rural and Remote Australians Speech Pathology Australia recognises the work carried out by the National Rural Health Alliance (NRHA) Services for Rural and Remote Allied Health (SARRAH) and the Stroke Foundation 5, in drawing together information about incidence and prevalence in rural Australia of some of the conditions and socioeconomic and behavioural risk factors that lead to communication and swallowing disorders. Australians in rural and remote areas suffer higher rates of hospitalisation for stroke, traumatic brain injuries and disability. Like other health services, and in particular specialist health services, rural and remote Australians face significant and pervasive barriers to accessing speech pathology services. Speech pathology as a profession suffers the same well-documented issues of workforce shortages, recruitment, retention and sustainability in rural areas as most other health professions. Significant improvements should be made in the provision of health services to rural and remote Australians but it is likely to involve a significant investment of funds, reforms to Medicare, innovation in service delivery and multi-targeted approaches to supporting primary care (including allied health care) provision and access to secondary specials support. Of note, support for speech pathology services provided through tele-health is a specific initiative that could improve access to services for rural Australians. Speech Pathology Australia continues to work within the National Rural Health Alliance to identify, support and advocate for improvements in health service provision to rural Australia. 5 NRHA (2014), SARRAH (2014) and the Stroke Foundation (2014) submissions to the Senate inquiry into the prevalence of different types of speech, language and communication disorders and speech pathology services in Australia. Available at Page 13 of 22

14 Indigenous Australians One of the most serious and pervasive health problems for Aboriginal and Torres Strait Islander children where access to early and appropriate speech pathology services is critical is the effects of recurrent otitis media in this population of Australian children. Robust data regarding communication and swallowing difficulties in Aboriginal and Torres Strait Islander people is scarce. Identification of communication disorders in these children is made difficult by the use of traditional languages and Aboriginal English in homes. However, there is a clear risk during the infant and preschool years for non-typical (abnormal) communication development due to the higher rates of otitis media and concomitant fluctuating hearing loss that are well reported in this population. Whilst otitis media is a medical issue, for some children, it impacts negatively on speech, language and cognitive development. This is more likely for Indigenous children given the early onset, frequent episodes of the condition and continued incidence through the primary school years. Thus, Indigenous Australian children are not only more at risk of otitis media, but more likely to experience negative outcomes as a result - including in communication development. Gaining access to early intervention medical services and early intervention in allied health services such as speech pathology is compounded by a range of factors including cultural appropriateness of services and rural access. Addressing this issue in indigenous children requires systematic interventions that cross the health and education sectors. To date, efforts have done little to remedy the incidence of otitis media in these children and a significant change in the approach and funding model may be needed to make improvements in health outcomes for these children. A significant gap also exists in accessing culturally appropriate speech pathology services for adult Aboriginal and Torres Strait Islander populations which is compounded by geographic access barriers in rural and remote Australia. For example, access to appropriate and timely stroke care is particularly problematic with the Stroke Foundation detailing that only 40 per cent of rural hospitals are able to provide a speech pathology assessment within the recommended 48 hour window after a stroke. Information about assessment of Aboriginal and Torres Strait Islander patients is not available, however reports from Speech Pathology Australia members indicate this is a profound gap in service delivery for this population. Integration and Coordination of Medicare Services As discussed previously, there are significant limitations in the current Medicare arrangements for Australians to access speech pathology services. Speech Pathology Australia advocates a systematic, national approach to providing access to speech pathologists for people with communication and swallowing disorders. This require a comprehensive review and investment of funds across public services accessed across health, education and disability sectors. An expansion of the current system of access via Medicare and specific funding programs will further help to achieve the goal of fair, equitable and adequate service provision. In the existing arrangements of Medicare rebates for speech pathology services for some patients, significant improvements could be made that would better coordinate and integrate these services with other health services likely to be used by patients. Recommendation four details specific changes to the MBS items that would act to better integrate and coordinate care for these patients and act to provide more effective, evidence based speech pathology care to these patients. Specific changes could include: The number of sessions allowed under the Chronic Disease Management program increased to reflect clinical need and evidence base for treatment of that condition (rather than capped at five). Ability for Medicare rebates to be used for speech pathology services that are flexibly delivered (home based or telepractice). The range of conditions not be limited to specific disability groups (e.g. Autism) but to include recognised specific communication impairments (such as severe language disorder, severe speech sound disorder, cleft palate, stuttering etc). Medical specialists (e.g. paediatricians) be accorded direct referral to speech pathology rights (for all Medicare items applicable to speech pathology) Page 14 of 22

15 General practitioners be accorded referral rights to speech pathology as a single discipline under the Chronic Disease Management items (without the patient requiring the services of at least one other health professional as is currently required). There are also opportunities to improve multidisciplinary clinical pathways for specific groups of patients including those with health and neck cancers and those with Progressive Neurological Diseases. The establishment of the Primary Health Networks provides an opportunity to better integrate and coordinate Medicare services. Whilst still early in the inception of this program, Speech Pathology Australia hopes that allied health professions will be seen as integral to the functioning of the Networks and not seen as an aligned stakeholder. It is recommended that there be a speech pathologist on every Clinical Council of every Primary Health Network and that there be a representative of people with communication and/or swallowing difficulty represented on the Community Advisory Committee of every Primary Health Network. Health Workforce Planning Speech pathologists in Australia provide high quality, safe care to patients despite a significant lack of workforce data, and associated workforce planning and supports for their profession. The last professional In Focus series published by Health Workforce Australia 6 prior to its absorption into the federal Department of Health, detailed known information about the speech pathology workforce in Australia. It recognised significant gaps in data governance issues associated with the profession. There are limited specific data on speech pathology professionals in Australia. National databases that collect information about the speech pathology profession include Speech Pathology Australia s member database, the Australian Census occupation data, and the ABS Labour Force Surveys. These data sources provide a fragmented and incomplete representation of the current speech pathology workforce, particularly when it comes to identifying gaps in existing workforce in relation to need, numbers entering the workforce and attrition rates and how the profession will meet the ever increasing demand for speech pathology services which is expected due in part to the effects of an ageing population, improved survival rates of premature, chronically ill and disabled infants, an increased in the detection of early speech and language disorders and the increase in opportunities to provide support to participants of the NDIS. Speech Pathology Australia advocated strongly for the inclusion of the speech pathology profession in the National Registration and Accreditation Scheme (NRAS) and continues to do so in the current Review of the scheme. Unfortunately, to date speech pathologists are not an included profession. The lack of inclusion of speech pathology in NRAS undermines the public confidence in the evidence based practice of speech pathologists, the safety of the health care provided and the unique role speech pathologists play in the Australian health care system. Speech Pathology Australia believes that professions included in NRAS are at a distinct advantage in attracting government funding investment in programs, innovations and professional supports to maintain and improve the quality of care they provide to the Australian public. We believe the registered professions also enjoy an advantage in relation to investment in data governance and workforce planning and sustainability initiatives. Many of the detailed recommendations made by the Senate Community Affairs References Committee relate to improved data collection and governance to aid in workforce planning and sustainability for the speech pathology profession. Until such a time as basic foundations of workforce planning are put in place for ALL health professions (not just those who are registered), it is difficult to see how the Australian health workforce can deliver the most effective, efficient and cost effective health care to Australians. 6 Health Workforce Australia, 'Australia's Health Workforce Series, Speech Pathologists in focus', July 2014, Page 15 of 22

16 Recommendations It is recommended that: 1. The Select Committee on Health support the recommendations made by the Senate Community Affairs Reference Committee into the prevalence of speech, language and communication disorders and speech pathology services in Australia. 2. A significant investment of funds for public speech pathology health services that are provided in healthcare, education and disability service settings for Australians with communication and swallowing disabilities. 3. An investigation be undertaken into the charging of informal co-payments for no cost publicly funded health services (including speech pathology services). 4. Revisions be made to the operation of the Medicare Benefits Schedule to minimise the out of pocket costs incurred by individual accessing speech pathology services and to increase efficiency of the MBS. Changes to include: a. The number of sessions allowed under the Chronic Disease Management program to reflect clinical need for treatment of that condition (rather than capped at five). b. Ability for Medicare rebates to be used for speech pathology services that are flexibly delivered (home based or telepractice). c. The range of conditions not be limited to specific disability groups (e.g. Autism) but to include recognised specific communication impairments (such as severe language disorder, severe speech sound disorder, cleft palate, stuttering etc). d. Medical specialists (e.g. paediatricians) be accorded direct referral to speech pathology rights (for all Medicare applicable to speech pathology) e. General practitioners be accorded referral rights to speech pathology as a single discipline under the Chronic Disease Management items (without the patient requiring the services of at least one other health professional as is currently required). 5. Private health insurers increase: a. The proportion of fee rebated for a speech pathology service b. The annual cap for speech pathology services 6. Governments recognise the urgent need for full cost funding of equipment needs for people with a laryngectomee and those with other special equipment needs. 7. Increased investment be made by all governments in health promotion, illness prevention and early intervention activities, with the view to reduce future health costs associated with preventable morbidity and mortality. 8. The Australian Government ensure that older Australians experiencing communication and/or swallowing difficulties have equitable access to appropriate and evidence-based speech pathology services, regardless of their age, medical condition, or place of residence. This should include: a. The Australian Government working with Speech Pathology Australia and the Aged Care Standards and Accreditation Agency Ltd to ensure that best-practice management of communication and swallowing disorders are a requirement of aged care accreditation standards. b. National dissemination of resources and information promoting maintenance of communication skills in ageing and increasing community awareness of communication impairment. c. Funding support for nursing, allied health assistants, and aged care support workers to implement and assist speech pathology services and recommendations. This should include awareness of, and adherence to, the National Standards for Texture Modified Foods and Fluids. Page 16 of 22

17 9. The Australian Government develop, in consultation with health practitioners (including speech pathologists), consumers and other stakeholders, and adopt a multidisciplinary clinical pathway for those with head and neck cancers, based on current evidence for the provision of best practice and consistent care. 10. The Department of Health in each state and territory establish clear pathways for early identification, referral, and management of people with Progressive Neurological Diseases, which includes a focus on transitions across services and sectors. 11. The Australian Government should mandate the use of a revised aged care funding tool that adequately identifies communication and/or swallowing impairment and provides funding for comprehensive assessment and management by a speech pathologist if indicated. This must ensure provision of funding for periodic review or follow-up as required. 12. The Australian Government work with Speech Pathology Australia and providers to develop and implement standard communication and swallowing training and professional development modules for nursing and aged care support workers as a requirement of National Aged Care and Accreditation Standards. 13. The Council of Australian Governments Standing Council on Health and the Standing Council on Education and Early Childhood Development collaborate to develop and implement systematic approaches to address the effects of Otitis Media on speech and language in Indigenous children. 14. Allied health professionals (including speech pathologists) be included on the Clinical Council for every Primary Health Network. 15. A representative of patients with communication and/or swallowing difficulties be included on the Community Advisory Committee of every Primary Health Network. Page 17 of 22

18 Appendix A: Community Affairs References Committee: Final Report into the prevalence of different types of speech, language and communication disorders and speech pathology services in Australia, September Page 18 of 22

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