On 25 February 2019 a roundtable public hearing was held with government agencies and hearing health stakeholders to discuss government progress against the 22 recommendations of the Hearing Health Inquiry (HHI) Report.
The evidence received at this roundtable, as well as information from the Government Response and the 2017-18 Annual Reports of the Department of Health and Australian Hearing, is discussed in this chapter.
Hearing Services for Children and Young Adults
The Australian Government’s Community Service Obligations (CSO) program, which is part of the Hearing Services Program (HSP), provides hearing services for children and young adults aged up to 26 years; adults with complex communication needs; and eligible Aboriginal and Torres Strait Islander people. All hearing services to CSO clients are provided exclusively by Australian Hearing.
The Department of Health stated that during the transition of eligible CSO clients to the National Disability Insurance Scheme (NDIS), Australian Hearing will remain the sole provider of hearing services to this cohort. The transition period is expected to continue until 1 July 2020.
The Department of Health further stated that the issue of whether Australian Hearing will remain the sole provider of hearing services to children after 1 July 2020 is ‘still to be resolved.’
First Voice stated that it had ‘major concerns’ about the possibility of Australian Hearing not retaining its role as the sole provider of hearing services for children. First Voice explained that this may ‘break the very excellent, now rapid, referral and induction [of children] into the NDIS.’ As such, First Voice recommended the ‘retention of Australian Hearing as the exclusively funded provider under the NDIS for the provision of paediatric audiology services.’
The Deafness Forum of Australia agreed and added that a decision regarding the future role of Australian Hearing needs to be reached:
All of our member organisations are anxious that the decision on the future role of Australian Hearing should have been and could have been made nearly two years ago. It's long overdue, and parents are entitled to expect that decision to be made. We would hate to think that the decision was going to be made in the last months before it runs out.
The National Disability Insurance Agency (NDIA) stated that ‘recent changes to the process of accessing the NDIS’ for eligible HSP clients meant that ‘there should be no disadvantage to participants.’ The NDIA further outlined the safeguards that were in place and stated:
To provide appropriate safeguards for participants and regulate the market, the NDIS Quality and Safeguards Commission is being introduced progressively before 1 July 2020.
New NDIS Hearing Stream for Children Aged Zero to Six Years
In response to concerns about delays to service provision under the NDIS, the NDIA stated that in August 2018 it ‘implemented the first phase of a new hearing stream’, which focused on ‘prioritising access to the [NDIS] for children from birth to six years of age with a newly diagnosed hearing loss.’
First Voice outlined the new ‘rapid referral pathway’ as including:
Subsequent to diagnosis a child engages with Australian Hearing as per the existing pathways.
Australian Hearing then initiates the process for an access decision and the decision will normally be made by the NDIS within two days.
An experienced planner trained in hearing loss and deafness then works with the family to have a plan approved, usually within two weeks ... This plan will cover standard funding arrangements for Early Childhood Intervention providers.
The family are linked to an Early Childhood Partner to support implementing the plan and linking to Early Childhood Intervention providers if required.
The NDIA highlighted that since this new hearing stream was introduced, it has:
… seen a significant increase in the number of plans that have been approved since August of last year, through that streamlined approach, which ensures that we've got plans approved within just over two weeks, which gets those early intervention supports in place much more quickly than had been the case prior to the new stream being introduced.
Australian Hearing added that since August 2018, 750 families had been supported through the early intervention pathway, and the feedback had been ‘overwhelmingly positive.’ Australian Hearing further outlined the process for children under the current NDIS transition arrangements and stated:
Children are seen within 10 working days at Australian Hearing. At that appointment, if we confirm that there is a hearing loss, at that time currently we start the NDIS process right on that day. Within two days they have their access approved. Within 10 days, approximately, everyone has a plan.
First Voice stated that the continued success of this pathway ‘requires Australian Hearing to remain the exclusive provider of paediatric audiology services.’
In addition, First Voice considered that Early Childhood Partners, who engage families during the NDIS process, should have performance benchmarks to ensure that hard-to-reach families (who are often the most in need of support) ‘are not allowed to drift.’
The Department of Health advised that not all CSO clients are expected to transition to the NDIS. As such, the Department of Health advised that a smaller CSO program will remain and that:
… there's some thinking that will be needed in terms of what the shape of it will look like when it's a smaller program with fewer clients and with perhaps not the extremity of hearing impairment, which the NDIA will pick up.
First Voice outlined its additional concerns regarding the transition of children with hearing loss to the NDIS. In particular, First Voice stated that the amount of funding and support provided by the NDIS is based solely on the degree of hearing loss. First Voice considered that additional factors that may ‘significantly increase the services’ a child requires should be taken into account. These include whether:
the child already has a diagnosed communication delay;
the child and/or family have challenges in accessing sound for language development (such as an ‘inability of the family to keep hearing aids on … or where the parents require increased support to ensure consistent integration of hearing technology and specialised therapy’; or
there is a ‘complex family context’, such as parents not speaking English and needing interpreters, lower family literacy, or a lack of understanding or commitment to the intervention program.
Reflecting these issues, First Voice recommended that ‘plans for children with hearing loss should recognise these factors in determining the level of funding required.’
Another issue raised by First Voice was that ‘the value of an approved plan for a child with multiple disabilities is often much less [than] the total cost of the required services.’ First Voice therefore considered that these families require guidance as to how their funding is allocated, and stated that:
… the NDIS should provide information to the families to assist in their choice, along the lines of ‘The total plan value has been determined from $x for specialised therapy for hearing loss and $x for other supports’.
While Australian Hearing is currently the sole provider of hearing assessments and devices for children, early intervention services are provided by other organisations. In response to concerns that the pathway from Australian Hearing to early intervention services may change following the full rollout of the NDIS, Australian Hearing stated that it was ‘not clear what happens from mid-2020.’
First Voice stated that the new early intervention pathway under the NDIS ‘is working exceptionally well and is a fantastic improvement from [where] we were before.’ At the same time, First Voice stated that the ‘system does not provide for the engagement of [a] child with a service provider beyond Australian Hearing’, and that the engagement of an early intervention service is up to a family to choose to take up.
The Department of Health stated that an 18 month pilot program is expected to commence on 1 April 2019 which ‘is looking at outcomes-based funding for early-intervention services.’ First Voice, which is developing the trial with the NDIS, outlined that the trial will:
… have an approach towards the provision of early intervention for children with hearing loss that isn't focused on the hours of direct service, which is the typical model within the NDIS, but, instead, is focused on a more holistic provision of service and then the assessments of the outcomes of those children a year later … we're very hopeful that it will be a very positive trial. It will, in effect, continue on the nature of the therapy that the First Voice members currently provide.
The NDIA acknowledged that the pilot will still be underway after the full rollout of the NDIS in July 2020. The NDIA stated that while ideally the ‘change should start …at the same time as a pilot’, the NDIA is ‘constantly adapting and moving very quickly to a range of requirements that have been requested of us from many peak bodies and government.’
establish a universal hearing screening program for children in their first year of school, with the aim of having all children tested within the first 60 days of the school year; and
investigate the use of an evidence based online screening program, to deliver a cost effective screening process.
Australian Hearing advised that it had been provided with a $4 million grant through the Department of Health to establish an online hearing assessment program for school aged children using the Sound Scouts application (app). Sound Scouts is free for school children within Australia, and was launched in March 2019.
Australian Hearing considered that raising awareness of Sound Scouts and ensuring appropriate referrals will be a challenge and stated:
The challenge now will be to actually get it being used across the country and having kids use it and, therefore, those children that need referral get sent into the referral pathways. There is more work to be done around the broad implementation of the recommendation.
Hear for You also emphasised the importance of education and awareness to accompany the rollout of Sound Scouts, particularly to ensure vulnerable groups do not get missed. These cohorts include Aboriginal and Torres Strait Islander children, children living in rural and remote areas, children who may not have access to the internet, and children who were born overseas and therefore may not have had access to newborn hearing screening.
First Voice explained that many parents of children who have undiagnosed hearing loss are ‘totally unaware of it’, and consequently may not have their children use Sound Scouts. This may mean that ‘without any mandatory requirement [Sound Scouts] will not pick up the vast majority of children with a hearing loss.’
The Department of Health stated that screening is part of the Roadmap for Hearing Health which was recently considered by the Council of Australian Governments (COAG) and stated:
It will definitely be the screening component, which Sound Scouts falls within, that will be discussed as part of sidebar conversations at the COAG meeting, and it's within the road map itself. The test is whether COAG adopts the road map and suggests that it's a great idea to take forward; if so that implementation work will then begin in earnest.
Australian Hearing highlighted that the Sound Scouts hearing assessment will include information on contacting Australian Hearing or a general practitioner (GP) if a hearing impairment is identified. Australian Hearing advised that as such, ‘the referral pathway from the app won’t be an issue’, and that ‘the broader issue is uptake and getting children to actually use [Sound Scouts]’.
First Voice supported the creation of a ‘Medicare item allowing audiologists to diagnose hearing loss and receive appropriate funding without requiring a doctor’s referral.’ First Voice considered that this should not only apply to school aged children, but those before school age as well. First Voice stated:
… for every child born with hearing loss there are a further two who acquire hearing loss sometime after birth but prior to school. We do not know when this occurs. A major impediment to the early identification of this acquired hearing loss is that for hearing tests to be able to be charged to Medicare they must be conducted under a medical referral.
The Department of Health advised that there is a current Medicare Benefits Schedule (MBS) review underway. As part of this review, the relevant expert committee is ‘conducting a clinical review of audiology items … and is considering the referral processes and access of audiology items.’ This clinical review will be considered by the MBS Review Taskforce, as part of ‘finalising recommendations to the government later in 2019.’ The Department of Health further advised that creating an item number for a referral from Sound Scouts to a paediatric audiologist has not specifically been considered as part of this process.
The Department of Health outlined the current MBS items that relate to audiology and audiometry and stated:
There are currently 24 MBS items that are available to patients to access audiology testing, including 15 items relating to audiology diagnostic procedures and nine mirrored items applicable only to audiometrist’s services. All of these items are accessible for paediatric treatments, where appropriate.
All states and territories in Australia provide newborn hearing screening programs at no cost to families. Australian Hearing stated that neonatal screening is ‘working very well, with 98 to 99 per cent of children being screened in a consistent way across the jurisdictions.’
In 2013, the Australian Institute of Health and Welfare developed ‘National Performance Indicators to Support Neonatal Hearing Screening in Australia’, but there is no requirement for states and territories to report against these indicators. The Department of Health stated that ‘the state and territory Neonatal Hearing Screening programs are not currently reporting’ in line with these indicators.
The Department of Health advised that an action item under the Roadmap for Hearing Health ‘is to determine the responsibility, feasibility and funding for standardised national reporting of hearing loss and an established database.’
Hearing Services for Aboriginal and Torres Strait Islander People
coordinating Commonwealth, state and territory services to ensure they are complementary and delivered in a coordinated manner;
developing a nationally consistent data reporting framework to record data on the prevalence of ear health conditions and the provision of services, including a treatment outcomes tracking method;
regular monitoring and evaluating of programs to ensure they are meeting their objectives; and
funding further research into Aboriginal and Torres Strait Islander hearing health issues.
The Department of Health stated that ‘total funding for Australian Government ear health activities is around $95 million over 2018-19 to 2021‑22.’ This includes $30 million for a ‘new program to provide hearing assessments for Aboriginal and Torres Strait Islander children prior to the commencement of school’. Other programs funded until 2021-22 targeting Aboriginal and Torres Strait Islander ear health include:
multidisciplinary outreach ear health services through the Healthy Ears, - Better Hearing Better Listening Program;
training for health professionals;
provision of equipment for ear health assessment;
ear health coordination activity; and
Additional programs and funding that the Department of Health drew attention to are:
‘Funding to expedite access to ear surgery for Aboriginal and Torres Strait Islander people is provided until 30 June 2020.’
‘The National Partnership on Northern Territory (NT) Remote Aboriginal Investment provides funds to assist the NT Government to reduce the prevalence and severity of ear disease among Aboriginal children in the NT.’
‘The Australian Government has contributed to the Hearing for Learning Initiative … [which] will train and employ 40 Aboriginal and Torres Strait Islander community members to raise awareness of ear disease and connect individuals to health professionals for treatment.’
‘The Roadmap for Hearing Health includes a specific focus on Aboriginal and Torres Strait Islander ear and hearing health.’
The Australian Health Ministers Advisory Council’s ‘National Aboriginal and Torres Strait Islander Health Standing Committee is considering the development of a national approach to addressing ear disease and hearing loss in Aboriginal and Torres Strait Islander children.’
Australian Hearing advised that it works closely with Aboriginal and Torres Strait Islander communities to establish working relationships with community leaders and to increase awareness of hearing health issues. These factors had driven an increase in access to services for Aboriginal and Torres Strait Islander children and adults.
Tracking the Effectiveness of Hearing Health Initiatives for Aboriginal and Torres Strait Islander People
In 2017, Siggins Miller was commissioned to conduct an Examination of Australian Government Indigenous Ear and Hearing Health Initiatives, which included consideration of whether the initiatives were meeting their objectives. The Department of Health stated that ‘overall, the examination found that investment is conceptually sound in that it addresses the range of activities needed to improve ear and hearing health.’
The Department further stated that recommendations of the examination ‘are being addressed’, including through the establishment of the hearing assessment program for Aboriginal and Torres Strait Islander preschool children.
The Department of Health also highlighted that the Australian Health Minister’s Advisory Council is ‘developing a national key performance indicator for ear and hearing health and considering mechanisms to improve data capture.’
Aboriginal and Torres Strait Islander Hearing Health Research
Australian Hearing stated that ‘there is increasing research into the hearing health of Aboriginal and Torres Strait Islander people.’ This included the priority under the Medical Research Future Fund (MRFF) to end avoidable deafness in Aboriginal and Torres Strait Islander people. Australian Hearing stated that it will ‘explore this opportunity to deliver additional high quality research to close the gap for Aboriginal and Torres Strait Islander ear and hearing health.’
Australian Hearing further highlighted research projects it was undertaking in 2017-18 in this area as including:
‘The Parent-evaluated Listening and Understanding Measure project. This project will develop and validate measures of listening and speaking abilities of Aboriginal and Torres Strait Islander children aged 0 to 5 years based on parent reports. This new tool is intended to be used in the $30 million hearing assessment program for Aboriginal and Torres Strait Islander children announced in the 2017-18 Budget and by health professionals.
The automated audiometer (AutoAud) project. This project will test the useability of the National Acoustic Laboratories' computer based automatic audiometer system for use in various locations, including in rural and remote locations.
The Prevalence of Hearing Loss and Spatial Processing Disorder in Aboriginal and Torres Strait Islander Adolescents in Juvenile Justice Centres project. This project will help determine the prevalence of hearing loss, spatial processing disorder and self-reported hearing issues in Aboriginal and Torres Strait Islander adolescents in juvenile justice centres.’
HHI Recommendation 2: The Committee recommends that the Department of Health and Australian Hearing significantly increase the resources devoted to providing hearing health services in regional and remote Aboriginal and Torres Strait Islander communities. The mobile outreach services of the Deadly Ears Program should serve as a best practice example for national implementation. This program should focus on expanding access to hearing health services in regional and remote locations and reducing the waiting lists for Aboriginal and Torres Strait Islander children requiring hearing health treatment.
In the 2018-19 Federal Budget the Government allocated $30 million over 2018-19 to 2021-22 for additional hearing assessments for Aboriginal and Torres Strait Islander preschool children. Australian Hearing advised that this program is expected to commence in April 2019, and will be designed to ‘reach as many children as [it] can in rural and remote communities.’ Australian Hearing outlined the main components of the program and stated that it will be:
... targeting zero- to six-year-old children because we know that that's the area of greatest need and priority. We will be sending in our trained audiologists with people on the ground to do everything from hearing checks and working with a provider to building capabilities so that they can actually start doing this work themselves and start referring people to us. We think this is an incredibly important opportunity to actually address that particular aspect of the challenge in terms of Aboriginal and Torres Strait Islander hearing health.
Australian Hearing stated that a key aspect of its work in rural and remote communities was engaging community members and local service providers to offer ongoing support for hearing impaired people in those communities. Australian Hearing further stated that one of the goals of the $30 million Federal Budget initiative was:
… to help build some of that capability within the community—working with primary care healthcare workers—and Australian Hearing will take some responsibility in terms of providing some training and support so they can provide some of those services, whilst there isn't an audiologist in the community. So it's trying to build some capabilities in there.
Australian Hearing also highlighted that it has implemented a teleaudiology program to reach remote and regional areas, and that it had worked closely with the Deadly Ears Program in this context. Australian Hearing stated that as a result of this program it had been able to:
… significantly reduce the age at which an Aboriginal child gets a hearing aid for the first time and also reduce the period in which they're provided with follow-up support once they've received that hearing aid.
Australian Hearing advised that access to Ear, Nose and Throat (ENT) consultations in rural and remote communities ‘is still an issue’, and that it provides hearing aids to children with chronic middle ear infections while they wait for access to ENT services and/or treatment. The Department of Health stated that it does ‘not collect information on the waiting times for access to Ear, Nose and Throat specialists.’
be responsible for the progressive installation of soundfield amplification systems in the classrooms of all regional, rural, and remote schools with a significant Aboriginal and Torres Strait Islander student population; and
provide support to deaf Aboriginal and Torres Strait Islander children to learn sign language and access interpreters where necessary.
The Department of Health explained that the content of Recommendation 3 may be picked up through the Roadmap for Hearing Health if it is agreed by COAG. The Department of Health stated:
… the work that we would anticipate occurring … post the COAG meeting for the road map would be to start those engagements around that education stream in terms of the role of schools at all levels and in all states and territories—both the investment required to put the loop systems in, but also that support around tackling some of the issues where sign language is learnt and able to be learnt, particularly in the Aboriginal and Torres Strait Islander communities. … What we would expect is a focused body of work, post road map, with our colleagues at the Department of Education, but also … the state and territory education departments.
Deaf Australia stated that the NT had previously offered bilingual programs for Aboriginal and Torres Strait Islander school children, but that these programs had not continued. Deaf Australia also stated that there is limited funding to develop and support Aboriginal and Torres Strait Islander sign languages and additional funding may help to ‘overcome those language barriers that are in place now.’
Hearing Services for Other At-Risk Populations
The Government’s Response to this recommendation stated:
The Commonwealth Government is committed to ensuring current interpreting services are maintained but does not intend to expand eligibility to the [Free Interpreting Service] to audiology and audiometry services.
In response to the Government not considering expanding the Free Interpreting Service, the Department of Health stated that the service:
… is a demand driven program operating within a fixed budget. There is currently no capacity to expand the [Free Interpreting Service] to cover allied health services. Any decision to expand coverage would need to be considered as part of the Budget process.
the use of assistive listening devices for aged care residents;
service provision for deafblind Australians in aged care facilities; and
the education of aged care facility staff.
The Department of Health outlined that the Aged Care Quality and Safety Commission ‘assesses and monitors the performance of residential aged care services against the Accreditation Standards (the Standards).’ Standard 2.16 covers sensory loss, and states that ‘care recipients' sensory losses are identified and managed effectively.’ The Department of Health further stated that:
It is also expected under the Standards that aged care providers demonstrate management and staff have the appropriate knowledge and skills to perform their roles effectively, which would include the management of care recipients’ sensory loss.
Cochlear suggested that a pilot hearing screening program for people accessing the aged care system could be beneficial. Cochlear explained that ‘at least one in three’ people over the age of 65 have ‘some kind of hearing loss’, and:
… that number rises. Once you get to around 80 [years of age] it would be around three people in four. If you do link some kind of screening with your access to the aged care system—whether you have in-home care or are going into an aged care facility—your access to My Aged Care, which is mandatory to be able to access federal government support for over-65s, would be a good way of rolling out some kind of pilot.
Cochlear also stated that it was investing in research into a potential link between hearing loss and cognitive decline and dementia, and the impact that addressing hearing loss may have on these conditions. The Department of Health stated that these research areas have been ‘an element of discussions and the items that have gone in the Roadmap for Hearing Health.’
The Department of Health also advised that a priority identified by the hearing health stakeholder committee in developing the Roadmap for Hearing Health was ‘that the quality of hearing health and care in aged care facilities [should] be lifted across the country with particular focus on identification, management and workforce training.’
The provision of education on farm-based sources of noise exposure and how the risks to hearing health from these noise sources can be minimised.
Hearing screening services targeted at workers in agricultural industries and referrals to treatment services for people found to have a hearing loss.
The promotion of communication techniques to assist people with hearing loss regardless of whether they choose to use hearing devices.
The Department of Health advised that currently, ‘there are no targeted programs to provide hearing services to Australians living in agricultural communities.’ The Department of Health further outlined that:
Australian Hearing provides hearing services to eligible clients of the Voucher component of the Hearing Services Program who live in a postcode defined as CSO remote under the legislation.
More broadly, the Department of Health advised that ‘workplace screening and workplace noise exposure’ had emerged as a theme under the Roadmap for Hearing Health.
Government Initiatives and Funding for Hearing Health
The Government Response did not support Recommendation 22 and stated that:
Since the National Health Priority Areas were established, there has been a policy shift away from a disease-specific approach towards a more integrated approach that is applicable across a broad range of chronic conditions.
The Government Response also stated that ‘to ensure that there is an appropriate focus on hearing health’, it has been working with hearing health consumer and industry groups to develop the Roadmap for Hearing Health. The Roadmap is intended to form the basis of a ‘collective understanding of the issues and actions that will lead to improvements in hearing health for all Australians.’
The Department of Health provided more information about the Roadmap for Hearing Health and stated:
… the hearing health road map, which has been commissioned by Minister Wyatt, is a sector-driven, sector-wide road map to identify opportunities within the hearing health sector, to look for opportunities and ways that governments can better support Australians who are deaf and hard of hearing to live well in the community, and to enable all Australians to value their hearing. That road map is designed partly to try and span the already mentioned fragmented ecosystem that we have in this particular space. It is one that has a variety of very interested stakeholders … and has to cut across the various parts of the state and federal government systems that are implicit in Australian government and in Australian healthcare delivery.
The Roadmap for Hearing Health was discussed by COAG Health Ministers on 8 March 2019. The COAG Health Ministers referred the Roadmap to the Australian Health Ministers’ Advisory Council for review and report back in November 2019.
Hear for You described the creation of a Roadmap for Hearing Health as a ‘positive step forward’. The Deafness Forum of Australia expressed similar sentiments, but cautioned that agreement and collaboration from all jurisdictions will be needed for the Roadmap to be effective.
Cochlear also stated that the Roadmap for Hearing Health is a positive step, but that it ‘remains an aspirational document at this stage’, without ‘clear accountability for actions’ and ‘no commitment for funding.’
Promote safe noise exposure practices in the workplace. (The department, in partnership with Safe Work Australia, should focus on encouraging businesses to enact measures to eliminate or isolate sources of noise rather than relying on personal hearing protection.)
Build on existing projects such as HEARsmart and Know Your Noise to promote safe listening practices in the music industry and among young people.
Encourage people who may be experiencing hearing loss to seek assistance and encourage general practitioners and other relevant medical practitioners to actively enquire about the hearing health of their patients, particularly those aged 50 years and over.
Include messaging aimed at destigmatising hearing loss and educating the public on the challenges faced by deaf and hearing impaired Australians.
The importance of raising awareness of hearing health was an issue widely discussed as part of developing the Roadmap for Hearing Health. In particular, the Department of Health stated that awareness campaigns could be targeted at ‘Aboriginal and Torres Strait Islander communities, the broader community, health professionals and early childcare and primary school care workers.’
The Deafness Forum of Australia stated that there are numerous organisations investing in awareness campaigns around hearing health, which leads to ‘duplication’ and ‘waste of finite resources.’ The Deafness Forum of Australia suggested that the Department of Health could have a ‘coordinating role’ in this regard, and also provide funding.
Hear for You made a similar point and recommended the departments of health and education work with the states and territories and consumer organisations to increase hearing health awareness among school aged children. Both the Deafness Forum of Australia and Hear for You considered that the Roadmap for Hearing Health may be the appropriate mechanism to progress this work.
In relation to the Government Response to the HHI, Cochlear expressed disappointment that there was a ‘lack of support for a national awareness and education campaign’.
Australian Hearing highlighted the HEARsmart program, which ‘targets people who in a social context are exposed to loud noise’, such as at live music events, and promotes safe listening practices. Australian Hearing stated that it was considering whether it could fund HEARsmart once its funding allocation ended at the end of this financial year.
The causes of balance disorders and potential treatment options;
Genetic and stem-cell based treatments for hearing impairment; and
Longitudinal research on the experiences of adults undergoing treatment for hearing impairment.
The Government Response outlined that the Government does not support Recommendation 8. The Department of Health stated that the National Acoustic Laboratories (NAL) does not have the ‘expertise and capability’ to conduct research into balance disorders or genetic and stem‑cell treatments for hearing impairment.
The Department of Health stated that since 2009, $64 449 693 has been provided through the National Health and Medical Research Council for ‘hearing research including balance disorders, stem-cell research and genetic treatment research.’ This included ‘$2 865 938 for hearing with stem cell research and $2 261 708 for hearing with genetics research.’ The Department of Health also advised that the MRFF has not provided research funding for balance disorders.
Australian Hearing stated that the NAL traditionally had a research focus on acoustics and hearing, but is now focusing on: hearing preservation, how to best assess people with hearing loss, rehabilitation, and how to support the hearing industry to assist people with hearing loss. Australian Hearing further outlined the process of determining the NAL’s research priorities and stated:
… first of all, NAL receives funding through the Department of Health. Those priorities are worked through each year through a memorandum of agreement. NAL also works with the sector and receives funding from partners in the sector around priorities that they want NAL to pursue. There's a research committee that oversees NAL's work and its priorities, of which the Department of Health is also a member. There's a multilayered approach to actually setting NAL's priorities and operating within those financial constraints from the Department of Health, plus the work that it delivers on behalf of its commercial partners.
Hear for You was concerned that hearing health researchers will leave Australia due to the limited availability of research funding and opportunity. Hear for You further stated that making hearing health a national priority would attract greater government interest and investment in hearing health research.
Cochlear and First Voice outlined a need for further research into an association between hearing loss, cognitive decline (including dementia) and mental health issues.
In addition, Cochlear suggested research is needed into the link between hearing loss and falls, as falls ‘make a large contribution to our hospital admissions every year.’ The Deafness Forum of Australia agreed and added that balance disorders are also linked to falls, which may signal a need for research in this area, and that the ‘savings in terms of avoiding all those hospitalisations would probably offset the cost’ of the research.
Australian Hearing outlined how it uses teleaudiology to assist clients (particularly Aboriginal and Torres Strait Islander clients in rural and remote areas) and stated:
… with the work … [with] Aboriginal and Torres Strait Islanders, we are now using teleaudiology services to follow up on appointments with children within weeks by having someone on the ground working with the family and the child so that we can see that the device is working the way it should and that the child is getting the maximum benefit from it. We're using it in our day-to-day operations where clinicians for whatever reason are unable to be at a hearing centre to see patients. We are able to provide teleaudiology services to people to whom we would otherwise say, 'Please come back at another time.'
Australian Hearing also highlighted that it recently launched an online hearing assessment which it described as ‘probably the best … in the world’. The online hearing assessment includes providing people with information about hearing loss, providing a hearing test, and then encouraging them to take action to address any hearing issues. Australian Hearing explained that it is funding this out of its own budget because ‘it is incredibly important in terms of service delivery for [its] clients.’
The Department of Health advised that reference groups established by the Department had made recommendations regarding ‘non-face-to-face access’ and telehealth consultations, particularly for rural and remote patients. The Department of Health further explained that:
… there is broad acceptance from all the reference groups that the tele-offering of services is a requirement that should be picked up and moved forward on.
The Department further outlined that the Allied Health Reference Group released a report for public consultation in February 2019, which includes a draft recommendation on introducing ‘a new MBS item allowing patients in rural and remote telehealth eligible areas to access telehealth consultations with an allied health professional, including audiologists.’ The Department of Health advised that the MBS Review Taskforce will consider feedback on this report when finalising its recommendations to the Government.
The NDIA acknowledged ‘the need to enhance and customise service delivery for participants in remote areas’. The NDIA further outlined some individuals' plans may include funding for virtual services and stated:
The NDIA’s extensive spread of remote Community Connectors across remote areas will assist in locating participants and aligning them to services funded in their plans, which may include using virtual methods where suitable and cost effective.
The Deafness Forum of Australia was of the view that private providers of hearing services ‘might not be aware of opportunities’ related to telemedicine, and that ‘businesses need to adjust themselves so that they can take advantage of these services.’
Cochlear outlined barriers it has faced when looking to roll out its new sound processor technology in Australia, and stated that it had chosen to start a pilot in the United Kingdom of Great Britain (UK) instead. Cochlear stated:
Cochlear's latest sound processors are Nucleus 7, which are cloud enabled. It's the enabler for remote care and checks through an iPhone. The real inhibitor to taking that up and rolling it out in Australia so far has been the lack of telehealth reimbursement for audiologists. We've actually started a pilot in the UK simply because they do have that funding pathway, even though this technology was, obviously, developed in Australia by Australian audiologists and Australian researchers.
Australian Hearing outlined that the Productivity Commission (PC) had undertaken an investigation into Australian Hearing’s compliance with competition policy, and that Australian Hearing was found to be ‘entirely compliant.’
Australian Hearing further advised that the PC made a ‘minor suggestion’ that Australian Hearing ‘pay an extra $100 000 per annum to cover what it considered to be a possible compliance issue around the national workers compensation scheme.’ Australian Hearing stated that it ‘agreed to that recommendation immediately.’
During the HHI, concerns were raised by some stakeholders that Australian Hearing was able to operate within Centrelink offices, which gave it a competitive advantage in the hearing services market.
In response to this concern, Australian Hearing stated:
… when [Australian Hearing was] operating in Centrelink offices, the allegation was we weren't actually paying to operate within those facilities, and that's actually not correct. We were actually purchasing space within Centrelink offices, in the same way that any other operator could do the same thing, and other operators do do that.
The Department of Health stated that currently, Australians aged 26 to 65 years who are deemed to be a complex client are eligible for the CSO program. The Department also advised that individuals who have a ‘pensioner concession card (including those on a Newstart allowance) are currently eligible to receive services from the Voucher component’ of the HSP.
The Department of Health stated that it had not undertaken any analysis of whether hearing impaired Australians aged 26 to 65 are receiving adequate support, or what it would cost to provide greater services to this group. The Department further stated that it ‘is willing to support any request from the Parliamentary Budget Office to develop a model for the costs of the provision of hearing services to this population cohort.’
Australian Hearing explained that some people aged 26 to 65 who are on low incomes cannot afford to purchase their own hearing devices, and ‘if they don’t qualify for the NDIS, they’re on their own.’ Australian Hearing stated:
We are aware of people who come to [Australian Hearing] looking for help, because they don't qualify for the government Hearing Services Program. Effectively, we say, 'You actually need to invest your own money,' and they can't. So we're very mindful of the fact there is a segment of the population aged between 26 and 65 who have a challenge in terms of meeting their hearing requirements.
Hear for You questioned what options people aged 26 to 65 with hearing loss had if they weren’t eligible for government support and stated:
If we get unemployed, we have to fund the devices out of our own pocket or go to one of the services … to get a second-hand device and hope that an audiologist will fit it. We work so hard to get to a point—to go for education, learn languages and get a job, if we can, through university—and then, by the time we're 26, we're told, 'Well, see you later; good luck,' and there's no other support.
Australian Hearing stated that it supported its clients through the process of leaving the CSO program when they turn 26 years of age. This support included seeing clients the day before they turn 26 years of age ‘to make sure they’ve got the most up-to-date device that they can have and the support that they can get.’
The Deafness Forum of Australia explained that the eligibility threshold for accessing the NDIS due to hearing loss is a hearing loss of 65 decibels in the best ear. The Deafness Forum of Australia stated that people who had a hearing loss under this threshold were likely to still require support, particularly to participate in employment opportunities:
If you have a hearing loss of 50 decibels in your best ear and you're a teacher, for example, or a businessperson working on the phone and you can't afford new devices, you pretty much won't be able to work, you pretty much won't be able to get promotion and you won't get any help from the Hearing Services Program. You're on your own.
Hear for You also made the point that if a person has a significant hearing impairment in their worst ear (and need a cochlear implant for example) but their best ear has a hearing impairment under 65 decibels, ‘you will not be on the NDIS, and then you’ll have to fund yourself.’
First Voice stated that it ‘would accept the fundamental approach of the NDIS’ that there should be a lower threshold for accessing early intervention for hearing loss, and a higher threshold for accessing permanent disability support for hearing loss. Nevertheless, First Voice considered that a level of support should be available to all individuals with hearing loss and stated that:
… the provision of hearing aids is a very appropriate way to maintain the functioning of an adult in the workforce and in society, and I think one of the critical issues at the moment is that it's all or nothing—you either get fantastic support or you get zero support—whereas some mechanism that is able to support an adult, enable them to maintain their independence through supported hearing aids, would be fantastic.
Hear for You questioned why hearing devices which are used in the workplace are not tax deductable, in the way that work bags, phones and tablets currently are.
The NDIA advised that in the six months to 31 December 2018, there were 56 providers of Auslan under the NDIS. The NDIS further stated that ‘there is often a lag in claims being made, so this is probably under-indicating the number of providers that are actually delivering those services.’
When asked if there was a shortage of interpreters in the NT, the NDIA stated that there is one provider of Auslan services under the NDIS in the NT. The NDIA added that ‘it is possible that participants who self-manage have accessed Auslan through other service providers’.
The Department of Health stated that ‘one of the desired outcomes’ under the Roadmap for Hearing Health is to increase the number of Auslan interpreters who receive professional training.
Hear for You stated that the NDIS had ‘exposed the shortage of interpreters.’ Deaf Australia similarly highlighted that there was an undersupply of Auslan interpreters and further stated that ‘a big gap in Auslan training’ was that TAFE had cut their Auslan training courses.
When asked if the NDIA is monitoring the impact of NDIS on demand for Auslan services, the NDIA stated that it had:
… looked at the baseline modelling. We're starting to look in more detail at the expenditure on Auslan interpreting. And then we would work with our federal policy agency the Department of Social Services in terms of market stewardship to increase access to Auslan services.
Hear for You highlighted that there was some confusion among Auslan users as to which program (such as the NDIS or the Employment Assistance Fund) to use to source Auslan interpreters. Hear for You stated that this confusion had on occasion led to a number of interpreters turning up at the same event, as they been booked through different government programs. Hear for You stated that this would impact on the availability of Auslan interpreters elsewhere on the day.
Deaf Australia stated that some families who wished to access Auslan services through the NDIA had instead been provided with access to speech therapy. In response, the NDIA stated that it:
… would expect that that was probably prior to the new hearing stream pathway development … In the new hearing stream we now have experienced planners in hearing and deafness, and we would expect that they would support families to help them make decisions in the best interests of their child. If Auslan is one of those I would expect that that would be put in their plans.
The Australian Government’s response to Recommendation 20 stated that it is:
… committed to ensuring current interpreting services will be maintained. The NDIS provides funding for support for participants with hearing loss and use of Auslan to access interpreting and translation services in activities of daily life. The [NDIS] provides choice and control for participants over how they use those services. This can include the provision of Auslan interpreting for medical appointments.
Deaf Australia stated that there is an undersupply of Auslan interpreters nationally, and that individuals wanting to use an interpreter (for example, for university) are often unable to source one. Deaf Australia also commented that some states ‘are really struggling to provide Auslan in schools.’
The Department of Health advised that the Australian Government’s position on deciding to maintain ownership of Australian Hearing had not changed, and that privatisation ‘had been ruled out’.
Hearing Industry Practices
Australian Hearing cease the use of commissions and similar sales practices as soon as is feasible.
The Department of Health amends contracts with service providers operating under the Hearing Services Program Voucher Scheme to prohibit the use of commissions and similar sales practices as soon as is feasible.
If necessary, changes be made to the Hearing Services Administrative Act 1997 (Cwlth), and any other relevant legislation or regulation, to enable the prohibition of commissions and similar sales practices as described above.
The Department of Health advised that it was aware of concerns about the ‘upselling’ of hearing devices, and that it was continuing to ‘monitor sales of hearing devices.’
The Department of Health further advised that 70 per cent of devices sold through the HSP Voucher Program are fully subsidised, and 78 per cent of Voucher Program clients receive fully subsidised devices. As such, the number of devices that are not fully subsidised is ‘relatively small’ in terms of volume.
The Department of Health also explained that the legislative instruments that support the HSP are due to sunset in October 2019. As such, the Department is undertaking a ‘thematic review’ which will consider ‘redrafting the legislative instruments that support the HSP’ in order to make the HSP ‘easy for people to understand and comply with.’ The issue of whether the Australian Government could amend its contracts with service providers operating under the HSP to ban commissions may be considered as part of this review.
First Voice highlighted that the issue of upselling was another reason why competition should not be introduced to the provision of hearing services for children under the NDIS. First Voice stated that it:
… wanted to raise the issue of this conflicted remuneration, given the possibility of losing the Australian Hearing exclusivity in the zero to fives [age bracket], because if that becomes competitive and if commissions are not banned … we'll get exactly the same thing: families will be pressured to upgrade their devices that they've provided for their children and then they'll feel a huge emotional pressure to do that, and I think that's another argument about why that should not become a competitive area.
In response to Recommendation 13, the Department of Health stated that:
… professions that are registered with the Australian Health Practitioner Regulation Agency [AHPRA] are those which have a significant risk to public safety, and that hasn't been the view in relation to audiology.
The Department of Health further outlined why some health professions are covered by the National Registration and Accreditation Scheme (NRAS) while others are not and stated:
There are 16 professions covered within the NRAS. One of the objectives of the NRAS is the protection of the public. For a new profession to gain entry to NRAS they need to demonstrate to Health Ministers that they meet the entry criteria outlined in the intergovernmental agreement, which established the NRAS. This includes that there is not another form of regulation that meets public safety requirements.
The Department of Health also advised that in 2015, COAG Health Ministers agreed to establish ‘the National Code of Conduct for unregistered health care workers’, to be implemented by the states and territories. The National Code outlines minimum standards for health care workers and ‘includes national prohibition orders.’ The Department stated that the National Code was established ‘in recognition of the risks associated with the provision of services by unregulated health workers’.
The Deafness Forum of Australia was concerned that many people who use audiology services are vulnerable and may also have additional disabilities (such as Down’s syndrome or autism). In addition, an error by an audiologist working with newborns or children could have ‘a lifetime impact on their education and work life.’ As such, the Deafness Forum of Australia considered that these groups may benefit from registration of the audiology and audiometry professions.
The Department of Health outlined the theoretical negatives of additional regulation in this area as including ‘increased cost to the end consumer’ and the potential for increased regulation to dissuade people from joining the profession. In addition, the Department of Health highlighted that ‘once you regulate something, you've got to make sure that you keep it current; otherwise, you unintentionally lock out innovation’.
The Department of Health also stated that ‘the NRAS is practitioner funded and the cost to practitioners for their annual registration is an important consideration.’
The Committee is pleased to have had the opportunity to follow up on the 22 recommendations outlined in its 2017 report Still Waiting to be Heard… Report on the Inquiry into the Hearing Health and Wellbeing of Australia (Hearing Health Report). Receiving topical information from government agencies and hearing health stakeholders has highlighted a number of areas of progress, and other areas where there is still significant work to be done. The Committee would like to thank the agencies and organisations who participated in the public hearing on 25 February 2019 and the valuable insights they provided.
Hearing Services for Children
The Committee received evidence that stakeholders remain concerned about the future of hearing services for children. The clear message from these stakeholders, both in the Hearing Health Report and this inquiry, is that Australian Hearing should remain the sole provider of hearing services to children under the age of six. Currently, Australia is considered a world leader in the provision of paediatric hearing services, and the Committee does not believe the market is large enough to support competition in this area at this time.
The Committee was pleased to hear that its recommendation of establishing a hearing screening program for school aged children is being rolled out through the use of the Sound Scouts online program. While this is an important first step, attention should now be directed to ensuring Sound Scouts reaches as many children as possible, and that there is a clear referral pathway from Sounds Scouts to a paediatric audiologist.
Hearing Services for Aboriginal and Torres Strait Islander People
The Committee determined in the Hearing Health Report that Aboriginal and Torres Strait Islander hearing health is at ‘crisis’ level. In particular, the high rates of otitis media infection in Aboriginal and Torres Strait Islander children (especially in remote communities) was a major cause for concern.
The Committee was pleased to hear that the Australian Government has directed funding towards addressing hearing health issues in Aboriginal and Torres Strait Islander children. Advice from Australian Hearing also indicated that it is reaching more Aboriginal and Torres Strait Islander clients, which is improving hearing outcomes.
Notwithstanding these positive steps, Aboriginal and Torres Strait Islander hearing health is not an area where we can risk complacency. The Committee strongly reiterates its three previous recommendations regarding Aboriginal and Torres Strait Islander hearing health and urges the Australian Government to maintain its focus on this issue.
Hearing Services for Other At-Risk Populations
The Committee was disappointed that its recommendation to expand eligibility for the Free Interpreting Service to audiology and audiometry was not supported. Culturally and linguistically diverse people with hearing loss are likely to experience additional barriers when accessing medical services, including the need for translation during hearing health appointments. The Committee urges the Australian Government to reconsider its position on this issue.
Older Australians are highly likely to experience hearing loss, signalling a need for a greater level of support for this cohort. The Committee heard that a hearing screening program for Australians looking to access aged care services may be an effective tool to identify hearing loss at the outset and provide adequate support.
The broader aged care system was examined by the Committee in its Report on the Inquiry into the Quality of Care in Residential Aged Care Facilities in Australia, and more recently as part of the Royal Commission into Aged Care Quality and Safety. These reviews and recent developments in the aged care sector present an ideal time to consider what further reforms are needed within aged care to support elderly Australians with hearing loss, including the implementation of recommendations made by this Committee in the Hearing Health Report.
Government Funding and Initiatives for Hearing Health
The Committee was pleased to hear about the development of the Roadmap for Hearing Health. The Roadmap has the potential to address a range of issues raised during this inquiry and the Committee’s previous Hearing Health Report and ultimately improve the health and wellbeing of Australians with hearing loss. The Committee, however, echoes the cautions of some stakeholders who highlighted that there is no funding attached to the Roadmap, and that clear delineation of responsibilities and timelines will be needed. Members will follow closely any progress of the Roadmap for Hearing Health.
The Committee was interested to hear that the National Health and Medical Research Council has provided $2.9 million for hearing with stem cell research and $2.3 million for hearing with genetics research since 2009, and has also provided funding for research into balance disorders. The Committee had previously recommended the National Acoustic Laboratories conduct research into these issues, which the Government did not support. The Committee considers that these research fields could lead to new developments in the treatment and management of hearing loss and as such are deserving of continued focus by the Australian Government. The causes and treatment of balance disorders appear to be understudied and may require additional attention and funding.
All agencies and hearing health stakeholders agreed that teleaudiology and online hearing services are an important part of service delivery, particularly for rural and remote people with hearing loss. Despite this general agreement, the Committee is concerned that there has not been sufficient progress in this area and reiterates its previous recommendation on this topic.
The Committee is concerned that Australians aged 26 to 65 with hearing loss are, in many cases, ineligible for government assistance for their condition. As such, they may struggle to afford hearing services and devices that would enable their participation in employment and society. Providing support to low income Australians in this cohort was recommended in the Hearing Health Report and the Committee reiterates that this is an area worthy of further examination by the Government.
In the Hearing Health Report, the Committee outlined that there is a shortage of Auslan interpreters. This problem is likely to be exacerbated as the National Disability Insurance Scheme increases demand for Auslan services. The Committee is concerned that the Australian Government has not responded to this additional need, and that many Auslan users may struggle to access interpreting services. As such, the Committee strongly reiterates the two recommendations it made regarding Auslan interpreters in its Hearing Health Report.
Hearing Industry Practices
The Committee was disappointed the Government only ‘noted’ the Hearing Health Report recommendation to amend contracts with service providers under the Voucher Scheme to prohibit the use of commissions. In the Hearing Health Report, the Committee found that the use of sales practices such as commissions ‘is not appropriate in a healthcare setting.’ The Committee continues to hold this view and reiterates its recommendation on this issue.
In its response to the Hearing Health Report, the Government stated that it did not consider that the audiology and audiometry professions posed a risk great enough to warrant regulation by the Australian Health Practitioner Regulation Agency (AHPRA). This assessment is clearly conflicting with the fact that other professions which are broadly comparable to audiology and audiometry (such as optometry and dentistry) are regulated by AHPRA. People experiencing hearing loss may be highly vulnerable, particularly if they also have other health conditions. As such, the Committee considers that greater regulation of hearing professions is warranted, to ensure quality care.
The Committee reiterates the following recommendations outlined in Still Waiting to be Heard… Report on the Inquiry into the Hearing Health and Wellbeing of Australia:
Recommendations 2, 3, 6, 7, 11, 12, 15, 17 and 20 (which were ‘noted’ by the Government);
Recommendations 4 and 13 (which were ‘not supported’ by the Government); and
Recommendations 5, 9, 18 and 19 (which were ‘supported-in-principle’ by the Government).
The Committee recommends that:
Australian Hearing remain the sole provider of audiology services for children aged zero to six years old under the National Disability Insurance Scheme (NDIS); and
The Australian Government outline service arrangements for hearing services following the NDIS transition period (which is due to end on 1 July 2020) as soon as possible.
The Committee recommends that the Council of Australian Governments establish a mandatory hearing screening program for children in their first year of school using Sound Scouts.
The Committee recommends that the Australian Government develop, implement and make public its plan for the Community Service Obligation program following the full rollout of the National Disability Insurance Scheme on 1 July 2020.
The Committee recommends the Department of Health consider developing a pilot hearing screening program for Australians accessing the aged care system.
The Committee recommends that the Australian Government commission research into the possible causes of balance disorders and potential treatment options.
The Committee recommends that the Roadmap for Hearing Health embed: a clear allocation of responsibilities between jurisdictions, timelines for implementation of key actions, and funding allocations.
Mr Trent Zimmerman MP