6. Future of Hearing Services in Australia

Overview

6.1
The introduction of the National Disability Insurance Scheme (NDIS) will result in changes to how hearing services are funded and delivered in Australia. This chapter will discuss how the NDIS will interact with the system currently in place to identify and treat young children with hearing impairment.
6.2
In addition, this chapter discusses possible improvements to universal newborn hearing screening programs and the potential for implementing additional screenings for young children and more mature adults. The availability of Auslan interpreters and the ownership of Australian Hearing will also be highlighted. Finally, whether hearing health should become a National Health Priority Area will also be discussed.

National Disability Insurance Scheme

6.3
The NDIS is in the process of being implemented across Australia and is expected, at full implementation, to provide cover for about 460 000 Australians.1
6.4
Hearing impaired Australians who currently receive services from the Hearing Services Program (HSP) will be transitioned to the NDIS if they:
are aged under 65 years of age;
meet residence requirements;
have a permanent hearing loss; and
have a significant loss in functional capacity to communicate and/or socially interact without support (such as hearing devices) or assistance.2
6.5
The majority of younger children accessing Community Service Obligations services,3 as well as adults with ‘substantially reduced functional impairment’4 are expected to transition to the NDIS by 2019-20.5
6.6
The National Disability Insurance Agency (NDIA) indicated that it expects approximately 16 000 to 20 000 hearing impaired Australians to enter the NDIS.6 The NDIA cautioned that the NDIS has a legislated scope that cannot be exceeded and that mainstream health services will remain responsible for providing support for most people with hearing impairment, particularly those with mild hearing loss.7
6.7
In March 2017, the NDIA stated that it was ‘currently working with the Office of Hearing Services and Australian Hearing to identify clients for transition from the [HSP] to the [NDIS]’.8

Services Funded by the National Disability Insurance Scheme

6.8
The NDIA advised that it may fund ‘hearing services and supports not available under the HSP’. The NDIA also stated that if a HSP client chooses a more expensive, top-up, hearing device that requires the client to pay a
co-contribution than the NDIS may cover some, or all, of these out-of-pocket expenses.9
6.9
The NDIA stated that the typical NDIS plan for a hearing impaired client would include:
Capacity building supports – this may include therapy identified by therapists working with the child, e.g. one on one or group based activities to promote social skills
Auslan interpreters
Assistive technology – for hearing aids that are not covered by the HSP, e.g. waterproof hearing aids, waterproof covers for cochlear implants, or other cochlear accessories. Occasionally an Augmentative and Alternative Communication service.
Core supports – for example for older children there could be support to sustain informal care or support coordination. This is not as common for younger children.10

Contestability in the Community Service Obligations Market

6.10
The HSP’s Community Service Obligations (CSO) scheme is currently delivered solely by Australian Hearing with funding provided by the Department of Health’s Office of Hearing Services.11
6.11
The NDIA acknowledged Australian Hearing’s ‘high level of expertise’ in the delivery of services to children and adults with complex needs. The NDIA stated that Australian Hearing’s functions would need to be ‘carefully analysed and understood’ to ensure these functions are preserved within the NDIS.12
6.12
The implementation of the NDIS may introduce a contestable market, allowing private hearing service providers to compete with Australian Hearing to deliver services to CSO clients. The Department of Health stated:
The NDIS will introduce major change to the way government funded disability services will be delivered by mid-2019, with the introduction of full contestability for services, and NDIS participant control to choose any service provider.13
6.13
In March 2017, the NDIA indicated that a final decision had not been taken on whether a contestable market for the provision of CSO services would be created, stating ‘the question of moving from a sole specialist provider for children and young Australians to contestability of services is under consideration.’14
6.14
The Australasian Newborn Hearing Screening Committee (ANHSC) stated that one of the difficulties regarding the introduction of the NDIS is that the provision of hearing services is ‘such a well-developed, mature service system that a lot of the ills that the [NDIS is] seeking to rectify do not exist in our system’.15
6.15
The ANHSC referred to the example of the United Kingdom of Great Britain which, following the introduction of contestability into the child hearing services market, experienced ‘market failure and a gap in the system’ when a major provider reduced its services in many areas.16
6.16
The ANHSC also contended that in a contestable market providers are not obligated to provide services in all locations and this could lead to reduced services in rural and remote areas.17 The ANHSC stated:
In the absence of that obligation on a service provider, we will see failure, and that failure will be in rural and remote locations … where it is less possible to provide a service in a commercially and economically viable way for someone who is in the market for what are, essentially, commercial reasons.18

Expertise in Paediatric Audiology

6.17
Aussie Deaf Kids and Parents of Deaf Children also referred to the risk that the introduction of a contestable market could impact on the quality of care provided to deaf children, stating that under a contestable system there are few safeguards:
… in place to ensure that children and young people receive services from appropriately trained audiologists with paediatric experience. Poor quality service delivery for children can have lifelong consequences but there is no system in place that will penalise providers who do not comply with proposed standards and guidelines.19
6.18
The Royal Institute for Deaf and Blind Children (RIDBC) raised concerns regarding whether new providers in a contestable environment will have the necessary experience in children’s hearing services. The RIDBC stated:
… the private market is untested in the delivery of services to children with hearing loss, with no mechanisms currently in place to assess competency for services or individuals delivering services to children, whose families on diagnosis are in a state of crisis and highly vulnerable.20
6.19
Aussie Deaf Kids stated it had recently surveyed its members and found that a ‘very low’ number of them ‘supported being able to choose a hearing service provider’. Aussie Deaf Kids explained that overall its members had a positive impression of the quality of care provided by Australian Hearing. Aussie Deaf Kids stated that ‘there is a really strong recognition amongst families that this is an amazing service … and they are really grateful to have that facility where they get the best aids and FM systems.21
6.20
The Hearing Care Industry Association stated, in relation to children’s hearing services, it was logical to ‘develop and concentrate expertise in one area, namely Australian Hearing.’22
6.21
The NDIA commented that it is:
… absolutely committed to ensuring that the approaches in early childhood are, as much as possible, based on the evidence of best practice. We absolutely recognise that in Australia the effort through Australian Hearing meets some of the best international standards so we are very keen to understand what are the core elements of that and how to integrate that into our early childhood approach.23

Early Intervention Services in the NDIS

Accessing Early Intervention Services

6.22
Currently, Australian children are screened at birth as part of the universal newborn hearing screening programs. If a potential hearing loss is detected, they undergo further diagnostic testing at the hospital. If a permanent hearing impairment is detected the child is referred to Australian Hearing, which aims to see the child within two weeks to begin the process of fitting a hearing device.24
6.23
First Voice stated that previously Australian Hearing had regularly referred children to early intervention providers but that ‘it has stepped back from that over the course of the rollout’ of the NDIS.25 In addition, First Voice stated prior to the introduction of the NDIS that almost all families of hearing impaired children in South Australia had visited the Cora Barclay Centre (as well as the other early intervention providers) before choosing a service. Since the introduction of the NDIS less than 40 per cent of the families of newly diagnosed hearing impaired children had visited the Cora Barclay Centre.26
6.24
Aussie Deaf Kids advised that since the introduction of the NDIS, state and territory governments have been reducing their provision of early intervention services.27
6.25
The NDIA stated that it ‘recognised the importance of early diagnosis and very streamlined, timely clinical pathways so that children get the right sort of supports early.’28 The NDIA further advised that it has established an Early Intervention Hearing Expert Reference Group which includes representatives of ‘hearing loss experts, peak bodies, service providers and organisations’ and has responsibility to:
… consider evidence relating to a range of issues including; the NDIS access criteria, potential for delays in referral from newborn hearing screening programs and the clinical standards, governance, and expertise required to deliver specialist hearing services for infants and young children.29

Choice of Service Providers

6.26
The introduction of a contestable market will allow parents to choose between different service providers. The Shepherd Centre questioned whether, without guidance, the parents of newborns recently diagnosed with hearing impairment had the ‘knowledge to make the informed choices for their child that would make possible the outcomes they wish.’30 Aussie Deaf Kids added that for most of these parents ‘the first deaf child that they have ever met is their very own child … so besides the stress of it and going through the grieving process and everything, you do not have a clue what you are supposed to be doing.’31
6.27
First Voice contended that the ‘choice-and-control’ principle in the NDIS Act giving clients the opportunity to choose the services they require is not always appropriate for highly specialised health care services.32 To highlight the point that, in some cases, the guidance of expert medical practitioners is crucial, First Voice drew a comparison with someone suffering a serious injury. First Voice commented:
If you break your neck, you go into a multidisciplinary rehab unit and people manage your rehabilitation … and it is individualised. They do not give you $150 000 and say ‘go and put your own team together.’33
6.28
The RIDBC commented that parents at this point are ‘highly vulnerable’ and are ‘in incredible levels of grief at the diagnosis of hearing loss. They are looking for a light, and any light will do.’34
6.29
The RIDBC contended that not all providers would be able to deliver a high quality outcome for a hearing impaired child, stating that ‘there is a very significant difference and evidence around outcomes for multidisciplinary … and transdisciplinary teams as opposed to sole providers’,35 and that:
… specialisation is really important, too. Not everybody can work with a paediatric caseload … we are a highly specialised organisation … small-based providers are somewhat challenged to be experts across all fronts.36
6.30
Aussie Deaf Kids suggested that ‘if we are going to a contested environment, parents are going to need significant help in understanding the process’.37 Aussie Deaf Kids also commented some families are more likely to be disadvantaged by the changes than other families, stating:
… those of low socioeconomic status, migrant families and regional and remote families … are going to be the people who are most disadvantaged by this. People in metropolitan areas – well-educated families – will manage. But we want every child to have the same opportunities. It should not be dependent on the capacity of your parents to understand the system.38

Delays Accessing Early Intervention Services

6.31
The ANHSC stated that with the introduction of new service providers parents will need a ‘period of shopping around’ to understand the different types of services available.39 This could result in the child’s engagement with an intervention service being delayed and ‘even small delays, measured in months — weeks even — can be represented in long-term delays to language and communication development that go on into childhood and potentially into adulthood.’40
6.32
Since the introduction of the NDIS in South Australia, early intervention services advised that children’s entry into their services had been delayed. The Cora Barclay Centre, an early intervention service based in Adelaide, has seen the average age of children commencing treatment rise from six months to over 12 months since the introduction of the NDIS.41
6.33
First Voice illustrated the negative impacts of delayed entry into early intervention services by relaying that the Cora Barclay Centre had recently received:
… a number of really quite late referrals … of children who were diagnosed at birth who had been receiving services from, say, a speech pathologist in their local area. [Cora Barclay] had a three-year-old who came to us a week ago with half a dozen single-syllable words, so they have got a three-year language delay because they have been to a person who is an accredited and registered NDIS provider but they have not been to an NDIS provider who has got the relevant skills and experience.’42
6.34
First Voice and the RIDBC summarised their concerns about the impact the NDIS was having on children’s hearing health.
The introduction of the NDIS is resulting in a huge backward step for children with hearing loss in Australia. Immediate action must be taken to prevent a generation of children growing up without the language they require.43

Funding for Early Intervention Services

6.35
The RIDBC was critical of the NDIA’s use of planners without clinical expertise to make funding decisions on cases of individual clients. The RIDBC stated:
Currently, decisions on service types and funding levels that are available … [for] early intervention are being taken by NDIA planners who in most cases have little or no knowledge of a deaf or hard of hearing child’s requirements and do not typically have relevant clinical expertise ... This has resulted in widely discrepant levels of funding availability for children with similar needs and stands to compromise the quality and adequacy of available services.44
6.36
First Voice expanded on the issue of variability in the plans provided to NDIS clients, stating that ‘children with apparently identical levels of hearing loss and need and family circumstances [are getting] widely varying packages. So what you get depends on who you see in the NDIA and how articulate and persistent you are.’45
6.37
Early intervention service providers were also concerned that the funding they received from the NDIA was insufficient to cover the costs of the services they were providing.46 A joint submission by First Voice and the RIDBC explained that currently funding under the NDIS is based on the expectation that therapy will be provided by a sole provider (such as a speech pathologist). The quantity of funding is based on the number of hours the client is directly served by the practitioner.47
6.38
First Voice and the RIDBC contended that, compared to single discipline services, multidisciplinary services produced superior language outcomes but were more expensive to deliver. First Voice and the RIDBC stated that ‘evidence clearly demonstrates that a specialised holistic multidisciplinary / transdisciplinary service is required to produce [positive language] outcomes; however this service comes with 30 to 50 per cent increased cost.’48
6.39
First Voice advised that, following the introduction of the NDIS, the Cora Barclay Centre’s state government funding was reduced and Cora Barclay was now ‘sustaining a monthly loss of $120 000’. First Voice added that the gap between the funding provided by the NDIS and the actual cost of providing services was between $6000 and $8000 per child. First Voice suggested that once the NDIS was fully operational in New South Wales the Shepherd Centre could expect a shortfall in government revenue of between $1.5 million and $2 million per year.49
6.40
The NDIA advised that the NDIS aims to use transdisciplinary services for the delivery of early childhood support.50 The NDIA also stated that ‘the NDIS provides individualised funding to participants, giving them choice and control over the services and supports they receive’. The NDIA further added that it:
… continues to work with providers to encourage development of alternative business models that align with the individualised approach to funding and the NDIS terms of business. Existing quality and safeguards arrangements continue to apply.51

Policy Options for Young Children

6.41
A number of organisations suggested that the creation of a ‘guided pathway’ to assist parents choose a service provider could help ameliorate the potential risks associated with a contestable market for children’s hearing services. The Shepherd Centre stated that a number of the states and territories have a:
… dedicated service that guides the referral of these diagnosed children into the specialised early intervention service of the family’s choice. However this service is absent in NSW, the ACT, Tasmania and the Northern Territory. With the introduction of the NDIS, the continuation of this service may be at risk in the other states.52
6.42
The Shepherd Centre suggested that the establishment of a nationally coordinated guided referral service would have an annual cost of approximately $3 million.53
6.43
First Voice and the RIDBC suggested that Australian Hearing is ‘ideally placed’ to provide a guided referral service due to its ‘national footprint, expertise, and independence’.54
6.44
The RIDBC advocated for the continued provision of an obligated provider to provide CSO hearing services under the NDIS, and stated:
… it is the fundamental position of RIDBC that there should continue to be a Single Obligated Provider under the Hearing Services Program or the NDIS for all Australians currently covered under the CSO obligations component of current policies. The Single Obligated Provider would be required to continue to deliver services to all current CSO clients, regardless of complexity, geography, or cost of service delivery.55
6.45
The RIDBC also questioned whether the advent of a contestable market would make it difficult for the government to invest in expanding the services provided by Australian Hearing. The RIDBC stated that, although Australian Hearing was a ‘world leading organisation’, there were:
… opportunities for improvement and expansion of services. The challenge that we see specifically in investing is that it is slightly at odds with the philosophical approach with the NDIS. Having full contestability of a space and the government seeking to be and remain to be a big player in it is an oddity to us.56

Hearing Screening Programs

Improvements to Universal Newborn Hearing Screening Programs

6.46
Australian Hearing put forward two potential improvements to newborn hearing screening:
Implementation of a national data collection system to monitor children’s progress along the clinical and intervention pathway, and their outcomes; and
National monitoring of the quality of newborn screening programs.57
6.47
Australian Hearing added that ‘the true magnitude of the impact of newborn hearing screening’ can only be measured if the progress of children with hearing impairment is tracked over time.58
6.48
The ANHSC also called for national data collection and management to provide:
information on the prevalence of hearing impairment across Australia;
a basis for ensuring newborns identified with hearing impairment are not lost to follow up;
a database that can be used for research purposes; and
a basis for tracking outcomes and cost-effectiveness of newborn screening.59
6.49
In order to monitor the quality of newborn screening programs, Australian Hearing and the ANHSC recommended state and territory newborn screening programs be required to report against the ‘National Performance Indicators to Support Neonatal Hearing Screening in Australia.’60 These indicators were published by the Australian Institute of Health and Welfare in 2013, but newborn screening programs are not required to report against them.61 The ANHSC recommended that national reporting and monitoring come under the responsibility of the Australian Health Ministers Advisory Council’s Standing Committee on Screening.62

Additional Hearing Screening for Children

6.50
Two thirds of children who have a hearing loss at school age developed the loss after birth.63 As such, newborn hearing screening programs cannot identify a hearing impairment in these children. The Australian Hearing Hub stated because of this:
… many children go undiagnosed and untreated, with communication problems misunderstood for lengthy periods during which development and learning delays manifest, and impact more negatively, than would have been the case if there had been early intervention.64
6.51
Hear and Say added that many children who were born overseas but are now living in Australia may not have had access to newborn hearing screening programs.65
6.52
A number of organisations advocated for the implementation of hearing screening programs for children either before66 or on entry to school.67 The Australian Society of Otolaryngology Head and Neck Surgery stated ‘hearing screening at age four to five would ensure each child has optimal hearing when starting school.’68 The Shepherd Centre advocated for screening at age three to four, to ensure a child’s hearing impairment is picked up and treated before they enter the school system.69
6.53
The ANHSC further explained why preschool or at the start of schooling were the recommended ages for screening:
… by that age a number of children will have developed a permanent hearing loss, so that is a good time to try and catch them. So, it is a clinical reason. The other one is really because of being able to catch a large group of children in fewer places rather than having to visit them in many places … So, it is for convenience and efficacy.70
6.54
The HEARing Cooperative Research Centre proposed that hearing screening should include screening for auditory processing disorders, which ‘affect the ability of the child to hear in noisy environments.’71
6.55
Sound Scouts Australia stated that the World Health Organisation has recommended hearing tests for children around the time they start school.72 Sound Scouts Australia also cited other international examples, stating that the ‘UK government has a goal of all children having their hearing tested within 60 days of starting school’ and the ‘New Zealand Government includes a hearing test as part of the comprehensive B4 School health check.’73
6.56
Screening at other ages in childhood was also suggested. The Royal Australasian College of Surgeons (RACS) considered that school entry testing was too late, and that ‘the one-to-three-year-old age group is crucial in picking up conductive hearing loss.’74 Sound Scouts Australia recommended school entry screening and then ‘a follow-up test in year 5, in line with NAPLAN, or upon high school entry.’75 The RIDBC,76 the Australian Hearing Hub,77 and Speech Pathology Australia78 also recommended screening before starting high school in addition to early childhood screening.
6.57
The South Australian Department for Education and Child Development stated that ‘the cost-benefit if you were doing population screening is unknown.’79 The department explained the prior research done in the South Australian setting suggested:
… the possibility of a screening process prior to school or upon school entry would be admirable, but the research that was done here with the health services at the time was just not cost productive. They were diagnosing one or two per cent out of every hundred children they were screening. It just was not worth it.80
6.58
The South Australian Department for Education and Child Development added that many children with hearing impairments are picked up through the school system already, when teachers notice they are struggling to hear in a noisy classroom.81 The RACS also commented that screening programs ‘are quite expensive and time consuming.’82
6.59
Hear and Say stated that in 2016 it launched a screening program in some schools in Queensland,83 aimed at children entering primary school.84 Hear and Say has screened approximately 15 000 children, and found that ’20 to 25 per cent of those children have had some sort of hearing issue on the day of screening’, and that of these, approximately 11 per cent will need to be referred to an audiologist or general practitioner (GP) for further testing.85
6.60
Sound Scouts Australia provided details of an app, Sound Scouts, designed by cmee4 Productions and the National Acoustic Laboratories. Sound Scouts is a tablet based application that uses an interactive game to test children for conductive and sensorineural hearing loss, and central auditory processing disorder.86
6.61
Sound Scouts is suitable for children from the age of four years and nine months to twelve years of age.87 To take the hearing test the child requires a quiet environment, a digital tablet device, a set of headphones and supervision by a responsible adult such as a parent or teacher.88 The results of the test are emailed to the responsible adult along with, if necessary, suggested options for treatment for any hearing issues discovered.89 Sound Scouts Australia stated that they were seeing a lot of use of the app in remote areas where there is a lack of access to hearing services.90
6.62
The Shepherd Centre estimated that screening all children aged four in Australia using an app such as Sound Scouts could cost approximately $8 million per year.91
6.63
Following a diagnosis of a hearing impairment at a screening, the Shepherd Centre recommended that children aged up to seven should be able to see a paediatric audiologist with bulk billing to Medicare and without a doctor’s referral (at a limit of one test per year).92 The Shepherd Centre stated that currently ‘there are no self-referral possibilities for parents to take their child to an audiologist and have that diagnostic done under Medicare.’93

Hearing Screening for Adults

6.64
Hearing screening of adults may enable them to stay productive and in the workforce for longer.94 The RIDBC recommended adults have their hearing screened at age 50 and periodically after that, as this would:
… improve the timely diagnosis and treatment of hearing loss in working age Australians, improving health outcomes for this demographic while reducing the negative impact hearing loss has on the nation’s productivity.95
6.65
The Australian Hearing Hub also suggested screening at ages 50 and 60, as this is when ‘other primary-health screening is prioritised.’96 Cochlear put forward a similar point, stating that:
There are a number of programs in place for Australian’s in the over 55 category to be reminded and supported to have health tests. It would not be complex to move towards this in Australia in the case of hearing tests.’97
6.66
The RIDBC outlined the benefits of screening for elderly Australians and stated:
Improved screening rates for hearing loss for the elderly will improve the uptake of hearing health services for seniors, with benefits in terms of better productivity and reducing the prevalence of hearing loss as a factor for cognitive decline and the onset of dementia.98
6.67
Audiology Australia also recommended aged care recipients receive a hearing screening upon entering an aged care facility.99
6.68
Cochlear advised that research in the UK has found an eight to one benefitcost ratio for ‘providing national hearing screening at ages 55 and 65.’100 A Deloitte Access Economics report found that the cost of implementing hearing assessments for all Australians over the age of 50 years was estimated to be $134.3 million.101
6.69
A study into the perspectives of GP’s on hearing screening for adults found some potential barriers. In particular, the study found that:
In the context of a typical consultation, routine screening for hearing impairment was generally not considered [by the GPs] to be an issue of high priority. Consequently, the prevailing view was that a proactive screening approach was inappropriate and not economically viable.’102

Availability of Auslan Interpreters

6.70
According to Deaf Australia, there are currently 961 Auslan interpreters accredited under the National Accreditation Authority for Translators and Interpreters, and that of these, there are 300 interpreters ‘actively working in Australia.’103 There are varying numbers of interpreters across the country:
Victoria does have the largest number of Auslan interpreters—I think the number is about 260. In New South Wales there are fewer, Queensland has fewer again and South Australia even fewer. In the Northern Territory I know that there are four.104
6.71
The Can:Do Group in South Australia also identified a shortage of qualified Auslan interpreters in Australia. The Can:Do Group advised that this was related to ‘problems around funding and incentives for Auslan courses’105, stating that:
The current size of the cohort in South Australia is only 15 students a year, and it only runs a course every two years, so demand far outweighs supply for these courses and for the profession in general. In regard to time frames to complete these courses, in South Australia it is up to six years, although we do know that interstate it is almost half this time.106
6.72
TAFE SA stated that the demand for Auslan courses exceeds the number of places they were able to offer, due in part to ‘the lack of appropriately qualified and experienced teachers of Auslan.’107
6.73
Deaf Australia considered that the rollout of the NDIS will see demand for Auslan interpreters ‘dramatically increase’, and that:
Deaf people's access to interpreters in the workplace will be compromised, because many of the interpreters there will not be working in employment settings; they will be working in NDIS related areas. That is a major risk that deaf people who are employed face in their workplaces.108
6.74
To address current and projected shortages of qualified Auslan interpreters, the Australian Sign Language Interpreters Association recommended the Australian Government ‘work with industry to devise and implement a National Strategy to significantly increase the pool of qualified professional interpreters across Australia.’109 Deaf Australia also recommended this course of action and further stated that ‘given the urgency, an interpreter training initiative must be established immediately to help alleviate the concerns created by the [NDIS].’110

Ownership of Australian Hearing

6.75
In February 2014, the National Commission of Audit recommended that Australian Hearing should be ‘reviewed with a view to privatisation’.111 The Commission of Audit suggested that Australian Hearing should be considered for privatisation in the ‘short term (2014 to 2016)’, stating ‘the Government could examine the potential to increase contestability in markets where Australian Hearing has a monopoly and allow, through privatisation, it to compete in markets where it is currently precluded.’112
6.76
In September 2015 the Senate Select Committee on Health released its third interim report Australian Hearing: Too Important to Privatise. As the report’s title makes clear, the Senate Select Committee recommended against the privatisation of Australian Hearing.113
6.77
In February 2016 the Australian Government received a ‘proposal from a consortium of consisting of the RIDBC, Macquarie University and Cochlear Ltd to transfer Australian Hearing to non-government ownership.’114
6.78
The RIDBC stated that following the Commission of Audit’s recommendation, the RIDBC formed a consortium with Cochlear and Macquarie University:
… not because we have wanted to entice government to privatise Australian Hearing but because, more importantly, we were concerned with the types of ownership that could happen should it go through a normal commercial sale process from the government into private ownership.115
6.79
The Australian Society of Otolaryngology Head and Neck Surgery recommended ‘against any structural change, privatisation among them, which would jeopardise [Australian Hearing]’.116 The Deafness Forum stated that ‘whatever the future ownership arrangement might be, it should not compromise Australian Hearing’s capacity to provide independent advice.’117
6.80
In the 2017-18 Budget the Australian Government announced that ‘following consideration of the future ownership of Australian Hearing Services, the Government [had] decided to retain full ownership and control of the entity.’118

National Health Priorities

6.81
The National Health Priority Areas (NHPAs) were established in 1996, in order to:
... focus public attention and health policy on areas contributing most to the burden of illness in the community, particularly where that burden had the potential to be significantly reduced through improvements in prevention and treatment.119
6.82
There are nine NHPAs:
arthritis and musculoskeletal conditions;
asthma;
cancer control;
cardiovascular health;
dementia;
diabetes;
injury prevention and control;
mental health; and
obesity.120
6.83
The potential addition of hearing health and wellbeing as the tenth NHPA was widely supported by organisations and individuals during the inquiry. Organisations who supported making hearing health and wellbeing a NHPA included: consumer advocate organisations,121 peak professional bodies,122 research institutions,123 and hearing service providers.124
6.84
The Deafness Forum of Australia suggested that ‘without hearing health and wellbeing becoming a National Health Priority the deep seated need for improvements in this area will continue to be inadequately addressed’.125 The Deafness Forum added that hearing health represents a ‘greater health burden than existing [NHPAs] such as asthma, diabetes, and musculoskeletal conditions’.126
6.85
Deaf Australia provided an alternative viewpoint suggesting there is a risk in including hearing health as a NHPA
… as it would couch deafness as “negative” and under a “deficit” model, which is out of step with current human rights based approaches and … would undo a lot of work that Deaf Australia has engaged in to “destigmatise” hearing loss and deafness.127
6.86
The Department of Health advised that ‘contrary to stakeholder expectation, not all NHPAs are supported by individual funding allocations or dedicated programs.’128 The Department of Health added ‘the government’s response to some of the calls for hearing to be considered [a NHPA] is that hearing is part of the national disability strategy and continues to be a focus under that.’129

Concluding Comment

The National Disability Insurance Scheme

6.87
The introduction of the National Disability Insurance Scheme (NDIS) is a major reform to the provision of disability services in Australia. Once fully rolled out, the NDIS is expected to provide support for approximately 460 000 Australians.
6.88
The Committee is pleased that Australia is considered to be a world leader in the provision of hearing services to children. The Australian system begins with universal screening of newborn children’s hearing, allowing children with hearing impairment to be identified, and treated, from a very early age. The Community Service Obligations (CSO) program, and Australian Hearing’s role as the sole provider of paediatric audiology services, was widely commended by inquiry participants. Further, not-for-profit early intervention services are providing therapy which is yielding remarkable communication outcomes for deaf and hearing impaired children.
6.89
There is some concern among hearing service providers and advocacy groups that these positive outcomes could be at risk due to the introduction of the NDIS. In particular, there is concern around the creation of a contestable (competitive) market for the provision of children’s hearing services. The Committee believes that it is vital that the strengths of Australia’s system of providing children’s hearing services are protected.
6.90
The Committee believes that the introduction of competition into the market for services for very young children carries too great a risk. The evidence shows that children who receive specialist treatment from a very young age can expect very positive outcomes but that any delays can have significant negative developmental impacts.
6.91
Australian Hearing has a wealth of paediatric audiology experience and the Committee sees little benefit in diluting this expertise. In addition, parents of children newly diagnosed with hearing impairment will need to make decisions quickly. On initial diagnosis parents may still be in shock and are unlikely to have the necessary experience or knowledge to navigate the different offerings of service providers. In this situation the introduction of new service providers may make it more difficult for parents to make a choice that guarantees a positive outcome for their children. Of paramount importance is that hearing impaired children continue to receive timely provision of evidence-based specialist treatment. The Committee believes the safest way to ensure this, is for Australian Hearing to remain the sole provider of audiological services for very young children.
6.92
In addition, the Committee acknowledges the positive impact on developmental outcomes gained from engagement with multidisciplinary early intervention programs. The Committee is recommending the creation of ‘guided referral pathways’ from Australian Hearing into these early intervention programs. This would involve ‘case managers’ advising parents and guiding them to expert providers who are able to provide their children with the best possible hearing health outcomes. These systems already exist in some jurisdictions but the creation of a national scheme based at Australian Hearing would provide significant benefits for a modest investment.
6.93
The Committee received evidence suggesting multidisciplinary early intervention services have encountered significantly increased funding pressure since the introduction of the NDIS. The Committee urges the National Disability Insurance Agency to work with these organisations to ensure they are able to continue to provide their services to all deaf and hearing impaired children.

Additional Hearing Screenings

6.94
The Committee was concerned that only a third of childhood hearing loss is identified at birth, leaving two thirds of hearing impaired children without a defined pathway for diagnosis and treatment. Having undiagnosed hearing loss when entering the school system is likely to negatively impact a child’s ability to learn in the classroom and establish social connections with classmates.
6.95
The Committee considers that, given the potentially lifelong impact of untreated childhood hearing loss, there is a clear need for hearing screening in preschool or the first year of school. Using a clinically validated mobile app, such as Sound Scouts, to deliver the screening test could significantly reduce the costs associated with delivering these screenings. The Committee is also of the view that changes to allow for bulk billing and a self-referral to an audiologist following the screening would streamline the process and ensure timely treatment.
6.96
The Committee received evidence that screening could also be used for adults aged 50 years and over. The Committee considers the most effective way to reach this cohort is through public health campaigns to raise awareness of hearing issues and the importance of seeking treatment early. This campaign should include a focus on ensuring general practitioners are aware of the importance of hearing tests and treatment options.
6.97
The Committee received evidence that, although universal newborn hearing screening is considered extremely successful in Australia, there is no data collection or monitoring of program outcomes at the national level. As such, we cannot be certain that all children are being captured by the screening programs and that no child is being lost to follow up. The Committee considers that national data collection and monitoring of newborn screening programs should be implemented to ensure children are not falling through the gaps. This approach should also be considered in the context of school age screening.

Auslan Interpreter Shortages

6.98
The Committee acknowledges the vital role that Auslan interpreters have in enabling Deaf and Hearing Impaired Australians to fully participate in society. The Committee witnessed the work of interpreters first hand, as they supported the Committee’s public hearings throughout this Inquiry, and thanks them for their contribution and expertise.
6.99
The Committee received evidence that there is a shortage of Auslan interpreters across Australia. In particular, there is a critical shortage in the Northern Territory, with only four interpreters working within this jurisdiction. The rollout of the NDIS is only going to increase demand for Auslan interpreters, and the Committee is uncertain as to whether there will be enough interpreters to meet this demand.
6.100
The Committee also acknowledges the important role of interpreters in enabling people to participate in the workforce. The Committee is concerned that the shortage of Auslan interpreters, combined with increased demand for interpreting from the NDIS, will mean people needing interpreters for employment purposes may have difficulty finding a service.
6.101
The Committee commented in Chapter 3 on the importance of the National Auslan Interpreter Booking and Payment Service (NABS), which provides interpreters for medical appointments. The NABS should continue to be accessible for all Auslan users, regardless of whether or not they qualify for the NDIS.
6.102
The Committee is concerned that the introduction of the NDIS may see a reduction in the support provided by state and territory governments, potentially creating gaps in the provision of hearing services. Services such as Auslan interpreters at hospitals should continue to be provided, as they are essential for the wellbeing of hearing impaired and deaf Australians.

Ownership of Australian Hearing

6.103
The Committee welcomes and supports the decision not to privatise Australian Hearing and believes that Australian Hearing should be retained in government ownership.

National Health Priorities

6.104
The possibility of hearing health becoming the next National Health Priority Area (NHPA) was the issue most commonly raised by inquiry participants. There was near universal support for hearing health to become the tenth NHPA. With 3.6 million Australians currently experiencing hearing impairment, and this number being expected to double by 2060, hearing health is clearly an issue that needs to be prioritised.
6.105
The Committee was surprised to hear from the Department of Health that the NHPAs have no policy significance, that is, that there is no funding attached to NHPAs, they do not result in specific plans or programs, and they do not require additional reporting.
6.106
Despite this, the Committee believes that hearing health is a priority health issue for Australia and does see value in it attaining the status of a NHPA.
6.107
The Committee notes that the NHPAs are a Council of Australian Governments policy but suggests that the Department of Health work to clarify what role NHPAs have in determining the health policy and funding priorities of the Commonwealth, state and territory jurisdictions.

Recommendation 14

6.108
The Committee recommends that audiological services for children aged zero to five years remain under the Department of Health’s Community Service Obligations program, with Australian Hearing retaining its role as the sole provider of these services.

Recommendation 15

6.109
The Committee recommends that the Office of Hearing Services fund the creation of a national ‘guided pathway’ system, based in Australian Hearing, to assist parents in choosing expert early intervention services for their children.

Recommendation 16

6.110
The Committee recommends the Council of Australian Governments:
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.

Recommendation 17

6.111
The Committee recommends the Department of Health establish a system of automatic referral to a paediatric audiologist, which can be bulk billed, following identification of a hearing impairment at a school screening program.

Recommendation 18

6.112
The Committee recommends that states and territories be required to report against the ‘National Performance Indicators to Support Neonatal Hearing Screening in Australia’, and that the Standing Committee on Screening coordinates the monitoring and reporting in this area.

Recommendation 19

6.113
The Committee recommends that the National Disability Insurance Agency undertake modelling to determine the likely demand for Auslan interpretation services following the introduction of the National Disability Insurance Scheme, and the capacity of existing services to meet this demand.

Recommendation 20

6.114
The Committee recommends the Government work with states and territories to ensure that Auslan interpretation services are available for interactions with medical, law and other essential services.

Recommendation 21

6.115
The Committee supports the decision not to privatise Australian Hearing and recommends that Australian Hearing be retained in government ownership.

Recommendation 22

6.116
The Committee recommends that hearing health is made a National Health Priority Area.
Mr Trent Zimmerman MP
Chair
7 September 2017

  • 1
    National Disability Insurance Agency (NDIA), Submission 45, p. 1.
  • 2
    NDIA, Submission 45, p. 1.
  • 3
    NDIA, Submission 45, p. 1.
  • 4
    NDIA, Submission 45.1, p. 3.
  • 5
    Department of Health, Submission 16, p. 17.
  • 6
    This figure does not include people entering the NDIS due to a different primary disability who may also be hearing impaired. NDIA, Submission 45, p. 3.
  • 7
    Ms Vicki Rundle, Acting Deputy Chief Executive Officer, NDIA, Official Committee Hansard, Canberra, 16 June 2017, p. 15; and Ms Louise Glanville, Deputy Chief Executive Officer, Governance and Stakeholder Relations, NDIA, Official Committee Hansard, Canberra, 3 March 2017, p. 25.
  • 8
    NDIA, Submission 45.1, p. 3.
  • 9
    NDIA, Submission 45, p. 4.
  • 10
    NDIA, Submission 45, p. 5.
  • 11
    Department of Health, Submission 16, p. 14.
  • 12
    NDIA, Submission 45.1, p. 6.
  • 13
    Department of Health, Submission 16, p. 17.
  • 14
    NDIA, Submission 45.1, p. 6.
  • 15
    Professor Greg Leigh, Chair, Australasian Newborn Hearing Screening Committee (ANHSC), Official Committee Hansard, Sydney, 6 April 2017, p. 10.
  • 16
    Professor Greg Leigh, ANHSC Official Committee Hansard, Sydney, 6 April 2017, p. 6.
  • 17
    Professor Greg Leigh, ANHSC, Official Committee Hansard, Sydney, 6 April 2017, p. 7.
  • 18
    Professor Greg Leigh, ANHSC, Official Committee Hansard, Sydney, 6 April 2017, p. 7.
  • 19
    Aussie Deaf Kids and Parents of Deaf Children, Submission 72, p. 8.
  • 20
    RIDBC, Submission 48, p. 6.
  • 21
    Mrs Ann Porter, Chief Executive Officer, Aussie Deaf Kids, Official Committee Hansard, Sydney, 6 April 2017, p. 19.
  • 22
    Hearing Care Industry Association, Submission 30, p. 13.
  • 23
    Ms Anne Skordia, Expert Advisor, Mainstream Interface and Government Relations, NDIA, Official Committee Hansard, Canberra, 16 June 2017, p. 8.
  • 24
    Ms Alison King, Principal Audiologist, Paediatric Services, Australian Hearing, Official Committee Hansard, Canberra, 3 March 2017, p. 13.
  • 25
    Dr Jim Hungerford, Chief Executive Officer, The Shepherd Centre and Board Member, First Voice, Official Committee Hansard, Canberra, 16 June 2017, p. 4.
  • 26
    Mr Michael Forwood, Chair, First Voice, and Chief Executive Officer, Cora Barclay Centre, Official Committee Hansard, Canberra, 16 June 2017, p. 6.
  • 27
    Mrs Ann Porter, Aussie Deaf Kids, Official Committee Hansard, Sydney, 6 April 2017, p. 20.
  • 28
    Ms Vicki Rundle, NDIA, Official Committee Hansard, Canberra, 16 June 2017, p. 4.
  • 29
    NDIA, Submission 45, p. 2.
  • 30
    The Shepherd Centre, Submission 19, p. 12.
  • 31
    Mrs Ann Porter, Aussie Deaf Kids, Official Committee Hansard, Sydney, 6 April 2017, p. 17.
  • 32
    Mr Michael Forwood, First Voice and Cora Barclay Centre, Official Committee Hansard, Adelaide, 3 May 2017, p. 3.
  • 33
    Mr Michael Forwood, First Voice, Official Committee Hansard, Adelaide, 3 May 2017, p. 5.
  • 34
    Mr Bart Cavalletto, Director, Services, RIDBC, Official Committee Hansard, Sydney, 6 April 2017, p. 37.
  • 35
    Mr Bart Cavalletto, RIDBC, Official Committee Hansard, Sydney, 6 April 2017, p. 37.
  • 36
    Mr Chris Rehn, Chief Executive Officer, RIDBC, Official Committee Hansard, Sydney, 6 April 2017, p. 37.
  • 37
    Mrs Ann Porter, Aussie Deaf Kids, Official Committee Hansard, Sydney, 6 April 2017, p. 18.
  • 38
    Mrs Ann Porter, Aussie Deaf Kids, Official Committee Hansard, Sydney, 6 April 2017, p. 18.
  • 39
    Professor Greg Leigh, ANHSC, Official Committee Hansard, Sydney, 6 April 2017, p. 8.
  • 40
    Professor Greg Leigh, ANHSC, Official Committee Hansard, Sydney, 6 April 2017, p. 5.
  • 41
    Mr Michael Forwood, First Voice, Official Committee Hansard, Adelaide, 3 May 2017, p. 3.
  • 42
    Mr Michael Forwood, First Voice, Official Committee Hansard, Canberra, 16 June 2017, p. 6.
  • 43
    First Voice and the RIDBC, Submission 111, p. 1.
  • 44
    RIDBC, Submission 48, p. 11.
  • 45
    Mr Michael Forwood, First Voice, Official Committee Hansard, Adelaide, 3 May 2017, p. 5.
  • 46
    RIDBC, Submission 48, p. 11.
  • 47
    First Voice and the RIDBC, Submission 111, p. 2.
  • 48
    First Voice and the RIDBC, Submission 111, p. 2.
  • 49
    Mr Michael Forwood, First Voice, Official Committee Hansard, Adelaide, 3 May 2017, p. 4.
  • 50
    NDIA, Submission 45.2, p. 2.
  • 51
    NDIA, Submission 45.2, p. 2.
  • 52
    The Shepherd Centre, Submission 19, p. 12.
  • 53
    The Shepherd Centre, Submission 19, p. 12.
  • 54
    First Voice and the RIDBC, Submission 111, p. 1.
  • 55
    RIDBC, Submission 48, p. 6.
  • 56
    Mr Chris Rehn, RIDBC, Official Committee Hansard, Sydney, 6 April 2017, p. 36.
  • 57
    Australian Hearing, Submission 58.2, p. 3.
  • 58
    Australian Hearing, Submission 58.2, p. 3.
  • 59
    ANHSC, Submission 68, p. 2.
  • 60
    Australian Hearing, Submission 58.2, p. 4, the ANHSC, Submission 68, p. 2.
  • 61
    Australian Hearing, Submission 58.2, p. 4.
  • 62
    ANHSC, Submission 68, p. 2.
  • 63
    The Shepherd Centre, Submission 19, p. 13.
  • 64
    Australian Hearing Hub, Submission 60, p. 3.
  • 65
    Hear and Say, Submission 67, p. 5.
  • 66
    These included the Audiometry Nurses Association of Australia, Submission 15, p. 6; the Shepherd Centre, Submission 19, p. 13; Speech Pathology Australia, Submission 51, p. 21; and the ANHSC, Submission 68, p. 2.
  • 67
    These included Sound Scouts Australia, Submission 41, p 13; Can:Do Group, Submission 50, p. 5; the HEARing CRC, Submission 59, p. 11; and Mr Dig Howitt, Chief Operating Officer, Cochlear Limited, Official Committee Hansard, Sydney, 15 November 2016, p. 9.
  • 68
    Australian Society of Otolaryngology Head and Neck Surgery, Submission 24, p. 5.
  • 69
    Ms Aleisha Davis, General Manager, Listening and Spoken Language Therapy, the Shepherd Centre, Official Committee Hansard, Sydney, 15 November 2016, p. 4.
  • 70
    Dr Zeffie Poulakis, Secretary, ANHSC, Official Committee Hansard, Sydney, 6 April 2017, p. 9.
  • 71
    The HEARing CRC, Submission 59, p. 11.
  • 72
    Sound Scouts Australia, Submission 41, p. 6.
  • 73
    Sound Scouts Australia, Submission 41, p. 7.
  • 74
    Associate Professor Kelvin Kong, Indigenous Health Committee, Royal Australasian College of Surgeons (RACS), Official Committee Hansard, Sydney, 6 April 2017, p. 69.
  • 75
    Ms Carolyn Mee, Director, Sound Scouts Australia, Official Committee Hansard, Sydney, 6 April 2017, p. 12.
  • 76
    RIDBC, Submission 48, p. 18.
  • 77
    Australian Hearing Hub, Submission 60, p. 3.
  • 78
    Speech Pathology Australia, Submission 51, p. 21.
  • 79
    Mr Quenten Iskov, Senior Adviser, Disability Policy and Programs, South Australian Department for Education and Child Development, Official Committee Hansard, Adelaide, 3 May 2017, p. 24.
  • 80
    Mr Quenten Iskov, Senior Adviser, Disability Policy and Programs, South Australian Department for Education and Child Development, Official Committee Hansard, Adelaide, 3 May 2017, p. 24.
  • 81
    Mr Quenten Iskov, South Australian Department for Education and Child Development, Official Committee Hansard, Adelaide, 3 May 2017, p. 24.
  • 82
    Associate Professor Kelvin Kong, RACS, Official Committee Hansard, Sydney, 6 April 2017, p. 69.
  • 83
    Hear and Say, Submission 67, p. 5.
  • 84
    Mr Chris McCarthy, Chief Executive Officer, Hear and Say, Official Committee Hansard, Brisbane, 21 April 2017, p. 2.
  • 85
    Mr Chris McCarthy, Hear and Say, Official Committee Hansard, Brisbane, 21 April 2017, p. 2.
  • 86
    Sound Scouts Australia, Submission 41, p. 1.
  • 87
    Sound Scouts Australia, Submission 41, p. 1.
  • 88
    Ms Carolyn Mee, Sound Scouts Australia, Official Committee Hansard, Sydney, 6 April 2017, p. 14.
  • 89
    Sound Scouts Australia, Submission 41, p. 12.
  • 90
    Ms Carolyn Mee, Sound Scouts Australia, Official Committee Hansard, Sydney, 6 April 2017, p. 14.
  • 91
    The Shepherd Centre, Submission 19, p. 13.
  • 92
    The Shepherd Centre, Submission 19, p. 13.
  • 93
    Dr Jim Hungerford, The Shepherd Centre, Official Committee Hansard, Sydney, 15 November 2016, p. 2.
  • 94
    Australian Hearing Hub, Submission 60, p. 3.
  • 95
    RIDBC, Submission 48, p. 18.
  • 96
    Australian Hearing Hub, Submission 60, p. 3.
  • 97
    Cochlear, Submission 91, p. 25.
  • 98
    RIDBC, Submission 48, p. 18.
  • 99
    Audiology Australia, Submission 49, p. 9.
  • 100
    Cochlear, Submission 91, p. 18.
  • 101
    This amount was ‘based on the assumption that in 2017 all people aged 50, 55, 60, 65, 70, 75 and 80 were to be invited for hearing assessment. At 50, 55 and 65, 55 per cent of people are assumed to participate in screening. At 65, 70, 75 and 80, 65 per cent of people are assumed to participate in screening…the cost of a hearing assessment as reported by the OHS Fee Schedule for 2016-17 was $136.25 per person.’ Deloitte Access Economics, Exhibit 18: An Update on the Social and Economic Cost of Hearing Loss and Hearing Health Conditions in Australia (June 2017), p. 65.
  • 102
    Dr Anthony Hogan, Exhibit 3: Barriers against the implementation of hearing impairment screening programmes for adults – a scoping study into the General Practitioners’ perspective, pp 13-14.
  • 103
    Mr Kyle Miers, Chief Executive, Deaf Australia, Official Committee Hansard, Melbourne, 1 May 2017, p. 34.
  • 104
    Mr Kyle Miers, Deaf Australia, Official Committee Hansard, Melbourne, 1 May 2017, p. 34.
  • 105
    Ms Heidi Limareff, Acting Chief Executive, Can:Do Group, Official Committee Hansard, Adelaide, 3 May 2017, p. 8.
  • 106
    Ms Heidi Limareff, Can:Do Group, Official Committee Hansard, Adelaide, 3 May 2017, p. 8.
  • 107
    Mrs Jenice Wheeler, Education Manager, Foundation Skills, TAFE SA, Official Committee Hansard, Adelaide, 3 May 2017, p. 12.
  • 108
    Mr Kyle Miers, Deaf Australia, Official Committee Hansard, Melbourne, 1 May 2017, p. 31.
  • 109
    Australian Sign Language Interpreters Association, Submission 85, p. 4.
  • 110
    Deaf Australia, Submission 82, p. 32.
  • 111
    National Commission of Audit, Towards Responsible Government: The Report of the National Commission of Audit Phase One, February 2014, p. 215.
  • 112
    National Commission of Audit, Towards Responsible Government: The Report of the National Commission of Audit Phase One, February 2014, p. 221.
  • 113
    Senate Select Committee on Health, Third Interim Report: Australian Hearing: Too Important to Privatise, Canberra, September 2015, p. xi.
  • 114
    Deafness Forum of Australia, Submission 17, p. 38.
  • 115
    Mr Chris Rehn, RIDBC, Official Committee Hansard, Sydney, 6 April 2017, p. 34.
  • 116
    Australian Society of Otolaryngology Head and Neck Surgery, Submission 24, p. 3.
  • 117
    Deafness Forum of Australia, Submission 17, p. 38.
  • 118
    Australian Government, Budget 2017-18: Budget Measures, Budget Paper No.2, p. 98.
  • 119
    Department of Health, Submission 16.2, p. 2.
  • 120
    Department of Health, Submission 16.2, p. 2.
  • 121
    For example: Better Hearing Australia, Submission 83, p. 16; The Deafness Forum of Australia, Submission 17, pp 33-35; Self-Help for Hard of Hearing People Australia, Submission 42, p. 24.
  • 122
    For example: Audiometry Nurses Association of Australia, Submission 15, p. 6; Audiology Australia, Submission 49, p. 13; Speech Pathology Australia, Submission 51, p. 19.
  • 123
    For example: Australian Hearing Hub, Submission 60 p. 2; The Bionics Institute of Australia, Submission 27, p. 4; The HEARing Cooperative Research Centre, Submission 59, p. 16.
  • 124
    For example: Cochlear Ltd, Submission 91, p. 26; Hearing Care Industry Association, Submission 30, p. 1; RIDBC, Submission 48, p. 20.
  • 125
    Deafness Forum of Australia, Submission 17, p. 33.
  • 126
    Deafness Forum of Australia, Submission 17, p. 33.
  • 127
    Deaf Australia, Submission 82, p. 3.
  • 128
    Department of Health, Submission 16.2, p. 2.
  • 129
    Ms Trisha Garrett, Assistant Secretary, Office of Hearing Services, Department of Health, Official Committee Hansard, Canberra, Friday 16 June 2017, p. 39.

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