CHAPTER 5

ADEQUACY OF ACCESS TO HEARING SERVICES

The family are dreading Nicole turning 21 when she will lose Australian Hearing support...

Quoted in Quota International of the Leisure Coast, Submission 22, p. 2.

Introduction

5.1        This chapter examines the adequacy of access to hearing services in Australia, including assessment and support services, and hearing technologies.

5.2        The issue of access is at the heart of everyday challenges for people with a hearing impairment. From access to audiological and clinical help, to obtaining the most appropriate assistive technology, to watching television, the committee understands that access issues of all sorts are never far from the consciousness of people with a hearing impairment.

5.3        The single most common issue raised with the committee during this inquiry was the eligibility criteria for Australian Government Hearing Services Program services and support, and in particular the eligibility cut off age of twenty-one years. The committee heard evidence of the distress and financial hardship this policy can cause, as well as other unintended consequences, such as people having to go without hearing aids and specialist audiological support.

5.4        Evidence was presented to the inquiry from both hearing health practitioners and their clients about accessibility to, and quality standards of, hearing assessments in Australia. The committee also heard concerns about the level of support that is available to assist people with a hearing impairment and their families adjust to life with hearing loss.

5.5        The committee heard about the issues some sectors of the community have experienced accessing the different technologies that are available to hearing impaired Australians. Evidence was also raised about the difficulties people with a hearing impairment sometimes have accessing services which other Australians take for granted, such as television and movies.

Access to hearing services

Eligibility for Australian Government Hearing Services Program support

5.6        As has already been noted, the issue of access to government services, and particularly to Australian Government hearing services, was of interest to most people making submissions to this inquiry.

5.7        The Australian Government provides hearing services through the Office of Hearing Services (OHS). Support is available to eligible Australians under the Hearing Services (Voucher) Payments and the Community Service Obligation (CSO) programs.[1]

Australian Government Hearing Services Program Hearing Services (Voucher) Payments: Payments are made to hearing service providers for the delivery of services under the voucher system to eligible clients. The services include hearing assessments, the cost of the hearing device and its fitting, and the government contribution to the maintenance and repair of hearing devices. Eligibility requirements to receive the services are as follows: Australian Citizens and Permanent Residents 21 years or older and: the holder of a Centrelink or Department of Veterans Affairs (DVA) Pensioner Concession Card; the holder of a Gold Repatriation Health Card (DVA) issued for all conditions; receiving Sickness Allowance from Centrelink; the holder of a White Repatriation Health Card (DVA) issued for conditions that include hearing loss; a dependent of a person in one of the above categories; a member of the Australian Defence Force; or undergoing an Australian Government funded vocational rehabilitation service and referred by their service provider. Community Service Obligation (CSO): Funds are allocated to Australian Hearing for the delivery of services under the CSO to meet the hearing needs of special needs groups. The CSO program, including National Acoustic Laboratories (NAL), is provided by Australian Hearing under an agreement with the Australian Government.[2] Clients under these categories receive the same services as those provided to voucher clients but receive additional services to address their specific needs. Special needs groups include: all children and young adults under 21 years of age (including replacement of cochlear implant speech processors); eligible complex adult clients; eligible Indigenous clients; eligible clients who live in remote areas; and an Aboriginal person or Torres Strait Islander who is over 50 years; or a participant in a Community Development Employment Projects Program. Program details from the Department of Health and Ageing website, viewed 8 April 2010, http://www.health.gov.au/hear

5.8        State and territory governments provide some hearing health services, such as screening, prevention activities, hearing assessments through community health centres, workers' compensation services and cochlear implantation at public hospitals.[3]

Eligibility for Australian Government Hearing Services among 21 to 65 year olds

5.9        Many submitters raised in evidence the fact that Australian Government Hearing Services Program support is available to all Australians up to 21 years of age and then, with the exception of people living on a Disability Support Pension, they are cut off. The committee heard that approximately 700 people lose their eligibility each year when they turn 21.[4]

5.10      The general view expressed to the committee could be summarised by this submitter:

[For people aged between 21 and 65 who are ineligible for Office of  Hearing Services support] hearing aids are treated like luxury devices...they are not, they are essential requirements...If a pair of glasses cost the same as hearing aids, would the [eligibility] policy be the same?[5]

5.11      The committee heard about a number of issues facing former clients of Australian Hearing when they turn 21. Australian and New Zealand Parents of Deaf Children (ANZPOD) explained in their submission that the nature of private audiological practice is different to that of government services:

[Former Australian Hearing clients turning 21] need to find an audiologist in the private sector who understands the issues of congenital deafness and has the knowledge and skills in the complexities of their needs. Most private audiologists are experienced in acquired hearing loss and the appropriate audiologist is almost impossible for our children to find.[6]

5.12      The experience of another submitter also picked up on this point:

[When I turned 21] I enquired from all my deaf friends of audiologists they used, but most people went without the support of an audiologist for as long as possible after losing the services of [Australian Hearing].[7]

5.13      One former Australian Hearing client related her feelings on losing the support of Australian Hearing at age 21:

Suddenly at the age of 21 years old, I found it difficult to find the means to obtain batteries and maintaining my cochlear implant equipment on...my own. A piece of rechargeable cochlear implant battery can cost up to $500 or a couple of hundreds if I need to replace a part...At only 23 years old, this is a lifelong commitment, and in order to remain integrated with the Hearing world, it is expensive and perhaps a little unfair that I should have to pay when a normal hearing person does not have to deal with those emotional and financial issues.[8]

5.14      Another person shared her experiences:

Suddenly at the age of 21, just when I was unemployed and studying full time at university, I was told I could no longer get any services through Australian Hearing; I developed extremely low self esteem and avoided social situations. I was constantly worried and panicky which affected those around me such as my parents and friends. When my hearing aids broke during crucial situations I felt like giving up because there was no one to turn to and no money to cover the cost of new ones.[9]

5.15      The greatest challenge facing 21 year olds is that they are not yet established in their careers, and indeed are often studying or in low paid jobs. Losing access to Australian Hearing support could have long term consequences for individuals and for society at large, as one witness told the committee:

I think it [i.e. cutting off Australian Hearing services at age 21] constitutes a disservice to Australia and the Australian community simply because, after all, if people cannot participate effectively in the workplace then you have lost production, lost opportunities and lost ability to function in the wider community. This has a very significant flow-on effect.[10]

5.16      The Shepherd Centre was passionate in their remarks to the committee on this issue:

If this committee can achieve anything the one group that needs really special attention—and you are beginning to hear it—is young adults who go through Australian Hearing until they are 21 and are then left to their own devices to find their way through their education and their vocation unaided in terms of any financial support. If they had a degree of hearing loss that warranted considerable support from Australian Hearing for 21 years then it seems to me to follow that they need some support to get themselves established in their careers. It seems to me to be a travesty that these children are unable to get any support whatsoever unless they end up as a pensioner, which is not really where you want them to be...It is in society’s interest to keep those young adults performing to their peak and self-realising.[11]

5.17      People with hearing loss aged between 21 and 65 who are not eligible for Australian Government Hearing Services Program support have the option of taking out private health insurance to help meet the costs of purchasing and maintaining hearing devices. The committee noted in chapter four that the cost of private health insurance for hearing devices is high and benefits are perceived to be low, which does little to ease the cost issues faced by young people and retirees.[12]

5.18      The committee heard from Mr Tony Abrahams that a no-fault National Disability Insurance Scheme could hold part of the answer for hearing impaired Australians who are ineligible for Australian Government support:

The basic principles behind a no-fault national disability insurance scheme are that we as a community would provide any individual with impairment...a voucher to exchange for access services that that individual was able to choose from a free market, [which] will enable them to participate in the workforce, get a job, earn an income, get off the disability support pension and pay tax—and they will pay it back.[13]

5.19      Evidence suggests that many former clients of Australian Hearing would be willing to pay a fee for Australian Hearing services after they turn 21 to continue the quality of care and the professional relationships they had built up, sometimes over their lifetime.[14]

5.20      The committee would like to note that many people testified to the high quality of service they and their families receive from Australian Hearing, and that their issue was with eligibility conditions and not the service itself. The following comments from one individual submission are typical:

...I cannot speak highly enough of the hearing services offered to [my 15 year old daughter] as a child living in Melbourne. At all points along the pathway from her diagnosis of a profound hearing loss just before her first birthday until now, we have been helped by caring professionals and supported financially by the Australian Government through Australian Hearing and the Cochlear Implant Clinic at the Royal Victorian Eye and Ear Hospital.[15]

5.21      The committee heard evidence that increasing access to OHS support for older workers would have economic benefits for those individuals and for the country in general. The Hearing Care Industry Association (HCIA) noted that employment rates for people with a hearing impairment between the ages of 45 and 65 are up to 20 per cent lower than for non-hearing people.[16] As has been noted in chapter three of this report, lost earnings is the biggest single cost of hearing impairment to Australia at around $6.7 billion per year.[17]

5.22      HCIA added that:

If Australia were to move towards world’s best practice, it should examine uncoupling access to hearing services and the pension age, so that people in the 45 to 64 age group (or part of that age group) could access hearing services at a time when they are highly motivated to use such services and thus remain productive for as long as they can.[18]

5.23      The National Seniors Association (NSA) also argued that lost productivity among older Australians could be eased if eligibility to OHS support was extended to those younger than 65 years,[19] as did Services for Australian Rural and Remote Allied Health (SARRAH)[20] and Deafness Forum of Australia.[21]

Access to hearing services in regional and remote areas

5.24      Another prominent issue arising from the evidence in regard to accessing hearing services was the difficulty of accessing services outside urban centres. The committee heard evidence that one of the main obstacles to provision of hearing services in regional and remote areas was attracting and retaining qualified staff. Connect Hearing claimed in their submission that:

The spread of hearing services is unbalanced between regional and metropolitan areas. This is in part due to the difficulties attracting and retaining hearing care professionals in regional and rural areas and also due to socio-economic factors making servicing rural areas less attractive to hearing service providers. Within Connect Hearing, there is currently a three month waiting list for services in regional New South Wales (NSW), but in Sydney 95 per cent of services could be provided within 5 working days.[22]

5.25      Attracting and retaining qualified staff is a major issue in Central Australia, according to audiologist Rebecca Allnutt:

[Audiology] is a master’s degree now. It is two years and it is very expensive—when I did it, it was only one year and it was a postgrad degree. There are very limited places, and new grads are tending to stay in the cities. We are competing with a very productive private market that [is] offering new graduates a lot of money to stay in town. We are dealing with hearing aid companies that are very wealthy. Trying to get young grads to come out and work here [i.e. Central Australia], we are finding very difficult.[23]

5.26      Dr Stuart Miller, President of the Australian Society of Otolaryngology Head and Neck Surgery (ASOHNS) noted that attracting Ear, Nose and Throat (ENT) surgeons and other hearing health professionals to regional areas should be a priority for policy makers.[24] Professor Robert Cowan of the HEARing Cooperative Research Centre (CRC) in Victoria agreed that placing qualified audiologists in regional areas is an issue:

...part of the problem is the regional disparity. This is a phenomenon in Australia: everyone wants to work in the cities; no-one wants to work in the country. Rural audiology services cry out for people. If any funding was going to go to scholarships for people to train with audiologists, I would think they should then be linked to country service.[25]

5.27      Farmsafe Australia noted that public hearing health services in remote and rural areas focus on children and Indigenous Australians. Whilst acknowledging that this focus is 'important and appropriate', Farmsafe pointed out that 'it has left a considerable cohort of individuals within the agricultural sector and rural communities more broadly, under serviced.'[26]

5.28      While there have been some assessment programs for the agricultural sector in New South Wales (NSW), South Australia, Tasmania and Queensland, only NSW through the Rural Noise Injury Prevention Program is currently functional. Farmsafe Australia proposed that the extension of such a program is crucial to efforts to prevent hearing loss in the agriculture sector, and that a core feature of this program must be the provision of screening and preventive advice in localities that are farmer-friendly, such as agricultural shows.[27] Further, the Hearing Impaired and Deaf Kindred Organisation Network (HIDKON) reported that the Farm Noise and Hearing Network which involves hearing screenings and information provision at rural field days, country shows and events is on the brink of folding due to a lack of funding and support.[28]

5.29      Recognising that services are difficult to access in regional areas, Mr Patrick Gallagher of Attune Hearing described to the committee different ways that organisation provides regional services:

At the moment...we are in the process of developing a model that will enable us to take services to communities. For example, we were recently in Bamaga, in North Queensland, as a pro bono initiative. In fact my colleague Jenny Stevens, who is an audiologist, went there with one of our surgeons and others from the health sector to provide services on a visiting basis.

To give another example, in Longreach we provide training, on our time, to Indigenous health workers. We travel to provide that service because we do not yet have a stand-alone clinic in Longreach. We see that as part of our provision of support back to the community.[29]

5.30      Other initiatives which aim to provide services in remote areas include the Deadly Ears project in Queensland[30] and the Earbus initiative in Western Australia.[31] These initiatives are discussed in detail in chapter eight of this report.

5.31      The committee heard evidence that hearing services provided by state and territory governments are sometimes provided on a very small scale, making them hard to access. For example:

Publicly funded audiology services are very limited in Tasmania. Audiology services are provided one day a week at the Royal Hobart Hospital in the south of the State. With the exception of a cochlear implant clinic, no other audiology assessment or rehabilitation services are provided in the [state] public sector.[32]

5.32      Some services previously offered in other states are being reduced. For example one submission claimed whilst audiology services in NSW are still provided, the number of audiology departments has been reduced, and hours of staffing reduced also.[33] In Victoria too, there was evidence that services have been reduced:

Audiology departments in many regional hospitals have been closed for several years now and, although some hospitals are now reinstating paediatric audiological services, there are still large areas of Victoria with no service within a reasonable travelling distance.[34]

5.33      Another issue that was raised with the committee in relation to rural and remote access was the lack of access to patient assisted travel schemes for people consulting audiologists.[35]

5.34      Australian Hearing noted that whilst 'Most States have programs to meet the cost of travel for families who need to access diagnostic services if their infant fails the initial hearing screening' that support does not extend to the families of older children who have to travel to attend audiological diagnoses.[36]

5.35      The committee heard evidence that the Patient Assisted Travel Scheme (PATS) does not provide assistance with travel for allied health appointments, including audiologists.[37] PATS is available for medical practitioner appointments however, and the committee heard that where possible appointments with audiologists are made to coincide with medical practitioner appointments so that patients can have access to PATS assistance.[38]

5.36      The problems of accessing suitable services for hearing impaired children living in remote and rural areas were highlighted during the inquiry. Children with hearing impairment may require a range of services including speech therapy and instruction in Auslan, as well as support for the family. There are major difficulties in providing these services outside large population centres. Ms Sheena Walters, Deaf Society of NSW, commented:

I think the service models that would be required in urban areas or where there are large populations compared to regional areas would be completely different. I think that realistically to expect that the services or the skills will be available in those areas is difficult in Australia, but certainly using technology is something that is becoming more and more prevalent and advantageous for kids out in those areas.[39]

5.37      In Sydney the committee visited the Royal Institute of Deaf and Blind Children (RIDBC) at North Rocks. The RIDBC is Australia's largest and oldest private provider of educational services to deaf children. It is also a major player in developing innovative educational programs to fill the gaps in the education of children who are deaf or blind and also those with additional disabilities. One of those innovative programs is the use of remote service delivery technologies. This program was pioneered by the RIDBC and currently serves more than 150 children and families in remote locations through the Teleschool program. That program provides for the delivery of both early intervention and specialist school age services through a range of video-conferencing and remote access technologies.[40]

5.38      Professor Gregory Leigh, Chair, RIDBC, stated that the Teleschool operates 'on the premise that children need good access, particularly at the early intervention level, to quality intervention regardless of where they happen to be'. [41] Children with hearing impairment are able to access high quality therapeutic and educational intervention based in Sydney through one of a number of different technologies such as ISDN based point-to-point technologies, and internet-based protocols. This has enabled a large number of families to access the Sydney centre with video conferencing equipment installed in their homes, cellular network based video conferencing technology and satellite technology. Over 150 children in various rural, typically remote areas of Australia are now receiving regular – weekly or fortnightly – early intervention that is analogous to the early intervention they would receive were they located in Sydney. In addition, RIDBC supports some children internationally because of an arrangement with the Sydney Cochlear Implant Centre.

5.39      Professor Leigh commented:

It has been very, very successful. Matched with the fact that the organisation provides for those families to visit Sydney at least once a year, that means that the quality of intervention that those families are receiving has really been brought up to a level much, much more similar, if not arguably in some cases better than their city based counterparts.[42]

5.40      Professor Leigh noted that the RIDBC if funded mainly through donation with about one quarter of its funds being provided by the Commonwealth and state governments.[43]

Access to hearing services for people from non-English speaking background

5.41      The National Ethnic Disability Alliance (NEDA) raised with the committee several issues that impact on people from non-English speaking backgrounds (NESB) who are attempting to access hearing health support services.[44]

5.42      The first of these issues is that existing support services are often provided only in English, and in written form. This can be a barrier for people who have poor English comprehension and literacy skills.[45]

5.43      NEDA also claimed that some people experience a lack of cultural sensitivity among healthcare professionals generally.[46] Insensitivity was also identified specifically in relation to parents of deaf children. NEDA pointed to a report for the Victorian Deaf Society which:

...claims that NESB parents of deaf children have been advised by health professionals not to teach their child their mother tongue. This has resulted in the cultural and linguistic isolation of deaf children from their family and ethnic community. The report heavily emphasizes that NESB children who are deaf be taught their mother tongue as well as English.[47]

5.44      NEDA also noted that poverty is a common experience for new immigrants to Australia, and that many are unable to access government support, including health and welfare support. The extra costs associated with hearing loss are a particular burden on these vulnerable members of the community.[48]

5.45      Dr Louisa Willoughby of the Victorian Deaf Society commented that whilst the situation for non-English speaking deaf people newly arrived in Australia is hard, in fact many are able to access support and hearing devices through philanthropic organisations.[49]

5.46      Australian Hearing provides support and resources to assist non-English speaking people to access their services. These include provision of interpreters at no cost to the client, provision of resource material in ten languages, engagement with organisations representing non-English speaking Australians and training for Australian Hearing staff in working with clients from other cultures.[50]

Access to assessment services

Universal screening for newborns

5.47      Many people providing evidence to this inquiry were highly supportive of the Council of Australian Governments (COAG) commitment to introduce universal newborn hearing screening by the end of 2010. The rationale behind the initiative is that children who are diagnosed and receive intervention within the first six months of life achieve better speech and language skills than children who are diagnosed after six months.[51]

5.48      Professor Harvey Coates cited research from South Australia which suggests that there is a:

...$1.2 million saving for each baby detected with bilateral severe or profound sensor neural hearing loss and habilitated before the age of 6 months. These savings [are] in future community costs particularly in education and to a lesser degree in health and in savings in the provisions of pensions and other special care programs.

In Western Australia for example since the first universal newborn hearing program commenced in February 2000 over 120,000 babies have been screened and the savings of the 130 babies detected with bilateral severe or profound sensorineural hearing loss to the community has been in the order of $140 million. If this is extrapolated ten times to the population of Australia of its birth cohort then the savings of the universal newborn hearing screening [initiative]...by the end of 2010 will be enormous.[52]

5.49      Deafness Forum of Australia also noted the benefits of universal newborn hearing screening:

In those areas and communities where newborn hearing screening is available, it has had a very positive impact in the community (both amongst parents/families and professionals) in raising the awareness of potential hearing loss in infants.[53]

5.50      Professor Harvey Dillon gave evidence that the real proof that universal newborn screening is having the desired impact was in the age take-up rate of hearing aids for children:

We are pleased to say that the age at which there are more children receiving a hearing aid for the first time than at any other age is less than one year, which is showing how well universal screening is working in the places where it is, which is now most of Australia.[54]

5.51      Whilst supportive of the principle of universal hearing screening for newborns, some submissions questioned the possibility of achieving such a goal for all Australians in all parts of the country. Audiology Australia expressed the view that 'regional inequities due to lack of qualified staff and equipment' will impact on the extent and effectiveness of the initiative.[55]

5.52      The committee also heard that even where universal newborn screening is achieved, there are concerns about the capacity of systems to provide the follow up necessary for the additional diagnoses and support for hearing impaired children:

It is imperative that appropriate services to follow up and manage the children diagnosed [under universal newborn screening] are also provided.[56]

5.53      One witness commented that resources for follow up diagnostics are not provided in Victoria:

Audiological services in Victoria (and indeed across Australia) are being asked to support Universal Neonatal Hearing Screening...without ...funding for the diagnostic component. Currently newly born babies are screened for hearing loss in hospitals and...those that do not pass screening, are referred for full diagnostic follow up. The screening component is fully funded by the state of Victoria. The follow up diagnostic component receives no funding and public audiology clinics support this important initiative without any provision of resources.[57]

Universal hearing screening for children on commencement of school

5.54      The committee heard from a number of people and organisations about the importance of screening children regularly during their early development years. Professor Harvey Coates informed the committee that:

It is well known that [the rate of] permanent hearing loss doubles by age five and triples by age 10 with acquired and progressive sensorineural hearing loss. Therefore, at-risk children should not only have the newborn hearing screening test, they should also have a test at six months, a year and then annually until they go to school. For children who are ‘normal’ then the newborn hearing test, one at age one, one at three and then the school tests would be adequate.[58]

5.55        One witness expressed concern that universal newborn screening is drawing resources away from screening other age groups:

I think [universal newborn screening] is fantastic; it is what has been needed for a long time. But what I am noticing now is that the community service—the nurses who used to provide that in the preschool year—seems to be dropping off... And there are a lot of hearing losses in children that develop from birth to year 4 or 5. So that screening component should not be dropped.[59]

5.56      Another witness commented that hearing screenings for older children seem to have declined since the implementation of universal newborn hearing screening:

Since the advent of newborn hearing screening programs, there seems to be less support of other hearing screening programs. Since newborn hearing screening will only identify approximately one third of children who will eventually require hearing aid fitting it is essential that access to primary hearing screening services be readily available. As a high proportion of children are identified around ages 5-6 years it would be highly beneficial if the school hearing screening program was reinstituted or if the child health check undertaken at age 4 years included an objective hearing assessment...[60]

5.57      This view was reinforced by Australian Hearing, which commented that 'most states no longer have school hearing programs'.[61] Professor Harvey Dillon explained to the committee the importance of screening children as they start their schooling:

Typically, these children [i.e. hearing impaired children aged six, seven and eight years of age who have not been previously diagnosed] will be picked up because basically they are not doing well at school and someone will notice they are having trouble coping in the classroom. That reinforces for us how much better it would be if these children could be picked up in preschool or right at the start of kindergarten, so they do not have that first bad experience of one, two or three years of not coping. In fact, the number who were picked up in those three age ranges is more than twice the number who are picked up by universal [newborn] screening. That is because with some of them the loss is too mild to have been able to be detected when they are a baby. For others it will be a case of a progressive loss and for others there will be hearing losses that have occurred through illness or injury during the intervening years.[62]

5.58      This view, that children should be screened again prior to, or on commencement of, their first year of schooling, was shared by other witnesses including ASOHNS[63], the Australian Newborn Hearing Screening Committee[64] and Audiology Australia.[65]

Access to the Australian Government Hearing Services Program for people in custody

5.59      The connection between hearing loss and increased engagement with the criminal justice system has been noted at chapter four of this report. This issue is of particular relevance for Indigenous Australians, for whom hearing issues may be compounded by cultural and language communication issues, as discussed in detail at chapter eight.

5.60      At the time of their submission to this inquiry (October 2009), Australian Hearing remarked that young Australians in juvenile custody did not receive Australian Hearing services. The Department of Health and Ageing (DOHA) has since updated its advice on this issue. People who were already in receipt of Commonwealth funded hearing services at the time they were incarcerated may continue to receive these services. However when a person in custody is diagnosed with hearing loss after their incarceration, the costs of intervention and support are to be borne by the state or territory government.[66]

Quality standards for hearing assessments in the private sector

5.61      A number of people gave evidence that the absence of agreed standards in audiological assessment may lead to incomplete diagnoses. Furthermore, according to evidence before the committee, whilst most Australians would be able to access free hearing screenings in the private hearing health sector, they should be aware of the level of assessment they will receive:

There are claims of a ‘diagnostic assessment’ when it is just a screening test...When you perform a hearing test, there are five components to the hearing test: air conduction, bone conduction, middle ear, acoustic reflex and speech discrimination. All those components may come together to identify an underlying medical problem...If you do one component of that test it is very limiting and only identifies hearing loss...It just says, ‘Yes, you’ve got hearing loss.’ If you do not perform the full range of that diagnostic assessment then you could miss some underlying medical pathology that is causing that hearing loss.[67]

5.62      In one example presented to the committee, a person claimed to have received poor quality care, and been left out of pocket for her trouble:

I had to find a private audiologist [when I turned 21], three of whom were not very good, and I bought hearing aids from each of them when one would have been enough. Each hearing aid is about $3500 to $4000. One of them also convinced me to buy an FM system for $1500 which I have never used, because it was not correct for my hearing loss.[68]

5.63      Donna Staunton, CEO of the HCIA, wrote to the committee condemning such practices:

I...wish to place on record the Hearing Care Industry Association’s total opposition to this kind of unethical and exploitative behaviour. Our members aim to deliver world-class hearing healthcare to all Australians. It has at the core of its mission, its clients and it aims to help all Australians who are suffering from hearing loss to achieve a better quality of life. In particular the Association’s members do not prescribe or provide hearing aids unsuitable or unnecessary for particular clients. They prescribe according to the client’s need, not their own and they do this after making a fully informed, professional judgement.[69]

5.64      Many submitters made a connection between the provision of free hearing screenings and the sale of hearing aids.

In my [hearing impaired] husband's experience, most private audiology practices are aligned with a particular brand (or brands) of hearing aids and therefore their advice is heavily influenced by the need to promote and sell those particular products. That means the client is rarely receiving advice which is in his / her best interests or which meets his / her needs.[70]

5.65      In a similar vein, the committee heard from one witness:

...I think [it] is very wrong is that, in a lot of instances, the hearing aid industry indulge in a lot of misleading advertising. To people who really do not know anything about hearing loss and people who are just starting to lose their hearing, these advertisements give the impression that if they get a hearing aid everything is going to be just right. I know a lot of people who have done that and have then discarded the hearing aid because it does not meet their expectation. I think all this advertising really needs to be modified so that the situation is a little bit more realistic, rather than just selling hearing aids for purely commercial purposes.[71]

5.66      The committee heard evidence from Better Hearing Australia (Victoria) that people with a hearing impairment are concerned about the independence of advice they receive from hearing aid practitioners:

Many hearing aid practitioners offer free hearing tests, but our experience with, and feedback from the public is that they have concerns about engaging with an organisation that they believe wants to sell them a hearing aid. This means that individuals are more inclined to delay having their hearing checked until it becomes much worse, or they are “persuaded” to do so by a family member. Easier access to free, and just as importantly independent, hearing checks for all Australians would encourage people to take action sooner.[72]  

5.67      Attune Hearing suggested that the nature of audiology practice in Australia had changed:

The hearing industry today is vastly different to what it was 3-5 years ago. A once small, privately owned ‘audiology’ industry has been replaced by a corporately consolidated, hearing aid product driven industry.[73]

5.68      Better Hearing Australia (Victoria) also commented that the culture of selling products sometimes prevails over quality advice and service:

There seems to be a culture of selling products rather than helping people deal with their problems...An inquiry about how much a hearing aid would cost, netted the response, “How much can you afford”, and another client was quoted a price which seemed very high so went elsewhere. When the original practitioner called to see why he hadn’t been back, he explained that he had [found] the same product for $2000 less, and was told they would match the price! He asked the “sales person” if he was selling health services or used cars.[74]

5.69      Attune Hearing provided the committee with a list of possible consequences of free hearing screenings conducted inexpertly:

...At great cost to the Commonwealth, many consumers have been fitted with hearing aids in circumstances where they will never benefit from them...Consumers have not been properly, diagnostically examined, such that serious medical indicators have been missed with resulting serious medical consequences for the patient...Consumers often do not maintain use of hearing aids because they did not receive adequate professional counselling prior to fitting, or adequate follow up service or support (if any).[75]

5.70      Evidence was provided to the committee that access to independent and high quality audiological assessment would improve if audiologists were given more capacity to provide audiological services under Medicare than is currently the case.[76]

5.71      A number of submitters remarked that a set of agreed standards for audiological assessments would help healthcare consumers make more informed choices about the services they need.[77] Nationally agreed standards may also help improve the overall quality of audiological services and assessments currently provided. As Patrick Gallagher of Attune Hearing stated to the committee:

I think [it is necessary to have] a properly regulated industry with appropriate quality standards, so that there is an even playing field. This industry is unregulated. I can sell a hearing aid on the street downstairs. ...We are a business that provides services for a profit. We do not hide behind that. We also provide services to clients in the medical community that we struggle to support in financial terms. We are not here to cry poor but we advocate a regulated set of standards in the for-profit sector so that there is a level playing field. The bar needs to be raised...The industry has become product focused. We are not knocking those that do it. We are not here to knock the manufacturers...But our business is in the market competing for members of the public. It is difficult to differentiate yourself in that market as a smaller business when there are no appropriate standards. So we say, ‘Raise the bar.’ We say that a diagnostic test is a diagnostic test, not a screen.[78]

Access to support services

5.72      The committee heard that diagnosis of hearing impairment at any age can be a traumatic experience for the hearing impaired person and for the people around them.[79] Access to appropriate support and advice at this time is very important, and may have some bearing on the success of any subsequent intervention. However many witnesses and submitters explained to the committee that they received little support and resources to assist them, and would like to see this aspect of hearing health improved.

 Counselling support at the time of hearing loss diagnosis

5.73      The North Shore Deaf Children's Association stated that 'Approximately 90% of children with a hearing loss are born to parents with little or no experience of deafness'.[80] The committee heard that for these parents there is a great need for independent support and advice at the time of birth, after the diagnosis appointment, and as they consider intervention options after the diagnosis.[81]

5.74      One submission commented that they found little support or advice to assist them:

The [Australian Hearing] audiologists were very nice but there was no follow-up to assist us with the shock of being told [that their 8 month old son was hearing impaired]. There was no program to get us into early intervention – no case worker support, no counselling – we were on our own. It was some time before we could even discuss our son's disability without being emotional.[82]

5.75      The evidence suggests that the shock of hearing loss diagnosis, and subsequent need for quality support and advice, is no less when made later in life for both the hearing impaired person and for their families:

My hearing loss was first discovered at age 11, and I was given hearing aids without any sort of rehabilitation or support. It took me ages to get used to them and to wear them. It was a traumatising experience as a child.[83]

When my daughter was first diagnosed [with hearing loss in both ears] I asked many departments for information for [her] teachers, and the only pamphlet I was given was so old it suggested pipes and cigarettes be removed from the teacher's mouths when talking to deaf children.[84]

5.76      One organisation commented on the link between universal newborn hearing screening, increased diagnoses of hearing loss, and the increased need for support:

Parents fully support newborn hearing screening and appreciate knowing that their child has a hearing loss early but they then need guidance and support and access to services to ensure the best outcomes for their child.[85]

5.77      Parents of children newly diagnosed with hearing loss are provided with 'Choices', a booklet produced by Australian Hearing.[86] The booklet presents information about the issues parents of children newly diagnosed with hearing loss may be experiencing, and the things they may be feeling. 'Choices' also provides practical information about the sorts of testing the parents should anticipate, and the choices they will have for their children.[87]

5.78      One submitter expressed their opinion that audiologists are not well trained to provide support for people to adjust to the changes their condition requires, particularly around access to services and specialised equipment.[88]

5.79        Support services in Australia are usually provided by volunteer organisations, often run by parents of hearing impaired children. This arrangement means that parents are most likely receiving the advice from people who have been through a similar experience, and who will understand. However there may be down sides, as Connect Hearing pointed out:

Support services are typically provided by volunteer groups such as Better Hearing Australia or SHHH or by service groups such as Quota. Because of this arrangement, support services are not universally available or of a universal minimum standard.[89]

5.80      The University of Melbourne Audiology and Speech Sciences department suggested that families would benefit from the support of a single case manager to help them navigate the services available.

There is a current gap in the clinical pathway for families of children with diagnosed hearing loss. The diagnosis itself is often a devastating and emotional experience and families are often left grieving while they are given sometimes conflicting advice from up to seven agencies or professionals that may claim part “ownership” of the case.

Many countries have established a family support scheme where a case-manager becomes the main point of contact and helps coordinate the necessary assessments and consultations until a degree of stability is reached. It is generally agreed that this is a service that needs to be established in the Australian context. Not many will agree, however, about who or how it should be achieved.[90]

Interpreters

5.81      For many people with hearing loss, interpreters can assist them to access services and advice in a hearing world. Interpreters are not a panacea however, as there are a range of issues that can impact on their accessibility and applicability.

5.82      To access interpreter support a person needs to be fluent in both English and Auslan, which is not always the case, sometimes to the embarrassment of people with a hearing impairment:

I don’t use sign language, don’t understand it, and I am always embarrassed when I have a medical appointment and the staff (if they know I am hearing-impaired) assume I know sign language and get an interpreter in.[91]

5.83      Interpreter services, like so many hearing health services, are not as accessible in rural and regional areas as they are in the cities.[92]

5.84      Another obstacle for widespread use of interpreters is the cost. The Australian DeafBlind Council told the committee that they have little funding to support their advocacy program, and that the cost of interpreters is their greatest expense:

We received a special one-off funding grant from the Department of Human Services. It was $12,000 to cover the costs for interpreters, as we require interpreters and they are the most expensive expense we have.[93]

5.85      The committee heard a considerable body of evidence about the particular issues that arise when interpreters are used in an educational setting. A major concern raised was the lack of required interpreter standards in Australia for people interpreting in classrooms:

There is not actually any specific training for interpreters to work in an educational setting. Currently, the department pays a teacher’s aide, and they are not necessarily professionally qualified as interpreters, or even fluent in Auslan. They have some degree of signing, however it is not necessarily proficient signing, and there is no testing on their level of proficiency.[94]

5.86      Inexpert translation can be frustrating for hearing impaired students, as one mother of a hearing impaired child explained:

One of the teachers has very poor limited sign skills and my daughter is so frustrated in class, because she looks around and [knows] that the other (hearing) students are going ahead with their work and she isn’t.[95]

5.87      Deaf Australia NSW suggested a professional standard that could be applied:

The solution we propose is the adoption of a benchmark for fluency for staff employed to work with children who access the curriculum using Auslan, whether teacher aides, learning support officers, interpreters or teachers of the deaf. This benchmark should be [National Accreditation Authority for Translators and Interpreters] Paraprofessional level accreditation or [National Auslan Interpreter Booking & Payment Service / Australian Sign Language Interpreters Association] Deaf Relay Interpreter Certification as a minimum.[96]

5.88      The Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) drew the committee's attention to its National Auslan Interpreter Booking and Payment Service (NABS). Under this scheme, accredited Auslan interpreters are provided to assist with any private medical consultation which attracts a Medicare rebate, at no charge to the deaf person.[97]

5.89      FaHCSIA also noted that not all deaf people use Auslan to communicate. According to their submission, there are over 500 interpreters available under NABS, and they have provided interpreters for over 60,000 private medical and healthcare appointments since January 2005.[98]

5.90      One submitter called for the establishment of:

...training, employment and government funding initiatives to provide more Auslan qualified interpreters/aides for schools, hospitals and government services and encourage uptake by [the] private sector where it is most beneficial (i.e. counter staff, call centres, sales floors).[99]

5.91      The issue of more general professional development for teachers with hearing impaired students in their classroom is discussed, and recommendations made, at chapter six of this report.

5.92      The committee also heard evidence about the use of interpreters to assist people to access legal services. This issue is dealt with in chapter eight.

Access to hearing technologies

A note on the scope of this inquiry with regard to technologies

5.93      The committee would like to note that it is inquiring into issues which impact on the ability of people with a hearing impairment to access appropriate hearing technologies. A comprehensive survey of the many types of technologies available would be a huge task in itself, and is beyond the scope of this report. Information and clarifications about different technologies are provided only where necessary to report on issues of access.

Hearing aids

Under usage of hearing aids

5.94      According to the HCIA, 24 per cent of Australians who would benefit from a hearing aid have one.[100] The association states this is 'quite good by international standards', but falls short of international best practice levels enjoyed by Denmark, which has 45 per cent.[101]

5.95      The committee heard that around 350,000 hearing aids are sold in Australia each year, and that 75 per cent of those are paid for with public funding.[102] Whilst provision of hearing aids may be high, the committee heard evidence that usage may be low. The rate of non- or under-usage of hearing aids was estimated by witnesses at between 20 and 40 per cent of all hearing aids provided with public funding [therefore  between 65,625 and 78,750 hearing aids may be under-used].[103]

5.96      Catherine Westacott of Deafness Forum Australia emphasised the importance of properly educating and counselling people when they are being fitted with hearing aids, and believes this will increase usage levels.[104]

5.97      Professor Robert Cowan suggested that inappropriate expectations may be behind low hearing aid usage rates:

Everyone talks about hearing aids being in the top drawer, and you would have heard that. The reason is that either people do not really understand at the outset what the limitations of a hearing aid are or the person who has fitted the device for them has not understood what their needs are. A holistic approach addresses needs at the outset. Someone might not need a hearing aid.[105]

5.98      Professor Harvey Dillon agreed that motivation was a critical part of improving usage levels, and that this be incorporated into hearing aid assessments:

We suggested that there be an element of testing of the motivation of the person before they become eligible to get a hearing aid. In fact, the Office of Hearing Services is in the process of putting that into place. I believe it is going to start in July.[106]

5.99      Neil and Susan Clutterbuck state in their submission that, in terms of hearing aid performance, the hearing aid industry has been 'over-promising and under-delivering' for a long time, and that this creates an unrealistic expectation of performance which, when it is not met, reinforces negative perceptions.[107]

5.100         The Clutterbucks are also sceptical about the extent to which the stigma of wearing hearing aids discourages use, citing research which shows that more people were unhappy about hearing aid performance than were concerned about stigma.[108]

5.101         The committee heard evidence that the structure of Australian Government Hearing Services Program funding has encouraged the sale and supply of hearing aids, rather than targeting the needs of people with a hearing impairment. For example Patrick Gallagher commented in his evidence that:

...a lot of this debate about hearing aids sitting in drawers can be drawn from [lack of an outcomes focus to provision of hearing aids under public funding]. If it is [only] about [selling] the product, it is about: how do you get people on a seat to be fitted with a hearing aid? It doesn’t matter [about outcomes]: it is a product sale. Firstly, if...a proper diagnostic test [is] done as part of that process, people who need a hearing aid will get a hearing aid. Secondly, if there is an interest post sale in providing ongoing services...then there will be fewer hearing aids in drawers.[109]

5.102         One audiologist who made a submission to the inquiry also remarked on the need to emphasise counselling and rehabilitation in addressing hearing loss, arguing that at present there is a 'device focus' in the OHS programs:

Whilst OHS has always allowed patients to opt for counselling instead of a hearing device, such counselling is limited and restricts access to devices. The counselling option results in only a small fee being paid to the service provider. OHS does not currently allow any gap fee for services, only for devices under the [top-up] scheme, making the offering of counselling services a less financially viable option to [service] providers.[110]

5.103         The Office of Hearing Services gave evidence to the committee that the voucher program is being amended so that it will better target provision of hearing aids to those in need. With the introduction of a Minimum Hearing Loss Threshold from 1 July 2010, for the first time hearing aids will only be provided to those with significant hearing loss:

The intention of the [Minimum Hearing Loss Threshold] measure was to direct hearing services and...devices to people who have significant hearing loss...That is so the devices, which are quite expensive to provide, are not directed to [people with normal hearing]. We can redirect them to those who really need a hearing device.[111]

Top-ups

5.104         The committee heard evidence that some people are concerned about the 'top‑up' aspect of the voucher program, and in particular that people accessing hearing services under the voucher program may be being pushed into taking out top-up options unnecessarily.

5.105            Clients of the voucher program are able to access a wide range of technologies at no cost to themselves.[112] The department, in consultation with a range of industry stakeholders, reviews the list of approved hearing devices every 18 months to incorporate technological advances.[113] In addition, clients have the option to purchase additional features to the free aids at their own expense, known as 'topping up'. Additional features might include enhanced user preferences, blue tooth connectivity or adaptable directional microphones.[114]

5.106         As was noted above, some audiologists were critical of the voucher scheme, arguing that it encourages hearing aid sales but not quality hearing health care. The top-up option creates another incentive for hearing aid manufacturers to push sales, as one submitter argued:

The voucher scheme has created a competitive marketplace for large hearing aid providers to make large profits from this government funding...it is disturbing to see large hearing aid providers 'cold calling' pensioners to entice them to their clinic for a hearing test (paid for by the federal government, whether or not it is indicated). Once the contacted person attends for a hearing test, these companies will often also have sales targets both for the number of people they manage to fit with hearing aids and for the level of hearing aid (how expensive) they are able to sell the person (as top-up aids with the additional contribution being made by the pensioner). I feel these practises have had a negative impact on how hearing professionals are viewed by the public.[115]

5.107         Noeleen Bieske of the Deafness Foundation gave evidence that people who are sold top-ups often do not need them:

The audiologists are just fitting hearing aids...and a lot of them are also saying, ‘The government hearing aids are no good; you need the top-up.’ But...these people...really cannot afford to spend $2,000 or $3,000 extra to top-up, and they do not need it. The government hearing aids are very good for most of these people.[116]

5.108         This view was shared by Self Help for Hard of Hearing People (SHHH) Australia, which commented that:

The hearing devices available on the ‘free list’ are all high quality products, and we wonder about the benefits of the ‘top-up’ regime, where older people are pushed into buying expensive ‘top-up’ aids that may not provide them with a better hearing outcome.[117] 

5.109         DVA also made a submission to the inquiry on the issue of veterans being sold unnecessary top-ups:

DVA receives numerous queries or complaints from the veteran community regarding the purchase of top-up hearing aids, that is aids which have additional features that are not essential to meet clinical needs...it appears that top-up devices are sometimes provided unnecessarily...DVA is concerned about the unnecessary up-selling of hearing aids.[118]

5.110         Professor Brian Pyman, also of the Deafness Foundation, added that in his view:

An audiologist earns their income on the basis of the number of hearing aids that they sell...[119]

5.111         The HCIA defended the practice of hearing aid retailers in regard to top-ups, claiming that the voucher program would not be viable without the extra income top-ups provide:

In practice, manufacturers and retailers use the 'top-ups’ as a cross subsidy. In other words, without a certain minimum percentage of 'top-up' clients, the voucher system would not be viable or sustainable for providers to provide “free to client” services. In general, providers in Australia need to see around twice as many clients compared to providers in other industrialized countries to operate a sustainable business given the current reimbursement system and the split between 'top-ups' and 'free to client' devices.[120]

5.112         Extending this point at a public hearing, Mr John Gimpel of the HCIA added that '...if we were in business fitting [hearing devices supplied solely under OHS] vouchers all day long we would not be in business'.[121]

5.113         One audiologist gave evidence that the restricted eligibility to Office of Hearing Services support is part of the reason the voucher scheme is not viable on its own:

We are encouraged to create top-up revenue because we cannot make up the revenue in private sales, [I]f we were able to create this larger client base [i.e. by expanding program eligibility] we would not need to be pushing so hard to make sales from low-income earners.[122]

Hearing Aid Banks

5.114         Hearing aid banks are one avenue for people on low incomes who are not eligible for OHS vouchers to obtain reconditioned hearing aids at little or no cost. These are usually run on a small scale by volunteer or charity organisations, such as Better Hearing Australia's Victorian branch, which explained that:

This free community assistance scheme aims to provide assistance to people who require hearing aids, but are not in a position to access the private system, and are ineligible for the Australian Government Scheme through the Office of Hearing Services. Many low income people are helped, including refugees and people who are unemployed. The resources are limited as we rely on donations of behind the ear hearing aids, which are then cleaned, reconditioned and fitted by a volunteer hearing aid practitioner.[123]

5.115         The committee understands that the following organisations run hearing aid banks in Australia:

• Better Hearing Australia (Victoria) – Victoria;
• H.E.A.R Services (Vicdeaf) – Victoria;
• Self Help for Hard of Hearing – New South Wales;
• Princess Alexandra Hospital – Queensland;
• Deafness Association – Northern Territory;
• Central Australian Aboriginal Congress – Northern Territory;
• Royal Adelaide Hospital – South Australia; and
• Hearinglink (Tasmanian Deaf Society) – Tasmania.[124]

5.116         Professor Harvey Coates gave evidence that hearing bank-like activities also take place in Western Australia (WA), though its coverage and extent are not clear:

So we started an ear alliance hearing aid bank, and we have used hearing aids, some of which are from [the Office of Aboriginal and Torres Strait Islander Health] and other groups, like the Office of Hearing Services...who have sent them to us. We then distribute them to these communities so people who would otherwise miss out have hearing aids.[125]

5.117         NSA provided evidence about the limitations of the service:

Hearing aid banks face a range of challenges including keeping up with the demand for services, maintaining and updating equipment required for testing and reconditioning of hearing aids and building awareness for the need for second hand hearing aids. Hearing aid banks play a small, but pivotal role in assisting consumers who are otherwise ineligible to access free or subsidised hearing aids. However hearing aid bank services are limited by supply factors, with services generally unable to cope with increases in demand. Additional funding is required for hearing aid banks to develop awareness about the opportunity for people to hand in their second hand hearing aids, and to assist hearing aid banks to keep up with technology demands.[126]

5.118         SHHH Australia, whose hearing aid bank marked its 21st birthday in 2009, explained that Health Care Card holders and low income earners are eligible for hearing aids under its system, and that applicants pay $100 towards the cost of the hearing aid.[127] This service provides 30 to 40 aids a year and does not advertise in an attempt to reduce demand.[128]

5.119         Rebecca Allnutt, an Alice  Springs-based audiologist, told the committee that hearing impaired prisoners in the Alice Springs Correctional Centre have benefited from the hearing aid bank service run by Central Australian Aboriginal Congress.[129]

5.120         SHHH Australia commented that in NSW demand for hearing aid bank services far outstrips supply. In Queensland too, demand for hearing bank services is higher than can be met. The hearing aid bank at the Princess Alexandra Hospital remarked in Audiology Australia's submission that 'We are only able to fit [approximately two] people per month and we have a 12-15 month waiting list which has remained fairly constant for many years'.[130]

5.121         Australian Hearing noted in its submission the existence of hearing aid banks, and commented that:

The hearing aids are donated, usually by people who no longer use their devices. Therefore the range of devices available through hearing aid banks is limited and knowledge about the existence of these schemes amongst those who could benefit is limited.[131]

5.122         SHHH Australia commented that some of their donated hearing aids come from deceased estates.[132] The committee notes that the Australian Hearing website directs visitors wishing to donate old hearing aids to the nearest hearing aid bank.[133]

5.123         Whilst most evidence was supportive of hearing aid banks, there were some criticisms. These were mostly criticisms of a health system which makes a hearing aid bank necessary, and of the obvious limitations of having to adapt to an aid that was fitted to someone else, rather than criticisms of the service itself. For example:

The Macquarie University Audiology Clinic runs a hearing aid bank providing second hand hearing aids for sale. We feel this is a third world solution because the aids cannot be tailored to the individual hearing loss.[134]

Cochlear Implant Speech Processors

5.124         Many submitters remarked on the fact that cochlear implant speech processors, the externally worn part of the cochlear implant, must be replaced every five to 10 years.[135] Speech processors are estimated to cost between $8,000 and $10,000.[136]

5.125         The committee heard evidence of an apparent inequity in the way the Australian Government funds speech processors. All Australians under 21 years of age are entitled to receive free replacements for lost, damaged or stolen speech processors, and free upgrades based on clinical need. However adults who are eligible for OHS services, by definition pensioners on low incomes, are not entitled to replacement or upgrade processors, and must pay for them out of their own pockets.[137]

5.126         Australian Hearing noted that whilst they are not able to provide replacement or upgrade speech processors to eligible adults, they are able to provide maintenance and replacement parts for their existing processors.[138]

5.127         The Cochlear Implant Clinic at the Royal Victorian Eye and Ear Hospital pointed out in its submission that whilst hearing aids are replaced on a clinical needs basis for those over 65, the same condition does not apply for speech processors:

Adult clients of [Office of Hearing Services] are expected to fund replacement themselves, and since all are pensioners this is not a realistic or a fair request. This may lead to a situation where some patients could be left without adequate hearing. The current cost of replacing a speech processor is at least $8050.  Most pensioners do not have access to this lump sum given their limited finances.[139]

5.128         ENT Cochlear Implant Surgeons Queensland noted the impact of a broken speech processor on individual implantees:

...the reality of a broken speech processor for a cochlear implantee, is that they have no auditory function at all, or to be blunt, they are stone deaf.[140]

5.129         Australian Hearing noted in its submission that Cochlear Ltd had recently announced that four models of cochlear implant speech processors were now considered obsolete.[141]

5.130         One submitter estimated the life-long cost to a 21 year old person with one implant averages out to $60 to $80 per week,[142] which is an unwelcome financial burden on low income earners.

5.131         The burden for people with two implants is even greater:

As a bilateral cochlear implantee I was facing an outlay of approximately $17,000 every 5 years. How many people can afford this just to be able to communicate in a society where the spoken word is the accepted form of communication?[143]

5.132         Australian Hearing gave evidence that the clinical costs associated with cochlear implants, including the initial implant and ongoing clinical costs, are covered by Medicare for all Australians, though clinical services connected to hearing aids are only covered by Medicare for clients of the Australian Government Hearing Services Program.[144]

Accessing media

Closed captioning on television and DVDs

5.133         The committee heard evidence about the limited extent that captioning is available to help people with hearing loss access television and DVDs.

5.134         Many submitters complained about the limited captioning currently provided with television services in Australia. One submitter claimed that relying on captioned television programs meant:

Only being able to watch TV between the hours of 5:30pm and 10:30pm as these are the only times that television networks are required to caption programs.  Not being able to watch all DVDs as they don't have English captions.[145]

5.135         Media Access Australia provided some useful data to the committee around the extent of captioning in Australia:

Closed captioning, while at increasing levels on some free-to-air television is too low to enable viewing of video for people with hearing impairments in a number of areas:

-    Overnight free-to-air television is rarely closed captioned.

-    Almost no digital multi-channel programming is closed...captioned.

-    Sports television programming is rarely closed captioned.

-    Subscription television is closed captioned at a very low level. Only 44% of subscription television content, including repeats, is closed captioned.

-    Only 55% of DVD video is closed captioned.

-    Only 24 out of around 500 cinemas in Australia show closed captioned sessions.[146]

5.136         According to advice provided on the website of the Department of Broadband, Communications and the Digital Economy (DBCDE):

The Broadcasting Services Act 1992 (BSA) requires each commercial television broadcasting licensee and each national broadcaster to provide a captioning service for television programs transmitted during prime viewing hours (6.00 pm until 10.30 pm) and television news or current affairs programs transmitted outside prime viewing hours.

A number of types of programming are exempt from this requirement. These include:

-     television programs that are not in English or mainly not in English

-     non-vocal music-only programs and incidental or background music

-     live sport coverage with unscheduled extended coverage that displaces a news program

-     programs broadcast on a digital multi-channel during the simulcast period (unless previously broadcast with captions on the broadcasters core/simulcast channel).

Codes of practice developed by sections of the broadcasting industry in consultation with the broadcasting regulator, the Australian Communications and Media Authority (ACMA), also require broadcasters to clearly identify which programs have captions in their television guides and other consumer information.[147]

5.137         In a discussion report about access to electronic media for the hearing and vision impaired, DBCDE noted that by December 2011, under agreements between the free to air television broadcasters and the Australian Human Rights Commission, 85 per cent of content broadcast between 6 am and midnight will be captioned.[148]

5.138         One submitter related his frustration at the inaccessibility of many DVDs due to lack of captioning:

...not all DVDs are captioned. It can be a daunting experience when my son wants a DVD to watch and for me put it back on the shelf at the video store. For him to throw a tantrum and for me to explain that this DVD is not accessible. This should not happen. It is not fair on my son.[149]

5.139         The committee notes that since 1 July 2007 all film and television productions that receive public funding through Screen Australia have been required to provide captioning for theatrical and DVD releases.[150] The committee further notes that since 1 January 2010, this requirement has also applied to all Australian films which receive film investment funding.[151]

5.140         One submitter argued the case for all publicly funded education and information DVDs to have closed captions, as without them a significant proportion of the population is unable to access public information.[152] The Deafness Forum of Australia added that 'research has shown that captioning of educational materials not only improves communication access for deaf and hearing impaired, but also improves literacy for all students'.[153]

5.141         FaHCSIA drew the committee's attention to its Captioning Services Program, which funds a service provider to deliver captioning and distribution of community service and education DVDs for the hearing impaired.[154]

5.142         In 2006 Access Economics estimated the annual cost of captioning in Australia to be $18 million, with the largest element by far (at $14 million) being free to air television captioning services.[155]

Captions in cinemas

5.143         The committee heard evidence that people with a hearing impairment have difficulty accessing movies because only very few cinemas provide captioning on very few films. Ms Leonie Jackson summed up the frustration of many in her submission:

I enjoy going to the movies. In order to access movies, I need to wait until the cinema in the city is showing a film with open captions. Most of the time, I miss out because they...pick films I do not want to see or films are scheduled at times when I cannot attend as I work full time. Last month, I was excited to see that the local cinema...[was] showing an English-speaking film with open captions and audio description. I went to see Public Enemy and enjoyed the experience like others. So you can imagine my disappointment when a mere two weeks later, the cinema stopped advertising films with open captions.[156]

5.144         Another person was quoted in a similar vein by Deafness Forum Australia:

My friends have stopped asking me to go to the movies with them because I can’t hear what is being said at our local cinema, and they don’t want to drive all the way to George St to go to the movies.[157]

5.145         Under a proposed voluntary agreement between Australian cinema owners and the Australian Human Rights Commission, cinema owners sought a suspension of the Disability Discrimination Act 1992 under section 55 of the Act while cinemas are upgraded so that the number of Australian screens capable of delivering captions can be increased to 35.[158] Critics noted that this target represents just 0.3 per cent of all movies screened each week in Australia.[159]

5.146         Protest group Action on Cinema Access staged a national rally on 13 February 2010 to protest against the proposed suspension of their capacity to lodge complaints about restricted access to cinemas under the Disability Discrimination Act 1992. Protestors also called for full captioning and audio description for all movies shown in Australia.[160]

5.147         The committee notes that on 16 April 2009 the Human Rights Commission decided that it would not grant an exemption under section 55 of the Disability Discrimination Act 1992, as requested by cinema company owners. No further details were available at the time this report was tabled.

Other assistive technologies

5.148         The committee heard that there are many other technologies available to assist people with a hearing impairment.

5.149         Assistive devices, such as specialised alarm clocks and fire alarms are essential in the day to day lives of those with hearing loss. In the words of one hearing impaired man quoted by a submitter:

How soundly would you sleep in your hotel room if you knew you would not be woken if the fire alarm went off?[161]

5.150         DOHA noted that there is no funding assistance available for assistive devices under the Australian Government Hearing Services Program.[162] The cost to individuals of assistive devices was drawn to the committee's attention:

Apart from hearing aids, essential assistive devices are expensive. These should have a tax deductible allowance for working people and be at a minimal cost to those who are on pensions.[163]

5.151         Better Hearing Australia supports people with a hearing impairment to access assistive devices by providing advice and demonstrations of technologies available.[164]

Hearing loops in public places

5.152         It will be useful to provide a description of a hearing induction loop here:

A loop system consists of a loop of wire around an area (eg a room) that is connected to an amplifier. A signal (eg television, stereo, PA system etc) goes to the amplifier, which drives a current through the loop. As the current from the amplifier flows through the loop, it creates a magnetic field within the looped area and transmits to the telecoil in a hearing aid or in a specifically [designed] induction loop receiver within the looped area.

When a hearing aid user switches their hearing aid to the ‘T’ position on the hearing aid, the telecoil in the hearing aid picks up the changes in the magnetic field and converts them back into alternating currents. The alternating currents are amplified and converted by the hearing aid into sound.[165]

5.153         The committee heard evidence that the provision of hearing induction loops in many public places would be of great benefit to hearing aid users, particularly in specific service environments. For example Ms Shona Fennell commented in her submission that '[all] facilities caring for the elderly ought to have hearing loops and assistive devices as a matter of course to make the quality of life acceptable for them.'[166]

5.154         Ms Nicole Lawder of Deafness Forum Australia described to the committee the experience of accessing an induction hearing loop, and the difference it can make for people:

The way a hearing loop works...is that you are not hearing what the person is saying through the room with other background noises and paper rustling. You turn your hearing aid over to the T switch and it is like a little radio receiver in your ear. When someone speaks into the microphone—even without amplification—that sound is going directly into your hearing aid, so you are getting a much better quality, especially at something like conferences, where people are talking to their neighbours and getting things out of their bags. It can be quite difficult for the person with a hearing aid to follow what is being said. So, they are really valuable in meeting rooms, theatres, convention centres and all types of conference centres...Some people even have them in their own car and lounge room and when they have their family there they may wear a little lapel [microphone]. It is not amplifying the voice but it is allowing the person with the hearing aid to hear much better what that person is saying...Some families where there are three or four members with a hearing loss find that looping their lounge or family room is really useful.[167]

5.155         Judith Raxworthy, who has been deaf for 30 of her 61 years, stated that:

 My greatest frustration is lack of hearing access to public buildings, transport, entertainment and education. There is a serious lack of access in any area where oral communication is used.[168]

5.156         Yvonne Batterham described the somewhat ironic situation she found herself in when she attempted to work for improved access:

Technology such as audio loops and captioning was slow to be introduced. This was an unfair situation and so I decided to join the disability access committee of my local council to broaden my knowledge of the situation. I also attended a couple of council meetings and discovered that not only did the room lack an audio loop but it did not even have a PA system. I could not participate in the meetings.[169]

5.157         Evidence was provided to the committee that theme parks and other public venues do not always make themselves accessible to people with a hearing impairment:

Many of Australia’s iconic tourist destinations are inaccessible to people who are Deaf or hearing impaired. Live performances at places like the Australia Zoo in Queensland should have captioning and an area with an audio loop so all can enjoy the proceedings.[170]

At Seaworld or Movie World the theatres and where they have the live shows with stuntmen doing all sorts of action could all quite easily be looped.[171]

5.158         Better Hearing Australia acknowledge the value of making public venues more accessible, and 'continually lobbies government, councils and the community for audio loop installations in public venues...',[172] and some witnesses commented that hearing loops are increasingly common: 'Many public halls, churches and cinemas now have installed induction loop systems to benefit people who are hearing impaired.'[173]

5.159         Deafness Forum of Australia noted the existence of portable hearing loop units, which could be moved from counter to counter as needed in a customer service situation. They note international examples where organisations are required to supply induction loops. Barclay's Bank in the United Kingdom has undertaken to install loops in all its branches. Church organisations in Switzerland and Sweden are required to install loops in churches.[174]

5.160         Deafness Forum of Australia made the following suggestion, which was echoed throughout the evidence before the committee:

Any service desk or information desk should have at least one audio loop installed to assist a hearing impaired person make an enquiry. If the building or office has regular verbal announcements these should also be provided in some visual format. All Australians have the right to access their government and other public areas. Government offices and public buildings should be showcasing best practice in the area of access as they are using taxpayer’s funds.[175]

5.161         The committee notes that the House of Representatives Standing Committee on Legal and Constitutional Affairs reported on proposed disability access standards for the Building Code of Australia in June 2009.[176] The committee found, in regard to draft hearing access requirements, that the proposed standards 'would provide a significant improvement over the existing provisions of the Building Code'[177], and that it would be 'appropriate for future fitout standards to include requirements for hearing augmentation systems as well as passive design features...such as counters and reception desks'.[178] These standards have now been accepted, and will apply to all building approvals of certain building classes lodged on or after 1 May 2011.[179]

5.162         The committee heard evidence that having building regulations in place may not be enough to ensure access to facilities. Richard Brading of SHHH Australia explained to the committee:

If you look at public buildings that are currently being built, certainly in New South Wales, which I know well, they get a huge list of planning conditions that may include compliance with Australian standards but when it comes to the final certification a lot of those things just get forgotten or they put in the cheapest option that may never work and tick it off because the people who certify these buildings do not know how to test it. It would need a system where some accredited testing body or private technical people who could be accredited tested these things to make sure they actually work. It is very disappointing for people with a hearing impairment to be told there is a loop and then no-one in the venue knows where the on-off switch is and that sort of thing.[180]

5.163         Mr Brading added that making a complaint may be the best way of achieving compliance:

We encourage people to make their own complaints in relation to [lack of access for the hearing impaired]. Many of them do...The Deafness Forum with great difficulty took one hotel in New South Wales to the tribunal and eventually they very grudgingly put a loop in. The Deafness Forum was so grateful they then held their conference there for the next couple of years.[181]

Committee comment

5.164         As the committee noted at the start of this chapter, issues of access are seldom far from a hearing impaired person's thoughts. The range of issues and depth of passions the inquiry found around access issues testify to their significance.

5.165         The committee heard from many people and organisations of the emotional and financial distress that often follows when former child clients of Australian Hearing lose their eligibility for support at age 21. The evidence indicates that these people struggle to find the specialised support they need in the private sector. It is obvious to the committee that the financial burden of finding between $4,000 and $17,000 every three to five years for replacement hearing devices is causing great distress to young people at a vulnerable stage of their lives, and may be disadvantaging them in the pursuit of their education, training and employment aspirations.

5.166         The committee accepts that whilst the cost burden of hearing impairment is particularly acute for young people, it is also a burden on all low income Australians. Evidence was heard from people in their thirties, forties and fifties that the cost of hearing devices – so essential for working and functioning in society - was a burden on themselves and their families.

5.167         The committee believes that the costs to the Australian Government of expanding Australian Government Hearing Services Program eligibility to provide assistance to more Australians, especially those on low incomes, would be off-set by the improved productivity and contribution those people would be able to make if their hearing needs were better met.

5.168         The committee is left in no doubt that access to hearing services in remote and regional Australia can be a significant challenge, and that the effect of this may be that people living in these areas with a hearing impairment are not receiving the support they need. The evidence suggests that the greatest challenge for providers of services in regional and remote areas is attracting and retaining qualified staff.

5.169         The committee's visit to the Royal Institute of Deaf and Blind Children (RIDBC) included participation in a teleconference session and speaking to the family of a hearing impaired child. Even though the committee had limited time to speak to the family, it was clear that the program was having a significant impact on the ability of the family to assist their child to gain language skills, to participate in family life and enhance the child's social interactions.

5.170         The program run by the RIDBC uses relatively inexpensive technology. By teaming the range of specialists in Sydney with each family, the program delivers services which address the needs of each child and provides much needed support to families who would otherwise be unable to access such services.

5.171         The committee considers that further expansion of the program should be considered by governments as a means of delivering specialist services in rural and remote areas as an effective and efficient means of enhancing the lives of children with hearing impairment and supporting their families.

5.172         The committee heard about the particular challenges of educating children with hearing loss in rural and remote areas. RIDBC's innovative Teleschool approach makes full use of new communication technologies to assist families to access the best possible support for their children, regardless of where they live. The Teleschool service delivery model should be considered by all providers of education to children with hearing loss.  

5.173         The committee is of the view that the hearing health industry, professional associations and the higher education sector might consider the problem of attracting qualified staff to rural and regional areas in the way that teacher education programs address this issue. Graduate teachers in their first year of teaching often undertake a term of rural or country service, before they can teach in places that may be more desirable to them, such as in the city. A similar 'country service' arrangement for graduate audiologists, whilst not necessarily a long term solution, would at least direct much-needed professional skills to rural areas in the short to medium term.

5.174         The committee found that the commitment by all Australian governments to universal newborn hearing screening was widely welcomed by the hearing health sector, and that there will be substantial long term benefits for individuals and for the community as a whole to early diagnosis and intervention.

5.175         The committee heard that the incidence of hearing loss in children doubles by age five and triples by age 10, and that these children are often only identified as hearing impaired when teachers and parents notice they have fallen behind academically, or are having behavioural issues. The committee believes that the individual children concerned would benefit greatly if children's hearing loss was diagnosed and managed when their schooling commences. The committee also believes that, given the implications of undiagnosed hearing loss for a person's life, society in general will benefit from earlier diagnosis and intervention.

5.176         Whilst the committee is pleased to note that Office of Hearing Services (OHS) support now remains available to all OHS clients who receive custodial sentences, the shifting of responsibility to the states and territories for those prisoners diagnosed after their incarceration seems inequitable, and is likely to be confusing to administer. The committee believes that widespread, easy access to hearing assessment and intervention is in the interests of hearing impaired prisoners, and the community at large.  The committee has made recommendations in chapter eight that address this issue.

5.177         The committee was concerned at the reports of inappropriate services being provided by some audiologists. The committee notes the Audiological Society of Australia Professional Standards of Practice, and believes that these standards should be promoted to help healthcare consumers understand the nature of services being offered by individual providers, serve as a reference point for hearing health professionals to benchmark their own practices, and design their services and products.

5.178         The committee was moved by the evidence which detailed the shock and emotional distress that sometimes accompanies initial diagnosis of hearing loss. The committee believes that diagnosis of a hearing loss is always likely to be a shock, and that there will always be a flow on impact for families. However the evidence suggests that the impact of the news might be reduced if it was related by someone with skills in counselling support. To that end, hearing health practitioners could benefit from professional development which addressed this area.

5.179         The committee heard that professional standards exist for sign language interpreters for the deaf, but that there are no agreed standards for interpreters working in an educational setting as interpreters or as aids. The committee believes that deaf children are already disadvantaged in educational settings, and that it is essential for high standards of support to be available.

5.180            Many people raised in evidence the issue of under-usage of hearing aids in Australia. The seriousness of this issue is twofold: first, that people who should be benefiting from a technological intervention are not doing so; and second, that Australian Government resources may be spent on these un-used devices which could be better spent elsewhere.

5.181         If under-use of hearing aids is as high as 30 per cent, as the committee heard, then there is a pressing need to understand why people choose not to wear their hearing aids, and what can be done to influence their future behaviour. The committee believes that earlier diagnosis of hearing loss and take-up of hearing aids may improve usage levels later in life, as people have more time to adjust to wearing and using aids. The committee has made recommendations in chapter six about research to understand and address this phenomenon.

5.182         The committee heard that one of the issues around under-use of hearing aids may be the supply-driven nature of the voucher program. In other words, that in the past there has been an emphasis on providing devices rather than addressing need and achieving hearing health outcomes. The committee notes that the OHS has responded to this by introducing a Minimum Hearing Loss Threshold into eligibility requirements for a voucher from 1 July 2010. Testing of voucher applicants' hearing against the new threshold is intended to help target the provision of publicly funded hearing aids to those with the greatest need.

5.183         The committee heard from a number of sources that people are concerned about being pressured into topping-up their hearing aid vouchers with additional features. The committee's greatest concern is that people feel as though they are pressured into taking top-up options which are not clinically necessary.

5.184         Evidence from representatives of the hearing aid industry was that promoting top-ups on voucher devices is necessary if private practices are to be viable. This  seems to justify the concerns of consumers, as the incentive is strong to push top-ups without necessarily having regard to clinical need.

5.185         The committee understands that people who are eligible for vouchers will receive devices which meet their clinical needs at no cost to themselves, and that having the option to top-up with optional features creates welcome flexibility for consumers. However the committee agrees with the Hearing Care Industry Association that up-selling hearing aids without clinical need to vulnerable consumers is an unethical and exploitative practice. It is in the interests of people with a hearing impairment, and hearing aid manufacturers and distributors that such behaviour be identified and addressed.

5.186         Allegations by witnesses from the private audiology and hearing aid industry that the OHS voucher program may in some way be financially disadvantageous to the interests of private hearing services warrant investigation by the OHS.

5.187         The committee would like to acknowledge the initiative and energy of those people and organisations operating hearing aid banks. Without their efforts and commitment, many Australians would have no access to hearing aids and their lives would doubtless be the poorer for it. The committee believes that if its recommendations are implemented, the most vulnerable members of our society will have greater access to hearing aids through government support in future.

5.188          The committee acknowledges the technological advances represented by the cochlear implant, and believes from the evidence before it that it is a great benefit for those people who have received implants. Like so many hearing aid technologies, the cost of cochlear implants is very high, in particular the cost of repairing, maintaining and replacing the cochlear implant speech processors.

5.189         The replacement costs of speech processors are met for Australian Hearing clients less than 21 years of age. However for clients of the OHS aged over 21 years, these replacement costs are not met. The committee was told that this situation appears inequitable. The implication of the policy is that older people who are eligible for OHS services, who by definition are usually on low incomes, can afford up to $17,000 every three to five years. This is plainly not the case, as the committee has often heard.

5.190         The committee acknowledges that the prevalence of hearing loss will increase, particularly among older Australians, and that speech processors are expensive items. Nevertheless, the committee believes that the policy should be reviewed with an eye to aligning the speech processor replacement policy for all eligible clients of Australian Government Hearing Services Programs.

5.191         The committee acknowledges that inadequate facilities are a source of frustration for many hearing impaired would-be movie-goers. Few things highlight the services that non-hearing impaired Australians take for granted as neatly as going to see a movie.

5.192         Similarly, the issue of limited access to television programs and DVDs through captioning emerged as a source of frustration for people with a hearing impairment.

5.193         The committee acknowledges the work that the Department of Broadband, Communications and the Digital Economy is already undertaking to improve access for the hearing impaired to television, DVDs and the movies. The committee also acknowledges the active role that the Australian Human Rights Commission has taken in these issues. The committee urges the department and the commission to note the issues that have been raised in this inquiry in the hope that they will guide future negotiations and regulation in the area of access to media for people with a hearing impairment.   

5.194         The committee heard that there are still many circumstances where people with a hearing impairment will experience difficulty accessing public services due to a lack of facilities, such as induction hearing loops. Access to public services is a fundamental precondition for living an independent and productive life. As was pointed out to the committee, communication is a problem not just for the hearing impaired, but also for the people with whom they want to communicate.

5.195         Relatively inexpensive and easily portable hearing loop technology exists to enable all services, including government services, banks and retailers, to welcome and assist hearing impaired Australians. With the rate of hearing impairment forecast to grow to one in four Australians, it is unacceptable that all organisations with a public shopfront are not easily accessible to people with a hearing impairment.

Recommendations

Recommendation 4

5.196         The committee recommends that eligibility for the Australian Government Hearing Services Voucher Program be extended to include all Australians, subject to eligibility and a means test.

Recommendation 5

5.197         The committee recommends that former child clients of Australian Hearing remain eligible for Australian Hearing support until the age of 25. This eligibility is to be subject to a means test. Former child clients of Australian Hearing who do not meet the means test are to have the option to access Australian Hearing support on a fee-for-service basis until the age of 25.

Recommendation 6

5.198         The committee recommends that state and territory governments expand eligibility for Patient Assisted Travel Schemes to include support for people accessing audiological services.

Recommendation 7

5.199         The committee recommends that the Australian Government provide funding to expand services for hearing impaired children in rural and remote areas through e-technology based programs such as that developed by the Royal Institute for Deaf and Blind Children.

Recommendation 8

5.200         The committee recommends that the Council of Australian Governments extends its commitment for universal newborn hearing screening to include a hearing screening of all children on commencement of their first year of compulsory schooling. Given the crisis in ear health among Indigenous Australians, the committee believes urgent priority should be given to hearing screenings and follow up for all Indigenous children from remote communities on commencement of school.

Recommendation 9

5.201         The committee recommends that the Audiological Society of Australia develop and make available to its members resources and professional development that promotes better understanding about the impact a diagnosis of hearing loss can have on people, and which provides resources and techniques for counselling and supporting people at the time of diagnosis.

Recommendation 10

5.202         The committee recommends that education providers develop professional standards for interpreters working in educational environments. These standards should be based on existing standards, such as the National Accreditation Authority for Translators and Interpreters paraprofessional level accreditation, or the National Auslan Interpreter Booking and Payment Service / Australian Sign Language Interpreter's Association Deaf Relay Certification.

Recommendation 11

5.203         The committee recommends that the Office of Hearing Services engage with representatives of the hearing aid manufacturing and distribution industry,  private providers of hearing health services, and hearing health consumers to investigate:

(a)        the relationship between the voucher program, top-ups and the financial viability of private health services; and

(b)        whether extending the capacity to audiologists to bulk bill Medicare directly for clinical services would have any impact on the financial viability of private health services (i.e. would it ameliorate the need to push 'top-ups' to stay viable?); and

(c)         that the findings of these investigations be made publicly available for the consideration of all hearing health stakeholders.

Recommendation 12

5.204          The committee recommends that the Office of Hearing Services review its policy with regard to the replacement of damaged, lost or obsolete cochlear implant speech processors for eligible clients over 21 years of age, and if possible align it with the replacement policy for eligible clients less than 21 years of age.

Recommendation 13

5.205         The committee recommends that the public counters in all government service shopfronts be accessible to people with a hearing impairment through the provision of hearing loop technology. The committee recommends that the Office of Hearing Services coordinate a project which sets targets toward that end for all government agencies, at all levels of government, and that these be publicly reported upon.

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