Chapter 4

Chapter 4

The demand for speech pathology services in Australia

4.1        The previous chapter's focus was on the prevalence and incidence of speech and language disorders in Australia. It found that, notwithstanding several studies into the prevalence of particular speech and language disorders and the incidence of these disorders among particular demographics, Australia-wide data is lacking.

4.2        This is an important starting point for this chapter's concern with the demand for speech pathology services in Australia. If there is no reliable data on the prevalence of these disorders in Australia, it is difficult to identify properly the dimensions of the demand for speech pathology services.

4.3        The committee has gathered anecdotal evidence from witnesses and submitters that the demand for public speech pathology services exceeds supply of these services. Many people join already lengthy waiting lists or, if there is no service, simply go without. The extent and cause of these waiting lists, particularly for paediatric speech pathology services, are discussed in detail in chapter 5 of this report. Much of the evidence in this chapter, on the strength of demand for services, foreshadows the themes of under-supply, under-service and unmet demand that are the focus of chapters 5 and 6.

4.4        This chapter discusses the following issues:

The number of speech pathology Medicare service items

4.5        Figure 4.1 (below) shows the number of speech pathology Medicare items processed for the calendar years of 2004 and 2013. The table is drawn from Medicare statistics, compiled by the federal Department of Human Services.

4.6        There has been dramatic growth in the number of speech pathology service claims made to Medicare. In 2004–05, only 3,051 speech pathology Medicare service items were reported; in 2012–13, this number had increased by a factor of 38 to 115 167. Over the last three financial years, however, there appears to have been a slowing in the rate of speech pathology services reported to Medicare. In the ten months to April 2014, the number of recorded speech pathology services was 105 257.

Figure 4.1: Number of speech pathology Medicare items—July 2004 - April 2014

Source: Department of Human Services, Medicare Statistics, https://www.medicareaustralia.gov.au/statistics/mbs_item.shtml Item number 10970 (accessed 15 August 2014)

Chart 4.1: Medicare speech pathology services by age & gender, 2009– 2014

Source: Department of Human Services, Medicare statistics, Item number 10970, (accessed 15 August 2014)

4.7        Chart 4.1 presents reported speech pathology Medicare service items over the past five years (2009–2014) by age and gender. It shows that the overwhelming majority of speech pathology Medicare services were in the 0–14 years of age category. Further, the number of boys receiving a service in this cohort outnumbered girls by a factor of more than 2 to 1. Over the period, there were roughly 50 000 girls in the 0–4 age cohort and 80 000 girls in the 5–14 age cohort, compared with roughly 140 000 boys in the 0–4 age cohort and 200 000 boys in the 5–14 age cohort.[1]

The lack of reliable data on the demand for speech pathology services

4.8        The exact dimensions of the demand for speech pathology services in Australia are not clear. There are several reasons for this, some of which are indicated in the following comments from (the now defunct) Health Workforce Australia:

We do not at this point have particularly good data on expressed demand or on the occasions of service in speech pathology people are receiving. The areas you might look to as areas of expressed demand would be in the data from the private health funds although that will be incomplete because of capped amounts of services that receive support through private health. The national hospital morbidity data set would provide some information. Under Medicare, services are provided under the Chronic Disease Management plan but not otherwise. The ABS undertook an Australian health survey in 2011 and 2012 which sought to gain an understanding of access to services across a range of health professions. I do not have that data to hand.[2]

4.9        The 2011–12 Australian Bureau of Statistics Australian Health Survey does not provide a breakdown of the number of people who visited a speech pathologist in the previous 12 months.[3]

4.10      Some submitters argued the need to collect data on the demand for speech pathology services in Australia. The Tasmanian Department of Health and Human Services recommended quantifying this demand:

...there is currently very limited data relating to the workforce and prevalence and treatment of speech related disorders in Australia. In the absence of adequate data regarding incidence rates, it is not possible to project future demand for services...

the Tasmanian Department of Health and Human Services recommends that: further work be undertaken to quantify the demand for speech pathology services...[4]

4.11      The Centre for Clinical Research Excellence Aphasia Rehabilitation identified the need for data on the incidence and prevalence of aphasia as 'essential to allow for adequate resource allocation and the formulation of realistic projections of future demand on aphasia services'. It noted that current estimates are often based on stroke figures with little information on the prevalence of aphasia arising from other causes such as Primary Progressive Aphasia.[5]

Demand as reflected in public waiting lists

4.12      One of the key indicators of pent-up demand for speech pathology services is the waiting list for these services. This issue is examined in detail in the context of the availability of services in chapter 5. It is worth noting here the following findings of a 2010–11 survey, conducted by researchers at the University of Sydney, of parents who sought access to speech pathology services:[6]

4.13      The following selection of quotes—from practising speech pathologists, occupational therapists and teaching staff—offers another perspective on the strength of demand for speech pathology services:

In my position as learning support coordinator I have had contact with a number of Speech Pathologist (sic). I have always found these professionals to be extremely helpful and supportive of what we as a school are implementing for particular students...The greatest difficulty experienced is the wait time for the service to have an assessment; this is due mainly to demand.[7]

In each setting I have worked in, there are barriers to accessing the service. In private services, this is obviously the cost of accessing the service. Many families, who are vulnerable and most need the supportive services, are prevented from accessing a health service...Within public services, long waiting lists and demand exceeding supply.[8]

I have never worked in a service that didn’t have some sort of waiting time to access speech pathology services. In multi-disciplinary services, the speech pathology waiting list was always the longest. This is due to the fact that most children with developmental difficulties will have some level of communication and / or feeding difficulty which are often parents’ primary concern. It is not uncommon for public services to have waiting lists of up to or over 12 months.[9]

[There is] difficulty [in] increasing service provision even with documented evidence that the demand is increasing. Even with documented waiting lists and increased referral rates, it is difficult to obtain increased funding to meet these demands.[10]

Client access to Speech Pathology Services is impacted by cost, location and availability. Limited funding for Speech Pathology Services within the public health care system equates to limited access with long waiting lists and a need to discharge clients quickly from services.[11]

The demand for Aspect's [Autism Spectrum Australia] services is continually increasing and we endeavour to respond rapidly to requests for service; however, this is not always possible. We currently have a waitlist of 150 families with children aged zero to eight waiting for service. A further 700-plus children are waiting for school based programs. Families with young children may have to wait up to three months to commence service, and Aspect will only be able to respond to a small proportion of those waiting for school based services. The principal barriers to accessing Aspect's services are location, availability of government funding and families' financial capacity to purchase services...We are of the view that there are significant opportunities to improve the availability of speech pathology services across Australia to assist people with communication impairments.[12]

The demand for therapy became so great and waiting lists so long that some parents of young children entitled to funding were highly distressed to find that they could not receive services before their child turned 6 and aged out.[13]

Most schools get only very limited funding for students with autism (I will use our school as an example. In 2013, we had 12 children diagnosed with an ASD but only 4 funded and of these only 3 were funded on the basis of autism). This means that access to speech therapy is either non-existent or again, comes from school’s SRP [global budget] if schools can afford a private practitioner. (Metro Primary School)[14]

4.14      The Sydney-based not-for-profit organisation, Northcott, argued in its submission that in its experience 'there is extreme unmet demand for one-to-one, individual speech pathology services for school children'.[15] The Australian Education Union noted in its submission that:

There is anecdotal evidence from teachers and principals that the level of demand for speech pathology services is rising. They report an increasing number of students identified as having speech and language difficulties who require some form of intervention and support.[16]

4.15      The committee also received evidence on the type of conditions for which services are in high demand. Dr Gabriella Constantinescu, a lead researcher at the paediatric Auditory-Verbal and Implantable Technologies organisation Hear and Say, told the committee that there is high demand for chronic middle ear pathologies. She argued that funding support should reflect this level of demand and there needed to be increased education at all levels of the medical, allied health and general community about the risk of delays in spoken language. Dr Constantinescu told the committee that:

When looking at microtia and atresia, which is earlobe and canal malformations, there is also a definite need for intervention. As these children have primarily unilateral hearing loss, Better Start funding is not available for them; therefore, they are currently underserviced. We think that increased awareness of the condition is needed as well as a range of options and services and, alongside those, increased funding to support the services.[17]

Demand for private speech pathology services

4.16      The demand for private speech pathology services is also high. For those able to afford it, private pathology services appear readily accessible, at least in metropolitan regions. However, the cost of these services is a barrier to meeting the high demand for them. The Australian College of Nursing (ACN), for example, argued that these costs were deterring people in aged care from seeking assistance:

ACN members who work in aged care have indicated that private speech pathology services are underutilised due to high costs. Speech pathology services are often used only for acute problems experienced by older people and rarely accessed for their treatment plans, rehabilitation or ongoing therapy.[18]

Demand for speech pathology services in rural areas

4.17      Identifying the demand for speech pathology services in rural areas is potentially a more challenging task than mapping demand in metropolitan regions. In cities and larger regional centres, the services—both public and private—are typically there which means that the services used and waiting lists are a rough proxy for demand. In rural and remote regions, however, services are often not there (see chapter 5). There will be people who, despite needing a speech pathologist, will forego the time and expense of travelling to access a service. It is difficult to identify this unmet demand.

4.18      Ms Debra Jones, the Director of Primary Health Care at the Broken Hill University Department of Rural Health, commented in her evidence to the committee on the extent of demand in rural and remote areas of Australia for speech pathology services. She began by noting the difficulty of tracking latent demand:¬†

Traditionally, where you do not have a service, it is very hard to map who is not accessing a service—if there has not traditionally been one there. One of the other interesting things about identifying unmet need is that a lot of public health facilities will have referral based systems. When clients or families do not present for referral, they are classified as 'failed to attend' or 'did not attend' and then can be removed or discharged from service without actually being engaged in service. So the concept of having a waiting list can be quite skewed...

I think what was also interesting was that because there was this culture of not expecting there to be a service, what would you refer to then? Parents were typically giving up on trying to actually access a service. Getting very distinct numbers is a real challenge, especially where families feel really disillusioned by lack of access, challenges in access or lack of responsiveness of access. The language of 'failed to attend' or 'did not attend' is really concerning language for me. That is because typically it means that we have failed to be able to respond in appropriate ways to communities and especially our more remote communities. That language opens up some really interesting philosophies on practice and how we provide services, especially around speech, language and communication.[19]

4.19      Ms Jones gave the committee an overview of the challenges that people living in regional and remote areas face in accessing speech pathology services. In the first instance, she noted, there is a reliance on 'fly-in fly-out' general practitioners to diagnose a speech or language communication need. Once the need is diagnosed, there is often difficulty getting to the service 'especially when you are talking about travelling up to two and a half hours, one way, to a larger regional centre to access those services'. Private speech pathologists' services are often beyond the financial means of her patients.[20] Where a public speech pathologist does offer a service in town, it is often on a short-term basis. As Ms Jones told the committee:

...prior to 2008–09, when we started thinking about working up our service learning speech pathology model, our conversations with our public health colleagues were very much around huge unmet need, huge waiting lists and lots of tension and frustration in communities. That was about not being able to access a service. There was also turnover and fragmentation in staffing. We were in a cycle where we would have speech pathologists come, but for very short periods of time. We were seeing a cycle of assessment, but limited therapy intervention. There was assessment, re-assessment, assessment, re-assessment, referral, re-referral and referral for service access.[21]

4.20      Ms Sarah Verdon, Dr Linda Wilson, Dr Michelle Smith-Tamaray and Dr Lindy McAllister argued in their submission that there was a distance for people living in Victoria and New South Wales beyond which they were unwilling to travel to access speech pathology services. The researchers noted that nearly a third of health services in their sample of 13 237 rural localities in NSW and Victoria were outside this distance:

Using the recommended service frequency of weekly and the recommended maximum travel time for a weekly service of 30 minutes a Critical Maximum Distance of 50kms was calculated for rural NSW and Victoria...

29.3% of localities were outside of the critical maximum distance for accessing speech pathology services.[22]

Mapping demand for speech pathology services

4.21      One of the challenges for service providers is to gather reliable information on the extent of demand for speech pathology services in particular areas. Ms Elizabeth Forsyth of Northcott told the committee that her organisation would like to be able to offer speech therapy services in areas of regional New South Wales. When asked to comment on the need for speech pathology services in these areas, she responded:

[A]necdotally, we encounter families that tell us that they require a range of allied health therapy services. Whether that is speech pathology specific I probably cannot say, but certainly families identify the need for those services. Clinically whether they need them or not, again, I cannot say because we do not have that detailed analysis. I think part of the problem broadly in the disability sector is being able to get accurate data on the unmet need. There is no mechanism to capture that, and that makes it hard for planning and for rollout of services.[23]

4.22      Speech Pathology Australia (SPA) argued in its submission that there needs to be more detailed information on the demand for speech pathology services so that providers can plan to meet these needs. It noted:

[T]he current lack of a detailed profile of the needs of people with communication or swallowing disability limits the planning for and provision of services to ensure the needs of individuals can be met and long term outcomes optimised.

Detailed service needs analysis and demand mapping is required to ensure those with communication or swallowing disability can access vital intervention and supports to optimise their future educational, health and social outcomes.[24]

4.23      SPA recommended that Health Workforce Australia and/or the Australian Institute of Health and Welfare (AIHW) undertake a comprehensive analysis of the speech pathology workforce, including the availability (taking into account part time working), demand (current and future) and geographic spread of speech pathologists in Australia.[25] Chapter 5 of this report addresses this recommendation.

4.24      The committee was impressed by the level of detail on projected demand provided in a submission from the South Australian branch of Speech Pathology Australia. The submission made the following observations about the demand for paediatric and early intervention services in the Adelaide metropolitan area:

Adelaide metropolitan growth is occurring at the extreme ends of the metropolitan area. Services are not being relocated to these areas as the population increases. An example of this is the growth in the Playford Council area in the Northern end of Adelaide:

The increasing demand in disadvantaged communities like Playford Council area may be more efficiently serviced should speech pathology staff be employed to build capacity amongst teachers and child care staff so they understood how best to support speech and language development.

Further, 50% of three year old children in Australia are in formal child care and an increasing proportion of children aged 0–4 years attend out of home care. Building the capacity of these environments to support the development of children’s communication abilities would help address communication and developmental needs at a population level and also help support children who are not able to access speech pathology services for a range of reasons.[26]

4.25      The committee believes that this type of analysis should be conducted in a thorough and methodical way across metropolitan, regional and remote areas of Australia. Chapter 3 of this report made recommendations to support this research.

Projected demand for speech pathology services

4.26      The terms of reference for this inquiry direct the committee to examine the projected demand for speech pathology services in Australia. The committee gathered various perspectives on this issue, but the differences related mainly to the quantum of the expected increase (rather than whether there will be an increase).

4.27      This section considers some of the reasons why submitters believe that demand for speech pathology services in Australia will increase in future years. SPA identified the following drivers:

The National Disability Insurance Scheme

4.28      The table below shows the speech pathology services and speech pathology equipment that is currently being offered in the National Disability Insurance Scheme (NDIS) trial sites.

Table 4.1: Speech pathology services and speech pathology equipment supports offered by National Disability Insurance Scheme, 12 May 2014[28]

Support

Description

Price*

Speech and Language pathology with an individual

Optimise ability to understand information and communicate thoughts and needs. Assistance to ensure safe and effective mealtime support for participants with difficulty feeding / swallowing

$168.26 per hour

Speech and language pathology in a group

Optimise ability to understand information and communicate thoughts and needs. Assistance to ensure safe and effective mealtime support for participants with difficulty feeding  / swallowing

$56.09 per hour

Speech and language pathology distance travel

Travel to participant to and from either providers work location where travel is more than 10kms

$168.26 per hour

Voice generators

Device held to neck which picks up vibrations and amplifies as speech

$650 each

Voice amplifiers for personal use

Device to amplify voice

$400 each

* Prices are the same in each of the trial sites

4.29      Many submitters identified the NDIS as a driver of increased demand for speech pathology services. Exactly how much extra demand the Scheme will create is not clear at this stage. As the Queensland Government stated: 'there is insufficient information to make an analysis of how much additional funding might be required, or how many additional speech–language pathologists might be needed'.[29]

4.30      National Disability Services foresaw an increase in demand for speech pathology services arising from the NDIS but did not comment on specifics:

Increased demand for speech pathology will also arise from the NDIS improving the access that adults with disability have to therapy services. In the case of speech pathology, it is expected that some adults with long-term disability will have improved access to communication services and equipment, and to services such as the treatment of swallowing disorders (dysphagia). Assessing and treating communication disorders improves a person’s quality of life and improves their ability to participate in the community and to work; diagnosing and treating dysphagia reduces the incidence of chest infections and pneumonia. Appropriate access to speech pathology services will, therefore, improve people’s lives and reduce acute health care costs.[30]

4.31      Northcott envisaged that the increase in demand for NDIS speech pathology services will require more speech pathologists and will challenge the profession to devise new models of practice and service provision:

The expansion of the NDIS to cohorts of people who have previously missed out on speech pathology services (e.g. adults), and the sheer increase in funding in the sector under the NDIS, is likely to significantly increase the demand for speech pathology services in Australia. The increase in demand for speech pathology services under the NDIS also highlights a major workforce issue within the disability sector, where the current challenges in the supply of speech pathologists available will only be compounded. Significant workforce development investment, flexibility in contractual and industrial arrangements, and exploration of new models of practice and service provision, must be considered for the sustainability of speech pathology (and arguably all allied health professional) services under the NDIS.[31]

4.32      Early Childhood Intervention Australia (ECIA) argued in its submission that the need for—and the shortage of—speech pathology services for very young children is evident from the federal government's decision to introduce the Better Start and Helping Children with Autism initiatives (see chapter 4). However, it argued that tight eligibility for these programs has meant there is still unmet demand which needs to be addressed prior to the full introduction of the NDIS (in 2018–19). ECIA anticipated a significant increase in demand for speech pathology services for children from the broader eligibility requirements of the NDIS.[32]

4.33      Down Syndrome Australia (DSA) foresaw that the advent of the NDIS will 'substantially' increase the demand for speech therapy services among people with Down syndrome. It noted the higher demand will result from the Scheme's closer targeting of service provision to need. Currently, there is a clear lack of services provided to:

4.34      To some extent, the NDIS may stimulate demand by raising awareness of speech and language disorders. The Association for Childhood Language and Related Disorders (CHI.L.D.) noted that this trend may already be occurring:

While evidence suggests that the incidence of primary language disorder has not increased over time, it is possible that increasing awareness of the condition at earlier developmental stages in conjunction with increasing awareness of other developmental disabilities (such as autism spectrum disorder) has increased the demand for services and specific intervention before and during school.[34]

Public awareness and research breakthroughs

4.35      Professor Mark Onslow from the Australian Stuttering Research Centre commented that Australian clinical research into the treatment of stuttering among 7–17 year olds will place pressures on the public waiting lists for speech pathologists. By his estimates, the fruits of this research are 'inevitable' with 'convincing randomised controlled trials to be completed 'within this decade'.[35]

4.36      In its submission, Autism Queensland did not identify what was driving the significant higher level of diagnosis of autism spectrum disorder, but it did highlight the likelihood of growing demand for speech pathology services. It put the following view:

The prevalence of children diagnosed with ASD has increased dramatically in the past two decades. Where a prevalence rate of around one in 2000–2500 was widely accepted until the 1990s (Baird et al., 2006), a recent American study revealed a prevalence rate of 1 in 88 (Centers for Disease Control and Prevention, 2012). Given this escalating prevalence rate, and the fact that speech pathology is the most widely used service in this field, the demand for speech language pathologist for individual (sic) with ASD and their families is likely to continue to grow.[36]

An ageing population

4.37      Several witnesses and submitters identified the ageing of the Australian population as a key driver of increased demand for speech pathology services. The Queensland Government was one of these submitters:

With a growing ageing population, the demand for speech–language pathology services from conditions such as stroke or dementia will likely increase. Specifically, the population of people with a disability are also living longer and thus there is a need for specialisation in speech–language pathology for older adults for speech and swallowing difficulties.[37]

4.38      The National Stroke Foundation identified significant prospective demand for speech pathology services among Australian stroke survivors. It noted that in 2012, there were around 420 000 Australians living with the effects of stroke, which is expected to increase to 709 000 by 2032. The Stroke Foundation estimated that if the rate of need remains static, by 2032 there will be:

4.39      The President of SPA, Professor Deborah Theodoros, identified a need for the speech pathology profession to make greater use of telehealth delivered services to cope with the demands of an ageing population. She explained this need as follows:

Population ageing will have a significant impact on the demand for speech pathology services. By 2030, persons over 80 years of age in Australia will increase by 140% (ABS, 2006). With increasing age, people will live longer with chronic diseases and conditions that may be associated with communication and swallowing disorders e.g., Parkinson’s disease and stroke (Morris et al., 2010). It is likely that older people will remain living in their own homes and communities, even though transport issues will arise as their capacity to drive decreases (Morris et al., 2010). Speech pathology services will need to evolve in order to accommodate these societal changes.

Alternative means of service delivery are also needed to meet the demand for equitable access to speech pathology services. In Australia, 68.7% of the population lives in major cities with the remainder (30%) living in regional and rural/remote areas (ABS, 2011). Previous studies have identified disparities in speech pathology services in rural and regional areas with residents in these areas having access to significantly fewer speech pathologists per head of population than counterparts in urban areas (Lambier & Atherton, 2003; Wilson et al., 2002).[39]

Other factors

4.40      Worryingly, the committee also received evidence that demand for speech pathologists services was likely to increase as the rate of child abuse and neglect and the number of children in out-of-home care continues to rise. The Benevolent Society stated in its submission that 'it is anticipated that demand from this group will increase in coming years'.[40] It recommended that all programs targeting disadvantaged and vulnerable children, whether funded by the federal or state governments, include provision for the employment or engagement of speech pathologists.[41]

4.41      Dr Jennifer Oates of La Trobe University commented on the projected demand for speech pathology services among transgender individuals:

At the recent World Professional Association for Transgender Health conference in Bangkok (February 2104), nearly all providers reported an increase in demand for their services, in particular an increase in the number of children and adolescents seeking help. This trend has been experienced in Victoria. The Victorian Gender Clinic has reported a significant increase in the number of new referrals in recent years (there have been 250 new referrals between October 2012 and October 2013). The Royal Children’s Hospital has also reported a 10-fold increase in referrals over the past year (38 referrals from September 2012 to September 2013). If 85% of these transgender individuals would benefit from speech pathology services (see above), it is clear that currently available services through the La Trobe Voice Clinic and other speech pathologists in the private and public health system will be unable to meet the projected demand.[42]

Models of care

4.42      A final and very important determinant of the future demand for speech pathology services in Australia relates to the model of care that is implemented. It is crucial that in projecting future workforce and service demands, careful thought is given to the most efficient model for introducing best practice care.[43] Chapter 6 of this report gives consideration to the most efficient models for delivering paediatric, education and aged care speech pathology services.

Committee view

4.43      This chapter has presented a range of evidence indicating the current and future demand for speech pathology services in Australia. Following from the evidence presented in chapter 3, its starting point was the lack of reliable data on the demand for speech pathology services. In the absence of this data, the committee has relied on anecdotal evidence from people with speech and language disorders, the parents of those with these conditions, and many practicing speech pathologists. This evidence was unequivocal:

In light of all these factors, the committee reiterates recommendation 2 (see chapter 3) that the federal Department of Health consider the data that is necessary to identify the areas of current and prospective need for speech pathology services.

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