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JCPSLP
Volume 18, Number 2 2016
Journal of Clinical Practice in Speech-Language Pathology
and are requiring a review of the current service provider
responsibilities and arrangements.
For example, in some jurisdictions the disability speech
pathology service provider has been part of developing
and providing a service within the state health system to
provide instrumental assessments of swallowing for people
with disabilities. The NDIS may provide a catalyst for the
state-based public health services to decide that they will
not provide instrumental assessment of swallowing such
as a modified barium swallow for people with disabilities.
Is it appropriate for these to be funded through the NDIS/
disability sector? Should community-based speech
pathologists who are providing support for dysphagia
assessment and management provide the clinical support
for private radiology services which may step into the
breach and offer an MBS? What if speech pathologists
are asked to work within the hospital setting to provide
the clinical support to the radiologist who works within the
hospital? Where does the responsibility lie to determine
whether or not these services might be more appropriately
funded and provided through the state health services?
Where and how should the advocacy for this occur, and
who should be doing this?
Ethical issues and challenges
specific to NDIS
Since the introduction of the NDIS, Speech Pathology
Australia (SPA) members have been raising concerns in
relation to the NDIS about a range of ethical issues. Many
of these are not new, but the changes brought by the NDIS
mean that issues which previously may have been
managed through existent structures and systems now
require a response by individual members, as well as by the
profession over all. Additionally, the NDIS is currently in a
process of very dynamic evolution and development. The
“rules of engagement” are constantly changing and it can
be difficult to get clear and consistent information about
what they are.
While many of the ethical issues may be familiar and
possible to anticipate, it is important to be alert for new
ethical challenges as they emerge in the NDIS environment.
People with disabilities who have communication and
swallowing difficulties are likely to have complex clinical and
service delivery issues. It is commonly identified that this
group are particularly vulnerable to abuse, including of their
communication rights (ASHA, 1992). These complexities and
vulnerabilities bring with them a responsibility for us to reflect
on our competencies, and on our relationships and interactions
with participants and their supports. We are required to be
aware of, understand, use and advocate for the range of
strategies and techniques (ASHA, 1992; SPA, 2012) which
facilitate communicative rights, access and participation for
people with disabilities. This includes their ability to take
part in life situations where knowledge, information, ideas or
feelings are exchanged (Eadie et al., 2006), using whatever
modes of communication are available for them in order to
successfully send and receive a message.
Speech Pathology Australia
member feedback
A brief survey in December 2015 of Speech Pathology
Australia members of the online SPA Disability member
community demonstrated that speech pathologists working
with NDIS participants are aware of a broad range of ethical
issues arising from this clinical context.
services from their organisation. Participants whose
understanding of speech pathology is limited may demand
a type, frequency, duration or model of services which
are not evidence based and which could have negative
consequences.
“It is hard sometimes to help families understand that
more isn’t necessarily better, and that it’s more about
what I can support them to do, and a lot less about
me being with their child.”
Providers have had to modify their service delivery as a
result of the NDIS pricing and support, and rules around
what activities can be included in billable hours. For
example, the restrictions around payment for travel are
creating a shift back to participants attending at clinics,
and provision of services in segregated and central rather
than community settings. Clinicians may have “quotas” of
billable hours that have to be achieved per day or week. It
is NDIS planners who are tasked to support participants to
develop and articulate their participation focused goals. It
is also planners who determine what and whether services
are “reasonable and necessary” and represent “value for
money”. From its implementation in July 2013, the NDIS
identified the provision of trans-disciplinary support as
the exemplar for early intervention services (NDIS, 2014).
Family-centred practice, routines-based and strengths-
focused intervention, and use of a key worker as a primary
provider of interventions are core components of this model
of service delivery (NDIS, 2013). These developments
have provided a catalyst for the early intervention sector,
including allied health providers, to explore and attempt
to clarify our understanding of the terminology and best
practice in early intervention, including the role and
responsibilities of a key worker as a primary provider
of interventions, issues around scope of practice and
responsibilities, and boundaries around knowledge transfer
and delegation. For example, when is it appropriate or
necessary for a speech pathologist to take the key worker
role? What knowledge and skills can be transferred to
colleagues to enable them to provide holistic and integrated
developmental support to a child’s communication and oral
eating and drinking and in turn model this to others? What
knowledge and skills can be effectively transferred such
that another early interventionist can effectively provide
an intervention themselves? Are there some situations, or
some interventions, where we should see our role as one
of delegation to another team member, and if this is the
case, what are our responsibilities for the quality of the
intervention that those other members provide?
The NDIS has also had an impact on the interface
and overlap between the disability, health and education
sectors. While the expectation of the NDIS that mainstream
services maintain provision of services to people with
disabilities is reasonable, and seems very clear, the
interactions and relationships between the sectors are
different within and across jurisdictions. Arrangements
at local, regional and state or territory levels have been
developed between the education, health and disability
sectors for pathways and processes for referral, continuity
of care and provision of services at all levels within the
International Classification of Functioning, Disability and
Health (World Health Organisation, 2001). The changes in
the funding have created the need to rework well-tested
and effective processes where these have been in place,