JCPSLP Vol 18 no 2 July 2016

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

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.” 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, Providers have had to modify their service delivery as a result of the NDIS pricing and support, and rules around

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.

76

JCPSLP Volume 18, Number 2 2016

Journal of Clinical Practice in Speech-Language Pathology