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Standing Committee on Health, Aged Care and Sport
03/03/2017
Hearing health and wellbeing in Australia

DILLON, Dr Harvey, Director, National Acoustic Laboratories, Australian Hearing

FITZGERALD, Ms Alison, National Manager, Governance Branch, Department of Human Services

HARKUS, Ms Samantha, Principal Audiologist, Aboriginal and Torres Strait Islander Services, Australian Hearing

HUTSON, Mr Jonathan, Deputy Secretary, Enabling Services Group, Department of Human Services

KING, Ms Alison, Principal Audiologist, Paediatric Services, Australian Hearing

SCANLAN, Ms Emma, Principal Audiologist, Adults, Australian Hearing

[09:48]

CHAIR: We will resume the hearing. We now welcome witnesses from the Department of Human Services and Australian Hearing. Do any of you have any objection to being recorded by the media during participation in today's proceedings? No? Would any of you like to make an opening statement? No? Well, we will go straight to questions.

Mr GEORGANAS: This is more of a discussion than a question, just so we can get a bit of discussion going. Walk us through client contact. When a client comes to you, what do you do exactly and what happens from there? It is just so we can get a bit of a picture.

Ms King : I will talk about infants who are diagnosed with a hearing loss. All infants in Australia are screened for hearing loss at birth. If they are referred from the screen, they attend a diagnostic service in hospital. If that service identifies a permanent hearing loss, they are referred to Australian Hearing. We would see them within two weeks of referral, provided that was acceptable to the parents. If the family agree, we would proceed with fitting amplification and, at the same time, we would also make sure they are put in contact with early intervention programs.

Older children would come to us from a variety of sources, such as diagnostic services in communities. Once again, they would come to us, and we would see them with the highest priority, and we would put them in touch with educational support for older students as well.

Mr GEORGANAS: And older people—adults et cetera?

Ms King : I will pass to my colleague.

Ms Scanlan : Adults can come to us in a number of ways. As discussed by the Department of Health, we have the voucher program and the CSO program. Some people need to obtain a voucher through the Office of Hearing Services before they can attend our service. They need a medical certificate signed by a GP in that case, and we are one of the 300-plus providers that the adult can select. If they meet certain clinical criteria, such as if they have severe or profound hearing loss, an additional disability in addition to their hearing problems or very poor communication—for some people, their hearing levels are not very poor but they have a lot of difficulty understanding speech and language—those people are referred to the CSO adult program, which Australian Hearing is the only provider for. We also see Aboriginal and Torres Strait Islander adults over the age of 50, and they may follow a different pathway, which my colleague Ms Harkus can outline.

Ms Harkus : For Aboriginal and Torres Strait Islander Australians, eligibility is the same except for the two criteria that Emma was just talking about, which are Aboriginal adults over 50 and Aboriginal adults who are participating in the Community Development Program, which is mainly in remote communities. Most Aboriginal and Torres Strait Islander clients that we see end up falling into the CSO part of the program. Many are seen at outreach locations, but I guess the main differences would be where we see them—yes, so many through the outreach program.

Mr GEORGANAS: What happens from there, once they have seen you?

Ms King : For children, it is not just a case of popping a hearing aid on someone and you are right to go; it is a lifelong concern. We would set goals with the families in the early stage, which at the point of diagnosis for most people is about, 'Can you please help my child to hear as well as possible, because I want them to develop speech and language.'

Mr GEORGANAS: So at that point you look at the hearing aid or whatever it is that they will require?

Ms King : Yes, we look at what hearing aid in relation to their hearing loss and at what knowledge the parents need. Sometimes they come to us—one in 1,000 babies are born with hearing loss, so it is odds-on that the parents have never, ever seen another baby with hearing loss. In the early stages, it is focused on the provision of the hearing aid, establishing the hearing and getting them to understand more about how the child uses that hearing, but we would review those children regularly. In the first three years of life, that would be at least three to four times a year. Little babies need to be seen every four or six weeks, because their ears are growing so quickly. Our goal is not a series of one-year programs. We have a 26-year program for children, and over that time we are building our knowledge of the child and their abilities, and helping them to hear as well as possible; we are building the family's knowledge of the child's hearing loss—

Mr GEORGANAS: That is about education—

Ms King : Education, empowerment—

Mr GEORGANAS: and everything else that you can assist them with.

Ms King : Yes. By the time they have turned 26, we want them to be astute consumers of hearing care who can advocate for themselves and who are managing as well they possibly can.

Mr GEORGANAS: Thank you. That has just given us a bit of a broad overview.

Dr Dillon : I learnt from your questions earlier that a chronic health condition was one of the 10 national health priorities, and it is increasingly being recognised around the world that hearing loss is a chronic health condition and has to be treated as such.

Dr FREELANDER: My question is initially directed to Ms King. My interest is predominantly paediatrics. Can you just explain how it is to deal with a baby when they are first diagnosed with severe hearing loss?

Ms King : From an audiologist's perspective?

Dr FREELANDER: Yes.

Ms King : Yes. The babies will come to us with their hearing diagnosed through objective hearing tests. That means that the baby has not had to respond; we have measured their brainwaves to measure their hearing. From that, we need to develop our best estimate of what their hearing loss would be if they responded as an adult, behaviourally, and we will prescribe a hearing aid based on that.

Early on, a lot of our work is in supporting the families. The shock and the grief of the diagnosis of hearing loss can have many impacts. For some people, it is a desire to take action urgently, and they are driving hard to get everything happening as soon as possible. For others, it can freeze them. So, in those early parts of our time, that is what we are working on—those two aspects.

It takes specialist services for the infants. We cannot evaluate the hearing aid function the same way as we would if you came for a hearing test yourself, so we have to once again use evoked potential measures—measuring the brainwaves in response to sound, and questionnaires that have been 'normed' for infants, which monitor their development. We have been very lucky that, from the research at the National Acoustic Laboratories, one of the questionnaires we have found actually can help us. It is linked to language development at three and five years of age.

At the same time that we are monitoring the children's progress, we would be looking for signs that hearing aids might not give them enough access to sound to develop speech. If that is the case, we would be referring them for cochlear implant candidacy evaluation if the family are willing.

Mr GEORGANAS: What age would that be? Is there a particular age at which you get to that point, or can it be different ages?

Dr FREELANDER: Some people want it straightaway, don't they?

Mr GEORGANAS: Yes.

Ms King : It depends on the hearing loss. We know that, if you are born with a severe or profound hearing loss, you get the best outcomes with hearing aids if you are fitted before six months of age. With cochlear implants, it is if you are fitted before 12 months of age—and, indeed, I believe some of the latest research is suggesting even younger.

Dr FREELANDER: The earlier the better.

Ms King : Yes. So we are working really carefully. If the hearing loss is profound, straight off, then we refer them for assessment straightaway if the family are willing. If it is not profound but it is borderline, we would be really rigorously monitoring how there are hearing with their hearing aids, and their listening function.

Dr FREELANDER: How often would you see them?

Ms King : In those early stages, we would aim to fit hearing aids within two weeks of the family agreeing, which is usually the first appointment. We would be following them up within a couple of weeks of that. Within about six weeks we would be using our HEARLab evoked potential test to measure their brainwaves with the hearing aids, and we would adjust that. We would be doing the questionnaire as soon as possible after that.

So, within the first year of life, I think we would be having at least—it is going to vary greatly, of course—six assessment appointments. But we would be seeing children a lot more commonly because, as their ears grow, the ear moulds that hold their hearing aids in their ears need to be replaced very frequently.

Dr FREELANDER: I know it is hard to be specific, but, with the initial consultation, roughly what sort of time would you be seeing the family for?

Ms King : You mean for one appointment?

Dr FREELANDER: Yes, for the initial appointment.

Ms King : For the initial appointment, bearing in mind they have already had their assessment at a hospital, it would be anywhere from 60 to 90 minutes. That is typical. It depends a bit on the families. If they cannot come in to the hearing centre as quickly as they would like, or we would like, we will often do that early discussion over a phone call, which would be things like taking a history and making sure they understand the results and finding out what their worries are, as well.

Dr FREELANDER: Do you also refer them to one of the childhood hearing centres?

Ms King : The early intervention programs?

Dr FREELANDER: Yes.

Ms King : Most definitely, because it is a team effort. Not only do we need to fit hearing aids and make sound audible; the families need to be given skills to promote speech and language development in their children.

CHAIR: So you do not do that yourself?

Ms King : No, that is a specialist—

CHAIR: So it is organisations like—

Ms King : Yes, it is teachers of the deaf and early interventionists.

Dr FREELANDER: What about the genetics assessments and things like that? Do you refer directly to them?

Ms King : Not to genetics. Our protocol requires that all children who are going to be fitted with hearing aids consult an ear, nose and throat surgeon or a paediatrician. One of the reasons for that is to make sure that there are no contraindications to putting a hearing aid in the ear, but the other reason is to instigate that medical management of the hearing loss, because, as you would know, hearing loss can be associated with other conditions and some of them can be quite serious. We have a process for monitoring that the children do actually go off and see their ear, nose and throat surgeon.

Dr FREELANDER: So you will follow up if they do not turn up? They will be phoned or—

Ms King : Yes, once the children have been referred to us we really try to monitor them very closely. If they do not turn up to their first appointment with us we would work closely with the referring hospital. If we have fitted hearing aids and they are not turning up, we would try to keep in regular contact. If we had permission from the family to communicate with their doctors or other professionals, we would work with them as well.

Dr FREELANDER: With the advent of the neonatal screen, the assumption was that we would be picking up everyone. Clearly, that is not the case. Are you seeing many older children with sensorineural hearing loss who are being missed, because the assumptions are that they are all fine?

Ms King : We have two peaks in hearing aid fitting. The biggest peak is from newborn screening, but there is another peak at primary school entry age, which goes out through the primary school years. Some of those are late -onset losses—if you have meningitis or illness, chemotherapy or things like that. But we fit an increasing number of children who have ongoing middle ear disease. I suppose there would be three reasons why we might fit children. There is later development of chronic middle ear disease, and perhaps children who have been diagnosed with a mild hearing loss or hearing loss in one ear where the parents have decided that the child is developing well and they are going to monitor them, and then we reach a point where everyone says, 'Look, we really need to act.'

Dr FREELANDER: Are there any problems accessing your service?

Ms King : No, we take referrals as soon as we get them. We monitor referral rates and—

Dr FREELANDER: And waiting times?

Ms King : For children with diagnosed hearing loss, the two-week appointment is our benchmark. Over 90 per cent or more of children who are fitted with hearing aids have come to us within that time.

Dr FREELANDER: Good. I have one more question for Ms Harkus. Do you have any recommendations about the timing of hearing tests outside the neonatal period for Indigenous kids?

Ms Harkus : In relation to chronic ear disease?

Dr FREELANDER: Just regular assessments.

Ms Harkus : The clinical care guidelines for ear disease in Aboriginal and Torres Strait Islander kids set out intervals at which children should have their ears checked. The guidelines recommend that every time an Aboriginal child goes into a health service they should have the ears checked, but they also recommend set intervals at which it should happen as well, throughout the early childhood period and ongoing.

Dr FREELANDER: What do you think are reasonable intervals?

Ms Harkus : I think the guidelines are based on good evidence, and they are in the process of being reviewed again, which is the third review since they were first published.

Dr FREELANDER: It is just that we seem to be having quite a lot of kids slipping through, and no-one can really tell me why that is the case.

Ms Harkus : I am talking about what is happening in the primary health sector, so of course that is not our area of expertise. I think it is probably complex. There are Aboriginal health services or health services in Aboriginal populations dealing with a multitude of issues. Perhaps it could be that there are a number of issues going on for a child and hearing, or ear health, has to be balanced in that, in the eyes of the professionals seeing the child. It could be, as you were talking about before, not picking up. As you were saying it is not always easy to look in a child's ear and decide that what you are looking at is a glue ear. Sometimes it is obvious and sometimes it is not. Ear disease in the Aboriginal community is known for often being sign or symptom free, so children are not experiencing pain. It is often not the acute presentation that we see in children with temperature, fever and pain. That is another factor.

CHAIR: I want to follow up that question a bit more broadly. We have already heard the case for universal screening, perhaps at school age and at the commencement at school. Then, there has been some suggestion that in fact there is even an equally strong case for testing somewhere between birth and entry to school. Do any of you have any thoughts in relation to that, both in terms of whether there is a need at those two points or whether one point would be adequate, and, particularly for preschool, how would you arrange some type of universal screening?

Dr Dillon : Based on the statistics of when the children are coming to us, there is quite a wide peak—from age 5 to age 9—where children are being fitted with hearing aids for the first time, and, anecdotally, we hear that some of those children have had trouble for some time and it has taken a while before somebody has recognised that hearing might be the problem. So there is a prima facie case that screening right at the start of school, or just before, or just after, would solve the problem for those children. The unknown is what impact it makes and how much it would cost, versus the benefit. There is no doubt that some children would have benefited from being picked up earlier. We are actually trying to gather some data right at the moment on what is the range of scenarios from parents who have had their children fitted in that age range over the last five years. We hope that in several months we will be a bit more informed about that. So, it would certainly benefit some children. The World Health Organization has various guidelines for when a screening program is justified. So I think it needs some careful work to ensure that it meets those guidelines.

CHAIR: Does the WHO suggest screening at entry to school?

Dr Dillon : No, I was referring to their general guidelines about when it is sensible to do screening. Of course, it is going to depend on the cost of the screening approach. When they are at school you could more efficiently test them, because the kids are collected. It is going to depend on the type of technology. An online type of service would be more cost-effective, probably. I think the jury is out, but there is a prima facie case that it would be useful.

CHAIR: In relation to screening at birth, are there many instances where families actually decline to fit hearing aids, when they are deemed to be necessary?

Ms King : It is very, very rare. I could not think of individual cases. Sometimes the fitting may be delayed. Often if you have a very sick baby who has come through intensive care and the family may be dealing with life threatening issues. Sometimes it can take families longer than others to agree, because of the grief.

Dr Dillon : There are some cases where people are not convinced of the need for the child to wear the hearing aid all the time. The brainwave technology that we have introduced to the hearing clinics can be very helpful there because parents can directly see that when the baby is wearing the hearing aid brainwaves occur when speech happens, and when they are not, there are no brainwaves there. It is a very compelling demonstration.

CHAIR: Are any of you able, or is the department able, to talk about the unsolicited bid for Australian Hearing?

Mr Hutson : Yes. If you have some questions about that I am happy to answer those.

CHAIR: Maybe you could just give us some advice about the interrelationship of Human Services and Health in relation to involvement in the assessment of the bid.

Mr Hutson : Just to explain the role of the Department of Human Services here, the role we have is really one of advising a minister about his responsibilities as the effective owner on behalf of the Commonwealth of Australian Hearing. We have a relationship, obviously, with the Department of Health, which owns the Office of Hearing Services and is the principle funding source for the community service obligation and also the voucher program, which is a very substantial part of Australian Hearing's revenue stream. The responsibility for managing the unsolicited bid rests with a third department, which of course is the Department of Finance. Both the Department of Health and ourselves are represented on the steering committee, which is chaired by the Department of Finance, which is examining the unsolicited bid from the consortium.

Dr FREELANDER: Does the hearing service deliver a surplus?

Mr Hutson : Australian Hearing is currently a profitable organisation, I think. That was in their last annual report. I think we can get a number for you.

Ms Fitzgerald : The revenue in 2015-16 was $243.5 million, and that was a 6.2 per cent increase on the previous financial year.

Dr FREELANDER: So it is actually increasing. Is there any way we can have copies or is it—

Ms Fitzgerald : It is in the annual report.

Mr Hutson : It is in their annual report.

Dr FREELANDER: Thank you.

Mr GEORGANAS: I have some questions that go back to something the Chair alluded to at the beginning. The committee has received some evidence suggesting that there is a lack of transparency and, in some cases, the use of aggressive sales techniques in the hearing service industry. Does Australian Hearing think that tighter regulations or greater regulations would be good for the industry?

Ms Scanlan : I can really only comment on what we are doing at the moment. We do have a clinical bonus scheme in Australian Hearing, which is a small bonus that is paid on the clinically successful fitting of some devices to voucher clients where the client also contributes towards the cost of the device. So it is the vast minority of our fittings. The majority of our fittings are of fully subsidised devices through the Office of Hearing Services. There are no bonuses paid for any devices fitted through the CSO program either. What we do is make sure that all clients have a 55-day return period on their devices and at the end of that time, having established goals with the client and having met those goals, the client signs off on that device and a small bonus can then be paid to the clinician in that case.

Mr GEORGANAS: So the bonus is for clients that are fitted with their hearing aid—

Ms Scanlan : Yes.

Mr GEORGANAS: I suppose there is a standard one that everyone who has hearing loss is entitled to that suits them. So for anything above that standard there would be a bonus attached to it?

Ms Scanlan : Yes.

CHAIR: Sorry, are those provided by Australian Hearing?

Ms Scanlan : By Australian Hearing.

CHAIR: It is not product dependent?

Ms Scanlan : They are product dependent only insofar as the bonus is a percentage of the cost of the device. The bonus criteria is clearly outlined both on our website and on the agreement we have with the client.

Mr GEORGANAS: If I could just very bluntly say this to simplify it for all of us to understand: a device is fitted and it is the standard they are entitled to. How do we analyse and work out what the extra is? Will that make the hearing better? Because, if there is a standard, that obviously means that this is what people are entitled to and will allow them to hear.

Ms Scanlan : Yes, I understand.

Mr GEORGANAS: There is a standard, obviously. So what is the extra that people are getting?

Ms Scanlan : What the extra is based on is a negotiation of the individual client's goals for every single person—

Mr GEORGANAS: Is it cosmetic?

Ms Scanlan : It can be cosmetic. It can be related to people who are in very complex hearing environments and wish to have other features that are available in higher-level devices that are not available as fully subsidised through the Office of Hearing Services program.

Mr GEORGANAS: It would have to be from the client requesting that they want extras, or would it be the service saying, 'Your environment is such and such; therefore, we think you should have this'?

Ms Scanlan : Yes. Every recommendation must involve the discussion of a fully subsidised device and, depending on the client's goals, some discussions will also include higher-level devices. It is, really, directly related to that process that we go through with clients, and that is also the process that we use to sign off on the devices at the end of the program—how well we have met those goals with the devices. That is the opportunity, as I said before, for clients, if they do not feel they are achieving sufficient benefit to warrant the additional cost, to return the devices and choose a fully subsidised device at that time.

Mr GEORGANAS: You might not be able to answer this, but what is the average cost of a standard device in dollar terms?

Ms Scanlan : There is a very large range, from, say, $500 to $4,000 or so per device.

Mr GEORGANAS: Someone comes in and they are entitled to a $500 device?

Dr Dillon : I think there is a miscommunication there. Five hundred dollars was on top of what the Office of Hearing Services pays for the fully subsidised device.

CHAIR: What is the most expensive device that Australian Hearing will pay for?

Ms Scanlan : Will pay for?

CHAIR: Yes.

Ms Scanlan : Do you mean that we would ask our clients to contribute towards?

CHAIR: No, what is the maximum subsidy?

Ms Scanlan : There is only one. The subsidy is only for the fully subsidised devices, and anything that we—

CHAIR: Let me rephrase. What is the most expensive fully subsidised device?

Ms Scanlan : It is approximately $4½ thousand.

CHAIR: It is $4½ thousand.

Ms Scanlan : Or less.

Mr GEORGANAS: Could you add on to that, or is that it? Could you add on to that $4½ thousand?

Ms Scanlan : Only if you wanted additional devices like smoke alarms or assistive listening devices.

Dr Dillon : Sorry, I think we had a miscommunication there again. The Office of Hearing Services pay—

Mr GEORGANAS: I am trying to get the difference between the standard and—

Dr Dillon : Yes, I understand.

Mr GEORGANAS: Then the follow-on question would be: what would the bonus be on that amount?

Dr Dillon : In round numbers, because I do not know exactly the Office of Hearing Services pays providers approximately between $400 and $500 per device, plus it provides $1,000 or more of fitting fees. So, for the average person who takes two fully subsidised devices, which is the norm, the provider will be paid in total by the Office of Hearing Services, in round numbers, around $2,000. On top of that, people can choose to buy higher-level technology, or top-up as it is often called, and those amounts can be anywhere from just a few hundred dollars to several thousand dollars across the industry in total.

Mr TIM WILSON: That is following on from what you were saying, which is connected smoke detectors and the like so they communicate directly to devices in case of particular risks that may occur. Is that right?

Ms Scanlan : At the moment, when we are talking about fully and partially subsidised devices, we are only talking about hearing aids.

Mr TIM WILSON: Sure.

Ms Scanlan : All the other assistive devices are outside of that.

Mr TIM WILSON: [inaudible] add-ons, I presume.

Mr GEORGANAS: I would like to ask about the amount that the bonus is in percentage of dollars terms.

Ms Scanlan : The percentage is between four and six per cent of the amount that the client pays.

Mr GEORGANAS: Of the dollar?

Ms Scanlan : Yes.

Mr GEORGANAS: Including the standard or above that?

Ms Scanlan : No, above that.

Mr GEORGANAS: So, it is six to?

Ms Scanlan : It is four to six per cent.

Mr GEORGANAS: You then go up to $7,000, $10,000?

Ms Scanlan : I am not aware of any devices we, Australian Hearing, have that are $10,000.

Mr GEORGANAS: What is the most expensive?

Ms Scanlan : Approximately $7,800 for 2 hearing aids in our standard hearing aid range.

Mr GEORGANAS: So the bonus would be four to six per cent on that?

Ms Scanlan : Yes.

CHAIR: I would like to follow up that line of questioning. What is the rationale for the bonus?

Ms Scanlan : The rationale has a number of factors. When we had the previous discussion with the Department of Health they mentioned 1997, when the voucher scheme came in. Some people thought that was a long time ago, but in fact I and my colleagues were all around at that time, so we did not think it was that long ago. Prior to that time there were only fully subsidised devices available to clients. The Office of Hearing Services, when it came into being, introduced a program where clients should be provided with choice in their devices and informed choice about what they should choose. A lot of our audiologists and clinicians at that time had never been in that situation before. Sometimes a clinical bonus can help to change behaviour and get people to offer a range of devices. Because it is linked directly to the positive clinical outcomes and the individual person's needs, and it is very common across the industry, we have continued to keep that bonus scheme up until now.

CHAIR: Are the providers accredited by Australian Hearing permitted to receive a commission directly from the hearing aid manufacturer? There are 300 providers working for Australian Hearing, if I can put it that way?

Ms Scanlan : They do not work for Australian Hearing. They are accredited with the Office of Hearing Services. We are one of the 300-plus providers that are accredited to provide service through the Office of Hearing Services.

CHAIR: The people who are providing advice and fitting hearing devices, they are contracted by Australian Hearing but are private audiologists, are they?

Ms Scanlan : No. Everyone who provides services through Australian Hearing is employed by Australian Hearing.

CHAIR: So the bonus is effectively a salary top-up for services supported by Australian Hearing.

Ms Scanlan : The bonus scheme that we have only applies to Australian Hearing clinicians. Other services have their own systems, which may be called different things. Some audiology clinics are sole providers who make profit on every client who comes in through the door. It might not be called a clinical bonus scheme, but it is still a profit-making enterprise and is dependent on the client's choice of devices.

CHAIR: Is the offering of commissions in the private sector widespread?

Ms Scanlan : As I understand it from the discussions around the ACCC inquiry, but I do not know enough about that to be able to comment, finally.

CHAIR: In relation to the market, people are receiving hearing devices through Australian Hearing if they meet the criteria. What proportion of the hearing aid market would that cover? Using hypothetical figures, if there are 10,000 hearing devices sold each year, how many of them would be provided through Australian Hearing and how many would be provided through the private market, if I can put it that way?

Ms Scanlan : I am not aware. Are you able to answer that, Harvey?

Dr Dillon : If we take the whole hearing aid market in Australia, about 80 per cent of that market is associated with the hearing services program of the Department of Health, and the other 20 per cent are people who are not eligible for government benefits in any way. Of that 80 per cent, in very round numbers, because I imagine it is commercial in confidence, approximately a third would be Australian Hearing.

CHAIR: I was also going to ask about Australian Hearing's interaction with the NDIA and whether Australian Hearing is feeling comfortable at this stage that the NDIA or NDIS will ensure the ongoing full suite of services that Australian Hearing is currently funding? Unfortunately the Hansard cannot record facial expressions.

Dr Dillon : I want to say something about the current system. I travel to conferences around the world very often. The way that Australia looks after children with hearing loss is applauded around the world. It is a very seamless system that has high-quality and uniform services. If any change occurs I hope we can preserve the same characteristics. At the National Acoustic Laboratories we have been running a longitudinal study of over 400 children since they were babies. The eldest ones are now 12 or 13 years old. As a side issue to that we looked at whether there was any loss to follow-up, that is children who either did not go from new-born screening to diagnosis to Australian Hearing for the hearing aids. In every country overseas that is an issue. In Australia we found virtually none. We only investigated New South Wales, but the system runs very similarly everywhere, and we found really no loss to follow-up, which is quite amazing. That alone is something we need to make sure we preserve.

Mr GEORGANAS: We heard that earlier from the previous witnesses, who said we are a model for the world.

Dr FREELANDER: Do you get any complaints about your services?

Dr Dillon : About Australian Hearing?

Dr FREELANDER: Yes.

Ms Scanlan : We get very few complaints. In fact our complaint rate is less than 0.01 per cent.

CHAIR: Where are the pitfalls in the transition to the NDIS that could most obviously lead to a diminution in services? What would you be looking for to ensure that that is a seamless transition if you were members of this committee?

Ms Scanlan : That is really discussion between the Department of Health and the NDIA, rather than something that we could comment on in this environment.

CHAIR: We obviously have world's best practice, but if there is somewhere where you think the Commonwealth could strengthen its involvement in supporting people with hearing loss, are there areas that you can easily identify?

Dr Dillon : In the area of Indigenous children with hearing loss it is sometimes complicated to know who is responsible. We have heard before about the intractable nature of the problem and the fact that there are many social determinants of hearing problems. It appears that we as a country have to break into that loop of negative results wherever we can. Children are born in poor circumstances, they have a lot of infections, they have hearing loss, they do not hear well at school, they get poorer education and do not get jobs, leading to poor circumstances, and around it goes. One of the areas where I would hope we can break in better is making sure that even if there is a hearing loss that cannot be fixed all the time, children can at least hear at school. When we try to make improvements there we quite often find that responsibility falls between state and federal and between health and education. In between that four way split it often feels like nobody is responsible.

CHAIR: Are there any other comments that any of you would like to make before we conclude?

Dr Dillon : You asked the Department of Health people about the numbers and they referred you to the National Acoustic Laboratories. I have done some modelling. Based on Australian Bureau of Statistics projections about the population and based on what we know very well, there is the steeply rising prevalence of hearing loss with age. At the current time, just for people over the age of 65, which is the bulk of people in the country with hearing loss, I estimate about 3.7 million people. By 2020, it will be 4.2 million, and by 2030 it will be 5.6 million. That is the number of people with more than a certain amount of hearing loss—25 decibels in the better ear, to put a definition on it—but technology is improving. People with mild loss are still meeting that definition, but at the moment about three and four of them, possibly for good reasons, do not take up hearing aids. But as the technology is getting better and hearing aids are able to work in more and more situations I would expect that that take-up would increase. Also we have the advent of hearables, devices that people are sticking in the ears to do various things. That is probably going to remove some of the stigma that is still associated with hearing aids. That may also impact on the take-up. So I expect a pretty substantial increase in the proportion of the population affected and an even bigger increase in the proportion taking up rehabilitation.

Mr TIM WILSON: What has been the trajectory in terms of the cost of hearing aids over time? I know that is very broad question. Like most other areas of technology, I presume that while technology has got better the cost has gone down.

Dr Dillon : Not a lot. In the mid-1990s the hearing aid industry internationally somehow managed to double the price of devices over a very short time. At a time when there were some small but genuine improvements in technology. That was used as the justification for that. They have largely stayed at those fairly high levels. It is an interesting time at the moment, because the new entrants to the market, making these things like hearables, are all realising they can make them function like hearing aids, and they are typically being sold at a very small fraction of what the main hearing aids are being sold at. They are also being sold over the counter and online, so without all the professional help. So it is very hard to get an apples-for-apples comparison.

CHAIR: You referred to the 5.6 million in, I think, 2030.

Dr Dillon : Yes.

CHAIR: Do you break down those figures based on the grade of hearing impairment?

Dr Dillon : I have not, but I could.

CHAIR: Would you mind, if you can, taking that on notice?

Dr Dillon : Sure. For the moment, it looks like that—just to scare you!—with age on the horizontal axis and the number of people there, and the different curves are the different years. Of course, as well as the numbers increasing, the average age of the people with the loss is increasing. Over that period up to 2040, it will go from about 14 per cent of the population with hearing problems to about 20 per cent of the population.

Mr GEORGANAS: I have a question on the differentiation between hearing aids and hearables.

Dr Dillon : Ha! Well, it is a very good question. Hearing aids are made by major manufacturers and largely fitted through professionals, with all the help that those professionals give. As Alison said, it is not just popping it in the ear. Hearables are being sold online. They are small devices that people just put in their ear. They may or may not be individually configured for the person. They may or may not be comfortable. So there is potential in that area, but it is early days to see exactly what the impact is going to be.

Mr TIM WILSON: I can see why you are looking at it. It seems they are also connected to a lot of fitness activity and things as well, as part of tracking, and apparently Tom Cruise wears them.

CHAIR: Well, it must be good!

Dr Dillon : The Fitbit that you may be familiar with is worn on the wrist. There are good reasons why you would want to put everything that it does in your ear instead. So it may well be a transition to things up in the ear.

CHAIR: It gives very subtle Scientology broadcasting! On that note, we might conclude. Thank you all for your time today. I just remind you that for any questions you have taken on notice—of which I can recall one—if you are able to provide a response to the committee secretariat by 10 March, that would be very helpful. If we have any further questions, we will send you those through the committee secretariat, and the Hansard transcript of today's proceedings will be forwarded to you by the secretariat. If there are any glaring errors in that transcript, please let the committee secretariat know as soon as possible. Thank you again for your time. It is much appreciated.

Proceedings suspended from 10:32 to 10:43