The Million-Dollar Question: What are the Ethical Considerations of Public Funding Provisions for Australian Speech-Language Pathologists Engaged in Independent Practice?

Abstract

Health funding arrangements subsidised by the public purse provide a necessary conduit for families to access private speech-language pathology (SLP) services in Australia. In principle, public funding models (PFMs) champion the ideals of universal access. However, stakeholders ministering contemporary public funding provisions anecdotally report being incessantly afflicted with ethical challenges and dilemmas. This qualitative research describes the perceptions of speech-language pathologists (SLPs) in observing principles and values of ethical practice when accessing public funding provisions for children and young persons with communication and swallowing needs (CSN) within Australian independent SLP practices. Original data analysis revealed five predominant themes: (a) securing funding provisions, (b) time as a commodity, (c) incongruence between funding provisions and SLP evidence, (d) trust as a multifaceted quality, and (e) consequences of funding models. When re-analysed through an ethical lens, data illuminated the diversity of ethical principles and values raised by participants. As stewards safeguarding scarce public resources and committed to ethical integrity, SLPs are challenged to rigorously appraise PFMs through health-economic measures of equity, efficiency, and acceptability.

Keywords::

• Ethics
• Public Funding Models
• Private Practice
• Children &Adolescents

In keeping with contemporary bioethics and principles of ethical enquiry relating to meta, normative, and applied ethics (Allan, 2020), Speech Pathology Australia’s (SPA’s) revised Code of Ethics (2020) explicitly refers to the ethical obligations of its members around funding: “We act with integrity, diligence and honesty when accessing and managing funding provisions for our services” (p. 9). As part of daily clinical practice, speechlanguage pathologists (SLPs) are constantly challenged to contemplate and navigate a range of bioethical issues specific to funding and suitable health care; that is, SLPs reflect on issues of moral judgement through informal/ formal decision-making and ethical reasoning processes and frameworks (e.g., principles based, narrative, ethics of care, casuistry approaches; SPA, 2022). As stewards of public funding, SLPs have a professional and moral obligation to intentionally and critically evaluate the most equitable, efficient, and acceptable pathway in managing public monies and associated resources. Taxpayers, governments, patients, public, and other professionals expect SLPs to act ethically when managing public funding; Certified Practising Speech Pathologists (CPSPs) must uphold SPA’s Code of Ethics (2020), specifically, (a) ethical values of respect/dignity, responsiveness, quality/safety, and professionalism/integrity and (b) ethical principles of autonomy, non-maleficence, beneficence, truth/veracity, and justice/fairness (Beauchamp & Childress, 2013). These values and principles guide SLPs’ daily decisions and conduct while advancing stewardship of public funding.

A diversity of public funding models (PFMs) for speechlanguage pathology (SLP) management within Australian independent practice has evolved since the early 2000s through a consistent campaign of sustained advocacy by key stakeholders. Throughout the past two decades, the delivery of community-based SLP health care has seen a transition away from public sector provisions for individuals with communication and swallowing needs (CSN) towards a burgeoning private sector supported by a range of public, private, and mixed funding options (Nickless et al., 2023). The Australian independent SLP sector is supported by an assortment of public funding typologies (Nickless et al., 2023). Table 1 provides a summary of these public funding typologies together with examples of funding provisions used by the families of children and young persons to access Australian independent SLP services.

With public funding comes a magnitude of ethical obligations, considerations, and potential dilemmas.

What constitutes a public funding model?

Within a healthcare framework, PFMs utilise provisions from the public purse to support universal access to crucial services such as SLP management through independent SLP practices. Funding embodies the allocation of resources (i.e., money, effort, time) by an individual, organisation, or government for a specific purpose, program, or activity (Collins English Dictionary, n.d.). As defined in our original qualitative study (Nickless et al., 2023), a funding model describes the mechanisms and arrangements (e.g., fund pooling to purchasing) by which resources arrive at a service or organisation in the denouement of the health financing process (Murray & Frenk, 2000; World Health Organization, 2010). Recipients of public funding provisions rely on PFMs to enable access to SLP services by independent practitioners. Many PFMs are intended as a public contribution to a mixed funding model where the balance is paid via private funding (i.e., individuals directly pay via out-of-pocket) such as Medicare Benefits Schedule as a subsidy towards the full cost of care provided by an independent SLP to address the financial barriers in accessing care experienced by many individuals with CSN.

Table 1 Summary: public funding typologies and examples of associated public funding models used in Australian independent speech-language pathology practices for children and young persons

Australian funding typology	Example: associated public funding model accessed within Australian independent practice
Health insurance	Medicare Benefits Schedule (MBS) Item 10970: Chronic Disease Management Plan (CDMP) Items 82005, 93033, 93041 (assessment) and 82020, 93036, 93044 (treatment): Complex Neurodevelopmental Disorders^a Item 81360: Allied Health Services for Aboriginal and Torres Strait Islander descent
Social insurance	National Disability Insurance Scheme (NDIS) Early childhood approach (under 7 years) Ages 7 to 64 years
Third party insurance	Transport Accident Commission, Victoria Speech-language pathology treatment related to accident injuries
Education	Independent Schools of Victoria, Students with Disabilities Speech Fluency Language Voice Alternative communication

Note. See Nickless et al. (2023).

^a As of 1 March 2023, both Helping Children With Autism (HCWA) and Better Start for Children with Disability (BS) have been categorised under a new Medicare Benefits Schedule (MBS) item titled Complex Neurodevelopmental Disorders (Department of Health and Aged Care, 2023).

Why is ethical behaviour important in public funding stewardship?

SLPs play a vital role in the stewardship of public funding. Stewardship “combines an ethical and moral dimension with managerial principles of efficiency and effectiveness directed toward addressing national health” (Brinkerhoff et. al., 2019, p. 4.). Applying this definition, we espouse that stewardship of PFMs requires the integration of both ethical (i.e., set of rules and codes shaping professional attitudes and practices) and moral (i.e., personal beliefs or values about what is right or wrong) management of finite resources (Beauchamp & Childress, 2013); PFMs must withstand rigorous appraisal using health-economic objectives of efficiency, equity, and acceptability (Duckett & Willcox, 2015) in order to confirm fair and optimal return on investment for taxpayers. Equity objectives seek to improve both horizontal equity (where individuals with equal need are treated the same) and vertical equity (where individuals with greater need are privileged) (Culyer, 2001; Duckett & Willcox, 2015; Kerr & Hendrie, 2018; Pulok et al., 2020; Raine et al., 2016; Wagstaff, 2010). Efficiency objectives seek to ensure the greatest health gain is attained for the level of funding involved (Duckett & Willcox, 2015; Raine et al., 2016). Acceptability objectives seek to ensure that services are affordable, appropriate, and approachable (Levesque et al., 2013).

As healthcare providers, SLPs have significant influence over how individuals with CSN spend their healthcare time and resources. It is an SLP’s ethical, moral, and professional responsibility to be effective stewards over resources (i.e., public funding provisions) used on behalf of individuals with CSN. Stewardship of PFMs embodies those abovementioned ethical principles presented by Beauchamp and Childress (2013) together with other health and bioethical management principles (i.e., health advocacy, clinical independence and professional autonomy, public education). For this reason, it is vital that stakeholders apply an ethical lens when managing finite public resources—namely, PFMs for SLP service access.

This paper reports on findings from a qualitative research study that investigated the perceptions of SLPs in accessing public funding for children and young persons with CSN within Australian independent SLP and specifically sought their perceptions in applying principles and values of ethical practice.

Methods

Recruitment

The qualitative study recruited participants from all Australian states and mainland territories and included SLPs who had experience in the provision of public funding available to children and adolescents with CSN in independent SLP services (the research population). This paper focuses on the specific dataset pertaining to the fairness and ethical use of public funding arrangements by the research population. Participants were recruited through special interest groups (i.e., Victorian Independent Practitioners Network, Queensland Private Practice Network, Private Speech Pathologists Association of Western Australia) aligned with SPA. Approval for this research was provided by The University of Melbourne, School of Health Sciences, Human Ethics Committee (reference: 1954683) prior to commencement of the study.

Data collection

Individual, in-depth semistructured interviews (Minichiello et al., 2008) explored the perspectives of Australian independent SLPs in relation to public funding for access to SLP services for children and adolescents. Participants were recruited and interviewed over a 6-month timeframe (August 2019 to February 2020). One participant withdrew from the study prior to interview citing time limitations. Written consent was received prior to each interview. The interviews were conducted via one of three mediums: telepractice (e.g., Pro Zoom platform, n = 12; Zoom Video Communications Inc, n.d.), in person (n = 6), and telephone (n = 2). An interview guide provided a flexible structure that was informed by the literature on health- economic objectives of equity, efficiency, and acceptability (Duckett & Willcox, 2015). Participants engaged in conversational-styled interviews and were encouraged to talk at length about their lived experiences of PFMs. With a median of 52.5 min, the interviews lasted between 42 and 93 min. Data saturation was achieved where information redundancy or further coding was unattainable (Braun & Clarke, 2021a, 2021b)

Sampling

Purposeful maximum variation sampling (Patton, 2015) methodology was used to explore the perceptions of SLPs who had experience of public funding provisions available to families in accessing independent SLP services in Australia. Participants were sampled to achieve a diversity of age, gender, location, size of practice, total years of clinical experience, total years of experience in independent practice, hourly service rate, and public funding as a percentage of total practice revenue. Participants were required to satisfy the following criteria: (a) had at least 5 years’ clinical experience working with a paediatric caseload in Australia, (b) were practising in any Australian state or mainland territory within an independent practice, (c) were a financial member of SPA, and (d) had the credentials of CPSP, which is a legislative requirement for service through many Australian PFMs. Twenty participants (17 female and three male; mean age 45 years) met the inclusion criteria, consented, and participated in a single semi structured in-depth interview (Table 2).

Table 2 Participant demographics

Participant (P#)	State	Independent practice experience (total years)	Hourly service rate ($AUD)	Public funding (percent of total practice revenue)
P01	NSW	11-15	151-200	30
P02	QLD	16-20	151-200	80
P03	VIC	6-10	151-200	97
P04	VIC	0-5	151-200	90
P05	VIC	16-20	151-200	97
P06	VIC	0-5	151-200	50
P07	SA	11-15	151-200	70
P08	SA	0-5	101-150	97
P09	TAS	21+	200+	60
P10	VIC	21+	200+	85
P11	VIC	16-20	151-200	40
P12	NSW	6-10	151-200	50
P13	NSW	0-5	151-200	70
P14	WA	6-10	151-200	75
P15	VIC	0-5	200+	40
P16	NSW	21+	151-200	70
P17	ACT	0-5	151-200	99
P18	QLD	0-5	151-200	60
P19	NT	6-10	151-200	2
P20	NT	0-5	151-200	50

Data analysis

All interviews were conducted, digitally recorded, transcribed verbatim (www.otter.ai; Transcription Software, n.d), deidentified and uploaded into NVivo (Version 12) software (QSR International, 2018) for data management and analysis by the primary researcher (TN, first author). Reflexive thematic analysis (Braun & Clarke, 2021a, 2021b) was conducted to analyse and interpret the dataset. A process of iterative review (i.e., repeated re-listening and re-reading of interview transcripts) was applied by the primary researcher. Open inductive coding was completed by the primary researcher that led to the identification of themes. In applying reflexive thematic analysis (Braun &Clarke, 2019, 2020), a process of arranging and refining coded data was employed to identify broad concepts and substantive descriptions. As part of the iterative process, codes and themes were revised and reorganised at regular intervals during analysis with the research team. A process of meticulous scrutiny of codes within each theme supported the identification of ethical issues in relation to PFMs.

Rigour

To ensure rigour, the following methods were undertaken to satisfy the four criteria of trustworthiness (i.e., credibility, transferability, dependability, and confirmability; Maher et al., 2018): (a) completion of two pilot interviews as an opportunity to review the interview schedule, conciliate ambiguity, and test equipment; (b) trialling transcription software (www.otter.ai; Transcription Software, n.d); and (c) preliminary analysis completed by the primary researcher with validation by an experienced qualitative academic (BD, final author). Credibility of the research process also entailed familiarisation of bracketing principles (i.e., preconceived bias; Minichiello et al., 2008) as the primary researcher represented the Australian SLP profession in establishing funding arrangements for use within private practice settings in collaboration with Australian Government departments (e.g., CDMP and HCWA initiatives). Such rigour mitigated potential prejudices through the identification of biases, thereby avoiding potential distortion relating to collection and analysis of data. Frequent debriefing with the research team became an integral part of the iterative process. Validation of participant interview transcripts were completed through a process of member checking; this was also endorsed through peer and participant feedback received during SPA’s 2021 National Conference (Nickless et al., 2021).

Results

Data analysis identified five overarching themes salient to the experiences of independent SLPs in relation to Australian PFMs available for children and young persons with CSN: (a) accessibility in securing funding provisions, (b) time as a commodity, (c) incongruence between funding provisions and SLP evidence, (d) trust as a multifaceted quality, and (f) consequences of funding models. Further analysis of data within these five predominant themes revealed examples of ethical dilemmas and participants’ discussions of ethical values and principles. The following participant quote illuminates ethical reflections by stewards of PFMs:

It’s about access. It’s about equity. It’s about dosage. It’s about evidence-based practice. It’s sometimes about informed consent and capacity decisions that are sometimes very complicated to make, particularly when you’re dealing with very complicated family dynamics. It’s about a blurring of professional boundaries between us acting as a healthcare professional on the one hand, as well as an advocate. (P12)

Findings from our research relating to ethical considerations will be reported under the five abovementioned overarching themes.

Accessibility

The ethical principles of beneficence and nonmaleficence featured throughout the theme of accessibility. According to participants, access to crucial SLP healthcare services in a timely manner benefited individuals with CSN. Without access to PFMs, participants feared that children with CSN risked harm should they have not received timely SLP management:

And that’s heartbreaking when it happens because you know that the child can respond well to therapy, but they don’t have the funding. Parents can’t afford it. Our public system only offers a few sessions in the child development service, so yeah, that’s where those kids are slipping through the cracks. (P17)

Participants reported that with the reduction in public SLP services, there were adverse effects on individuals with CSN accessing suitable services. In considering the core ethical value of responsiveness, participants highlighted that inaccessibility due to reconfiguration of public service provisions for some communities resulted in limited access to critical and timely healthcare:

Public services are shrinking … now that the early intervention programs have closed. A lot of the children from early intervention programs are now taking up the positions in the community health … And so those children are completely missing out. So unless the family has their own income or funding and attend private services, then the child misses out altogether. (P10)

In providing SLP services to individuals with CSN, participants also reported horizontal and vertical inequities as a result of inadequate PFM packages. Participants conveyed the ethical conflict they frequently experienced relating to accessibility and inadequacy of PFMs:

I see some children. who have tiny NDIS [National Disability Insurance Scheme] packages. So we can’t see them when they might have really big needs … Whereas there are some children who might have massive NDIS packages. Their parents are asking for multiple times per week, but their need really isn’t that great. (P17)

Time

The ethical principles of justice and fairness were implicated in the overarching theme of time. Time was considered a commodity by participants; they had to deliberate which client(s) would be more efficient on their use of time. For participants, such considerations raised questions around justice and fairness:

And I like to think whether I’m working for somebody pro bono or in a purely private funded capacity, that I’m providing the same level of service. But it is very hard to ignore the extra admin. [administration] bureaucracy, report writing … other obligations … that may have an impact on client care. … Being aware of cognitive biases and … philosophical biases can help. But … if you have two clients of equal weighting to appear at the same time with the same demand … it can be very hard to ignore the fact that one is going to take you significantly less time to administer than the other. (P12)

With respect to time, the predicament of waitlisting as reported by participants also challenged their (a) ethical value of responsiveness and (b) ethical principles of beneficence and fairness. Participants reported that the time clients spent waiting for service triggered intrinsic ethical conflict:

We’re trying to be really ethical and fair … And unless there is a clinical reason to make this person wait for longer than they have to … then we don’t do that. Because I couldn’t sleep at night, if I was operating an unethical practice. (P6)

Incongruence

Participants highlighted incongruence between the evidence base and public funding provisions available to children and adolescents with CSN for access to independent SLP services. This implicated a range of ethical values, specifically, responsiveness to attend and respond to the needs of individuals with CSN and the quality and safety required to achieve evidence-based practice:” … trying to meet evidence-based research … that we know what these families need. And then you get a model that will partially rebate one session, five times a year. It just doesn’t match” (P11).

Additionally, participants expressed how the ethical principles of beneficence and nonmaleficence were implicated through successive dissociations between recommended differential treatment intensity (i.e., dose, frequency, and intensity; Baker, 2012; Warren et. al., 2007) identified in the literature and current PFMs:

The evidence clearly says that what you’re funding them for, is not adequate. You know, I think if the public hospitals funded half a course of chemotherapy, and you’d have to have the other $10,000 to finish the course, and can cure the leukemia, or whatever other kind of cancer it is, there would be uproar. (P01)

and

If I look at Medicare … inefficient funding … ethically … we’re at risk of … breaching our ethics if we’re providing services that are not going to have beneficial outcomes. And they might actually do harm if we can’t finish a treatment program. So if we start, say, for example, if they were funded to have some fluency intervention, and we got five sessions in … we’re only halfway through a parent training program, we withdraw the service. We might actually do more harm. So we’re at risk of not doing good but also doing harm. (P16)

Trust

Professionalism and integrity were important ethical values when accessing funding provisions for SLP services. One participant implied how trust in fulfilling their role as both an advocate and healthcare professional was diluted and considered a “conflict of interest” (P08):

I’m finding that I’m having to sort of say, “Well, I can’t do that advocacy role”. Which is part of my job … I can’t do that advocacy role because they’re seeing it as a conflict of interest if I come, cause [because] I’m pushing my own barrow. (P08)

In addition, the sustainability of PFMs within independent practice settings was considered by one participant as core to the ethical values of respect, professionalism, and integrity as cited in SPA’s (2020) Code of Ethics. Contemporary PFMs were deemed “revolutionary” (P14) and required ethical treatment in order to sustain “funding sources” (P14) into the future. Participant 14 affirmed how independent practice had a responsibly to ensure PFMs’ longevity within independent practice settings. Tenets of trust were inferred:

So we have a responsibility … to make this thing [NDIS] sustained because it is revolutionary … and it will improve the quality outcomes for people who are vulnerable … But if we don’t treat it with respect, and treat it [in]appropriately, it will get cut … there’s a responsibility of private practice, I think, to ethically deliver to the principles and the values of the funding source; to sustain the funding source. (P14)

Conversely, one participant reported that the ethical principles of truth may implicate the emerging theme of trust: “And you see this constantly where people are exaggerating stories, exaggerating situations in order to access funding. And that’s not right” (P14). In supporting this premise, the juxtaposition as to why exaggeration occurs was explained (i.e., SLPs’ aspiration to uphold social justice and truth telling):

I don’t think … speech pathologists are unethical in how we deliver service … we’re a bit righteous and entitled in how we see someone shouldn’t access … I think we over exaggerate the need in order to ensure available resources are given to someone. But then, if you don’t need that many hours what do you do [with] it? So … the ethical dilemma … it’s servicing hours rather than servicing goals. (P14)

Consequences

A diverse set of consequences specific to the use of PFMs developed from the dataset. For SLPs, fairness was vital to the credibility of professional practice. One participant (P03) described the importance of ensuring service provision, regardless of whether a client was a recipient of funding:

I made a very conscious decision … that funding would not impact on my ethical decisions … as a practice [we] prioritise fairness above funding and if something needs to get done for a family and for a child, even if there’s no funding available, we will provide that service. … Because if we purely did things based on funding, kids won’t get what they need. (P03)

Adding to the ethical value of fairness, SLPs were cognisant of their responsibility to prioritise and manage waitlists, regardless of PFM type:

…degrees of fairness. But we do also get stuck in that spot of. … there’s a person here with approved NDIS ready to go, and then there’s a person there with their five Medicare [sessions]. Who do we prioritise … Who’s more likely to cancel? Who can we recoup our losses with when someone cancels last minute. We can’t get cancellation fees out of our Medicare families … I have to keep reminding my admin. [administration], you can’t choose based on who is sitting there with the biggest bucket of money. Right now we need to go through fairness. (P18)

Contemporary funding models have accelerated the debate regarding ethical conflict relating to fee setting and/or potential price gouging. Participants had opposing views as to whether specific PFMs should be charged out at higher rates due to associated costs in delivering services:

I choose not to charge people a different amount just because [they’ve] got funding or not funding. . If we say to people, “Okay, because you don’t have funding, we give you a discount”. … Automatically the other people perceive they’ve got a penalty because they’ve got funding. (P04)

Conversely, another participant (P05) explicated why fees should differ between PFMs:

My only dilemma … we do charge NDIS families the $193. Whereas, a family who doesn’t have NDIS funding still pays $175 … And the main reason that we are doing that is … I will have to find $13,000 to … go through an auditing process. … I’ve got 30 years’ experience … and I’m charging that base [NDIS recommended rate] even though my other families that are paying less … I have to be honest with families when they say, “Why do I have to pay more?” I have to say that my costs have increased because I’ve got an audit coming along. (P05)

Discussion

This research highlighted a breadth of ethical considerations deliberated daily by SLPs working within Australian independent practice settings when interacting with public funding provisions. The ethical dilemmas materialising from Australian public funding arrangements are not one dimensional and demand reflection by funding stewards. The results from our study highlighted how PFMs impact SLPs’ ethical values (i.e., responsiveness, quality and safety, professionalism, and integrity) and ethical principles (i.e., autonomy, nonmaleficence, beneficence, veracity, and justice/fairness).

The profession’s guiding ethical canon, SPA’s (2020) Code of Ethics, demands observation of the highest standards in ethical practice by Australian SLPs. The diversity of PFMs prompts exploration and discussion of a range of ethical issues highlighted by our research findings. This research has illuminated the need for the Australian SLPs to embed a culture of ethical reflection (Kenny & Nickless, 2023) into professional practice: “Reflection is key to ethical competence at individual, team and organisational levels. Through reflection, individuals may critically analyse and set goals to develop ethical practice” (Kenny & Nickless, 2023, Chapter 4, Proactive Reflective Ethical Practice, para. 2). In considering the abovementioned results, we propose that SLPs reflect on how PFMs impact directly on each of the five predominant themes.

Ethical reflection: accessibility

This study identified the ethical responsibility of SLPs in ensuring the sustainability of access to public funding arrangements within the independent sector. Participants from our study were challenged by balancing clinical/ bioethics with business ethics (Eiser et al., 1999). Our research identified a possible overreliance of public funding as a percentage of total revenue (see Table 2; Nickless et al., 2023) that may leave practices exposed and vulnerable to economic and commercial risks. Such vulnerabilities may impact future access to services by individuals with CSN should there be policy changes to PFMs by governments.

Ethical reflection: time

For participants, the ethical dilemmas and conflicts associated with time as a commodity served as an instrument for funding stewards to reflect on those inherent ethical values and principles chartered in SPA’s (2020) Code of Ethics. In this study, participants detailed ethical dilemmas associated with time: time associated with the management and selection of clients from waitlists, time spent on PFM administration requirements (i.e., report writing; CDMP legislation requirements to correspond with general practitioners), time spent comparing funding criteria and determining which PFMs have less demands on clinical caseloads, and time spent considering PFM arrangements and the ability to adhere to and/or satisfy terms of service (i.e., ability to implement cancellation fees that may be absorbed under specific PFM arrangements, for example, NDIS). These abovementioned examples of time may lead to ethical conflict in managing (un)ethical discrimination based on funding type (Johar et al., 2013); SLPs had to contemplate which client(s) would be more efficient on their use of time (see also “Results: Consequences”).

Ethical reflection: incongruence

Participants reported ethical dilemmas arising from incongruence between funding provisions and scientific evidence. Such dilemmas required funding stewards to use an ethical lens when determining appropriate SLP management with public funding provisions. Moreover, SLPs are entrusted to identify and address low-value care (Baskin et al., 2021); SPA’s (2020) Code of Ethics requires members to practise using the latest scientific evidence. This study identified ethical implications pertinent to incongruence between contemporary PFMs and the scientific evidence impacting communication and swallowing disorders, which can result in ineffectual SLP management and/or harm.

Ethical reflection: trust

Although SLPs attempt to correct social injustices, our results imply that PFMs are vulnerable to unethical behaviour and that trust can be exploited by funding stewards. Thus, aspiring to eliminate egregious (un)ethical behaviours that defraud funders (Kirby, 2022) is central to the tenets of trust for SLPs. Although evidence of fraudulent behaviour of PFMs by SLPs has not been reported in the literature, this study highlights the potential for clients’ CSN presentations to be exaggerated in order to access PFMs.

Ethical reflection: consequences

Within the context of consequences of funding models, a number of ethical dilemmas were identified by participants. Often, these ethical considerations required contemplation ofthe ethical values and principles outlined in SPA’s (2020) Code of Ethics. One consequence reported was the unsubstantiated inference that some allied health practitioners (including SLPs) are price gouging (Daniel, 2022). As reported in Nickless et al. (2023), independent SLPs called for trust in the integrity of their professional conduct. Our research highlighted ethical dilemmas associated with fee setting for PFMs. To counter this perceived price gouging, participants in this study reported varied cost expenditures when delivering services through the auspice of different Australian PFMs; some PFMs were exposed to disparities in expenses (i.e., audit costs) and/or diverse client/family complexities (e.g., NDIS versus Medicare’s CDMP) that incurred additional costs. Moreover, Australian independent practices include individualised operating structures with differing standard fees charged (see Table 2) and differing operating costs (due to differences in geographical location/rent, clinician experience/salaries, administration costs, mobile versus clinic-based servicing).

Future research: vision for SLP public funding stewardship

As a profession committed to quality improvement and safety, an opportunity exists for the SLP profession to conduct future research into the development and implementation of a public funding stewardship program (e.g., data analysis evaluating PFM behaviours by an independent third party; advising on performance of PFMs; analysis of factors influencing health care [i.e., trends, pressures, and costs]; proposing changes to address equity, efficiency, and acceptability challenges of PFMs). Such a program may assist the Australian SLP profession to better understand current funding models and behaviours within independent practice settings and develop, evaluate, and implement practical strategies to improve the equity, efficiency, and acceptability of PFMs. In turn, this may advance advocacy by stakeholders to funding gatekeepers for future inclusion of communication and swallowing disorders that are not already explicitly supported by the suite of taxpayer funding models—for example, specific learning difficulties (i.e., developmental language disorder, dyslexia, and dysgraphia), speech sound disorders (i.e., articulation disorder, phonological disorders and childhood apraxia of speech), fluency disorders of speech (i.e., stuttering), and swallowing/ feeding disorders (i.e., paediatric feeding disorder). Future research may draw on learnings from already established and successful Australian stewardship programs (e.g., National Centre for Antimicrobial Stewardship, Product Stewardship Centre of Excellence, Agriculture Biodiversity Stewardship). Additionally, the Australian SLP profession could benefit from the development of a funding stewardship position statement similar to the Australian Medical Association’s (2016) position statement outlining the role of medical doctors in stewardship of healthcare financing and funding arrangements. Such future undertakings would complement the ethical values and principles (as described above) expected of Australian SLPs.

Limitations

Even though the primary aim of the research was investigating SLPs’ perceptions of access to public funding, our findings included SLPs’ discussion of ethical issues related to public funding of services for children with CSN within independent SLP settings. The findings, thus, raise awareness of ethical considerations that invite further research and attention by the Australian SLP profession. This study explored only the experiences of SLP service providers. The results, therefore, do not provide discussions pertaining to ethical perspectives from consumers of public funding arrangements or of policymakers.

Future research is indicated to also include the perspectives of SLPs with less than 5 years’ clinical experience including their ethical conundrums and perplexities, as our study’s inclusion criteria purposively selected SLPs with more than 5 years’ clinical experience. Most SLPs graduating within the last 5 years, however, may have only had exposure to one funding typology (i.e., social insurance through the NDIS as this has been the dominant PFM within independent practice settings). NDIS brings with it a plethora of ethical dilemmas (e.g., discharging clients with lifelong disabilities in order to offer other clients access to SLP services via different public funding typologies). Finally, as this study was conducted between August 2019 and February 2020, caution must be exercised as this manuscript employed SPA’s (2020) revised Code of Ethics, a new Code of Ethics released and circulated to members in July 2020 some 5 months after our study was completed. Therefore, the ethical values and principles are detailed differently than in the previous version of the Code of Ethics (SPA, 2010).

Conclusion

Equitable access to independent SLP services for families with children and young persons presenting with CSN through private providers is dependent on the appropriateness of PFMs. Without adequate public funding, children and adolescents with CSN are at significant risk of academic and lifelong challenges (Snow, 2016). Findings from this preliminary research correspond with SPA’s (2016) call for improved funding advocacy (pp. 10, 20). Our research also records the perceptions of SLPs in applying principles and values of ethical practice when accessing public funding for children and young persons with CSN within Australian independent settings. The development and implementation of PFMs within the independent SLP sector require ethical leadership and courage (Kenny & Nickless, 2023) by a range of stakeholders. Independent SLPs, as funding stewards, have a role in ensuring the sustainability and safeguarding of critical public funding, through rigorous appraisal of health-economic performance measures of equity, efficiency, and acceptability.

Acknowledgements

The authors wish to thank all participants who shared their experiences and time for this study.

Disclosure statement

The authors report no conflict of interest. At the time of manuscript submission, Mr. Tristan Nickless served as a reserve member of Speech Pathology Australia’s Ethics Board.

Additional information

Funding

Tristan Nickless was funded by the Australian Government Research Training Program Scholarship.

Notes on contributors

Tristan Nickless

Mr. Tristan Nickless is Principal Speech Pathologist at Word By Mouth Pty Ltd. He is currently a PhD candidate at the University of Melbourne and served as an elected member of Speech Pathology Australia's Ethics Board from 2015-2022.

Lisa Gold

Professor Lisa Gold is a health economist and leads research in the economics of maternal and child health at Deakin Health Economics, Deakin University

Richard Dowell

Emeritus Professor Dowell is a senior consultant at the Royal Victorian Eye and Ear Hospital Cochlear Implant Clinic and has been involved in clinical work and research in cochlear implants for over 40 years.

Bronwyn Davidson

Associate Professor Bronwyn Davidson is an Honorary Principal Fellow, Department of Audiology and Speech Pathology, The University of Melbourne.