Submission No 290

INQUIRY INTO IMPLEMENTATION OF THE NATIONAL DISABILITY INSURANCE SCHEME AND THE PROVISION OF DISABILITY SERVICES IN NEW SOUTH WALES

Organisation: Occupational Therapy Australia Date Received: 10 August 2018

Occupational Therapy Australia

Parliament of New South Wales

Legislative Council Portfolio Committee No. 2 – Health and Community Services

Implementation of the National Disability Insurance Scheme and the provision of disability services in New South Wales

Occupational Therapy Australia submission

August 2018

Occupational Therapy Australia Limited ABN 27 025 075 008 | ACN 127 396 945 NSW Division PO Box 6921, Silverwater NSW 2128 Ph +61 2 9648 3225 | Fax +61 2 9737 0023 | Email ot.nswact@otaus.com.au | Website www.otaus.com.au

Introduction

Occupational Therapy Australia (OTA) thanks the Health and Community Services Committee of the Legislative Council for this opportunity to comment on the implementation of the National Disability Insurance Scheme and the provision of disability services in New South Wales.

OTA is the professional association and peak representative body for occupational therapists in Australia. As of March 2018, there were approximately 5,700 registered occupational therapists working across the government, non-government, private and community sectors in New South Wales.

Occupational therapists are allied health professionals whose role is to enable their clients to participate in meaningful and productive activities. They provide services such as physical and mental health therapy, vocational rehabilitation, chronic disease management, assessments for assistive technology and home modifications, and key disability supports and services. As such, occupational therapists are key service providers in the National Disability Insurance Scheme (NDIS).

Terms of Reference

(a) the implementation of the National Disability Insurance Scheme and its success or otherwise in

providing choice and control for people with disability

The National Disability Insurance Scheme (NDIS) represents a major shift in the model of support for people with a disability in NSW. The focus on individualised funding aims to provide opportunities for choice and control by people with a disability and their families. The implementation of the NDIS has been positive for participants who are proactive, who are strong advocates for their own needs and who have a sound understanding of local services and assistive technology (AT) suppliers.

It should be noted, however, that this new approach is unfamiliar to some participants, and these people require additional support to understand the potential benefits of allied health services such as occupational therapy (OT). For people who are less literate and unaware of local services, it has been a more stressful time. Some NDIS participants, particularly in rural and remote areas, have not previously had experience of occupational therapy due to limited access and are therefore unaware of how their functional outcomes could be enhanced by such therapy. The provision of information, linkages and capacity building around the nature of therapy supports would promote genuine choice by informing participants of these possibilities.

Some participants with very high expectations of the NDIS have been disappointed to find that it has not been possible to obtain services and equipment that they considered reasonable and necessary. The concept of choice and control is supported by OTA, however clearer parameters are required regarding the choices that can be accommodated by the NDIS. The concept of reasonable and necessary has been interpreted in multiple ways, resulting in confusion for the participant and others involved. The scheme has the potential to positively impact the lives of many and to be a leading model in disability services, however there are numerous issues that need to be addressed.

(b) the experience of people with complex care and support needs in developing, enacting and

reviewing NDIS plans

The effectiveness and appropriateness of plan development and review is highly dependent on the individual Planner’s experience and understanding of a given participant’s functional needs. Often plans and reviews focus on one aspect of the participant’s function without addressing the complex support needs of a person who has multi-dimensional impairments causing disability across many

functional performance areas. Sometimes planning appears to be more about budgeting and how costs can be reduced. Too often, the time required to assess, recommend and supply complex AT for participants (e.g. powered wheelchairs) is underestimated.

Participants have waited long periods of time for the supply of essential AT as it was not originally listed in their plan, and the unscheduled plan review has only occurred months later. Some participants have paid for AT themselves rather than endure the protracted plan review process required by the NDIS.

Access to occupational therapy in early intervention services has become increasingly difficult, as the workforce fails to keep pace with growing demand. In rural and remote areas in particular, there are poorly developed service options for participants, with plans being unrealised in some circumstances due to the lack of available providers. Another issue for families with limited transport and financial resources in remote areas is the physical distance to services.

Early intervention support in north-west NSW is also limited, with long waiting lists. As the NDIS limits travel time for therapists to attend family homes and schools, some therapists have withdrawn their services when lengthy travel is necessary.

Plans in general do not include funding for support workers to implement the recommendations of the therapist when a child is required to practice skills. The plans often do not include funding for the purchase of resources to promote specific learning and function.

A lack of focus on childhood mental health has been noted by therapists. Of concern is the fact that children with generalised anxiety disorder and obsessive-compulsive disorder have been denied NDIS support on the grounds that these conditions are not permanent. These children are at risk of becoming suicidal teenagers and/or long-term unemployed adults with even more complex mental health presentations.

(d) the effectiveness and impact of privatising government-run disability services

The privatisation of Ageing, Disability and Home Care (ADHC) has had significant consequences for occupational therapy service delivery in NSW for people with a disability. The shift to a fee for service and a billable hours framework represents a major shift, giving rise to concerns about the resourcing of, and support for, practice development and continuous quality improvement. ADHC had developed the Core Standards resources for therapists in the disability sector, including specific resources for occupational therapists that were freely available on the ADHC website. These resources were very helpful for therapists new to the disability sector and also provided a consolidated evidence base that all therapists could refer to. This is a regrettable loss, and one that impacts adversely on the delivery of care to clients.

The privatisation of services has led to an unintended consequence in the delivery of supports to school aged children. When ADHC was operating on a local team model, individual schools were supported by a small number of locally connected therapists. With new individual funding arrangements, large numbers of therapists are now seeking access to schools to support students in their natural environments. This can be disruptive for the school and students, and does not allow for optimal support for the NDIS participant. The NDIS and NSW Department of Education have therefore arrived at a policy position that NDIS supports should not be provided in the school context where possible, which is contrary to the best practice principle that a child with disability should receive occupational therapy supports in the actual environment where functional performance is required.

OTA does not consider the removal of children from classrooms for the purposes of providing therapy to be best practice, as this singles out children and disrupts their education. Ideally, occupational therapists will be permitted to work alongside teachers and classroom aides in the classroom itself. Therapists are able to provide advice on potential changes to the environment and the structure of the school day which can benefit all students. If working with one student in particular, they can do this in a manner that is non-disruptive to others.

OTA draws the Committee’s attention to our Guide to Good Practice for Working with Children, which provides practice guidelines for occupational therapists who work with children (aged 0-18 years) and their families/caregivers. The Guide is available to view here: https://www.otaus.com.au/advocacy/guides-to-good-practice.

The shift away from the NSW assistive technology provision system, EnableNSW, has resulted in considerable disruption to the provision of AT to NDIS participants, with extremely variable consequences. Occupational therapists are receiving inconsistent advice about the process to follow and do not receive direct, timely or consistent feedback about their AT applications. This has resulted in occupational therapists spending excessive time on AT reports and follow up, threatening the viability of services and leading some therapists to opt out of providing AT services. The provision of inconsistent or delayed advice to therapists impedes the timely realisation of clients’ goals.

(e) the provision of support services, including accommodation services, for people with disability regardless of whether they are eligible or ineligible to participate in the National Disability Insurance Scheme

Too frequently, services are simply not being provided to people who are found not to be eligible for the NDIS. In many cases, those that once relied on support with domestic tasks, shopping and accessing social activities have lost these supports even though they have been deemed ineligible for the NDIS.

State funding has been withdrawn from Home and Community Care (HACC) services, leaving those ineligible for the NDIS with no support. Some local home modification services have advised occupational therapists that subsidies are not available to people unless they are aged or an NDIS participant.

(f) the adequacy of current regulations and oversight mechanisms in relation to disability service providers

While the NDIS is introducing some useful regulation, there appear to be some emerging problems. There is inadequate regulation of product suppliers. Therapists have observed significant increases in the price of products quoted by some NDIS suppliers. Some product suppliers advise participants to choose products with little or no clinical evidence to support such advice. EnableNSW will not advise occupational therapists or participants of the cost of equipment so that they can compare prices. This does not appear to be consistent with the NDIS’ stated commitment to consumer choice and control.

Participants therefore have only personal experience and word of mouth to rely on when assessing the suitability of providers. Hopefully this situation will improve with the establishment of the Quality and Safeguards Commission.

We remind the Committee that occupational therapy is a registered profession. Occupational therapists take their professional and ethical responsibilities extremely seriously. As with all other

registered health professions, occupational therapists are required to observe codes of ethics, standards, guidelines and boundaries. Despite this proven commitment to clinical excellence, state and territory governments, and increasingly the NDIA itself, are requiring additional proof of competency. The administrative burden and financial cost associated with this is placing such pressure on smaller private practices that some occupational therapists are choosing to cease working with NDIS participants.

g) workforce issues impacting on the delivery of disability services

The dismantling of public services for people with disabilities has meant the loss of vast experience and knowledge from the disability sector. The capacity of the NDIS to replace and improve upon those dismantled services is highly questionable.

The introduction of the NDIS has created increased demand for occupational therapy services and this has led to private practices needing to recruit staff. With the recruitment of experienced staff difficult, there is a growing need to employ and train new graduates in the disability sector. Service delivery is therefore impacted by new demands around human resource management and the support of junior staff.

There is an emerging need to promote student placement opportunities to grow the future disability workforce. Providers should be assisted to take on student placements and to connect with occupational therapy graduates. Anecdotal evidence suggests that providers are in fact struggling to provide placements for occupational therapy students due to the changes in service funding models.

In addition, the majority of private practices now have extensive waiting lists. Many services are prioritising non-NDIS clients and withdrawing their NDIS provider status, having found the NDIS process too stressful and difficult to manage.

With the workforce displacement from government services to private practices and NGOs, there has been a consequent isolation of some practitioners and a discernible decline in collegial support. New graduates with limited experience are trying to provide services which require a high level of expertise.

And across the state, there is competition between services in some areas and no providers in others.

h) challenges facing disability service providers and their sustainability

New pricing arrangements for provider travel are threatening the viability of some occupational therapy services, with providers having to review the reach of their service delivery footprint.

Many therapists would prefer to not service NDIS clients due to the stress, cost and paperwork that accompany them. The cost to a small practice is significant. In one practice, 90% of an administrative staff member’s work is related to the NDIS, which is wildly disproportionate to the revenue generated by NDIS clients.

Another therapist found the administrative burden of 40 NDIA managed clients too stressful. That therapist made the decision not to accept any new NDIA managed clients and to encourage all those currently managed to move to self-managed or plan managed status.

(i) incidents where inadequate disability supports result in greater strain on other community services, such as justice and health services

There is a lack of clarity around the boundaries between the NDIS provision of occupational therapy services and both health and education related services. Some participants face the likelihood of falling through the cracks. For example, if a person with a disability has an acute inpatient event at a hospital, the activation of an NDIS plan may not occur in a timely manner to facilitate their discharge from hospital.

Similarly, the educational needs of a child with disability overlap substantially with their needs at home and in the community. There is the possibility that supports will be poorly coordinated or inefficiently provided if two therapists are engaged due to funding arrangements.

It should also be noted that some health problems only occur because a person has a disability. A case in point is a pressure injury due to paralysis. Waiting periods for the supply of essential pressure care equipment to prevent development of pressure injuries are often quite lengthy. Discussions between the NDIS and health services as to whether a person’s need is the responsibility of disability or health authorities often results in the person receiving no support at all. It has on occasion been necessary to supply equipment borrowed from health loan pools until permanent equipment is supplied.

The process for obtaining AT and completing complex home modifications for a person in hospital with a newly acquired disability has not been clearly conveyed. Waiting for the supply of these products and services can result in an extended hospital stay for the client.

(j) policies, regulation or oversight mechanisms that could improve the provision and accessibility of disability services across New South Wales

The integration of allied health assistant models of service delivery is an important consideration in improving access to occupational therapy supports for NDIS participants. There needs to be an extensive consultation and engagement process to develop strong governance around these models, ensuring they support quality practice and optimal outcomes for participants.

Telepractice is an emerging mode of occupational therapy service delivery that has some potential to expand the choices available to participants. An education and consultation process leading to the development of practice guides and standards would enhance the development of this important service delivery model.

Equipment supply through the NDIS lacks flexibility. Previously, EnableNSW replaced like-for-like AT however this is not available through the NDIS, resulting in delays in the supply of essential equipment. Currently any need for new equipment that was not anticipated at the time of plan development triggers a review of the plan.

There is also inconsistency in the application of policies and regulations. While we understand the individualised nature of the NDIS, too often a course of action that has been approved for one client is not possible for another.

Inconsistencies in policy and approval with regard to equipment and modifications mean some participants obtain swift approval and can access necessary AT and modifications with relative ease. Most other participants, however, require report amendments, documentation, supplementary evidence, multiple quotes and other procedures – all of which takes time. Often, opinions vary between the NDIA staff.

Conclusion

In summary, the implementation of the NDIS has given rise to the inconsistent application of policies and regulations, unacceptable delays addressing the urgent needs of participants, and a shortage of appropriately trained people in positions such as that of NDIA Planner and Local Area Coordinator.

There are emerging shortages in the provider workforce, particularly in rural and remote areas of New South Wales. Too often, inexperienced providers are working without adequate support and supervision.

And, perhaps most troubling, the needs of people found to be ineligible for the NDIS are being neglected.

OTA thanks the Health and Community Services Committee of the Legislative Council for this opportunity to comment on the implementation of the National Disability Insurance Scheme and the provision of disability services in New South Wales. We would be happy to appear before the Committee to elaborate on the content of this submission.