NDIA Accountability Project

Inquiry into the implementation, performance and governance of the National Disability Insurance Scheme

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Inquiry into the implementation, performance and governance of the National Disability Insurance Scheme

March 2018

The Dietitians Association of Australia (DAA) is the national association of the dietetic profession with over 6400 members, and branches in each state and territory. DAA is a leader in nutrition and advocates for food and nutrition for healthier people and healthier nations. DAA appreciates the opportunity to provide feedback on the Inquiry into the implementation of the National Disability Insurance Scheme by the ACT Legislative Assembly.

Contact Person: Annette Byron
Position: Senior Policy Officer
Organisation: Dietitians Association of Australia
Address: redacted

DAA interest in this consultation

The Dietitians Association of Australia (DAA) supports the rights of people with disability to access nutrition support products and Accredited Practising Dietitian services which meet their unique needs to promote physical, mental and social wellbeing.

The inclusion of the services of Accredited Practising Dietitians and nutrition support products in NDIS participant plans is reasonable and necessary for participants to realise their goals and aspirations, and to increase their social and economic participation.

Summary or key messages

DAA wants to see people with disability prosper under the NDIS. We would like to see

  • More communication with peak professional bodies in building and implementing the NDIS.
  • More work in developing policy which is translated clearly and consistently by planners and is clearly expressed in NDIA publications.
  • Processes at the disability-health interface which resolve disputes quickly
  • Registration processes which are genuinely risk proportionate, are simple and inexpensive
  • Greater adherence to the principles of consumer choice and control in planning
  • Monitoring of workforce and investment in workforce development in the ACT and nationally.

Discussion

Access to advice for NDIS development

From the outset of the NDIS, DAA has been motivated to work with the NDIA to develop the NDIS. This has generally proven difficult, and DAA is concerned that the NDIA has had very limited consultation with allied health peak bodies such as the Dietitians Association of Australia, in the implementation of the NDIS. Policy positions have been determined by the NDIA without consulting peak professional bodies which has ultimately disadvantaged NDIS participants, as well as Accredited Practising Dietitians as providers. Communication has been difficult

when DAA has wished to follow up issues with the NDIA, which routinely provides an 1800 number and PO Box Number.

APD hours and nutrition products in NDIS Plans

Prior to the NDIS, a relatively small number of people with disability accessed Accredited Practising Dietitian services from private providers while others accessed services through ACT Health. Accredited Practising Dietitians were not employed in Therapy ACT, unlike other allied health. The reasons for this appear to be historical, where the allocation of budgets is an administrative issue not related to the needs of the person with disability. DAA understands that arrangements with ACT Health have continued for some 25 participants who require nutrition support (i.e. enteral nutrition/tube feeding) on an ‘in kind’ basis. It seems however that dietetic services are not included in plans, which places doubt about access to dietetic services in the longer term. We understand that some participants have had difficulty accessing prices for nutrition support products at ACT Health negotiated prices, rather than paying full market rate.

Inconsistency of decisions by Planners

Accredited Practising Dietitians report that some participants whose function with respect to eating and drinking is clearly impacted by their disability may not have APD hours included in their plan, or if hours are included they are not sufficient all of the activities needed to support the participant. This includes assessment, planning, implementation and review, education of the participant and their supports.

Inadequate preparation of Planners

Interventions by Accredited Practising Dietitians involving a person and their support networks, which provide strategies for that person to achieve adequate nutrition, can decrease costs in both social and financial costs to the person and the community. This is particularly relevant given the insurance like nature of the NDIS.

DAA members relate that NDIA planners are underprepared for their role as gatekeepers in the NDIS with insufficient knowledge of the range of impairments which people with disability experience, and the supports they require. Planners seem particularly unaware that people with disabilities are at greater risk of experiencing nutrition-related diseases and conditions which can negatively impact functional capacity and ability to participate in social and economic activities.

When participants have been able to access services of Accredited Practising Dietitians for reasonable and necessary supports, participants have accrued benefits. For example, a person with an acquired brain injury who accessed the services of an Accredited Practising Dietitian to lose weight was able to increase

his mobility such that he was less dependent on his wheel chair and was able to increase his hours of work. Unfortunately, at his review the planner considered the participant no longer needed dietetic services. This impacted greatly on the self esteem of the participant, who had developed a sound working relationship with his Accredited Practising Dietitian.

Feedback from participants to Accredited Practising Dietitians, and feedback in public consultations indicates that participants value professional advice and want this to determine funding allocation in NDIS plans, rather than being overridden by planners with administrative skills.

Workforce

Workforce studies by National Disability Services indicate there are limited numbers of allied health in the ACT. Only seven Accredited Practising Dietitians from the ACT who are listed on the DAA website ‘Find an APD’ function are registered with the NDIS. While there are other APDs who are available for self-managed clients who may not list on Find an APD, these numbers are thought to be small. One contributing factor to the slow growth in the workforce is the uncertainty arising from participants being denied reasonable inclusion of Accredited Practising Dietitians in plans.

DAA is concerned that there will be limited opportunities for dietetic students to have exposure to disability as an area of practice, as the private practice environment is not currently set up for student placements. Also, there is a shortage nationally of post-graduate training for dietitians in disability although DAA provides some training at DAA National Conferences, and through DAA sponsored webinars.

DAA is also concerned about the limited skills and knowledge of support workers in disability. Even workers who have completed Certificate III or IV may not have studied basic nutrition and may lack basic skills in food purchasing, preparation and storage. This puts the worker and participants at a disadvantage, given the prevalence of food and nutrition-related disorders experienced by people with disability. Feedback from service providers who are employers of support workers is that the funding provided by the NDIS is not sufficient for service delivery and training of staff.

Early childhood services

Some children with disability have been able to access Accredited Practising Dietitians through their plans. Many have not been supported to do so however from unwarranted limits published in the NDIS Provider Registration Guide to Suitability. Dietitians have inexplicably been omitted from the Early Childhood category, and editions published from June 2017 onwards state dietitians and others are only able to register for Therapy Supports for participants aged seven

years or older. DAA has taken this matter up with the NDIA which acknowledges some children might access Accredited Practising Dietitians but they have not yet changed their written advice in the Registration Guide.

Quality and safeguarding

DAA recognises the need for robust quality and safeguarding processes. However we are concerned that the arrangements for registration of providers will be complex and expensive, and will deter Accredited Practising Dietitians and other allied health providers from entering the market. Briefings by the Department of Social Services indicate that allied health providers will have to submit up to 11 pieces of evidence to a third party auditor for certification or verification as part of the registration process. The cost for this is unknown, though there are estimates of several hundred dollars at least. This is purported to be a risk management approach, but we contend this will merely put dollars in the pockets of auditors, as allied health professions have already demonstrated a low risk to the public. The evidence for this is the decision by health ministers nationally not to register a number of professions under the National Registration and Accreditation Scheme, including dietetics and speech pathology. Even the professions, such as physiotherapy, which are under the Australian Health Practitioner Regulation Agency demonstrated a very low number of complaints when the National Registration and Accreditation Scheme was reviewed.

Lack of clarity for providers in accessing budgets

DAA members report there is a lack of clarity about which part of an NDIS participants budget may be accessed, particularly in the area of Improved Daily Living. Members also report short notice in changes to NDIA processes, and that they were disadvantaged when the change to the NDIA portal occurred. There are also accounts of misinformation where planners or coordinators have informal ‘cheat sheets’ which omit dietitians, or where rumours of changes to budget categories are relayed without formal evidence of such rumours.

Lack of clarity at disability- health interface

The NDIS will fund supports related to healthcare that are required as a result of the participant’s impairment. (NDIS factsheet: Mainstream Interface: Health) However, the two documents which outline the disability-health interface (COAG Principles to Determine the Responsibilities of the NDIS vs Other Service Systems and the NDIS Operational Guideline on Planning) are not clear and have resulted in confusion amongst participants, coordinators, and NDIS planners during the planning and review process for a person’s NDIS plan.

This confusion can be demonstrated by the following experiences, which have been reported by NDIS participants and Disability Support Providers in the ACT:

  • Funding denied for dietitian services for a person with physical and intellectual disability resulting in complete inability to prepare meals. Reliance upon Disability Support Workers for meal selection, preparation, and serving has resulted in weight gain and further decline in functional capacity. NDIS planner denied funding on the basis that this is a health system responsibility.
  • A Coordinator for a Disability Support Organisation was told that dietitians are only funded by NDIS for things like enteral feeding
  • Funding denied for dietitian services for a person with profound intellectual disability, altered body composition, impaired dentition (from birth, not as a result of poor dental maintenance), and complete reliance upon support workers for meal selection, preparation and serving.
  • Funding approved for dietitian services for a person with a mild intellectual disability that has capacity to understand nutrition and is independent in meal selection and preparation.

DAA would like to see clearer guidance for NDIS participants, providers and other stakeholders. Where there is lack of clarity for individual situations, DAA would like to see a process negotiated by health services and the NDIA which facilitates a timely response.

Appendix

DAA statement: NDIS participant access to Accredited Practising Dietitian services and nutrition support products

Dietitians
Association
of Australia
•

NDIS participant access to Accredited Practising Dietitian services and nutrition support products

February 2018

Contact Person: Annette Byron
Position: Senior Policy Officer
Organisation: Dietitians Association of Australia
Address: 1/8 Phipps Close, Deakin ACT 2600
redacted
redacted
redacted
redacted

DAA statement on Accredited Practising Dietitian services and nutrition support products for NDIS participants

The Dietitians Association of Australia (DAA) supports the rights$^{1-3}$ of people with disability to access nutrition support products and Accredited Practising Dietitian services which meet their unique needs to promote physical, mental and social wellbeing.

The following principles focus on National Disability Insurance Scheme$^{4}$ (NDIS) participants in Australia. NDIS participants experience physical, intellectual, sensory or psychiatric impairments that lead to unique and complex food and nutrition needs.

People with a disability have food and nutrition needs related to function, which are in addition to those for growth and development, defence against infection, repair of injury, physical activity, maintenance, and mental health.$^5$

The inclusion of the services of Accredited Practising Dietitians (APDs) and nutrition support products in NDIS participant plans is reasonable and necessary for participants to realise their goals and aspirations, and to increase their social and economic participation.

Key Principles

  1. Many NDIS participants are vulnerable and have complex nutritional needs and live in complex social situations requiring more time to work with an APD. NDIS Plans should include sufficient APD hours to undertake activities which will enable the participant to realise their goals and aspirations, whether the participant is living independently, with family or friends, or in supported accommodation.

  2. NDIS participants living in rural or remote locations should be able to access APD services and nutrition products to achieve good life outcomes.$^6$

  3. Consistent with the principle of self-determination, the NDIS participant should be free to choose an APD provider with the skills and experience relevant to the NDIS participant goals and aspirations to maximise their independent lifestyle and full inclusion in the community. Choice is important in building participant self-esteem and a strong working relationship between participant and an APD.

The use of Medicare Chronic Disease Management items$^7$ to access dietetic services will rarely meet the complex functional needs of NDIS participants. Health agencies may not have the resources to meet NDIS participant needs.

NDIS participants may not be able to access an APD to achieve their goals and aspirations if APD services and nutrition support products are not included in their NDIS plan.

  1. Access to APD services may be needed by NDIS participants of any age but is particularly important for NDIS participants aged 0-7 years with global developmental delay or disability including Autism Spectrum Disorder (ASD). Early intervention supports should allow for inclusion of APDs in a collaborative team approach.$^5$

  2. NDIS participants should have access to affordable nutrition support products (including tube feeds, consumables, oral supplements, fluid and food thickeners). Access to food is a human right$^1$. NDIS participants with complex needs should be food secure i.e. the cost of nutrition support products in an unregulated market should not place them at risk of food insecurity$^8$.

  3. NDIS participants should be empowered with NDIS plan set up and review processes which identify necessary supports, are timely and do not place them at risk of harm$^9$ or compromise their activities of daily living, social inclusion and functional wellbeing.

  4. APDs are food and nutrition professionals who are qualified and credentialed to work with NDIS participants, families, support staff, professionals and others. APDs must meet regulatory and professional standards including the DAA Code of Professional Conduct, the DAA Statement of Ethical Practice$^{10}$ and DAA Scope of Practice Framework$^{11}$. APDs work within an evidence-based paradigm and use relevant guidelines, including the Dietetic Core Standards for Disability$^{12}$.

  5. APDs advocate for the rights of NDIS participants and have the right to speak out against situations that discriminate against people with a disability and may compromise NDIS participant well-being.

About the Dietitians Association of Australia

  • DAA is the leading body for nutrition professionals and the national association of the dietetic profession with branches in each State/Territory. It has been nationally organised since 1976. DAA is a member of the National Alliance of Self Regulating Health Professions and Allied Health Professions Australia.
  • The Association has over 6000 members constituting approximately 80 percent of the dietetic workforce in Australia.
  • DAA was approved in 1999 by the Australian Government Department of Employment Training and Youth Affairs as the assessing authority for dietitians trained in other countries, and prior to this advised the Australian Government on recognition of dietitians trained overseas.
  • DAA has accredited dietetic training courses in Australian universities since 1984.
  • The interests of dietitians are broad and derive from training in three dominant areas of practice i.e. individual case management of medical nutrition therapy (clinical care), community and public health nutrition, and food service management.

About the Accredited Practising Dietitian (APD) program

  • The Accredited Practising Dietitian (APD) program is the foundation of DAA as a self-regulated profession with over 98 percent of eligible members participating in the program.
  • The APD credential is recognised by the NDIS, Medicare, the Department of Veterans Affairs, private health funds and for access to the Healthcare Identifiers Service.
  • The APD program meets the requirements of the National Alliance of Self Regulating Health Professions and has similar requirements to professions regulated under the Australian Health Practitioner Regulation Agency, including
    • Work within scope of practice framework
    • Subject to code of conduct
    • Compliance and disciplinary processes in place
    • Minimum annual continuing professional development required, and subject to audit
    • Resumption of practice requirement
  • APDs work in diverse settings including disability, aged care, hospitals, mental health, private practice, public health, community health, food service, food industry, research and teaching.
  • APDs will often work extensively in one area and develop high level skills and experience in that area e.g. APDs that work with people with a disability.

References

  1. Universal Generation of Human Rights http://www.ohchr.org/EN/UDHR/Documents/UDHR_Translations/eng.pdf
  2. United Nations Convention on the Rights of Persons with Disabilities http://www.un.org/disabilities/documents/convention/convention_accessible_pdf.pdf
  3. Convention on the Rights of the Child https://www.humanrights.gov.au/convention-rights-child
  4. National Disability Insurance Scheme Act 2013 https://www.legislation.gov.au/Details/C2016C00934
  5. Position of the Academy of Nutrition and Dietetics: Nutrition Services for Individuals with Intellectual and Developmental Disabilities and Special Health Care Needs. J Acad Nutr Diet 2015;115:593-608
  6. National Disability Insurance Agency Rural and Remote Strategy 2016 — 2019 https://www.ndis.gov.au/medias/documents/h2c/hb0/8800389824542/Rural-and-Remote-Strategy-991-KB-PDF-.pdf
  7. Chronic Disease Management - Individual Allied Health Services under Medicare — Provider Information http://www.health.gov.au/internet/main/publishing.nsf/content/health-medicare-health_pro-gp-pdf-allied-cnt.htm
  8. Booth S, Smith A. Food security and poverty in Australia — challenges for dietitians. Aust J Nutr Diet 2001; 58: 150-156
  9. United Nations General Assembly resolution A/RES/70/1, Transforming our world: the 2030 Agenda for Sustainable Development
  10. United Nations General Assembly resolution A/RES/70/1, Transforming our world: the 2030 Agenda for Sustainable Development
  11. DAA Code of Conduct and Statement of Ethical Practice https://daa.asn.au/maintaining-professional-standards/professional-standards/
  12. DAA Scope of Practice https://daa.asn.au/maintaining-professional-standards/dietitian-scope-of-practice/
  13. Dietetic Core Standards for Disability 2017 https://daa.asn.au/resource/dietetic-core-standards-for-disability/

Review date: May 2018