PRODUCTIVITY COMMISSION
STUDY TO REVIEW THE COSTS OF THE NATIONAL DISABILITY INSURANCE SCHEME (NDIS)
OCCUPATIONAL THERAPY AUSTRALIA (OTA) SUBMISSION
MARCH 2017
Introduction
Occupational Therapy Australia (OTA) welcomes the opportunity to make a submission to the Productivity Commission as part of its study into the costs of the National Disability Insurance Scheme (NDIS).
Occupational Therapy Australia is the professional association and peak representative body for occupational therapists in Australia. As of December 2016 there were more than 18,000 nationally registered occupational therapists working across the government, non-government, private and community sectors in Australia. Occupational therapists are allied health professionals whose role is to enable their clients to participate in meaningful and productive activities.
Occupational therapists provide services such as physical and mental health therapy, vocational rehabilitation, assistive equipment prescription, home modifications and chronic disease management, as well as key disability supports and services.
Occupational Therapy Australia is a strong supporter of the NDIS and the scheme’s focus on providing individualised support for participants with informed choice and control over their plans. Occupational therapists work across all NDIS launch sites and contributed to the design and implementation of the scheme during its trial period.
Responses to questions in the issues paper
Are there other aspects of the eligibility criteria of the NDIS that are affecting participation in the scheme (to a greater or lesser extent than what was expected)? If so, what changes could be made to improve the eligibility criteria?
OTA members have raised concerns about the shortcomings of the NDIS eligibility criteria for people with particular disability support needs, including:
- People with psychosocial disabilities – concerns have been raised by a number of mental health stakeholders that the NDIS does not take into account the relapsing/remitting nature of mental illness. The access requirements for becoming an NDIS participant stipulate that an individual may meet the disability requirements if they ‘have an impairment or condition that is likely to be permanent’. This seemingly conflicts with principles of recovery oriented mental health practice, which underpin the provision of mental health services by clinicians such as occupational therapists. OTA believes that these principles should be used to guide the delivery of the NDIS for people with psychosocial disabilities. We have also called for the Department of Social Services (DSS) to commission another review of the legislation underpinning the NDIS (the NDIS Act), with particular attention being paid to the concept of permanency.
- People with dual diagnosis/comorbidity – people with co-occurring conditions have experienced barriers to accessing support through the NDIS. These people require integrated access to services, rather than having to apply for and access several pockets/agencies for funding. They should have access to an NDIS Local Area Coordinator (LAC) who can assist them to access information about supports that are available in their community. OTA believes that funding should be provided to increase the number of LACs and therefore reduce the number of people assigned to one LAC. Additionally, there should be a greater focus on recruiting people who have experience working with clients with a dual diagnosis or co-occurring disorders to fill LAC positions.
- People with autism spectrum disorder (ASD) – an expert panel convened in 2015 by the NDIA to provide advice on what constitutes best practice for ASD intervention therapies highlighted the importance of being clear about eligibility guidelines. Our members have
reported that people at the lower end of the autism spectrum have been deemed ineligible for the NDIS, despite the fact that their condition has impacted their functional capacity.
- People with chronic health conditions resulting in a functional disability – there have been reports of inconsistent decisions regarding the eligibility of those who fall within this category. For example, a person with obesity who uses a power wheelchair had their application declined and was advised that their condition was considered a temporary one.
OTA believes that the NDIS access requirements should be refined to provide greater clarity for prospective participants and their families, and to ensure that decisions around eligibility are consistent and not open to interpretation. The access requirements need to clearly articulate situations where are person would be eligible for the NDIS (such as particular conditions, severity level and degree of functional impairment), and where they would be better supported through an alternative funding source.
Is the current split between the services agreed to be provided by the NDIS and those provided by mainstream services efficient and sufficiently clear? If not, how can arrangements be improved?
OTA believes that the current split between the NDIS and mainstream services is not sufficiently clear. The impact of the NDIS on access to therapy supports in the education sector is a concern that has been repeatedly raised by OTA members. The current provision of therapy services is often intertwined with school participation and assisting students to access the curriculum alongside support for participation outside school activities. It is unclear how this will be managed when the NDIS is implemented.
OTA believes that a coordinated interdepartmental approach between the NDIA and each state education department is needed to provide policy and funding clarity around the implementation of the NDIS in educational/school settings to ensure students and families understand how to navigate funding resources for their supports.
Therapy supports, including behavioural strategies, environmental adaptations, and assistive technologies, will usually have application in other areas of life than the school. Despite this, certain therapeutic interventions (such as assistance with handwriting) have not been funded by the NDIS because they are considered to be ‘school skills’ rather than ‘life skills’. OTA recommends that a specialist taskforce be established to determine how one consistent therapist can work across NDIS-specific and education-specific goals, how to ensure consistent access to assistive technologies used across different settings, and how to best realise choice and control for the child and family in both the education and broader NDIS setting.
How has the interface between the NDIS and mainstream services been working? Can the way the NDIS interacts with mainstream services be improved?
Our members have raised concerns around the interface of the NDIS and mainstream services, particularly in states where government-funded services have transitioned, or are expected to transition, to the private sector. Several state governments have announced that they will be withdrawing from their role as a service provider, raising uncertainty around whether existing services will continue and whether staff who transition to the private and not-for-profit sectors will continue to receive an appropriate level of support. In New South Wales, a number of staff from the Department of Family and Community Services (FACS) have moved across to the private sector following the transfer of the Home Care Service of NSW to Australian Unity. OTA has maintained an active dialogue with state governments around transition arrangements for service providers and the effectiveness of quality controls in the private and not-for-profit sectors.
How will the full rollout of the NDIS affect how mental health services are provided, both for those who qualify for support under the scheme and those who do not?
As noted above, OTA is concerned that the scheme’s focus on permanency neglects the fact that people with mental illness can see their condition fluctuate greatly over the course of their lifetime. There also appears to be confusion around the provision of services for people who have been diagnosed with multiple conditions – for example, autism spectrum disorder and depression. There is a tendency to ‘split’ a person’s needs to determine where funding should come from (eg. is this issue related to their autism diagnosis or their depression?), which prevents them from receiving holistic care.
Given the lack of clarity around the access criteria for the NDIS for people with mental illness, it is clear that a significant number of people will be deemed ineligible. It is feared that the transition of funding for federal programmes and services to the NDIS will increase pressure on state-funded services and leave many worse off. This is despite the Federal Government’s commitment to ensuring continuity of care for those who are ineligible.
Occupational therapists are well placed to provide practical, thoughtful and functional support to children and adults with mental health concerns. Our members who provide services to children through government programmes such as Helping Children with Autism (HCWA) and Better Access to Mental Health (BAMH) have found that the number of focused psychological strategies and/or interventions approved through these initiatives is very limited. Additionally, strategies and interventions that are funded do not always take into account the skills that occupational therapists can offer children and their families.
Occupational therapists are further hampered by the fact that GPs and paediatricians often overlook the services that occupational therapists provide, resulting in limited referrals for their services.
OTA recommends that consideration be given to increasing the number of assessment and treatment services available through programmes such as HCWA and BAMH. This will ensure adequate support for people who are not eligible for the NDIS. We also recommend that the number of claimable allied health services available through the Medicare Benefits Schedule (MBS) be increased to allow for follow-up and other evidence based best practice interventions that are currently excluded. Additionally, GPs should be provided with comprehensive information on the various mental health services funded through Medicare to ensure that referrals are consistent with a client’s therapy needs.
Is the planning process valid, cost effective, reliable, clear and accessible? If not, how could it be improved?
OTA believes that occupational therapists should play a key role in working alongside NDIS Planners to assess the functional needs of NDIS participants. Following extensive consultation with OTA members, it is apparent that Planner inconsistency is a significant issue nationwide. The quality of NDIS plans varies considerably from person to person, and depends on the Planner’s level of experience and understanding of the different services available to participants. Due to the fact that Planners are recruited from a variety of backgrounds, their understanding of the role of occupational therapists is often poor. It is clear that NDIS Planners frequently underestimate the hours of therapy required for a participant to achieve their goals, which subsequently affects the quality of their plan. OTA acknowledges that some Planners do have an allied health background and have developed plans that adequately reflect the complexities of a participant’s needs.
Many NDIS participants and their carers have been left frustrated by a lack of face-to-face contact with Planners, with meetings instead being held over the phone. Planners are often difficult to get
hold of, resulting in providers having to advocate on behalf of participants. There are also inconsistencies with regards to Planners requesting reports from therapists in support of a participant’s need for particular services. When reports are requested, therapists are often given insufficient time to provide these to Planners.
Providers frequently request plan reviews if a participant’s plan does not adequately reflect their needs, or if their circumstances change and they require additional supports. These reviews can take months to complete, resulting in added frustration for families and potentially affecting the relationship between participant and provider.
How should the performance of planners be monitored and evaluated?
OTA believes that the training provided to NDIS Planners should be revised to provide for more comprehensive participant plans and to reduce the frequency of plan reviews. Our understanding is that the in-house training provided to Planners is very much focused on the policies and processes of the NDIA rather than the roles of health professionals who deliver supports. Planners should be required to have a minimum understanding of therapeutic supports and their value in helping participants to develop key skills and enhance their independence. OTA recommends that consideration be given to how the skill level of Planners can be increased with respect to occupational therapy practice. We also call for the training of NDIS Local Area Coordinators (LACs) and Support Coordinators to be enhanced to allow for greater understanding of the roles of different health professionals. NDIS providers should be consulted throughout the process of developing or refining training material.
OTA is engaged in ongoing discussions with Allied Health Professions Australia (AHPA) around developing material to increase Planners’ knowledge of the different allied health professions.
OTA believes that the NDIA should develop a set of key performance indicators (KPIs) to monitor and assess the performance of Planners and the overall effectiveness of the NDIS planning process. There should also be clear timeframes for Planners to action requests for plan reviews and to respond to queries from participants and providers. The NDIA should consult more widely with participants and providers on the planning process to address specific concerns and ensure that the performance of Planners is in line with community expectations.
Are the avenues for resolving disagreements about participant supports appropriate? How could they be improved?
There is a need for a clear pathway for providers to submit supporting documentation and make recommendations about participant supports. NDIS providers across the country have repeatedly expressed frustration at the lack of response to phone calls and emails from staff at the Agency. As a result, they are having to constantly follow up on requests for plan reviews and queries about participant supports.
What factors affect the supply and demand for disability care and support workers, including allied health professionals? How do these factors vary by type of disability, jurisdiction, and occupation? How will competition from other sectors affect demand (and wages) for carers? What evidence is there from the NDIS trial sites about these issues?
One factor affecting the supply and demand for allied health professionals in the disability sector is the availability of mentoring and clinical supervision for new graduates. It is critical that clinicians who have recently entered the workforce have access to professional development opportunities to enable them to adapt to a changing market environment and to prevent high turnover rates.
OTA believes that funding should continue to be provided for workforce readiness initiatives in the form of workshops and training programmes that promote evidence based interventions for people with disability. This should include training for allied health professionals to assist them to transition to the NDIS. OTA is supportive of initiatives such as the Sector Development Fund (SDF) and Innovative Workforce Fund (IWF), which allow individuals and organisations to apply for grants to support the development of the disability workforce.
There is ongoing concern about the availability of disability care and support workers in rural and remote areas, particularly in the Northern Territory. Providers working in areas that are especially remote can be affected by a lack of Internet access. OTA acknowledges that providers will often be required to travel considerable distances to deliver services to clients in remote communities. However, more can be done to improve the quality of service delivery in remote Indigenous communities, such as consulting with Indigenous elders. Ensuring that providers are equipped to provide culturally responsive services to Indigenous Australians will remove many of the current barriers to servicing this client group.
Are prices set by the NDIA at an efficient level? How ready is the disability sector for market prices?
Our members have reported that there are often ‘hidden costs’ associated with working in the NDIS, with many therapists working outside of normal working hours to complete tasks. The way costs are calculated needs to be clearly communicated to participants and their family members, as the rationale for certain prices is not always immediately clear. Additionally, participants need to be made fully aware of the fact that the prices set for therapeutic supports take into account preparation time and report writing, which can reduce the length of the actual consultation.
What are the barriers to entry for new providers, how significant are they, and what can be done about them?
The implementation of the full scheme is revealing problems that need to and can be addressed before roll out is complete. These problems, in conjunction with negative publicity, have likely prevented many health professionals from registering as NDIS providers. During the early stages of full roll out, there was significant feedback that the new NDIS payment portal was proving difficult to navigate. While it appears that these issues have now been largely resolved, any outstanding issues need to be addressed as a matter of urgency and additional funding provided if necessary.
Our members have reported that the provider section of the NDIS website can be difficult to navigate, as providers are required to sort through an abundance of information to find what they need (such as a particular set of guidelines). There is also a lack of user friendly information for prospective providers who are interested in learning more about the scheme. OTA believes that the NDIA should adopt a co-design approach to developing operational guidelines. Providers often have no input into these or any opportunity to submit feedback on whether what has been proposed will work in practice.
Some occupational therapists have reported that the registration process can be quite lengthy, which may deter some people from signing up as providers. As noted above, another issue is the fact that providers quite often receive no response to phone calls and emails from NDIA staff. This could present a barrier to entry for new providers who may wish to speak to someone or ask questions about the scheme.