Submission to
Productivity Commission
National Disability Insurance Scheme (NDIS)
Costs
July, 2017
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Table of Contents
- Introduction……………………………………………………………………………… Community Care…………………………………………………………………………………………………………… 3 Nursing……………………………………………….………………………………………………………………………… 4
- Carers…………………………………………..………………………………………… Industrial Matters………………………………………………………………………………………………………… 6
- Costs and Governance………………………………………………………………………………
- Accessibility……………………………………………………………………………… Conclusion……………………………………………………………………………………………………………………. 7
- References…………………………………………………………………………………
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Introduction
The Queensland Nurses and Midwives’ Union (QNMU) thanks the Productivity Commission (the Commission) for the opportunity to provide feedback on the position paper National Disability Insurance Scheme (NDIS) Costs.
Nursing and midwifery is the largest occupational group in Queensland Health and one of the largest across the Queensland government. The QNMU is the principal health union in Queensland covering all categories of workers that make up the nursing workforce including registered nurses (RN), registered midwives (RM), enrolled nurses (EN) and assistants in nursing (AIN) who are employed in the public, private and not-for-profit health sectors including aged care.
Our more than 56,000 members work across a variety of settings from single person operations to large health and non-health institutions, and in a full range of classifications from entry level trainees to senior management. The vast majority of nurses in Queensland are members of the QNMU.
The QNMU recommends:
- the nursing support and services provided as part of the NDIS should be undertaken by nurses. Only qualified nurses can provide total nursing care that delivers high quality and cost-effective outcomes;
- the QNMU must be fully funded to enabled those with a disability to receive proper nursing care where necessary.
Community Care
The community care sector in Australia is moving towards a demand driven model of service delivery in the disability and aged care service sector under the NDIS and consumer directed care (CDC). Where once these services were delivered in a block funding model spread across consumers, providers will now operate within individualised budgets. This means that consumers will have more choice and control.
As the NDIS and CDC are becoming embedded in the home care sector, there has been an associated rise in the number of agencies that seek to match clients to care workers including RNs and ENs. These workers are not directly employed by the agencies and therefore not subject to the rigorous recruitment and training requirements of regulated
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services. Within the health sector, the emergence of these unregulated services raises concerns on many levels about the quality of care people might receive and the level of protection for both the workers and the public. This may put consumer safety at risk.
Nursing
Nursing services are a crucial part of the NDIS through their care and support of people with a disability, their families and carers. Nursing takes a holistic rather than task oriented approach to health care and includes the physical, mental and emotional care of the person. With the full roll-out of the NDIS requiring more carers, care requirements that fall within the nursing scope of practice must be undertaken by qualified, regulated professionals. Service providers need to acknowledge and accept professional nursing boundaries so that unqualified carers are not engaged to perform nurse-specific tasks.
This means there must be a clear understanding of who is responsible for co-ordinating and monitoring care plans. The appropriate level of nursing support is imperative to the health of people with a disability.
Nursing practice is undertaken by RNs, ENs and nurse practitioners (NPs) who are regulated to practise as nurses. AINs are delegated aspects of nursing care by RNs and provide that care under the direct or indirect supervision of RNs. Current nursing regulation also requires that the outcomes of any nursing care provided by employed AINs or carers, whether in the home or the residential setting, must be evaluated by a RN. Individuals practising nursing should undertake relevant education and possess the required qualifications for registration. RNs, midwives and ENs must comply with the Nursing and Midwifery Board of Australia National (NMBA) Standards for Practice.
The provision of personal care to individuals enables them to live independently and facilitates their integration and participation in the community. Decisions about whether personal care should be provided by a nurse or another level of worker should only be made by a RN. A RN assesses the characteristics of the person requiring care, the activities to be performed, and the competence, education and authority for practice of the person providing the care.
It is important the consumer has a role in directing the care provided, is aware of the different types of workers who will be providing their personal care and is empowered in the knowledge that any nursing care they receive will be delivered, or supervised and evaluated, by a RN. As health care workers have a range of different qualifications and experience, consumers will need education and support in making decisions related to the type of care they receive and who delivers it.
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The QNMU opposes the erosion of nursing positions and/or services in any setting by the employment of other staff categories (however titled) to manage or provide nursing care.
Example
We use the following example of the management and administration of medicines to demonstrate why the qualifications and responsibilities of a ‘carer’ are important.
In the nursing sense, a carer is any person who is not registered to practice as a registered or enrolled nurse. Two risks arise from this.
The first is a service provider’s engagement of carers to administer medicines with no nationally accredited qualifications in pharmacology or in the administration of medicines. Current Australian Qualifications Framework certificate courses have an elective unit which teaches carers how to assist with the administering of medicines, particularly with those clients who self-administer, but they do not provide those students with the necessary pharmacology knowledge to administer medicines safely.
Secondly, RNs who are directed or coaxed into allowing carers to administer medicines in contravention of the national professional nursing standard risk liability for disciplinary action by the nursing and midwifery regulatory authority, the NMBA.
Further, it cannot be assumed that a person receiving a health service in their own home is mentally competent. If the care recipient is not mentally competent to self-administer their medicines, they will require a registered health practitioner (with qualifications in medicines recognised by their National Board) to manage and administer their medicines.
Carers
The number of disability support care workers needs to increase significantly to meet the predicted demand of the NDIS. Yet, the NDIS will compete with other rapidly growing industries such as aged care and healthcare for nurses and care workers. Policies and measures must be established to ensure community care providers do not position their carer workforce as a cost effective alternative to the more highly trained nurses (Deloitte, 2015). There is a need and scope for both the caring and nursing professions in the NDIS and the work they perform should be kept distinct.
Not all persons with a direct or implied obligation or responsibility for caring for individuals or groups are necessarily engaged in nursing. For example care by carers or relatives in the home environment, ‘informal carers’, is not considered to be nursing. However, just as the paid carer workforce is vital so too are the informal carers who play an important role in the
lives of many people. The contribution of informal carers is vast and extends beyond societal and economic expectations as many carers report personal satisfaction. Yet, the wellbeing of carers is often poor with many neglecting their own health due to limited time or the ability to afford appropriate treatments (Australian Medical Association, 2014).
The flow-on benefits of the NDIS for informal carers is included as one of the positive outcomes of the scheme with some carers being able to take respite, return to work and experience less financial pressure and stress (Laragy, Sanders & Brophy, 2015). With the Government’s proposed Integrated Plan for Carer Support Services intending to complement the NDIS, the provision of support for informal carers to improve their long term social and financial outcomes and participation in everyday activities such as education and the workforce, is welcomed by the QNMU (Department of Social Services, 2016).
Industrial Matters
How the NDIS impacts on and interacts with mainstream services including those provided by professional nursing practices may have an industrial flow-on. For example, consumers may require care outside the normal spread of hours and only for a limited duration. This calls into account industrial standards such as penalty rates, shift allowances and minimum call out payments.
It is the position of the QNMU that service providers must remunerate all nurses and carers according to the relevant industrial instrument, including adherence to health and safety legislation and standards. Service providers cannot contract out of their obligations under industrial law.
Any shift towards a reduction in occupational licensing, reliance on private certification schemes and reputation mechanisms, avoidance of industry specific regulatory frameworks and the exclusion of certain types of health workers from employment law will inevitably impact on the nature of the nursing workforce.
The QNMU maintains that only qualified nurses can provide total nursing care that delivers high quality and cost-effective outcomes.
Costs and Governance
As stated in the Productivity Commission position paper, the Commission has been asked to review a number of issues which includes the cost of the scheme and cost pressures, including wages. The QNMU contends that in order for the highest quality of care to be provided, nurses must deliver nursing and this cost should be incorporated into the NDIS
budget. Replacing nurses with unregulated workers may yield immediate cost savings, but will have long term implications on the provision of safe care. The initial financial gains that may be made through using unregulated workers and not nurses, is short-sighted and may leave consumers less able to exit the scheme or reach their full potential. In the long term, the financial and human costs are greater when they arise from both adverse incidents and sub optimal outcomes for people with a disability. Appropriate levels of nursing support must be included in the consumer’s NDIS plan.
The QNMU backs the Commission’s assessment that the governance arrangements, planning and administration of the NDIS should be transparent and in line with the community’s expectations.
In our view:
- The NDIS must meet its own objectives and quality standards;
- There must be transparency and visibility around the billing of services;
- The funding of the scheme should not be to the detriment of other social expenditure.
Accessibility
The QNMU supports the view that the NDIS must be inclusive for all. This includes those consumers from different cultural and linguistic backgrounds, those who live in rural and remote locations, older participants and Indigenous Australians. Access to the correct supports and provider information should also be inclusive, flexible and easily navigated. If nursing services are considered not to be appropriate to be included in the consumer’s NDIS plan, or the funding is insufficient, the review process must be straightforward and timely for the consumer.
Conclusion
The QNMU supports the development and roll-out of the NDIS. As part of this national reform and to ensure quality care is provided for people with a disability, nurses must be the workforce that provides nursing. This work should not be outsourced to lesser qualified, unregulated carers. People with a disability deserve no less.
References
Australian Medical Association. (2014). Women’s Health – 2014. Retrieved from https://ama.com.au/position-statement/womens-health-2014
Deloitte. (2015). How consumer driven care is reshaping the community care sector. Retrieved from http://www2.deloitte.com/content/dam/Deloitte/au/Documents/life-sciences-health-care/deloitte-au-lshc-consumer-driven-care-reshaping-community-care-sector-180614.pdf
Department of Social Services. (2016). Delivering an integrated carer support service: A draft model for the delivery of carer support services. Retrieved from https://engage.dss.gov.au/wp-content/uploads/2016/11/draft_service_delivery_model_0.pdf
Laragy, C., Sanders, F. & Brophy, L. (2015). Implications for family carers when people with psychosocial disability have individualised funding packages – literature review. Retrieved from https://www.mindaustralia.org.au/assets/docs/News%20&%20Media/Mind_Literature_Review.pdf