Australian Music Therapy Association

Consultation response: Access & Eligibility Policy with independent assessments

About the Australian Music Therapy Association

The Australian Music Therapy Association (AMTA) is the peak body for music therapy in Australia. AMTA represents Registered Music Therapists (RMTs), music therapy students and advocates for access to music therapy on behalf of the community. Our mission is to enable, advance and advocate for excellence in music therapy.

AMTA is the regulating body responsible for registering music therapists, accrediting music therapy courses, and maintaining professional standards and ethics. A member organisation of Allied Health Professions Australia (AHPA) and National Alliance for Self-Regulating Professions (NASRHP), AMTA supports Registered Music Therapists (RMTs) to use research-based practice that actively promotes the health, wellbeing and functioning of Australians.

RMTs work in private practice and in allied health teams in hospitals, residential facilities, community services and schools. They use evidence-based music therapy techniques to promote better health outcomes for vulnerable and unwell Australians. There are currently 626 RMTs in Australia with 152 registered as NDIS providers of music therapy services.

AMTA welcomes the opportunity to provide this response to proposed changes to the NDIS.

Our response:

provides some commentary on the proposed changes
provides more specific responses to the consultation’s questions.

AMTA has prepared this response in conjunction with the Disability Working Group of AMTA, and with feedback from participants of the scheme.

Key points

AMTA strongly recommends more accessible and equitable services for all people with disability, regardless of their location and socioeconomic status.
AMTA strongly supports development of an equitable and reasonable pathway to Scheme entry, and streamlined processes for determining eligibility.
AMTA welcomes funded functional assessments and removing costly and time-consuming processes of gathering reports from professionals to validate access requirements.
AMTA is concerned by costs associated with meeting eligibility requirements (e.g. specialist assessments), prior to scheme access.
AMTA notes potential duplication and waste associated with documentation to illustrate a potential participant meets eligibility requirements, and subsequent independent assessments.
AMTA is concerned by the removal of access lists (e.g. List A and B conditions, disability programs on List C) which have previously streamlined eligibility and access. Compulsory independent assessment of functional capacity is likely to provide replicate information, will increase costs and, in these cases, may be traumatic for the person and their family /carers.
AMTA is concerned by potential inequities in access to timely independent assessments and NDIS participation due to workforce limitations and shortages, particularly in rural, remote and very remote communities.

AMTA suggests allied health professionals already known to the applicant may be well-placed to conduct assessments

Negotiating plans and budgets

Based on the delivery of a functional assessment, planners will have guidance on the size of a plan to be assigned to the participant. This is similar to the typical support package lists currently used by planners (Tune review p. 64). AMTA is not clear how this is an improvement on the current approach. Participants have expressed concerns there will be cost cutting of plan budgets as a result.

Flexible budgets are welcomed. The ability for participants to determine how their budget is spent delivers choice and control, a central tenet of the NDIS.

However, access the funding at monthly or quarterly intervals is determined by the planners, with no redress. This restriction is not appropriate and will affect participants and their service providers. Access to consistent services by the participant will be limited if funds are not available in a timely manner. If funds are exhausted by one-off purchases and capacity building supports are reduced as a consequence, there may be significant impacts on the wellbeing of the participant. It is disempowering to mandate the access to funds without review and reduces the capacity of plan flexibility to be effective.

Right to appeal

AMTA welcomes the ability for participants to review an access decision. However, that the Independent assessment results themselves will not be directly reviewable is concerning. The assumption that Independent Assessments are sound and robust is contentious as these assessment tools are not fit for purpose but collected as the best currently available.

The process for undertaking the assessment is also highly contentious. An independent assessment which is not reviewable puts additional stress on the assessor to produce an assessment in a very limited time frame, using assessment tools not purposefully designed for this function. This non-reviewable document has far reaching consequences and should be available for review.

Workforce considerations

As potential participants/applicants to the scheme need to access information from existing health providers to prove eligibility, it would be efficient and logical for the NDIS to use these current treating professionals to undertake independent assessments. Funding the training of treating professionals to deliver the assessments, within the bounds of professional practice is expedient. This approach would address some issues of thin markets, and of accessing professionals with the requisite experience and qualifications to perform the assessment comprehensively.

Allied Health professionals are bound by Standards of Practice and Ethics through their professional registrations. Their relationship with the participant, and understanding of the

environmental and contextual factors relating to their participant’s functional capacity is invaluable.

Conflict of interest issues could be addressed through refreshers on standards of practice and ethics so that professionals understand the boundaries of undertaking the Independent Assessment and how this is differentiated from delivering services. A certificate of, or registration to provide Independent Assessments could be awarded to participating providers. Audits of all Assessors should be undertaken for compliance and quality assurance and to maintain this registration.

Separating the assessment process from the planning process would be required to ensure that decisions relating to service provision are decided separately to the professional who has completed the IA. In this way, conflicts of interest could be ameliorated.

AMTA recommends allied health professionals, known to the potential participant may be best placed to undertake Independent Assessments at the current NDIS rate for service provision. Allied health professionals could apply to undertake required training for registration as an independent assessor and agree to biennial audits. This would:

increase the workforce available to undertake assessment
provide skilled and experienced assessors
increase confidence applicants and participants and their families/carers would have in undertaking these assessments
increase the capacity of the Assessment to fully represent the functional capacity of the applicant
reduce the need for reviews.

Learning about the NDIS

What will people who apply for the NDIS need to know about the Independent Assessment process? How is this information best provided?

A substantial amount of work, honest and clear communication needs to be done by the NDIA to gain participants’ trust, understanding and commitment to the Independent Assessment process. AMTA is concerned that the new access and eligibility process represents a cost-cutting measure, and has questions about the independence of independent assessors. These concerns are shared by participants, who report they fear a reduction or cessation of their funding.

It is in the NDIA’s best interest to ensure that information about the Independent Assessment process acknowledges participants’ concerns, provides them with accurate and transparent information about the purpose of the assessments, and engages them in process design to minimise any sense of judgement and disempowerment.

Potential participants on the Independent Assessment Process should:

understand how to submit an access request form
understand eligibility criteria, and the NDIA’s focus on functional capacity rather than diagnosis

have access to information in a range of accessible formats (e.g. multilingual, braille, audio format, easy English, via interpreters etc.), easily located on the NDIS website, promoted widely and disseminated to key stakeholders. The information should be developed through consultation and codesign with participants to ensure information is meaningful and available in formats suitable to their needs.
understand timeframes for the completion of Independent Assessments.
support participants’ rights to choice and control. This includes choice of assessment timing and location, and the process for complaints and appeals.

For the Independent Assessment process to be successful:

NDIS referral sources (e.g. general practice, outpatient services, allied health) must be involved in ongoing consultation and communication to ensure clarity on access requirements and Independent Assessments.

Accessing the NDIS

What should we consider in removing the access lists?

AMTA is concerned by the potential for access lists removal to limit or complicate access to the Scheme, be damaging or traumatic for potential participants, and increase costs.

AMTA notes the following opportunities and concerns in relation to removing access lists:

Opportunities	Concerns
- Functional assessment removes the focus on diagnosis and shifts focus to function and ability - Process provides opportunity for support for individuals who do not have a formal diagnosis - Focus on function reduces ‘labelling’ - Reducing focus on diagnosis alone takes into account that disabilities have a broad spectrum of needs e.g. ASD.	- Independent assessment requires participants to prove their disability impacts function – deficits focused - NDIA delegates do not have access to named diagnoses when making access/eligibility decisions – potential to misunderstand the range of effects of disability on functional capacity - Functional focus may reduce understanding about who is/isn’t eligible for NDIS support for individuals seeking to access the scheme and for referral services outside of the sector. - Additional cost of providing assessments for people who are clearly eligible (such as people diagnosed with Autism level 3; people with severe and profound intellectual disabilities etc.) for whom additional assessments on their functional capacity should not be necessary.

Opportunities

Concerns

- Functional assessment removes the focus on diagnosis and shifts focus to function and ability
- Process provides opportunity for support for individuals who do not have a formal diagnosis
- Focus on function reduces ‘labelling’
- Reducing focus on diagnosis alone takes into account that disabilities have a broad spectrum of needs e.g. ASD.

- Independent assessment requires participants to prove their disability impacts function – deficits focused
- NDIA delegates do not have access to named diagnoses when making access/eligibility decisions – potential to misunderstand the range of effects of disability on functional capacity
- Functional focus may reduce understanding about who is/isn’t eligible for NDIS support for individuals seeking to access the scheme and for referral services outside of the sector.
- Additional cost of providing assessments for people who are clearly eligible (such as people diagnosed with Autism level 3; people with severe and profound intellectual disabilities etc.) for whom additional assessments on their functional capacity should not be necessary.

How can we clarify evidence requirements from health professionals about a person’s disability and whether or not it is, or is likely to be, permanent and life long?

AMTA recommends continuation of List A and B access lists as evidence that a person’s disability is likely to be permanent and lifelong. In this current proposal, Health professionals may benefit from decision support tools that provide clear criteria and continuums to support decision making. Information can be communicated via a template form for health professionals to complete
provider contact information held by the NDIA, and through peak and regulatory bodies for all NDIS providers and referring professionals e.g. RACGP, AHPA, SPA, OTA, AMTA.

Undertaking an independent assessment

What are the traits and skills that you most want in an assessor?

An assessor must be a highly qualified professional with knowledge and experience in the disability sector. Assessors should be:

well trained in the administering of the assessment tools and an ability to do so flexibly based on the participant’s needs at the time of the assessment
able to communicate clearly and adapt their communication style to the needs of the participant
warm, empathetic and respectful
non-judgmental, non-biased, non-ableist in their role
focussed on facilitating participant choice and control.

An assessor should have a strong sense of ethics and recognise they are in a position of power during the assessment process.

AMTA highlights the potential difficulty recruiting, training and retaining health professionals as independent assessors. Participants already experience limited workforce and lengthy waitlists for most allied health services (particularly in regional and remote communities). AMTA calls on the NDIA to ensure workforce shortages do not result in compromises to the professional qualifications, skillset and training of the assessors.

AMTA suggests allied health professionals already known to the applicant may be well-placed to conduct assessments. In Australia, both registered and self-regulating allied health professionals have clear national competency standards, accredited university courses of study, and robust and enforceable regulatory mechanisms. Well-regulated professions (including accreditation standards, codes of ethics, professional memberships) are central to safe and high-quality care.

A member organisation of Allied Health Professions Australia (AHPA) and National Alliance for Self-Regulating Professions (NASRHP), AMTA supports Registered Music Therapists (RMTs) to use research-based practice that actively promotes the health, wellbeing and functioning of Australians. Almost one quarter of all music therapists in Australia are registered NDIS providers of music

therapy services, and would be well-placed to conduct independent assessments with additional training in the assessment tools.

AMTA suggests planning an independent assessor workforce may be a challenge, and raises some questions about independent assessors:

How will the participants and the NDIS be assured of the experience and expertise of the assessors?
Who will provide this service if it pays less than that rate for service provision through the NDIS?
Who will provide services in an already thin market?
How will rural and remote areas receive this service when the current service provision in these areas is already thin?
If rural and remote service providers give preference to providing ongoing allied health service for their communities rather than tendering for independent assessment work, who will provide independent assessments?
When allied health professionals are well-regulated, why are current service providers deemed to have a conflict of interest and unable to provide independent assessment services?

“My son has chronic, complicated disabilities and it’s taken me much hard work to find health experts to support and gotten to understand my son’s needs over the years: how can some unfamiliar expert/s, albeit highly qualified, able to assess my son’s needs in a few hours?” (Participant’s mother)

What makes this process the most accessible that it can be? For example, is it by holding the assessment in your home?

AMTA strongly asserts the importance of participant choice and control in assessment planning and delivery. Participants should:

make choices about the time and place of the assessment e.g. home, health professional’s office, NDIA office, park, café, other community setting.
choose who supports them during the assessment process e.g. family/carer, friend, therapist, support worker, interpreter etc.
have access to additional support workers to assist whilst assessments are being completed (such as the Vineland questionnaires).

As well as drawing in expertise from a range of allied health professionals to develop a functional profile, AMTA notes that allied health professionals who are known to the potential (or existing) participant may be best-placed to administer independent assessment tools. This would allow for assessment to be undertaken by people who have already established a relationship of trust and confidence, and who have a greater understanding of the person’s capabilities.

How can we ensure independent assessments are delivered in a way that considers and promotes cultural safety and inclusion?

Assessors must be well trained to recognise and consider the impact different settings will have on the assessment outcomes. For some participants, holding the assessment in their home will provide accessibility and familiarity. It will enable their functional capacity in their everyday environment to be adequately assessed. For others, holding the assessment in their home will be a source of stress, shame, anxiety, judgement, and may lead to inaccurate assessment outcomes. . AMTA also notes that standardised assessment tools are often heavily culturally biased. These tools may not be most appropriate for assessing functional capacity of Aboriginal and Torres Strait Islander and culturally and linguistically diverse people. The use of parent report assessment tools may be inappropriate for some migrants for whom there is stigma and denial attached to disability and therefore may produce skewed responses of functional capacity. More research and consultation is required in this vitally important area to ensure equity of access.

The adequacy of the assessment tools is central to meeting the needs of prospective participants. These have been assembled from the best currently available assessment tools. However none were designed for this purpose.

Our concerns are summarised as follows.

Fit for purpose tools are required which can adequately reflect functional capacity for:

Psychosocial, cognitive and Intellectual disability,
Complex trauma of those with social disability.
Trauma and disability
ATSI and CALD populations,
Progressive neurological and fluctuations in disability including homeless people.
Dual diagnoses such as mental health and Intellectual disability

AMTA notes that information reported by a provider who has worked closely with the participant is of greater importance and accuracy when making access and funding decisions when compared with the 3-hour independent assessment conducted by an unknown assessor.

Exemption

What are the limited circumstances which may lead to a person not needing to complete an independent assessment?

A potential participant should not have to complete an independent assessment:

where the assessment will cause harm to the participant or their family/carer, accompanying support person, or the assessor (including emotional/psychological harm not just physical harm).
where the person has had no change to their diagnosis, support needs, or living arrangements and is not seeking a change to their funding or plan. Participants should not be required to constantly prove they are worthy of support/funding if there has been no change to their circumstances.

AMTA expresses concern about page 21 of the consultation paper: “the delegates decision not to grant an exemption for an Independent Assessment will not be a reviewable decision … if an applicant chooses not to complete an Independent Assessment, we will consider that an applicant has withdrawn their access request”. Participants should be enabled and supported to exercise choice and control, and be able to negotiate a mutually acceptable process for independent assessment, and to request a review of decisions made about their eligibility and access.

Quality Assurance

How can we best monitor the quality of independent assessments being delivered and ensure the process is meeting participant expectations?


Participant outcome and experience	- person-reported experience and outcome measures - rapid and accessible feedback mechanisms, including complaints and appeals processes - experience and outcome measures that include a wide variety of participants (e.g. from different regions, diagnoses, age groups etc)
Experience of those delivering assessments	- person-centred experience measures - staff satisfaction e.g. adequate renumeration, training, support
Service quality	- assessment audits, inter-reliability studies, review of access decisions over time - patterns of access to the scheme - regular and planned feedback from NDIS service providers about processes and outcomes - workforce skills, training and qualifications - workforce recruitment and retention
Sustainable costs	- utilisation of other healthcare and support services, particularly inpatient and residential services - duplication of effort (e.g. highly detailed service access requests with attached health reports followed by independent assessment)

Communications and accessibility of information

How should we provide the assessment results to the person applying for the NDIS?

AMTA recommends all people applying for NDIS receive access to their complete and full assessment results, in a format of their choice.

The NDIA has an ethical responsibility to ensure that participants are well-supported when reviewing their assessment results. The NDIA has committed to ensuring the assessment process focuses on participant strengths. It is therefore important that the assessment results are not interpreted as deficits by the participant. Participants need to be provided opportunity to discuss their results with the assessor – to ask questions, seek clarification and reassurance. This is particularly important where there is a rejection of the eligibility and access to the scheme.

Applicants need to receive careful and comprehensive information about an alternative range of supports available if they do not qualify for NDIS funding.