Submission to:
Independent review of the National Disability Insurance Scheme
March 2023
Introduction
Music therapy is a research-based practice and allied health profession and in Australia is delivered by registered music therapists (RMTs). RMTs are Masters and Bachelor level qualified, and accredited nationally by the Australian Music Therapy Association (AMTA).
RMTs design and deliver individualised music-based interventions that support social, communicative, sensory, emotional, cognitive and behavioural skills. RMTs are allied health professionals with expertise in music engagement to activate complex neurological structures. RMTs use targeted music therapy techniques (e.g. improvisation, songwriting, therapeutic singing, music-assisted counselling, active and receptive music engagement) to influence behaviour, improve cognition and communication, develop and rehabilitate motor skills, and develop emotional awareness and competence. For NDIS participants, music therapy can significantly impact mood, thinking, behaviour, communication, and movement, and increase independence and community participation. RMTs are recognised therapy service providers for the NDIS and provide crucial and life-changing supports for people with disabilities and their carers.
AMTA is the national peak body for music therapy in Australia, and is responsible for registering RMTs, accrediting music therapy courses and maintaining professional standards and ethics. There are currently nearly 800 music therapists registered with the AMTA. AMTA is a member organisation of Allied Health Professions Australia (AHPA) and the National Alliance for Self-Regulating Professions (NASRHP). Membership of NASRHP requires all RMTs across Australia to meet 11 regulatory standards to ensure consumers receive quality and safe services from qualified and certified RMTs.
AMTA acknowledges and welcomes this independent review of the NDIS. AMTA has been consistently involved in past NDIA consultations; however, many of these consultations resulted in no change or reflection of the content of submissions. We trust that this Committee’s consultation is genuine and will deliver meaningful recommendations for change.
Below we comment on our past consultation experiences and respond directly to the terms of reference:
- The nature of consultation and communication with the NDIS
- The design, operations and sustainability of the NDIS
- Building a more responsive and supportive market and workforce.
We welcome further conversation and consultation with the NDIA on the Scheme’s implementation.
1. The nature of consultation and communication with the NDIA
Our consultation experiences with the NDIA have been that genuine engagement is limited and largely tokenistic. When they do occur, consultation processes are so constrained, in terms of scope, lines of questioning, and methodology, that findings are rendered largely meaningless and do not represent the views of participants or providers. There is rarely an opportunity for two-way conversation or discussion. AMTA communicates regularly with the NDIA; however, we often receive no response. This is our continued experience of consultation with the NDIA.
AMTA is firmly committed to the NDIS and the potential it offers participants. However, this potential is often overshadowed by operational roadblocks and communication issues. Changes to NDIS plans, processes and practices without consultation directly impact participants, carers, providers and workforce availability.
2. Design, operations and sustainability of the NDIS
Putting people with disability back at the centre of the NDIS
The processes and procedures within the NDIS are protracted, complex and often lack transparency, consistency and predictability for participants and their support people.
Experiences of engaging with the Scheme
The planning process continues to be the aspect of the NDIS causing the most distress to participants and the most concern to providers. Choice and control for participants is best facilitated by coordinators and planners who understand the breadth of supports available to participants and the benefits and outcomes these deliver. NDIS participants and our members continue to express concerns that decision-makers, often coordinators and planners, may not have sufficient knowledge, training or skills to enable participants’ active role in decision-making, make valid decisions about participant goals and plans or identify the most suitable providers for support. NDIA planning and coordination requires a high-level understanding of complex disability and a detailed understanding of the disability sector and the value of available supports. AMTA is concerned that planner workloads and time pressures negatively impact the decision-making process. AMTA is concerned about the knowledge and skills of planners and coordinators who have made decisions based on incorrect information or without an understanding of the available evidence base, particularly relating to music therapy. We have previously presented evidence to the Committee and the NDIA on this subject.
AMTA members continue to advocate on behalf of participants and are concerned by participants’ levels of distress when planners disregard their choices and opinions. Our members continue to witness participants’ being disempowered to make their own choices and decisions due to administratively-driven and economically-motivated processes within the NDIA. We have heard
from participants who have had plans drawn up on their behalf without their or their family’s consent or engagement and denied the opportunity to have input. Participant supports have been removed or drastically reduced without consultation with participants. Such experiences are in direct conflict with the intent of the NDIS. Any further objections or appeals are extraordinarily difficult and cause significant distress for participants and their support people.
Our members’ concerns about some of the individual planning decisions made by NDIA staff have raised questions about the qualifications, skills and training of those working at the NDIA. Despite our involvement in numerous workforce-related meetings and consultations, AMTA remains uncertain about the qualifications, competencies and capabilities of NDIS Planners. While this uncertainty may be the result of a communication issue, it reflects deeper concerns about the quality of decision-making, a lack of transparency about agency conduct and process, and provider and participant trust in agency staff.
Limited information about the decision-making process limits participants’ ability to question and challenge the planning and decision-making process. It undermines the principles of choice and control. Transparent and collaborative decision-making would enable participants and providers to question decisions, troubleshoot, and work together with the NDIA to develop a plan that genuinely meets participant needs. It would also minimise waste and administrative burden, reduce AAT reviews and potentially improve access to relevant supports for participants.
AMTA draws attention to the increasing number of AAT processes over the past few years. This represents participants’ responses to approaches and decision-making they perceive as incorrect or unjust. Participants, their carers and support people would not need to take this action if the NDIA engaged in genuinely transparent, person-centred and equitable decision-making. AMTA suggests that decision support tools and increased education for planners and coordinators would better support this process. It seems clear that the decision-making processes in the NDIS are not currently working.
| Impact | People with disability and their support people are actively disempowered by protracted planning processes and procedures with limited transparency, consistency and predictability. People with disability and their support people are experiencing harm as a result of NDIA processes and practices. |
| Solution(s) | Ensure planning processes place people with disability at the centre, in accordance with the intent of the NDIS. Ensure planning processes are transparent, easily understood, and consistent. Actively enable choice and control for people with disability. Ensure review processes are timely, transparent and fair. Ensure NDIS staff have the skills, expert knowledge and resources to engage with people with disability and their support people in a way that actively promotes choice and control. |
Fragmentation and inconsistency
Fragmentation within the NDIA is extremely problematic for participants and providers and frequently results in inconsistent and sometimes conflicting information being delivered by different staff. This includes information about what is/is not funded, how planning works, and provider information about supports and billing. Inconsistencies are also experienced across teams and regions, resulting in inconsistent decision-making and funding outcomes for participants. Our members have identified trends in music therapy approvals/rejections based on participant location/region. Inconsistencies within and across teams impact the participant experience, their ability to access vital supports, and waste precious and finite resources, both within the NDIA and external to the NDIA, as providers seek to clarify or correct information.
Inconsistent decision-making also occurs over time for individual participants. Participants report to AMTA that music therapy may have been a primary support one year yet is not approved for the following year, despite ongoing needs and a clinical recommendation for continued funding. AMTA is concerned by decisions to remove primary supports despite participant choice and clinical recommendations. These decisions have serious consequences for a participant’s health and wellbeing. AMTA also questions the need for frequent planning reviews for those participants with stable and ongoing needs. Less frequent reviews for participants could promote continuity and minimise the stress associated with the NDIS funding and planning process. For providers, less frequent reviews could enable longer-term planning for participant supports, reduce proportionate funds expended on non-contact activities, and reduce the workload for the NDIS. NDIA could review a plan when there was a change in circumstance, as needed, or at a 2-3 yearly period.
The complexity of funding guidelines also impacts the ability of applicants and participants to make informed choices and decisions about their support needs, priorities and goals. The participant perspective is often lost when conversations take place with NDIA. LACs and Planners must have the requisite skills to manage conversations about finite resourcing and personal support needs meaningfully and sensitively. These skills and interactions significantly impact the relationships of planners and coordinators with participants, often placing them as an adversary rather than a facilitator. Participants and providers refer to their, at times, combative relationships with the NDIA. Participants and providers tell us that those with bureaucratic literacy and the available mental and emotional resources can ‘fight’ for NDIS access and supports. Funding and procedural complexities push the participant experience further from an ‘ordinary life’ with processes protracted, complex, distressing and exhausting.
| Impact | People with disability and their support people experience an inconsistent and complex system. People with disability and their support people are experiencing harm as a result of NDIA processes and practices. Providers are investing valuable time and resources in providing guidance, education and support in navigating the complexities of the NDIS or challenging planner and LAC assumptions. |
| Solution(s) | Ensure planning processes place people with disability at the centre, in accordance with the intent of the NDIS. |
| Solution(s) | Ensure planning processes are transparent, easily understood, and consistent. Actively enable choice and control for people with disability. Ensure review processes are timely, transparent and fair. Ensure NDIS staff have the skills, expert knowledge and resources to engage with people with disability and their support people in a way that actively promotes choice and control. Ensure NDIS staff have access to appropriate, high-quality and current information about music therapy and associated outcomes for participants. AMTA would be pleased to work with the NDIA to increase understanding of music therapy for people with disability and their support people, planners, and coordinators. |
Improving the evidence-based understanding and usage of services
AMTA stresses the importance of safety and strong clinical governance as accepted foundations of the Scheme. RMTs are a self-regulated allied health profession recognised by AHPA and NASRHP. RMTs have specific qualifications, accreditation and expertise in evidence-based approaches to the use of music to improve health and wellbeing.
The processes of the NDIA demonstrate the limited understanding and regard for allied health professions, our expertise and value. This is reflected in:
- participant experiences of working with planners and LACs
- the low value placed on our reporting and professional advice
- the suggestion that allied health can be substituted with other workers
- inconsistent access to music therapy
- consultations with the NDIA.
In discussions with NDIA about the importance of allied health therapy supports, we have repeatedly been met with concerns about costs, and suggestions that less qualified health workers could do the same work. Substitution of allied health professionals with assistants, unqualified or unregulated workers reduces the quality of supports, risks participants’ outcomes, and is potentially unsafe.
Knowledge and understanding of music therapy
Music therapy is a specialist, evidence-based allied health profession, equivalent in terms of qualifications, accreditation and registration status to professions such as speech pathology or dietitians. RMTs are Masters- and Bachelor-level qualified and accredited by AMTA. However, approvals for music therapy are inconsistent, both across different regions and over time for individual participants. We hear too often of participants who are going to AAT to resolve issues with the processes within the NDIS. We hear from consumers that their preferred, evidence-based therapies have been un-funded without justification. This is not in keeping with the underlying principles of the NDIS.
AMTA often hears of misrepresentations of music therapy by LACs and planners who have told participants that music therapy is not an approved funded support. AMTA continues to receive
complaints from its members regarding some NDIS planners’ misinformation about music therapy and ultimately, their refusal to fund music therapy in NDIS plans - irrespective of participants’ requests and comprehensive reports describing strong outcomes across all domains of daily functioning. Some participants and RMTs report that the NDIA denies participants access to music therapy supports without reading clinical reports (which incidentally have been paid for with their NDIS funds). AMTA has communicated regularly with the NDIA about these ongoing issues and provided information, evidence reviews and case studies. We have offered training. We would urge the NDIA to collaborate with AMTA to address these ongoing issues.
| Impact | People with disability and their support people experience an inconsistent and complex system. People with disability have inconsistent access to evidence-based services. NDIA is considering lower-quality, less-safe services for people with disability by substituting allied health professions with unsupervised assistants or workers. People with disability and their support people have inconsistent access to music therapy. Providers and peak bodies are investing valuable time and resources to provide guidance, education and support to NDIA staff or challenging planner and LAC assumptions. |
| Solution(s) | Ensure planning processes place people with disability at the centre, in accordance with the intent of the NDIS. Ensure planning processes allow for inclusion of a range of evidence-based supports. Actively enable choice and control for people with disability. Ensure review processes are timely, transparent and fair. Ensure people with disability and their support people have ready access to information about available supports so they can make informed choices about their plans. Ensure NDIS staff have the skills, expert knowledge and resources to understand the range of evidence-based available supports, including music therapy. Ensure staff are equipped to have complex and sensitive discussions about prioritisation of supports. Ensure NDIS staff have access to appropriate, high-quality and current information about music therapy and associated outcomes for participants. AMTA would be pleased to work with the NDIA to increase understanding of music therapy for people with disability and their support people, planners, and coordinators. |
Effectiveness and sustainability of the NDIS
Financial and actuarial modelling and forecasting are essential for the NDIS’ longevity - AMTA acknowledges that NDIS costs are continuing to rise. However, financial modelling provides only one lens to inspect the inputs, outputs, outcomes and impacts of the Scheme. AMTA would urge the NDIA to review measures used to identify the social, individual and economic impacts of the NDIS, to obtain further insights into the critical outcomes the Scheme is achieving with people with disabilities and communities more broadly. To exclude these measures is to misunderstand the purpose of the Scheme.
AMTA draws attention to the complexity of the existing funding model, the NDIS Pricing Arrangements and Price Limits for 2022-23. This complexity results in significant administrative burden (time and costs) for providers – to ensure they understand the scheme and meet requirements to deliver supports. This complexity negatively impacts the ability of providers to think, plan, and provide supports differently.
The NDIA may improve its sustainability by identifying and addressing waste, such as burdensome administrative processes and increasing rates of AAT reviews. Participants and their support people must not bear the consequences of recent modelling, forecasting and sustainability concerns. AMTA reasserts the importance of a stable and informed NDIA workforce that is suitably prepared and supported to effectively collaborate with participants and their support people to make high-quality and meaningful decisions.
Stable rural, remote, and very remote services rely on consistent funding arrangements to attract and retain rural and remote practitioners and enable design (and co-design) and delivery of flexible and innovative service delivery models. We would welcome a detailed study of rural and remote service costs to ensure funding models do not drive further inequities in access, health and outcomes for people living in rural and remote areas.
AMTA recommends the NDIA commits to a 3-year pricing model (with CPI increases) to give providers the stability to undertake future-focussed business modelling, build some momentum and systems in the field, and enable more significant innovation and program model development. Allied health professionals must have the opportunity to collaborate on this pricing model. AMTA recommends AHPA as the lead party in this process as Australia’s national voice for allied health.
| Impact | Annual review of pricing arrangements creates instability in the market. Providers are dedicating significant resources to understanding and responding to frequent changes to administrative requirements associated with the NDIS. NDIA should increase its focus on the value of NDIS outside of purely financial accounting. Complex funding and pricing arrangements create complexity in the system, leading to inconsistency. Some health professionals are GST-inclusive, while others are GST-exempt. |
| Solution(s) | Commit to longer-term pricing arrangements to give providers the stability to undertake planning and develop innovative programs and approaches. Provide rural and remote markets with greater ability to plan and establish much-needed services through longer-term pricing arrangements (e.g. 3 years). Consider specific funding arrangements for rural and remote areas. Ensure planning processes place people with disability at the centre, in accordance with the intent of the NDIS, to minimise issues and reduce administrative processes. Ensure staff are equipped to have complex and sensitive discussions about prioritisation of supports. |
GST inconsistencies impact people with disability, support people, providers and planners
Unlike other therapeutic supports, music therapy is not GST-exempt within the NDIS (except when delivering early intervention supports or supports in residential care services). This issue has arisen because music therapy was omitted from the table referred to in paragraph (a) of subsection 38-10(1) of the GST Act. These arrangements are a result of A New Tax System (Goods and Services Tax) (GST-free Supply—National Disability Insurance Scheme Supports) Determination 2021. AMTA seeks to include music therapy as a GST-exempt support within the NDIS.
AMTA has serious concerns about the impact of music therapy’s GST status within the NDIS:
- GST payable for RMTs comes from NDIS participant funds, reducing their available plan funds and access to music therapy.
- Inconsistencies in GST exemptions add to the complexity for planners, who need to determine the funding value for participants’ plans. This is more complex when planners have to negotiate both GST-exempt and GST-inclusive services.
- Inconsistencies in GST exemptions bring complexity to service purchasing by participants. Current GST rules result in changes to prices for individuals over time (for example, as a child turns seven, their music therapy will no longer be GST-exempt). NDIS GST rules also impact individual participants across services (for example, a participant accessing physiotherapy and music therapy will be paying two different hourly rates - one GST-exempt and one GST-inclusive).
- Disparity in GST exemptions results in an uneven market, where some therapy supports (our allied health colleagues) are funded at the $193.99 rate (GST-free). For music therapy, $193.99 is the GST-inclusive rate.
- Due to their GST status, RMTs experience increased administrative and cost burdens in their private practices and small businesses. After deducting GST, RMTs receive the equivalent of 2018 therapy support prices from the NDIS - significantly lower payment than their allied health colleagues. This disparity has the potential to negatively impact market availability in the NDIS.
- The disparity in GST exemption for different participant groups has the potential to skew the market towards early intervention and make it increasingly difficult for older children, young people and adults to access music therapy, limiting participant choice and control.
| Impact | Complex funding and pricing arrangements create complexity in the system, leading to inconsistency. Some health professionals are GST-inclusive, while others are GST-exempt. Music therapy is not GST-exempt within the NDIS (except when delivering early intervention supports or supports in residential care services). Music therapy’s GST status impacts fund expenditure for participants, complexity for planners, parity with other allied health, sustainability of small practices and workforce availability. |
| Solution(s) | Deliver music therapy as a GST-free support within the NDIS by: - amending Other Health Services listed under s38-10 of Division 38 of the GST Act, - issuing a new Determination updating GST exemption within the NDIS (similar to A New Tax System (Goods and Services Tax) (GST-free Supply—National Disability Insurance Scheme Supports) Determination 2021) to include music therapy and other regulated and self-regulated allied health professions as recognised by AHPA and NARSHP, or - implementing off-plan payment options for GST. |
Our optimism for the future
We recognise the value the NDIS is bringing to the lives of people with disability, their support people and the broader community. AMTA asserts that the NDIS could be doing more. Experiences of our members point to a system that is largely managed via algorithms, which stifles innovation and the ability to truly deliver individually-tailored supports and approaches. Participants tell us that the Scheme is bureaucracy-heavy, complex and inconsistent. We hope there is positive change to come that reorients practices, processes and policies toward the original intent of the Scheme. We hope that this change will be led by participants and their support people, and embed participant choice and control as a necessary part of how the whole of the NDIA functions. This will require a readiness for change at all levels and capability development with NDIA staff. AMTA welcomes meaningful collaboration with the NDIA to improve the Scheme for participants and ensure appropriate access to music therapy.
AMTA believes strongly that the potential of the Scheme is yet to be realised – we have a long way to go. We are optimistic about further developing a positive and collaborative relationship with the NDIA to maximise the benefits possible through the NDIS. This Scheme has the potential to positively transform people’s experiences and lives – we hope to work with the NDIA to make this a reality.
Contact:
Bridgit Hogan RMT Chief Executive Officer Australian Music Therapy Association ceo@austmta.org.au