Submission to the Joint Standing Committee on the National Disability Insurance Scheme

The Occupational Therapy Society for Hidden and Invisible Disability (OTSi) warmly welcomes the Joint Standing Committee on the NDIS (the Committee) to the 48th Parliament. We thank you for your commitment to ensuring the safety, sustainability, and long-term vision of the NDIS. We commend the Committee’s important role in providing oversight and guidance during this period of reform and acknowledge the critical contribution you make to ensure that the NDis continues to remain accessible, equitable and fit-for-purpose.

the Ndis is facing an unprecedented confluence of reform activities, legislative change, and policy development. While many reforms are welcome and necessary, their pace, scope, and lack of coordinated implementation planning are contributing to instability, confusion, and fear among participants, providers, and families.

we appreciate the opportunity to provide this submission at a time of significant transformation within the scheme. Otsi made a submission in January 2025, yet to be reviewed by the committee , which we have included in attachment b below. This submission proposed a cost-effective, trauma-informed model for the development of ndis support needs assessments, which could be funded through an alternative funding stream, such as medicare or other mechanism.

we appreciate the opportunity to update the submission to reflect the broad, rapid and unprecedented ndis policy change that has occurred since january. This submission outlines four recommendation for urgent committee attention and action.

Key Recommendations

1. Develop and publish an urgent national plan to stabilise the nDIS, including an independent risk assessment of concurrent reforms such as funding period changes, assessment tools, support lists & eligibility reassessments (See Section 1).

2. Ensure transparent and inclusive policy decision-making, including publication of economic modelling, eform impacts, and meaningful co-design with the disability community, for example including the use of mechanisms like citizens’ assemblies (see section 2).

3. Safeguard Ndis access for people with psychosocial and other hidden or invisible disabilities who meet eligibility criteria and confirm their place in the Scheme in response to recent policy proposals that have heightened uncertainty and fear within these communities (See Section 3, Attachment A).

4. Support development of an alternative support needs assessment model that is trauma-informed, cost- effective, and maximises participant choice and control, such as that outlined in our January 2025 submission to the Committee (See Section 4, Attachment B).

Annual Report No.1 of the 48th Parliament

Submission ¹

CONTENTS

ATTACHMENTS:

Attachment B – DELIVERING TRAUMA-INFORMED, BEST PRACTICE SUPPORT NEEDS ASSESSMENT FOR THE NATIONAL DISABILITY INSURANCE SCHEME (NDIS) THROUGH THE MEDICARE BENEFITS SCHEDULE

OTSi Submission to the NDIS Joint Standing Committee January 2025

2

Annual Report No.1 of the 48th Parliament

Submission 1

1. An urgent need to stabilise the NDIS amidst complex reform executed at pace

The scale and speed of simultaneous reforms—including the introduction of new support lists, new funding periods, therapy travel cuts, and escalated eligibility reassessment —have created an environment of significant disruption and anxiety. A national joint statement, to which OTSi was a signatory, alongside 254 national organisations, called on governments to slow the pace of reform, citing concerns for participant safety¹.

1.1 Support Lists (NDIS Act Section 10)

every Australian Counts recently released the results of a national survey involving over 500 respondents— including NDIS participants, family members, advocates, and providers—examining the impact of new “in-and-out” support lists implemented under the NDIS. The findings reveal alarmingly high levels of concern: 88.2% of respondents believe that the government has failed to properly assess the risks posed by these support-list changes, while only 3.3% felt confident those risks were being appropriately evaluated. Additionally, 75% of participants reported already experiencing problems with the Section 10 rules—citing confusion over what is allowed, conflicting messages from the NDIA, loss of flexibility in plans, and worryingly, actual loss of previously funded supports. Many survey respondents warned that these rigid lists threaten their health, safety, and wellbeing by undermining the Scheme’s foundational principles of choice, control, and responsiveness to individual circumstances². The Every Australian Counts findings are consistent with the experiences reported by OTSi members.

1.2 Funding periods (NDIS Act Section 33)

While the intention was positive, to safeguard funding in plans, the new funding periods introduced on May 19th, were not co-designed and took both participants and providers by surprise. There have been some media reports of their early impact³, and full impact is yet to be understood. In early July, national organisations, including OTSi, compiled a joint statement⁴ calling for the NDIA to adopt twelve-month funding periods as the default, with flexibility for shorter durations where participants prefer or where overspending has occurred. Any changes must include timely processes to respond to risk and changing needs, a transparent feedback mechanism that tracks how participant input is addressed, and a commitment to providing clear, accessible information to all participants before further reforms are implemented.

1.3 NDIS changes impacting on occupational therapy service delivery

e Therapy travel cuts

Therapy travel cuts commenced from July 1st halved the hourly travel subsidy for therapy providers⁵. This change has already forced many providers to reduce or cease service provision citing financial viability impacts, with rural and remote services disproportionately impacted. Families, especially those with young children receiving home-based therapy, have reported immediate loss of access to essential supports and fears of losing their therapist teams entirely.

¹ Media Release: Take the Time for Codesign: 255 Organisations Demand More Time to Codesign NDIS Reforms - Every Australian Counts ² Every Australian Counts Survey Results Highlight Impact of NDIS Support Lists - Every Australian Counts ³ NDIS confusion leaves disabled man stranded - ABC listen ⁴ Joint Statement on New NDIS Funding Periods – from Every Australian Counts and Disability Rights Organisation - Every Australian Counts ⁵ Petition · Stand Up for Disability Support: Stop the NDIS Cuts - Australia · Change.org

Annual Report No. 1 of the 48th Parliament

Submission 1

Concerns have been raised regarding access to support for people with psychosocial disability and other groups who have difficulty leaving their homes; and access to assistive technology⁶. OTSi is concerned regarding access to, and continuity of, therapeutic support at a time of significant NDIS change, will hugely impact safety, well-being and progress towards goals, for people with psychosocial disability, autism and other hidden and invisible disabilities.

The NDIS Market Stewardship Role and Workforce Considerations

the NDIS plays an important role in market stewardship by monitoring, evaluating and intervening where necessary to address market gaps and ensure a sustainable and participant focused marketplace (ndis.gov.au). We request that the NDIA commit to providing clearly defined timelines that allow businesses sufficient time to adapt to any process changes that may affect their operations.

Occupational Therapists provide essential services including functional assessments, home and assistive technology evaluations and capacity building supports. Any changes to funding, processes or commissioning arrangements must include reasonable notice periods. We request that the NDIA provide advance advice on such changes to allow providers adequate time to adjust.

We also request transparent and detailed information regarding future plans for blended payment models and commissioning arrangements, including how these reforms will support the broader care economy. The NDIA has identified value based approaches such as outcome based, enrolment and blended payment systems to better align provider incentives with participant outcomes⁷. Clarity is needed on the timing and sequencing of these reforms and how they will be implemented.

We request that the government publish a comprehensive timeline outlining when businesses will be formally notified of changes that could materially affect their finances. This should include key milestones for major reforms such as commissioning changes, payment model transitions and adjustments to fee schedules to enable providers to plan effectively.

Many Occupational Therapists working within the NDIS also live with disability or chronic illness or have unpaid caring responsibilities for elders, children or people with disability. Approximately 70% of the OTSi membership is comprised of therapists identifying as having a disability, or as a carer. The flexibility of the Scheme has enabled these professionals to continue working. We urge the NDIA and the government to consider workforce sustainability when designing and implementing new commissioning models, including the impact on workers with lived experience and caring responsibilities.

The Eligibility Reassessments

over the past year, the NDIA has significantly escalated eligibility reassessments, with nearly 12,000 participants reassessed between July and September 2024—up sharply from just over 4,000 in the previous half-year—resulting in approximately 50% being found ineligible⁸. This spike is deeply concerning.

A recent national survey by Children and Young People with Disability Australia (CYDA) found that 99% of respondents considered the process unfair or unreasonable; 70% felt worried, 51% felt afraid, and distressingly, some reported suicidal thoughts in response to reassessments⁹. The abrupt removals, especially impacting children, raises urgent questions about the fairness, communication, and the trauma-informed capacity of the eligibility reassessment process—made more critical given the absence of foundational supports for those who lose scheme access.

⁶ ARATA - Australian Rehabilitation & Assistive Technology Association ⁷ Providers change their service offerings in response to payment approaches | NDIS Review ⁸ Growing Concern Regarding Increased Rate of Eligibility Reassessment - Every Australian Counts ⁹ “It’s breaking our family”: Survey reveals devastating impact of NDIS eligibility reassessments - News Hub

Annual Report No.1 of the 48th Parliament

Submission I

otši calls for the urgent publication of a NDIS stabilisation and reform implementation plan that includes:

• An independent risk assessment of all concurrent reforms;
• Clear timelines and transitional supports for affected participants;
• Mechanisms to monitor and respond to unintended consequences as reforms roll out.

2. Transparency and Public Accountability in Reform Decision-Making

given the ndis is one of Australia’s largest social infrastructure investments, reform decisions must be both transparent and accountable to the public. Currently, economic assumptions, cost-modelling frameworks, and decision-making tools driving policy reform remain opaque.

The Committee recommends advocating for:

• The publication of economic modelling underpinning recent and proposed reforms;
• Public consultation processes that go beyond closed-group ‘co-design’ with a small group of select organisations. We propose an innovative approach to community consultation and consultation including deliberative mechanisms such as Citizens’ Assemblies or open, and structured broad community engagement initiatives..

3. Protecting the Rights and Access of People with Psychosocial and Invisible Disabilities

Access to the ndis for people with psychosocial disability is narrowing at an alarming rate, with approval rates dropping from 49% in 2023 to just 23% in early 2025¹⁰, despite no corresponding increase in support outside the NDIS. otsi raises deep concerns that current reforms influenced by flawed assumptions for example in the Grattan Institute’s report Saving the NDIS risk creating. The Grattan report’s suggestion to cut NDIS core funding for this group by 40–60%, on the basis that they can be supported through “recovery-oriented” foundational supports, is not justified by evidence or data within the paper. Recovery is a personal, subjective, and non-linear journey, not a justification for cost-cutting.

otši has written to the Productivity Commission inquiry on the National Mental Health and Suicide Prevention Agreement highlighting concerns regarding the future for psychosocial disability within the ndis, and proposing solutions. The Committee was copied to this letter, included in Attachment A below. Otsi warns that removing people with psychosocial disability from the NDIS without properly funded and fit-for-purpose alternatives could lead to increased clinical system use housing instability homelessness policy segregation and return to institutional care.

The committee urges:

• Seek public clarification from government regarding continued inclusion of psychosocial disability within an equitable ndis;
• Monitor any eligibility reform impacts on this group and other hidden disability cohorts; Promote development accessible inclusive responsive access to support both within the ndis outside..

¹⁰ Quarterly Reports | NDIS

4.A Viable Alternative Model for Support Needs Assessment

OTSi calls for renewed transparency in NDIS planning decisions for individual planning decisions for NDis participants. There are ongoing concerns regarding planner consideration of participant-provided evidence of support need, following disclosures by the former NDIA CEO that officials may not read allied health reports¹¹, earlier this year.

The proposed new assessment framework under the NDIS Amendment Act 2024 has generated concern, especially regarding how support needs will be measured and translated into funding decisions. The NDIA has indicated they will roll out new support needs assessments from September 2025¹², approximately 4 weeks from now; however there has not yet been any information provided on the commencement, who will deliver them, the role of participant-provided evidence, what participants can expect, or how to prepare. Anecdotally, there are some reports that support needs assessments have already commenced as ‘desk-top’ assessment, however this has not been verified. Existing participant cohorts have not yet received the “impairment notices” required under NDIS Act Section 32BA that would enable support needs assessments and new framework plans to proceed.

TSI has proposed an evidence-based, trauma-informed, and cost-effective model of support needs assessment that:

• Aligns with international best practice in function-focused evaluation;
• Allows for choice of qualified provider by participants;
• Minimises assessment-related trauma and protects participant dignity.

This model was outlined in our submission to the Committee in January 2025. We respectfully request a formal review of that submission as part of this Committee’s forward work plan. Please see Attachment B.

Further, OTSi has commenced rollout of a training package to assist occupational therapists working with key participant groups, to understand the NDis legislation and document requirements. TSI has written to the Agency a number of times in recent months, to seek collaboration around NDIs assessment development, and to seek that the Agency work with us to ensure documentation that occupational therapists provide to the NDIA is provided in a format, and with content, that can assist agency decision making. We have not yet had a response to requests to meet.

The conclusion section reads: “OTSi acknowledge the immense responsibility the Committee holds during this time of transformation. We hope this submission assists your deliberations and highlights the lived impact of system decisions on the everyday lives of participants. OTSI remains committed to supporting solutions that are sustainable, person- ccentred, and grounded in human rights and professional evidence.”

¹¹ https://www.linkedin.com/feed/update/urn:li:activity:7302095261042941954 ¹² NDIS Act Explained: Needs assessments and new framework plans - Team DSC

ABOUT OTSI

OTSi is a national society whose purpose is to enable occupational therapists who work alongside people with invisible and hidden disabilities, to reduce barriers to full participation in our world as active citizens of Australia.

our focus is ensuring access to resources, opportunities, and supports for people with invisible disabilities of all ages, including access to occupational therapy. OTsi has a strong voice in systematic advocacy and policy direction, as well as enabling individuals to build better lives. currently, over 70% of Otsi members identify as having a disability and/or as carers.

Contact: admin@otsi.net.au

website: www.otsi.net.au

ATTACHMENT A

Date: 15 July 2025

to: The Honourable Commissioners Productivity Commission Via email: mental.health.review@pc.gov.au

cc:

• Professor Rosemary Kayess, Disability Discrimination Commissioner, Australian Human Rights Commission
• Ms Louise Glanville, CEO, Quality and Safeguards Commission
• Chair, Joint Standing Committee on the National Disability Insurance Scheme
• Ms. Priscilla Brice, CEO, National Mental Health Consumer Alliance

Re: Urgent safeguards needed to prevent disability discrimination in psychosocial support reform Dear Commissioners,

on behalf of the Occupational Therapy Society for Invisible and Hidden Disabilities (OTSi), we write in response to your Interim Report on the Mental Health and Suicide Prevention Agreement Review. We commend the Commission’s commitment to lived experience inclusion and system-level reform. The Productivity Commission’s candid assessment of the current Agreement’s failings – including its fragmentation, lack of accountability, and sufficient lived experience involvement – resonates deeply with the experiences of our members and the communities we serve. OTSi agrees that a new policy architecture is urgently needed to create a truly person-centred, integrated mental health and suicide prevention system.

This letter specifically relates to the establishment of psychosocial supports outside the NDIS, and the NDIS. We write to you now with serious concerns about the potential direction of psychosocial support reform and the human rights implications for people with psychosocial disability.

otsi strongly supports your call for a new national architecture for foundational psychosocial supports, to respond to unmet need for psychosocial support outside the NDIS. Yet without immediate action to ensure clarity, integrity and equity in how psychosocial disability is defined, funded, and supported, Australia risks epeating past policy failures—reverting to underfunded, outdated, and segregated models of care. This would entrench the systemic discrimination long experienced by people with psychosocial disability and violate australia’s obligations under the UN Convention on the Rights of Persons with Disabilities (UNCRPD).

the current policy discourse—influenced by proposals like those in the recent Grattan Institute report [1]– suggests a shift toward generic, under-specified programs outside the NDIS, while access to the Scheme for thist group is simultaneously shrinking. People with psychosocial disability now make up only 9% of NDIS participants, with access approval rates falling to 23% as of March 2025 [2A], down from 49% in 2023[2B] l likely reflecting a shift in the NDIS access threshold for this group. Many are being excluded not because their eeds are less significant, but because those needs are harder to quantify with traditional tools. This trend will aise the complexity of unmet psychosocial need outside the NDIS; and the trajectory could lead to structural discrimination.

Annual Report No. 1 of the 48th Parliament

The consequences are not theoretical: they may include systemic underinvestment, reemergence of legacy programs unsuited to contemporary needs, and entrenchment of the ‘poor cousin’ status that has long shadowed this group across health and disability systems. The ‘poor cousin’ status reflects chronic underfunding and minimisation of the impact of disability arising from long-term mental illness.

The Productivity Commission must not shy away from the hard questions—how psychosocial disability is understood, measured, and recognised—and must instead seize this opportunity to affirm the reality psychosocial disability presents. This is a moment to set the tone for a modern, inclusive, and functional system: one that respects lived experience, demands innovation, and refuses to leave psychosocial disability behind.

We highlight five key areas requiring immediate leadership from the Commission.

1. Conceptualise psychosocial disability using a rights-based, contemporary

framework

the ongoing absence of consistent terminology and conceptual clarity for‘psychosocial disability’, ‘psychosocial support’ and ‘recovery’is placing reform at risk. We urge the Commission to adopt the International Classification of Functioning, Disability and Health (ICF) as the primary conceptual framework to define psychosocial disability and psychosocial support needs. The ICF provides internationally accepted functional and participatory definitions. The Australian Institute of Health and Welfare (AIHW) already applies the ICF to almost all other disability groups [3]. The ICF is the standard conceptual framework utilised by the AIHW [3], and the emerging NDIS assessment framework. A focus on the ICF framework for mental health and psychosocial disability policy reform would modernize the conceptual understanding of psychosocial disability and bring greater equity in funding systems, standardize data collection for population- level analysis, and assist with outcome monitoring. An ICF focus would enable consistent and equitable service design and outcome measurement—while avoiding a return to deficit-based models grounded in diagnosis or medicalised approaches.

in the recent Grattan report, the concept of‘recovery’is used to justify diminished funding apparently on the expectation that people with psychosocial disability will recovery functionally – this is a misunderstanding of the concept of psychosocial recovery, a personal journey, distinct from the constructs of functional and medical recovery. For example, the Grattan report recommends arbitrarily cutting‘core’support for all people with psychosocial disability on the NDIS by 40–60%on the unjustified assumption that they don’t need it, and that they will be“better served”by recovery-based approaches [1] .

2. Ground reform in real understanding of unmet need

the recent Unmet Needs Analysis [5] relies on population-level models that may not capture the real-world complexity and diversity of psychosocial disability support needs. These models do not capture lived experience, cultural relevance, or intersectional needs. For example, the 77%of people who apply for the NDIS and are rejected remain invisible in service planning. A rights-based system cannot continue to design services in the absence of understanding this cohort. New research must urgently be commissioned to explore unmet need through the eyes of those living it.

otSi understands that the Productivity Commission has considered drawing on the National Mental Health Planning Framework (NMHPF)to plan future foundational supports, the same framework that underpins the Unmet Needs Analysis. OTSi requests that an ICF-based planning framework is given consideration as an alternative framework.

Occupational Therapy Service Review Disability

Submission #1 The NMHPF, generating high-level population service-demand data based on underpinning assumptions [4], is not designed to capture the nuanced, functional needs of people with psychosocial disability. It does not reflect lived experience or culturally specific needs; it may underestimate the complexity of support needed by people who fall outside formal diagnostic categories or who have co-occurring conditions. While the nMHSPF may be a useful planning tool for estimating population-level demand for mental health services [4], t has significant limitations when it comes to identifying granular psychosocial support needs, especially for people living with psychosocial disability. The Unmet Needs Analysis does not describe the nature of unmet needs for the groups examined. The NMHSPF estimates ‘required hours’ of support, but not the quality, cultural safety, or appropriateness of those supports. It cannot determine whether they actually lead to improvements in functioning or life participation – as such, it is likely to be a crude planning tool for the task of planning for psychosocial supports.

The Unmet Needs analysis [5] utilised the NMHSPH and concluded 61 hours of (undefined) support could meet needs for those experiencing complex psychosocial issues - this is one hour per week on average, a drastic underestimate based on practical experience. The average NDIS plan for people with psychosocial disability is over 10 times that amount. Equitable support needs assessment processes must be designed, developed and implemented to ensure individual support needs can be identified and met. Please refer to Appendix 1 below for a comparison of the NMHPF and the ICF, with respect to features indicating capacity to model the need for psychosocial support for people with psychosocial disabilities.

Establish transparent, functional-need focused stepped care thresholds

As psychosocial disability is pushed out of the NDIS, there is still no clarity on who will qualify for what level of care within a stepped care framework. This ambiguity creates systemic confusion, and sets up people to fall through the cracks. We call on the Commission to recommend clear, ICF-aligned thresholds across the stepped care system—including for foundational supports, early intervention, and NDIS access. These thresholds must distinguish functional impact of psychosocial disability from clinical mental illness and protect the rights of people with long-term functional impairment who do not “recover” in the medical sense.

There are very significant and under-recognised complexities experienced by those who live with psychosocial disability, that contribute to reduced lifespan of 20 years compared to the average Australian [6]. For example, current research highlights the high rates of persistent disability experienced by the cohort identifying with an impairment of schizophrenia, which includes two-thirds with a cognitive impairment [7]; 24% experience hearing impairment [8]; 26–70% of people experiencing vision or visual processing difficulties with functional impact impacting literacy and social engagement[9]; motor skills and gait difficulties [10] [11]; and a 2.5 fold increase in lifetime risk of developing early-onset dementia [12]. An individual experiencing one or a combination of these issues will be inappropriately placed within a foundational support program (e.g., a social skills group, a recovery college, or a Clubhouse) for example without prior recognition and accommodation of functional capacity; and addressing a range of disability support needs.

Preserve equitable access to the NDIS for psychosocial disability

Foundational supports are not a substitute for legislated, individualized disability support. There is growing evidence that expansion of foundational supports is being used to justify a quiet reduction in access to the NDIS for people with psychosocial disability. We reject the Grattan Institute report [1] proposal to remove Section 25 of the NDIS Act and reiterate that early intervention for psychosocial disability, and other groups must remain within the Scheme.

Annual Report No.1 of the 48th Parliament

Submission 1

The recent recommendations by the Grattan Institute^[1] that propose slashing psychosocial core funding by 40–60%, and placing 33% of their total projected $46 billion NDIS budget ‘savings’ on the heads of people with psychosocial disability who are NDIS participants (ie 9% of total NDIS participants), and funding foundational supports from within the same shrinking NDIS budget, are reckless, and have led grassroots groups to commence independent harm-tracking. Implementing the Grattan report ecommendations would make psychosocial disability a major cost-cutting target with funds cut not fully einvested in foundational support provision for the cohort. The Grattan report neglects to consider that NDIS ‘core support’ funds and supports are essential to sustaining independent living, and cutting these funds will increase risk of preventable mental health clinical system reliance; homelessness; justice system contact; and risk of inappropriate return to congregate care and institutional living for a significant proportion of the court.

Without legislative protection, people with psychosocial-disability related functional impairments will be left owithout safeguards or recourse. The NDIS must remain equitable and rights-based—aligned to individual s \support needs, not impairment-based assumptions of need or cost-efficiency logic.

5. Innovation, investment and co-design

The PC Interim Report’s repeated emphasis on co-design is laudable. It highlights that “the Agreement does not adquately embed the voices of people with lived and living experience” and that

Annual Report No. 1 of the 48th Parliament

Submission

• Setting clear expectations for co-design, innovation and genuine investment in foundational supports outside the NDIS.
• Meeting with the Occupational Therapy Society for Invisible and Hidden Disabilities (OTSi) at your earliest opportunity to ensure our profession’s perspective informs the final report.

Thank you for your attention to these vital matters. We would welcome the opportunity to contribute further to your work and are available for urgent consultation. We were finalizing an additional submission focused on workforce as it relates to the scope of the current inquiry.

At this moment of national significance, we urge the Commission to lead with courage, clarity, and a deep commitment to human rights.

Yours sincerely,

The OTSi leadership team, Occupational Therapy Society for Invisible and Hidden Disabilities (OTSi) admin@otsi.org.au www.otsi.net.au

Appendix 1: Comparing service planning features of the NMHSPF and the ICF

\egin{tabular}{|l|l|l|}\ oprule Feature & NMHSPF & ICF \\midrule Purpose & Service planning tool for mental health system needs & Global framework for understanding functioning & disability \[2pt] Level of Analysis & Population-level estimates & Individual and system-level assessment [2pt] Focus & Clinical service hours and resource modelling & Functional impact, participation, environment [2pt] Grounded In & Epidemiology and health system usage & Biopsychosocial model (WHO)[2pt] Data Sources & Mental health prevalence & service use data & Person-centred assessments & lived experience [2pt] Scope of Disability & Focused on mental illness severity including psychosocial & Inclusive of all types of disability, including psychosocia l[2pt] Captures Psychosocial Disability? & Only partially & Yes—via functional limitations & participation restrictions [2pt] Culturally Responsive? & Limited & Adaptable to cultural and contextual factors [2pt] Incorporates Lived Experience? & No & Can be applied with lived experience input [2pt]Service Design Insight & Tells us how much service is needed & Tells us what kind of support is needed \end{tabular}

References

1. Grattan Institute report Saving the NDIS: How to rebalance disability services to get better results.
2. A. National Disability Insurance Agency. (2023, June 30). Psychosocial dashboard. https://www.ndis.gov.au/ NDIS Quarterly Report published - March 2025 | NDIS
3. ICF Australian user guide version 1, Summary - Australian Institute of Health and Welfare
4. National Mental Health service Planning Framework – AIHW
5. The Unmet Needs Analysis Analysis of unmet need for psychosocial supports outside of the National Disability Insurance Scheme – Final Report | Australian Government Department of Health, Disability and Ageing
6. Mental Health & Physical Health Research | Lived Experience Aus ([livedexperienceaustralia.com.au])
7. Howes, O. D., Bukala, B. R., & Beck, K. (2023). Cognitive impairment in schizophrenia: aetiology, pathophysiology, and treatment | Molecular Psychiatry ([nature.com]).
8. Saperstein, A. M., Meyler, S., & Medalia, A. (2023). Hearing Loss Among People With Schizophrenia: Implications for Clinical Practice. Psychiatric Services (Washington, D.C.), 74(5), 543–546. https://doi.org/10.1176/appi.ps.20220226
9. The Phenomenology and Neurobiology of Visual Distortions and Hallucinations in Schizophrenia: An Update - PubMed (nih.gov) (Retrieved Jan 2023)
10. Petrescu, Petrescu, et al (2022). Neurological Soft Signs in Schizophrenia, a Picture of the Knowledge in the Last Decade: A Scoping Review.
11. Feldman, Ron & Schreiber, Shaul & Pick, Chaim & Been, Ella. (2020). Gait, Balance and Posture in Major Mental Illnesses: Depression, Anxiety and Schizophrenia.
12. Psychotic disorders may increase the risk of dementia ([healtheuropa.com])

ATTACHMENT B:

DELIVERING TRAUMA-INFORMED, BEST PRACTICE SUPPORT NEEDS ASSESSMENT FOR THE nATIONAL DISABILITY INSURANCE SCHEME (NDIS) THROUGH THE MEDICARE BENEFITS SCHEDULE

31 JANUARY 2025

EXECUTIVE SUMMARY

Support Needs Assessments (SNA), introduced into the NDIS through legislative changes in October 2024, are set to begin by September 1, 2025. These assessments represent a seismic change to NDIS opérations and are crucial for determining participants’ disability-related support needs, evaluating eligibility under Sections 24 or 25 of the NDIS Act, and setting individualised budgets and supports.

This discussion paper synthesises international best practices from 10 jurisdictions, alongside insights from key Australian policy documents, to propose a trauma-informed SNA for the NDIS, delivered as a bulk billed Medicare Benefits Schedule (MBS) item. It proposes A National Endorsed Assessor Team (NEAT) as a model for SNA delivery as a bulk-billed MBS assessment. Delivering assessments as a bulk- billed MBS item was a recommendation of the NDIS Joint Standing Committee Inquiry to Independent Assessments [1].

This paper highlights the need for a trauma-informed and trialled SNA. It emphasises the need for transparent co-design in advance of full roll-out and rigorous trialling of processes to ensure reliable ranslation of assessment findings into effective, safe and individualised support packages.

KEY RECOMMENDATIONS

1. Prioritise the co-design of a trauma-informed NDIS SNA, in tune with recognised international best practice, for delivery as a flexible bulk-billed MBS item. This will optimise safety, choice, and fitness-for-purpose of the SNA which will hold responsibility for establishing eligibility pathways, informing budget-setting, and defining stated disability supports in NDIS plans.

2. Establish a regulated National Endored Assesor Team (NEAT) to ensure bulk-biled MBS SNA are delivered by a pool of qualified AHPRA-registered allied health professionals operating within their scope of practice, who have capacity to formulate, draw on theory of change, and make evidence-based decisions by synthesising a range of evidence sources to provide an individualized assesment report, as per legislative arequirements

3. SNA proceses and outputs that inform budet setting and define stated disabilty suppots in NDS plens must be rigorously trialed and proven prior to rol out wthin te NIS Tis is essential step protect participant safey minimize potential harm nd to ensue disablity suport needs can reliably met.

Annual Report No. 1 of the 48th Parliament

Submission #

The NDIS, supporting over 660,000 participants under a social model of disability, has introduced mandatory Support Needs Assessments (SNA) through the NDIS Amendment Act 2024. These assessments aim to determine participant support needs based on NDIS Rules, with key purposes including evaluating support needs tied to eligibility, and ensuring equitable and evidence-based funding decisions.

The Act states that individual plans must include a participant’s “reasonable and necessary budget” for supports, and these budgets, including ‘stated’ (prescribed) supports, are to be informed by a needs assessment report. This ensures that funding and supports for participants are personalised and aligned with the participant’s individualized support needs. The SNA is likely to determine if the person is likely to benefit from early intervention under Section 25 of the NDIS Act. The Act highlights the need for a codesigned, evidence-based approach but does not define SNA processes or methods [2].

PRIORITISING A SAFE AND TRAUMA-INFORMED SUPPORT NEEDS ASSESSMENT

Safety and trauma awareness must be prioritized in the co-design of NDIS SNA, and in translating assessment findings to support budgets. There are known risks associated with disability assessments that determine access to support and resources. International studies evidence the potential for harmful outcomes when disability assessment is conducted via a point-in-time standardized assessment by a mandated assessor [3]. These harmful outcomes include increased rates of suicide, increased mental health impacts and increased reliance on prescribed medication. An Australian study published May 2023 documents an increase in anti-depressant use and need for medical intervention when disability entitlements were re-assessed, regardless of the outcome of the assessment [4]. Understanding these risks will help shape a safer, evidence-based approach for future SNA delivery.

The NDIS Review report and the Disability Royal Commission report emphasized participant-centered and trauma aware approaches to government-mandated assessment, due to the significant proportion of people with disabilities with trauma histories [5] [6].

The NDIS Joint Standing Committee Inquiry to Independent Assessments (hereafter called the JSC report) highlights the importance of trauma-informed approaches in NDIS assessments, emphasizing the need for sensitivity to participants’ emotional and psychological safety to prevent retraumatization. It stresses the value of culturally safe and inclusive practices, particularly for Aboriginal and Torres Strait Islander participants and those from diverse backgrounds, to foster trust and improve assessment accuracy. The report cautions that rigid, impersonal procedures and power imbalances can exacerbate trauma, especially for those with past negative experiences in institutional systems [1]. Successive reviews and reports have highlighted the need to rebuild trust between the NDIA and the disability community, including participants [5] [6]. Many participants describe how interactions and assessments by NDIA assessors and contractors can bring a fear of losing supports, fear of not being believed, fear of experiencing discrimination, fear of abuse and neglect, and fear of systemic co-opting of concepts such as recovery [7]. The pressure to meet certain criteria, alongside the fear of having support needs minimized or rejected, can further intensify anxiety and trauma [1].

Annual Report No. 1 of the 48th Parliament

Submission I

Strategies that restore a sense of control and choice can minimise the risk of trauma and harm and foster a sense of safety. The JSC report highlights that a community-based choice of provider approach to assessment is safer and more trauma-informed because it empowers participants to self-select qualified professionals with expertise in their particular disability, reducing the risks of stress and anxiety associated with mandated, assigned assessors (Chapter 9, recommendation 5). This approach respects the participant’s autonomy and ensures that assessments are conducted in a way that aligns with their preferences and specific needs. This is particularly important for individuals from marginalised or culturally diverse backgrounds, as well as those who have experienced trauma or institutional harm [1].

A range of safeguards will need to be co-designed to ensure support needs assessments can be safely and accurately translated into support budgets capable of meeting individualised support needs, particularly where automated decision making and algorithms may be embedded in the process [6] [10].

THE SUPPORT NEEDS ASSESSMENT DELIVERED AS A BULK-BILLED MBS ITEM

The JSC report recommended the Australian Government should consider funding bulk-billed NDIS assessments with allied health professionals. MBS funded assessments are proposed to support access to the NDIS and assist in the development of plans for participants. The rationale outlined in the JSC report was that MBS bulk-billed assessments could improve equity and accessibility and reduce financial barriers for NDIS access and planning by eliminating out-of-pocket expenses for participants.

While the JSC focused on functional assessments, the findings are highly relevant and aligned to support needs assessment processes. The JSC report highlighted that MBS bulk-billed assessments could support choice of provider, which is framed as a trauma-informed and empowering feature for participants. Specifically, the JSC report described that assessments should be carried out by allied health professionals nominated by participants, aligning with the core NDIS principle of choice and control.

Further, the JSC report proposed that MBS bulk billed assessments could be cost-effective in the context of NDIS. It notes that government-funded, bulk-billed assessments can potentially reduce administrative costs for government and reduce administrative burden for the NDIA.

The cost-effectiveness of MBS bulk-billed assessments was referred by the JSC to the Parliamentary budget Office (PBO) for evaluation. The PBO compared the delivery of flexibly delivered bulk-billed assessments under a new MBS item with the costs of a contracted panel of independent assessors and found the MBS item to be cost effective and providing additional efficiencies such as integration with existing Medicare infrastructure, potentially avoiding the setup and operational costs associated with creating a new assessor framework.

The PBO costing was based on the assumption that assessments would be conducted by allied health professions - als (occupational therapists, psychologists, physiotherapists and other relevant practitioner), delivered flexibly over 1–8 sessions, depending on individual participant needs. The analysis considered these profession involvement in providing comprehensive, multidisciplinary assessments for NDIS participants and prospective participants. This approach designed ensure assessment were carried out qualified professional who address varied nuanced need individuals disabilities. Alignment Allied Health Professional also intended maintain quality depth Assessment essential Effective NDI planning access decision .

Summary, JSC Report emphasises Bulk Billed Assessments not only Reduce Financial Barrier Preserve Participant Ability Retain Choice Provider They Would Enable Access Skilled Assessor Bring Administrative Efficiency Thereby Reducing Delivery Costs [1].

Annual Report No.1 of the 48th Parliament

Submission 1

The NDIS Review final report recommended SNA be funded by government. This report recommended functional capacity assessment for NDIS access, be funded through MBS (Supporting Analysis p. 242) [5]

We recommend the cost of NDIS SNA delivery though MBS is further reviewed, updated and costed by the PBO to obtain current cost and benefit comparison, to reflect the cost of delivering both functional capacity assessment for NDIS access, and SNA for current participants.

PROPOSING A NATIONAL ENDORSED ASSESSOR TEAM (NEAT)TO DELIVER ASSESSMENTS

The National Endorsed Assessor Team (NEAT) is a proposed model for NDIS functional assessment at access, and for NDIS SNA delivery. It would require the development of a national endorsed assessor program, which appropriately skilled and experienced allied health professionals could select to unertake in order to qualify to provide MBS bulk-billed SNA for the NDIS. Endorsement credentials are papplied to individual allied health professionsls, rather than umbrella organisations, to uphold quality ststandards.

This model avoids the costly setup of a nationl service infrastructure nd workforce, s it wold utilise the existing NDIS provider base. This woild ensure MBS blk-illed SN re completed by experien ed lled helth profession ls, skiled n nderstnding he prticipnts ptrcular disbility needs. An essessr endorsement program wod meet the NDIS requirements f more consistent nd regul ted aproach o ssessment, while enbling pticipsnts nd pplcants ot retin choice nd control fo nprovider. Assessrs wd utilize their professional judgement nd clinical resonin skills to conduct
determined ssessment process culminating in support ne ds report or te NDIA, as required under The NDIS Amendment ct 204. The assessment eport wolld include tlored, need specific recommendations fr supports t inform pl budgets. Conflict ft interest concerns regarding rparticipant existi providers completing th assessments would ned be clrified and mitigated through co designedssment guidelines.

ALIGNING SUPPORT NEEDS ASSESSMENTS WITH INTERNATIONAL BEST PRACTICE

Thi discussion paper proposes the NEAT mode nd anchors i within intern tional best practice b drawing on findings from Scoping Review Inform Standards Assessment of Need (August 202) [8], conducted by Health Information Quality Authority (HIQA), an independent statutory body Ireland. The Scopeg Review examined disability suppor needs sses ment approaches processes ten jurisdictions internationally identify considerations for bes prctice.

Using multi-method approach, including desktop research authoritative sources consultations wth international experts, he Scopig Revie explored established disbility supplort needs essmen models; relevant legislation; standards, guidance frameworks strategies policies; methods fo regulation, monitoring inspection o fassessment nee . Ten jurisdictions studied were England, Scotland Wales Northern reland Irela New Zealand Iceland Romania Hong Kong Singapore. these jurisditions ere chosen or in depth review s there ws shared commitment establishing bes practice ssessment diability support need as evidenced through recent reform, nd ther wer valuable sights to e gained rom their experiences delivering suppot ne ds assessments.

this discssion pape applies thematic nalysis t te scoping revies findigs identifying be st practi ce rprinciples inform a NET SNA model the Austrlian context The themtic analysis identified best

Annual Report No. 1 of the 48th Parliament

practice principles for SNA process, 8 best practice principles for SNA workforce, and 11 best practice principles for SNA assessment instruments. These are applied to the NEAT model in Appendix 1 below.

6. SUPPORT NEEDS ASSESSMENT WORKFORCE CONSIDERATIONS

The NDIS Review Final Report highlighted the critical role of skilled and qualified professionals, such as allied health practitioners, in conducting NDIS SNA [5]. The National Framework for Assessing Children’s Functional Strengths and Support Needs (2024) further highlights the need for professionals to conduct the SNA and stresses the need for assessors to possess cultural competency, the ability to create structured yet flexible formulations, and expertise in synthesising diverse inputs into actionable support plans. This collaborative approach involves input from participants, families, carers, and other relevant professionals [9].

The NDIS SNA will hold multiple functions. It is likely to determine eligibility pathways and expected outcomes of early intervention; assess disability support needs; and use findings to inform budgets and ‘stated’ supports in the participant’s budget plan. To fulfil these functions, the assessor will be required to use high-level decision making and formulation skills. The assessor qualifications and skillset must match the complexity and decision-making requirements of the support needs assessment.

The international Scoping Review highlights that while some countries involve non-allied health professionals (e.g., navigators or administrative staff) in disability support assessments, these individuals primarily provide supplementary information and do not determine support needs or formulate decisions. To ensure accurate and comprehensive assessments, allied health professionals or multidisciplinary teams currently working with the person living with a disability are typically involved, particularly for individuals with complex or multifaceted needs. Relying solely on non-health professionals or simplified scoring systems risks under-identifying or misidentifying support needs, leading to resource misallocation and potential adverse outcomes[8] .

A skilled and qualified workforce, such as the NEAT workforce proposal, is critical for effective SNAs. Addressing the international best practice considerations identified in Appendix 1, will ensure that the workforce can deliver timely, equitable, and high-quality assessments to meet the multiple requirements of the NDIS SNA. Allied health professionals registered with the statutory, independent Allied Health Practitioner Registration Authority (AHPRA) meet regulated standards for practice and continuing professional development requirements. Engaging AHPRA-registered allied health professionals to deliver SNA will ensure a skilled and independently-regulated assessor workforce, and protect participants as AHPRA -registered professionals are bound by a code of conduct setting the standard for professional practice. AHPRA’s primary role is to protect the public and set ethical and competency standards and policies that all registered health professionals must meet. An endorsed assessor program further ensures quality, standards, and consistency.

7. ASSESSMENT INSTRUMENTS AND METHODS TRANSLATING ASSESSMENTS TO SUPPORT BUDGETS

7.1 Assessment instruments

The Both the NDIS Review Final Report and the National Framework for Assessing Children’s Functional Strengths and Support Needs (2024) emphasise the importance of using reliable, valid, and contextually appropriate instruments for SNA. Both reports emphasize assessment tools aligning with the World Health Organisation International Classification of Functioning (ICF). Assessment instruments must be

Annual Report No. 1 of the 48th Parliament

Submission 1

The National Framework for Assessing Children’s Functional Strengths and Support Needs (2024) indicates that a variety of methods may be used, including semi-structured interviews, administering questionnaires and assessment instruments, observation (informally and/or formally), and evaluating any existing professional reports, alongside standardised assessment [9].

The countries examined in the Scoping Review utilise various assessment instruments and frameworks, tailored to their specific disability systems. Both tailor-made and existing assessment instruments are utilised across the jurisdictions reviewed [8]. A co-design process, combined with examining available literature and evidence, will optimally determine the assessment instruments and format required for the NDIS SNA.

7.2 Translating Assessment Findings to Support Needs Budgets

A highly complex aspect of building the NDIS SNA is the need to translate findings from the SNA into a safe, effective support budget capable of meeting disability support needs. International experiences indicate this will need to be rigorously trialled and tested to ensure it is fit for purpose, and capable of upholding Australia’s human rights obligations under UNCRPD. Over-reliance on algorithmic decision making in disability assessments has been questioned from a rights-based and CRPD perspective [10]. The concern is that these inequities are ‘baked’ into the system through the ‘averaging’ of support packages, grounded for example, in impairment-based assumptions that overlook individualised support needs.

The Working Together to Deliver the NDIS: NDIS Review Final Report (2023) emphasised iterative and inclusive co-design and rigorous testing of processes, involving people with disabilities and relevant experts [5]..

the international Scoping Review reveals that some of the countries examined, do in fact reduce Support Needs Assessment findings to categorical outputs or single scores to streamline decision-making for the purpose of funding or resource allocation e.g. Romania, and New Zealand. However, the Scoping Review cautions that, while these categorical outputs often aim to condense the complexity of assessments into simple steps, they risk oversimplifying nuanced, complex and multi-dimensional needs and have been criticised for potentially missing subtleties in individual circumstances, particularly when combined with impairment-based, or other, assumptions of support needs. The safety risks associated with overly simplifying complex support needs to generate a support budget underscore the importance of trialling such SNA processes prior to commencing large-scale SNA rollout [8]. These risks include risk of inadequate or inappropriate support budgets, or risk to life.

The NDIS SNA process will hold responsibility for critical elements of NDIS functioning, including determining eligibility pathway under Section 24 or early intervention under Section 25; informing budgetsetting, and defining stated disability supports. Development of a robust SNA process for the NDIS will require rigorous trialling and deep co-design with disabled people, their representatives, and expertise of allied health professionals skilled in formulating theory of change and designing support needs assessment. Rigorous trialling will ensure the process is transparent, safe, and evidence-based, and equitable across disability cohorts. Further, it will ensure the SNA process has capacity to translate assessment findings into safe, effective and individualized participant budgets and support packages.

the Disability Royal Commission into violence, abuse and neglect and exploitation of people with disabilities highlighted that access to suitably tailored supports and access to adequate funds are preventative of harm for people with disability [6]..

CONCLUSION

in conclusion, the implementation of a trauma-informed, bulk-billed MBS NDIS SNA represents a significant opportunity to enhance equity, accessibility, and safety for participants. Grounded in international best practices and informed by local evidence, the proposed model prioritises co-design, rigorous trialling, and the integration of endorsed allied health professionals to ensure the delivery of high- quality assessments. By emphasising participant choice and cultural safety, an MBS bulk-billed SNA process aligns with the NDIS principles of empowerment and inclusion, while fostering trust and mitigating risks of harm. The establishment of a regulated workforce, such as the proposed National Endorsed Assessor Team (NEAT), ensures the reliability and integrity of bulk-billed MBS assessments, supporting the development of effective, personalised support packages. Ultimately, this approach underscores the importance of a participant-centered, transparent, and evidence-based system to meet the diverse and complex needs of individuals with disabilities in Australia.

ACKNOWLEDGEMENTS

otSi is grateful to all the therapists, advocates and people with lived experience who provided input to this submission.

ABOUT OTSi

oTSI is a national society whose purpose is to enable occupational therapists who work alongside people with invisible and hidden disabilities, to reduce barriers to full participation in our world as active citizens of Australia.

our focus is ensuring access to resources, opportunities, and supports for people with invisible disabilities of all ages, including access to occupational therapy. OTsi has a strong voice in systemic advocacy and policy direction, as well as enabling individuals to build better lives. www.otsi.net.au

REFERENCES

1. NDIS Joint Standing Committee Inquiry to Independent Assessments Final Report (2021) - Independent Assessments – Parliament of Australia Retrieved 26/01/2025
2. National Disability Insurance Scheme Amendment (Getting the NDIS Back on Track No. 1) Bill 2024 – Parliament of Australia Retrieved 26/01/2025
3. Barr, B; Taylor-Robinson, D; Stuckler, D; Loopstra, R; Reeves, A. (2015). ‘First, do no harm’: are disability assessments associated with adverse trends in mental health? A longitudinal ecological study. Journal of Epidemiology and Community Health Vol 70 (4). BMJ Publishing Group Ltd.
4. The impact of Disability Insurance reassessment on healthcare use - Badji - Health Economics - Wiley Online Library Retrieved 26/01/2025
5. Working together to deliver the NDIS: NDIS Review Final report (2023) Working together to deliver the NDIS | NDIS Review Retrieved 26/01/2025
6. Final Report | Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability Retrieved 26/01/2025

Annual Report No.1 of the 48th Parliament Submission

7. Improving the NDIS for people with psychosocial disability: NDIS Participant & Mental Health OT Codesign 2023 - Allied Retrieved 26/01/2025
8. Health Information and Quality Authority (2024) Scoping review to inform standards for assessment of need. Dublin, Ireland. Scoping review to inform standards for assessment of need Retrieved 26/01/2025
9. Fitzpatrick, A., et al. (2024). National Framework for Assessing Children’s Functional Strengths and Support Needs in Australia. Autism CRC. National Framework for assessing children’s functional strength and support needs in Australia | Autism CRC Retrieved 26/01/2025
10. Full article: Disability assessments and the algorithmic veil: lessons from the abandoned ‘independent assessments’ proposal for the National Disability Insurance Scheme Retrieved 26/01/2025

AAPPENDIX 1

FIG 1. APPLYING INTERNATIONAL SUPPORT NEEDS ASSESSMENT BEST PRACTICE PRINCIPLES TO THE NATIONAL ENDORSED ASSESSOR TEAM

FIG 2 APPLYING INTERNATIONAL SUPPORT NEEDS ASSESSMENT BEST PRACTICE WORKFORCE PRINCIPLES TO THE NATIONAL ENDORSED ASSESSOR TEAM

FIG 3 APPLYING INTERNATIONAL BEST PRACTICE ASSESSMENT INSTRUMENT SELECTION PRINCIPLES TO

The NDIS SUPPORT NEEDS ASSESSMENTS

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