Submission to the Joint Standing Committee on the National Disability Insurance Scheme: Assistive Technology

Background information:

I am a speech pathologist who has worked in the disability sector in South Australia since 2005 and until recently held a management role for an Assistive Technology (AT) service leading a specialised team of Physiotherapists, Occupational Therapists and Speech Pathologists whose roles were focused on the assessment, prescription, training and support of a broad range of Assistive Technology (excluding aids for vision and hearing) within a large state-wide provider. I have recently established my own private company, Wayfinder Disability Services, to provide Speech Pathology services, including Augmentative and Alternative Communication (AAC) Assistive Technology related services for people with complex communication needs.

My submission is influenced by:

my personal experiences as a Speech Pathologist seeking funding for AT under both the previous system and the NDIS
my experiences supporting staff and participants who are seeking funding for AT through both the previous system and the NDIS
my active membership of both AGOSCI and ARATA
my extensive experience and understanding of the previous State Government system,
a close working relationship with Domiciliary Equipment Services (DES), and
my involvement in a number of committees where people living with disability and using AT have been represented.

a. The transition to the NDIS and how this has impacted on speed of equipment provision;

While the NDIS has enabled some items of equipment to be funded that would not have been funded under the previous system, it is my experience that overall the transition to the NDIS has seen a significant negative impact on many aspects of equipment provision including the speed. Prior to the introduction of the NDIS, and particularly in recent years, the state government equipment scheme administered by DES was able to provide and maintain most essential equipment. Under the state government funding, the key issues for South Australians who needed AT were: insufficient funding to meet all the needs for equipment, lack of availability of state funded service providers to complete assessments for AT (due to workforce issues) and a narrow scope of equipment that meant that some items that would have made a significant difference in peoples’ lives were not funded.

The NDIS system has:

inconsistent outcomes for participants with similar needs and presentations
relied on planners with often limited background and training regarding the different AT types, functional needs of participants and the attributes of a skilled or unskilled AT assessor to make decisions about equipment funding
an excessively time-consuming and inefficient request process for equipment, including for replacement of existing items
a lack of transparency regarding the status and outcomes of requests
significant delays in the provision of equipment
inconsistent availability of funding for equipment maintenance and repairs

increased participant, carer and AT assessor stress and uncertainty regarding the provision
no clear system for escalating urgent and high-risk needs
a lack of understanding and acknowledgement of the professional skills, responsibilities and ethics of AT assessors.

Regarding speed of AT provision, the introduction of the NDIS has resulted in slower, time consuming, confusing and inequitable equipment provision. People are waiting months and even years for equipment that would previously have been provided within 1 day to a typical maximum of 3 months (when funding was available) from the time of application. There have been hundreds of applications for equipment that have been waiting for many months without resolution in South Australia. This is exposing individuals to high levels of risk including risk of hospitalisation and death, reduced independence, function and skill development. This needs to be addressed as the current situation is not sustainable and is likely to get worse in South Australia as the adult population transitions to the NDIS.

b. whether the estimated demand for equipment to be sourced through the assistive technology process in each roll out area was accurate;

This is not yet able to be known because the issues described in sections a. and d. mean that there are large numbers of participants whose equipment has not been approved and funded. This means that the actual spend to date by the NDIS on AT would understate the actual current demand for AT. For example, the November 2017 NDIS Market Insight publication on Assistive Technology (https://www.ndis.gov.au/medias/documents/market-insight-at/Market-Insights-Assistive-Tech.pdf) indicated that about 3% of the spend for the 16-17 Financial Year was on AT, the full scheme projection of $1 billion out of $22 billion suggests a 4.5% spend should have been seen. This cannot be taken to mean that there is less demand for AT than was projected as there are many unresolved requests for AT that are awaiting an action or decision from the NDIA.

c. whether market based issues impact the accessibility, timeliness, diversity and availability of assistive technology;

Accessibility

South Australian participants are typically able to view and sometimes trial the required range of Assistive Technology, however for complex equipment there can be delays of several months and freight costs as equipment is shipped from interstate suppliers. Some items require funding for trial and this is not easily or consistently made available in participants’ plans.

The main category of equipment that is not readily accessible in the Australian market is equipment that has not passed Australian safety standards testing.

There is limited access to skilled AT assessors in South Australia. This was an issue prior to the introduction of the NDIS and is likely to become more apparent as South Australia’s adults transition to the NDIS. The complexity and frustration of interfacing with the NDIS AT process is extremely challenging for service providers. This means that some service providers are opting not to offer this service and many see it as a high risk, low reward aspect of practice. Not all equipment requires expert assessment, but for those equipment types that do, there is a high probability that the market will not have adequate supply of appropriately skilled people to provide these assessments. This will have consequences for the participants, but also for other operators in the AT sector.

Timeliness

There is sufficient demand for the majority of “basic” and “standard” assistive technology (https://www.ndis.gov.au/medias/bin/documents/h5d/h43/8804365008926/Assistive-Technology-Complexity-Level-Classification.docx) that many non-complex items can be held by suppliers for reasonably prompt distribution. This was supported very well in South Australia through the refurbishment equipment model that was managed by DES. This system enabled certain standard items to be provided on the day of request if urgent and certainly within the week of the request being submitted.

Custom and highly specialised equipment items are much less readily available for participants in a timely manner. The majority of AT manufacture occurs in other countries, so for custom items e.g. made to measure wheelchair frames, this means that there is routinely an 8-12 week time-period between the finalised order being made and the item being received by its new owner. This can then be followed by a further time-period of up to several weeks for the local manufacture of custom seating. This is already challenging for participants with predictable needs (e.g. A child outgrowing their equipment, or an adult whose equipment is wearing out), but creates an extremely difficult and at times unsafe situation for people with rapidly changing or unpredictable conditions.

Diversity and Availability

The Australian market for AT is smaller than many international markets and so the number of people requiring highly complex and specialised equipment is small. This can make it difficult for manufacturers, suppliers and distributors to justify developing or supplying products for such a small population of people. This relatively small market may discourage manufacturers from going through the cost of pursuing Australian Standards Testing for their full range of products. This also means that the price of these highly specialised items is often very high (and higher than a person would think the manufacture and materials would justify).

d. the role of the NDIA in approving equipment requests;

This has been extremely problematic and has resulted in a poor experience for many participants and a significant amount of time being wasted by participants, carers, AT assessors and other therapists, suppliers and NDIA staff. The system wide issues that are experienced across the NDIS with poor communication, inconsistent experiences (that cannot be explained by the individual differences between participants), errors in plans and confusing processes are impacting on the approval of equipment requests.

The process for AT provision is fundamentally flawed as it assumes that a participant is going to know their AT needs for the coming year (or longer) at their planning meeting and that the planner is going to have enough information and knowledge to be able to build the correct items into the participant’s plan. This is often not the case as needs and available options can change significantly over a 12-month period. Even when participants have taken AT assessments to their planning meeting there have been cases of the plan being built without the reasonable and necessary AT included. There are considerable delays in getting equipment funded if it is not in the plan from the beginning and it often needs to wait for the next plan.

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There is also a lack of transparency regarding whether any item of equipment is likely to be approved for funding. Planners present inconsistent information about the NDIA’s stance on particular equipment items. The NDIA’s decisions are based on individual application of the reasonable and necessary criteria of Section 34 of the NDIS Act and, except for items like Home and Vehicle Modifications which have Operational Guidelines, there is no published information to indicate what is likely to be funded. Information from Planners suggests that the NDIA has internal guidelines which are not made public. For example, a Planner stated that the NDIA does not fund Environmental Control (e.g., the ability to independently control a TV or light switch) for people under the age of 16. This lack of transparency is unhelpful as it is not clear whether these statements are accurate or are misunderstandings on the part of the planner. It also makes it difficult to support participants to have a realistic expectation of the likelihood of an item to be funded and to know how to proceed if a decision has been made that does not seem in keeping with the NDIS Act.

In addition, there is no visibility for participants, the NDIA, the state AT program (DES) and AT assessors regarding the status of an equipment request once it has been submitted to the NDIA. There has been no process for acknowledging that a request has been received and assigned and it is relatively common for a person to be told that there is no record of a request having been received. This means that participants and assessors often feel the need to follow up to enquire about the status of their request. This is time consuming and not best use of time for the person making the call/sending the email, nor for the person at the NDIS who receives the contact.

The internal management of AT requests is also unclear. The equipment items in the NDIA’s AT and Consumables Guide are very specific, often not terminology that is used in the sector and have benchmark pricing that is not visible to the participant or assessor. It is my understanding that NDIA staff with a certain level of seniority can approve items up to a certain value against the benchmark, but that higher cost items need a higher level of seniority to approve. There is also the Technical Advisory Team within the NDIA who I understand have an allied health background and give an opinion to planners about whether a request is likely to meet the reasonable and necessary criteria. It is not clear when requests are sent to this team. If this information was visible, the participant and assessor would have better understanding of the approval process, the level and type of information that they need to provide, and the likelihood of their request being approved.

AT assessors have an extremely challenging role in this process as they work with participants to identify the needs and make the application to the NDIA. The lack of transparency and consistency from planners leave assessors confused about how much information to provide in their AT Assessment as the current form does not naturally generate all the information that planners need to make their “Reasonable and Necessary” determination. As planners do not necessarily have background knowledge and experience of the equipment and the individual participants’ needs, they can easily misunderstand and overapply information that is provided. Planners are reported to Google to understand clients’ diagnoses and equipment features, and on occasion have used this research to suggest to highly experienced clinicians who have completed a thorough and appropriate assessment with the participant, that alternative equipment would be more suitable than the item that has been recommended. This is poor use of everyone’s time and reflects that there can be a lack of trust between planners and AT assessors.

The communication when a request is declined has also been poor and inconsistent. In many cases there is no response at all to a submission. In other cases, only the participant, DES or the assessor are advised of the outcome, leaving the contacted party to communicate the decision to the other person/people. There have also been instances where planners have communicated to participants that an item has been declined because the AT assessor failed to provide adequate information,

without having attempted to contact the AT assessor to clarify the situation. This can be extremely challenging for the working relationship between the participant and assessor as it often unfairly directs blame at the assessor and is also inefficient as once a decision is made, the formal “Review of a Reviewable Decision” process needs to be followed. In some cases, a brief conversation could have efficiently clarified the concern rather than creating the extra delay and administration of a formal review.
In the case of essential equipment, it is also not acceptable that an item is declined without an automatic opportunity to submit an alternative solution. If a person has outgrown their wheelchair, but the NDIA does not find that the model that has been recommended is “reasonable and necessary”, the outcome is likely to be that the person is without a safe means of mobility through the review process and until an item is funded. There should be a process for discussion with the planner to identify an alternative (if available), explain and be heard on the rationale for the requested item, or to expedite a review of a reviewable decision, as the risks to safety and impact on participation and quality of life are significant.

e. the role of current state and territory programs in the assistive technology process;

Under the NDIS, DES has maintained a role in the procurement of NDIS funded AT (excluding vision and hearing equipment) and also the repairs and maintenance of AT. DES performs a number of other functions in relation to AT including advice for AT assessors, investigation of equipment malfunction and training in equipment assessment and process. There is no funding under the NDIS model for DES to provide this training to AT assessors, nor for investigation of equipment malfunction. Where NDIS funded equipment has failed, DES have not had a way to cover the costs of their involvement in co-ordinating a recall of equipment and loan of alternative equipment. Without des co-ordinating the response, it is unclear how the recall could have been achieved.

During the transition to the NDIS, des has been a point of contact for many assessors, participants and planners regarding equipment provision under the NDIS. This has happened in large part because of the difficulty in communicating with the ndis. Des have also had to engage with the ndis portal to process claims for equipment purchase and repairs. The portal is an inefficient system. It is my understanding that these issues have significantly increased the administrative load of staff at des, while the issues with the process have drastically slowed the rate of equipment approvals. This has made it more difficult for des to provide a responsive service and led to a perception by some that it is preferred to access equipment directly from a supplier without going through des. This may be the experience for some participants, but for many participants who rely on their equipment and have multiple items of complex equipment, the ability to contact des for any repair need and have a rapid response is critical. They are not able to do this if their equipment has not been procured by des and if they do not have ndis funding for repairs.

The delays and uncertainty about whether a requested item will be funded has also made it extremely difficult for DES to provide refurbished equipment under the NDIS. For example, if a suitable wheelchair is available, but needs funding for modifications (such as a replacement headrest), the process to access funding can be as slow as if you were requesting a whole wheelchair. The chair then needs to be stored “on hold” for the participant until the NDIA makes their decision. This means that the chair cannot be considered for another participant and may not be funded anyway. This then becomes a waste of time and resources.

The current NDIS processes regarding Assistive Technology do not support efficient, effective,

responsible and safe provision of equipment to participants of the NDIS. The NDIS states that the “Key registration requirements in the Provider Toolkit, provides details of the criteria that would qualify a provider for the different AT assessments” This does not detail the criteria for a suitably qualified Allied Health Professional. There is no accreditation for AT prescription in Australia, so the system relies on subjective individual determinations by the service provider about whether their experience is adequate. It is my understanding that the main regulatory frameworks governing AT prescription under the NDIS are the professional registrations/memberships of AT assessors (e.g. AHPRA, Speech Pathology Australia) and the ACCC. Without guidelines or criteria relating to specific types of AT/participants, these bodies are not equipped to appropriately consider whether someone has adequate experience to recommend a particular item for AT funding. Participants do not necessarily understand the relative skills and experience required for a quality AT recommendation and there is a shortage of people with these skills in the sector.

Without an accreditation process, clear guidelines regarding the characteristics of a qualified AT assessor, or personal understanding of the equipment and participants’ needs and function themselves, planners are not equipped to appropriately evaluate an AT request and do not know the difference between the quality of a request from a highly experienced clinician and someone without experience or appropriate support. This has led to some equipment being funded by the NDIS that has not been appropriate and would not have been prescribed by an experienced assessor. These experiences of waste have meant that planners are wary of approving items and so can engage in lengthy correspondence with assessors to try to work out whether to approve the item. This is either expensive for the NDIS/the participant if the assessor’s time is funded from an NDIS plan, or for the service provider if they are not being funded for the follow up. It is also expensive for the NDIA as these staff are then spending NDIA funded time in this protracted follow up. If there were clearer guidelines and an ability for the credentials of the assessor to be relied upon, then this would be a much more efficient process and one where the professional registrations/memberships and ACCC could realistically be used as a regulatory framework. For example, if the NDIA or other regulatory body were to advise that “a recommendation for eyegaze technology can only be made by an OT who has at least x years’ experience in recommending this technology/has completed at least x supervised assessments”, then an OT without this experience would be aware that they were operating outside of their experience and need to seek support to make this recommendation.

The environmental impact of the NDIS AT model needs to be considered. Where items are purchased outright by participants without a refurbishment option, there is a high likelihood of items becoming clutter or landfill when they are no longer needed. There should be consideration of how to create incentives for participants to easily recycle their old equipment and to be open to using refurbished equipment where appropriate.

Impact of NDIS transition on assistive technology provision in South Australia

Submission to the Joint Standing Committee on the National Disability Insurance Scheme: Assistive Technology

Background information:

a. The transition to the NDIS and how this has impacted on speed of equipment provision;

Timeliness

Diversity and Availability

Page 4

e. the role of current state and territory programs in the assistive technology process;

The current NDIS processes regarding Assistive Technology do not support efficient, effective,

Suggested solutions:

Impact of NDIS transition on assistive technology provision in South Australia

Submission to the Joint Standing Committee on the National Disability Insurance Scheme: Assistive Technology

Background information:

a. The transition to the NDIS and how this has impacted on speed of equipment provision;

Timeliness

Diversity and Availability

Page 4

e. the role of current state and territory programs in the assistive technology process;

The current NDIS processes regarding Assistive Technology do not support efficient, effective,

g. any other related matters.

Suggested solutions: