Vision Australia submission on: Joint Standing Committee NDIS

Introduction

Vision Australia appreciates the opportunity to provide a submission to the Joint Standing Committee on the NDIS Inquiry on Assistive Technology.

Vision Australia has always advocated for people who are blind or low vision to have the right to access assistive technology and to live independently, inclusively and with dignity in the community. Our position is informed as the nation’s leading provider of services and supports to people who are blind or have low vision.

Our stance on access to equipment is long standing and well known and is demonstrated in our publically available policy statement:

“People who are blind, deafblind or have low vision have a right to convenient and affordable access to the equipment and technology they need in order to participate fully, independently and with dignity in the social and economic life of the community. This includes mainstream equipment such as accessible consumer appliances, as well as specialised equipment (assistive technology) such as hand magnifiers and closed-circuit televisions for reading, and white canes and GPS technology to facilitate independent orientation and mobility.”

The blind and low vision community represents a relatively small percentage of the disability client base. While this is a small segment, it is specialised and supports that may not deliver large benefits for other cohorts can result in significant improvements in quality of life. This is particularly pertinent in the areas of as assistive technology and the adaptation of mainstream technology.

The NDIS market is forecast to reach $1 billion spend on AT by time of full rollout. At present, 34% of plans have AT or Home modifications (this doesn’t account for consumables, which is a far more common inclusion). However, there are long delays in approving AT assessments, for multiple reasons:

• Insufficient number of experts within NDIA,
• Inappropriate supports included in plans (requiring reviews for AT to be included),
• Lack of expertise by experts within NDIA, not understanding specialist equipment,
• Poor quality of AT Assessments submitted by providers (requiring re-submission or review of a decision).

We note that the Agency is in the process of developing and trialling a new model for Assistive Technology. To highlight concerns with this approach and reduce future issues we wish to draw the Committee’s attention to our response to the term of reference d. the role of the NDIA in approving equipment requests.

Recommendations

Vision Australia recognises that significant work is being undertaken to improve the provision of assistive technology under the NDS, and also that the scheme needs to have controls in place to regulate the costs of the scheme and we are supportive of these initiatives.

Vision Australia is also supportive of the creation of a vibrant, evolving and innovative market that provides choice and control to clients.

Our key recommendations are:

• That effort is put into standardising the assessment and approval process and work is made towards having achievable timelines that can be clearly communicated to participants and providers.
• Effort needs to be put into achieving a standard set of guidelines regarding assistive technology to create a stable market for providers. This should be clear, transparent, and include consultation with providers and participants ahead of any substantial changes.
• To ensure clarity of process, regular communications on decision making and determination for AT approvals or rejections should be provided, both at the sector and individual participant level.
• Approval of AT supports from the NDIS should be at a general level leaving clients the choice of specific equipment that will best meet their goals and fostering the development of a vibrant and innovative market.

Terms of Reference

a. The transition to the NDS and how this has impacted on speed of equipment provision Ready access to assistive technology has a profound and immediate positive impact on the quality of life, social inclusion and wellbeing of clients with blindness or low vision.

Vision Australia has noticed significantly longer processing times for Assistive Technology. In some instances the process has taken 6-9 months for approval, and in extreme instances, where a plan review is involved, clients have not seen a resolution or approval prior to their next annual plan.

The face to face contact with retail teams for consumables orders can take up to 90 minutes especially due to the specialist advice and service provided at this stage. This is exacerbated by the NDIS approval and claims process which often leaves the cient unsure of the equipment they are funded for. Seeking approval for purchases

from plan managers prior to releasing equipment to clients also reduces the effectiveness of the purchasing process. Overall, the NDIS processes for the procurement of equipment places significant strain on customer satisfaction at the retail level.

A primary cause of these delays is the lack of clear process with known response times provided by the NDIA regarding assistive technology assessment and approvals. Assistive technology assessment reports and quotes are required for certain equipment. Even when correct specified templates, which take considerable hours to complete (often in an unfunded capacity) are used and sent in, there is no response indicating receipt or action of these reports. This then becomes a waiting game with no clear indication of turnaround times with the client and provider left in the dark, sometimes for months with no follow up from NDIA or any process for providers to follow up on the client’s behalf.

Even once approval is advised to clients it is still common for delays to occur in the creation of service bookings required for the client to complete their AT purchase. In these cases the provider commonly acts on behalf of the client in liaising with the NDIS to have this process completed. This again is unfunded time spent by providers.

There are however good new stories, below is a positive case study:

  “A Vision Australia staff member received a call from an NDIA planner in
  which the planner advised that approval had been given for a client’s

equipment based on a submitted assistive technology assessment report and quote. The NDIA planner asked the Vision Australia staff member to make the service booking for the equipment whist the planner waited on the line. This was done successfully. Vision Australia was then able to process the order at that time and the order was processed on the same day. A call was then able to be made by the staff member to the client to confirm the order was completed.”

This is an example of how smooth the process can be when the NDIA and the provider work as a cohesive team to achieve an efficient approval process for the client. It also shows respect to the client and their needs by giving sufficient focus to the expediting of the approvals and order process. Communication, ownership and a level of respect between the NDIA and providers is the key to ensuring the process works in this way.

b. whether the estimated demand for equipment to be sourced

through the assistive technology process in each roll out area was accurate

Vision Australia has not yet encountered issues with unmet demand from the supply side of AT. The biggest concern from a commercial perspective is the lack of consistency in approval turnaround times (as above) meaning it is hard to order and maintain stock effectively, or for equipment with manufacturing timeframes, hard to feel confident about pre-ordering.

Differences across NDIA regions combined with changes in policy on specific items of equipment, cause substantial angst for providers. The lack of consistency around approval of specialised equipment also erodes confidence around maintaining stock levels on hand.

The protracted and inconsistent approvals for AT has a deleterious effect on the ability for providers of assistive technology to operate commercially and sustainably. The NDIA effectively controls the demand for technology in a fashion that is adverse to the tenets of a free and vibrant market that the NDIA wishes to encourage.

c. whether market based issues impact the timeliness of

provision of equipment

The most significant market based issue currently faced by Vision Australia under the NDIA is the lack of consistency and constantly changing goalposts in the assistive technology area. In their 2015 Assistive Technology Strategy, the NDIS outlined several key strategic priorities, the first two of these were:

• Support and stimulate a vibrant and innovative supply side market
• Empowering participants to choose technology that best support their needs

As a specific example, in the August 2016 NDIS AT Complexity guide special mention was made to the availability of “Universally designed versions of everyday use products: microwaves, electric kettles etc.” as level 1 basic AT. In the same guide released in May 2017 this has been completely removed. This type of short term change of decision on applicability of assistive technology makes the market incredibly challenging for providers.

Another clear example is the over prescriptive provisions outlined in the recently published NDIA guide to Basic and Standard AT 2018:

Vision • Everyday use products with specific features that address the participant’s visual limitations due to their disability, these can include items such as: replacement canes or cane tips throughout the year. (NOTE: This is only if the participant has already had a mobility assessment and it is a replacement).

• Replacement magnifier e.g. hand held magnifiers

• adaptive daily living equipment e.g. liquid level indicator, talking kitchen scales
• tactile dots

NOTE: The following items would generally not meet Reasonable and Necessary criteria and NDIS funding should not be used for purchasing these items: talking microwave, oven mitt (extra-long), chopping boards, measuring cups, talking food thermometer. Items such as a Victor Reader/Daisy Player should generally be trialled (rented) for a period to determine suitability when lower cost options are not available.

This appears to contradict the (still current) Assistive Technology Complexity Level Classification document released in March 2017. In that guide under Basic Domestic AT, “hand held devices for addressing severe vision impairment” are considered Level 2 – a definition which applies to oven mitts, talking food thermometers, etc.

There appears to be little or no rationale, even under the reasonable, necessary and value for money guidelines. For example:

1.     Liquid level indicators and talking kitchen scales are acceptable, however

talking food thermometers are not. This appears an arbitrary decision: each perform a similar function of reducing risk and increasing independence, each are low cost, and each low risk. 2. Talking microwaves frequently encounter rejections, a particular piece of equipment that is sought by the blind and low vision cohort for the independence and freedom it provides consumers.

These guidelines appear to apply very specific controls on the type of equipment available. This goes directly against the strategic goals of the NDIS AT strategy as it has the effect of constraining ‘a vibrant and innovative supply side market’, and limits the participant’s ability to choose the technology to best support their needs.

Not specifically defining the term ‘reasonable and necessary’ can be beneficial, giving participants choice and control about what they deem to be reasonable and necessary and which supports they choose to access. However, it has negative outcomes when applied to mainstream technology that might be considered an ‘everyday item’ for many people, but acts as a specialist AT equipment for people who are blind or vision impaired.

We are commonly seeing devices such as iPhones and iPads denied as they are mainstream technologies. However, for someone who is blind vision impaired, these items have in-built accessibility functions that contribute to a participant meeting their goals. They hold great benefit in mobility and social inclusion for a blind or vision impaired client.

For someone who is blind or has low vision, a smart device frequently is what helps people reach their NDIS goals.

There are in-built accessibility features not present in other devices, including:

• Voiceover/Narrator (speaks items on screen and enables different touch functions to navigate a screen and apps without relying on sight)
• Zoom
• Magnifier
• Contrast and colour inversions
• Switch control.

There is a great deal of inconsistency in the approval of mainstream devices. For example, in the weekly Q&A section of the NDIS website the following guidance was posted in June 2017: “Generally the NDIS won’t fund the purchase of an IPad. If there are certain apps that relate directly to your goals and support needs… than the cost of those apps can be funded by the NDIS”.

This direction again appears to go against the proposed initiative of the NDIS AT strategy to “stimulate the uptake of mainstream technologies”: on page 8 of the NDIS Strategy for the provision of Assistive Technology there is a case study outlining the increased independence and confidence for the client and the cumulative overall savings to the scheme that resulted from the provision of an iPhone to a participant (not just apps). These are examples of continually changing and conflicting advice that results in inconsistent decisions by planners and makes the assistive technology market extremely challenging for any provider.

In addition there are two factors that commonly slow down the approval and provision of equipment: the time for providers to generate the assessment; and the subsequent waiting time to for approval from the NDIA. As seen in the example above, clients expect the providers and the NDIA to work cohesively together to deliver an efficient and effective outcome for the clients. Frequently, providers bear the brunt of client dissatisfaction with the AT process.

Again, the inconsistency in turnaround times for approval and the unpredictability of what items will be approved also makes it hard to operate in any commercial and market based way as a provider.

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• A positive outcome was achieved for a client that is completely blind and has a multitude of complex medical conditions. The client was granted all access technology equipment that was presented including a ReadEasy Move 2 which has allowed her to manage her bills and medical letters. The client has advised that the machine is ‘running hot’ and as her husband is also vision impaired, it’s been a fantastic addition to their life. There was no chance they could have funded these items themselves.

• A client whose vision is deteriorating and who has recently been told that at some point over the next few years, they may lose all vision. Two reports for NDIS were completed. The reports specified that a priority was a reading machine so the client could maintain independence at home especially with self-directed study and reading. Neither reports to date have been looked at by the NDIA. Vision Australia has engaged in multiple follow-ups, and the client has partitioned the Ombudsman twice, laid multiple formal complaints and to date, neither the client nor the provider have received communication related to the outcome of those reports (note that the reports are well over 12 months old). This has been increasingly difficult for the client and also difficult for Vision Australia to help support her in achieving her goals.

We are also increasingly seeing a price cap referenced for various classes of products – such as a hand held video magnifier. We are not aware of a standard schedule of pricing as exists for other types of accommodations and AT. The price cap never references basic aspects of an item, things such as screen size, type of user interface etc., nor have we seen written evidence of this.

This may not be an official policy of the NDIA, as we see different regions attempting to adapt and respond in their own way. However, Vision Australia is opposed to a schedule of prices as it completely eliminates the highly individual spectrum of needs that people with vision impairment have. It is the thin edge of a one-size fits all policy.

Vision Australia has seen an increase in clients who are being told that a particular device won’t be included in an application because there have been too many rejections and so it is being seen as a waste of time by planners – despite it being recommended by a vision assessment. This particularly applies to OrCam which is very new technology and poorly understood, but also to particular brands of desktop CCTV’s and video magnifiers. This goes against the goal of supporting innovative AT, and of getting the best outcome for participants.

In August 2017, the Australian Blindness Forum (ABF) wrote to the NDIA to raise concerns on the inconsistencies and deficits of the approvals process for AT – the

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same issues are present, for a new cohort of participants. A section of that letter is excerpted below:

• Specialised assessment: The role of specialist assessment being subordinated to cost pressures. If an AT assessment has been completed properly the recommended product is what best meets the participant’s needs, and is most likely to provide long term meaningful benefit.
• Choice: The participant’s choice is being ignored. Again through a comprehensive AT assessment there are many factors that influence choice; things such as the design of the user interface, prior experience, the amount and availability of training and support, ergonomic considerations, reading and learning preferences, cognitive function and many more. These are often not given any consideration due to the planner’s insistence on getting a cheaper product that, in their opinion, is equivalent. This issue can be exacerbated if the planner or NDIA delegate in question has personal experience of low vision or blindness, but their preferences or capacity differs from that of the participant.
• Deviation from the insurance model approach: where equipment that may be higher cost has substantially improved long term application to reduce ongoing supports and future costs – this approach is rarely taken.
• Innovative solutions are being side-lined: technology is changing rapidly and new solutions that may be marginally more expensive but offer big increases in functionality are rejected on the basis of cost, perhaps due to a misapprehension of the benefits of the equipment.
• Compromised outcomes: an NDIA Delegate suggested a person who is blind obtain a refreshable Braille screen that is only 18 characters long (because it is cheaper), when they had asked for one that was 32 characters long. Imagine telling a sighted person that they were limited to a PC screen that would only display 18 letters at a time, and that the device is meant to be their primary productivity tool and link to the wider world. In Europe an 80 cell display is the standard.
• Competitive Bidding: some planners are rejecting plans that do not have a competitive quote included, which does not account for AT where there is only one supplier of a highly specialised product.

Proposed changes to the AT Model

We note that there are proposed changes to the current model for Assistive Technology. This has led to improvements in the consumables budget for participants: low cost, and low risk. We are conscious that the proposed model is still under development: yet although there has been limited publically available

• information to date, and limited consultation, the proposed approach for complex technology and assessments presents a number of concerns.

At present, Vision Australia and other providers often bear the brunt of consumer unhappiness with AT approval delays. We present as the face of AT for the NDIS – a participant gets an assessment from one of our staff, they speak to us about the progress of the report, they come to us for the equipment and express their frustrations to us about the delays.

The proposed new approach appears to push the current bottleneck back on providers – rather than the AT approval getting delayed within the NDIA, the panel of assessors could see a dramatic increase in assessments, leading to delays. This may well have an impact on plan approvals – if AT assessments occur prior to plan approval, a delay in that assessment could be reflected in the plan approval.

If something is not considered in this pre-plan assessment phase, or is not included in their plan, the participant will need to seek a plan review in order to obtain the AT. This appears to reduce flexibility, although more detail is needed.

Vision impairment is a low incidence cohort, currently 2% of the market. There are concerns with the new model for specialist, low incidence markets, where technology is niche, unique, or has specific applications not aligned to other disability cohorts. It is unclear how the proposed independent panel of assessors for complex AT would ensure adequate knowledge of specialist AT equipment. We have requested clarification and sought to work with the NDIA to resolve these issues and are yet to hear further.

g. any other related matters.

We are seeing negative flow on impacts for some Assistive Technology approvals. A Seeing Eye Dog, as a Dog Guide, is considered and assessed under the Assistive Technology framework. In the past four months, we have seen multiple instances where other funded supports were cut due to provision of a Dog Guide.

• A client with an existing Seeing Eye Dog was given no transport funding in their first plan. The rationale given was that a Dog Guide acted to replace the required transport funding. This client had previously been on the higher level of the Mobility Allowance, and relied on this funding to support employment and connection to the community. In their words: ‘I think the planner expects me to ride my dog to work’. This is currently under appeal. This is an increasingly common issue.
• A client with a newly funded Dog Guide had their core supports cut by a third. The planner emailed: ‘As per our discussion, taking Dog support into consideration if you want to go ahead that will impact your core funding. Currently, there is $34331.60 has been allocated in this category. If we go ahead with approval of Dog in the plan this funding will change. Core funding will be around $23,000 as your funded support will decrease with the help from Dog.’ None of the intended Core Supports represented a like-for-like replacement with a Dog Guide. This is currently under appeal.

Some additional points supplied by our service teams are listed below:

• There are some circumstances where NDIS planners are telling clients they will approve a particular piece of equipment without any knowledge of how the equipment approval works within the scheme.
• The NDIS state at times they will not fund everyday items, but this does happen (iPhones for example). While individual participant’s goals vary, all too often the reasonable and necessary criteria appears to be applied arbitrarily.
• Clients have advised they are prepared to wait for assistive technology, however not knowing an expected timeline of when they will receive an answer is frustrating: leading to poor outcomes and the potential for a damaged relationship between participant and provider.
• Clients are concerned that when they come up for plan review and they haven’t spent their money, that they will lose those funds. The issue is they haven’t required any AT equipment for that period but as they are being told ‘use it or lose it’ they are requesting equipment that isn’t really required as opposed to waiting until they have a suitable goal they want to achieve. This seems to be a systematic issue with the annual planning mindset where assistive technology has a useable lifespan that exceeds the yearly cycle.

About Vision Australia

Vision Australia is the largest national provider of services to people who are blind, deafblind, or have low vision in Australia. We are formed through the merger of several of Australia’s most respected and experienced blindness and low vision agencies, celebrating our 150th year of operation in 2017.

Our vision is that people who are blind, deafblind, or have low vision will increasingly be able to choose to participate fully in every facet of community life. To help realise this goal, we provide high-quality services to the community of people who are blind, have low vision, are deafblind or have a print disability, and their families.

Vision Australia service delivery areas include:

• Allied Health and Therapy services, and registered provider of specialist supports for the NDIS and My Aged Care
• Aids and Equipment, and Assistive/Adaptive Technology training and support
• Seeing Eye Dogs
• National Library Services
• Early childhood and education services, and Felix Library for 0-7 year olds
• Employment services, including National Disability Employment Services
• Accessible information, and Alternate Format Production
• Vision Australia Radio network, and national partnership with Radio for the Print Handicapped
• Spectacles Program for the NSW Government
• Advocacy and Engagement, working collaboratively with Government, business and the community to eliminate the barriers our clients face in making life choices and fully exercising rights as Australian citizens.

Vision Australia has gained unrivalled knowledge and experience through constant interaction with clients and their families, of whom we provide services to more than 26,000 people each year, and also through the direct involvement of people who are blind or have low vision at all levels of the Organisation. Vision Australia is therefore well placed to provide advice to governments, business and the community on the challenges faced by people who are blind or have low vision fully participating in community life.

We have a vibrant Client Reference Group, with people who are blind or have low vision representing the voice and needs of clients of the Organisation to the Board and Management. Vision Australia is also a significant employer of people who are blind or have low vision, with 15% of total staff having vision impairment.

• Vision Australia also has a Memorandum of Understanding with, and provides funds to, Blind Citizens Australia (BCA), to strengthen the voice of the blind community.
• We also operate Memorandums of Understanding with Australian Hearing, and the Aboriginal & Torres Strait Islander Community Health Service.