NSW Government Submission

Inquiry into Assistive Technology provision

Joint Standing Committee on the National Disability Insurance Scheme

14 September 2018

Executive Summary 3
1. Introduction 3
1.1 Scope of the submission 4
1. NSW support for the NDIS 4
1. NDIS transition 4
1. The role of EnableNSW following NDIS transition 5
1. EnableNSW role as a Registered Provider 5
1. Opportunities to improve support 5
1. Challenges to health and wellbeing outcomes 6
1. Specific issues raised in the terms of reference 6

Executive Summary

NSW Health provides state-wide services to assist eligible residents of NSW with a permanent or long term disability or chronic health conditions to live and participate within their community. This service is primarily delivered through EnableNSW. Enable provides aids and equipment (‘assistive technology’ or ‘AT’) to assist with mobility, self-care, communication and respiratory equipment.

This submission outlines the AT supports and services provided by NSW Health, either directly or through supply contractors, to people with a disability under the National Disability Insurance Scheme (NDIS).

NSW Government supports the NDIS and has been actively supporting the implementation and full scheme operation of the Scheme. Under the NDIS, there is significantly increased funding available for AT than under the previous state arrangements. In addition, the Scheme will be able to fund AT for a broader range of purposes including for recreation and vehicle modifications purposes.

NSW Government is aware that the NDIA is facing administrative challenges, including in relation to AT. These challenges – specifically long delays in the approval and delivery of AT - are frequently having a direct impact on the health of participants. NSW Health is working with the NDIA to resolve these problems and is assisting by providing interim equipment or one-off funding to help participants as an interim measure.

1. Introduction

NSW Government welcomes the opportunity to make this submission to the Joint Standing Committee on the National Disability Insurance Scheme (NDIS).

NSW Health has a proud history of delivering services to people with disability, including providing AT that allow individuals to maintain independence in the community.

NSW Health is the main AT funding body in NSW, delivered largely through EnableNSW, providing AT for health needs and to assist people with disability.

The following equipment funding programs are operated by EnableNSW and are relevant to this submission:

Aids and Equipment Program - providing mobility, self-care and communication equipment including wheelchairs, bathing equipment and augmentative communication devices and consumable products for continence and Home Enteral Nutrition to adults and children
Prosthetic Limb Service - providing funding for prosthetic limbs to adults and children, and
Home Respiratory Program - providing respiratory equipment (including oxygen concentrators and respiratory support devices) to adults and children.

EnableNSW also operates a comprehensive repairs and maintenance service for supplied equipment.

1.1 Scope of the submission

This submission provides an overview on:

the role of NSW Health in:
- administering individualised Government funding for AT
- operating as a Registered Provider under the NDIS, and
- managing health effects resulting from delays in providing AT funding in NDIS plans.
responses by NSW Government in relation to the Inquiry’s Terms of Reference.

4. The role of EnableNSW following NDIS transition

EnableNSW will continue to provide respiratory equipment for all eligible NSW residents.

EnableNSW will also continue to provide equipment in all categories for people who are not eligible for the NDIS or other equipment funding sources.

It is estimated that EnableNSW will continue to support approximately 26,000 people under the Aids and Equipment Program.

5. EnableNSW role as a Registered Provider

At the request of the NDIA, EnableNSW became an NDIA Registered Provider during the transition years providing services under Working Arrangements up to June 2019.

Key objectives of the Working Arrangements are to:

secure the supply of high quality AT for NDIS participants that is both ‘reasonable and necessary’, while also enabling NDIS participants to exercise choice and control; and
ensure that the supply of AT promotes NDIS sustainability, particularly by allowing NDIS participants a way to access AT at the efficient prices achievable under NSW Government contracts, while the NDIA implements it’s AT strategy. As part of this role EnableNSW assists NDIA participants to obtain equipment, consumable items and equipment repairs. EnableNSW estimates that it is providing AT for participants valued at approximately 10% of the NDIA AT spend in NSW this year.

EnableNSW also provides a quality and safety check on requests of NDIA Category 2 complexity and above (higher risk categories). Following this check, information is provided to the NDIA which the delegate may consider in making a ‘reasonable and necessary’ determination about some AT requests. The NDIA delegate’s role is to make the determination as to whether requested AT is reasonable and necessary and to assign relevant funding in the participant’s plan.

Outside the Working Arrangements, EnableNSW operates two Rural Orthotic and Prosthetic manufacturing services in locations where no service providers exist. It is anticipated that these two services will continue to provide orthotics and prosthetics for NDIA participants on a fee for service basis in full scheme (that is, from 1 July 2018 and continuing).

6. Opportunities to improve support

EnableNSW regularly meets with NDIS officials to resolve issues and share information which may assist in improving NDIS AT funding in NSW. EnableNSW has undertaken education and training sessions for Local Area Coordinators (LAC) and planners. EnableNSW has also held joint information sessions on transition arrangements with the NDIA for other stakeholders groups.

EnableNSW has provided individualised funding for AT for people with disability and chronic health conditions for 10 years. EnableNSW processes approximately 75,000 requests for AT funding per annum including for equipment, repairs and consumable reorders.

EnableNSW has developed efficiencies in processes and decision making that provide for a streamlined approach to service delivery, including:

22 days on average from application to delivery for new equipment requests (this includes all applications, including those that are incomplete and need additional information)
13 days on average from application to delivery for new prosthetic limb requests, and
24 hours from request to placement of order for repairs for 92% of people.

The streamlined process developed by EnableNSW for reviewing it applications is built on: 1. Allied health staff with extensive clinical expertise in AT train and support administrative staff in the exercise of their functions 2. 80% of requests/applications for funding are approved by trained administrative (that is, non- clinical) staff 3. Allied health staff also review administrative staff decisions and ensure consistency of approach under a protocol which includes random reviews 4. Allied health staff directly approve the remaining 20% of high complexity requests and liaise with consumers and assessors regarding queries or appeals. EnableNSW has offered to share its internal processes including its approvals process in more detail with the NDIA.

Challenges to health and wellbeing outcomes

As at 7 September 2018 at least 990 participant requests reviewed by EnableNSW at the request of the NDIA are yet to be finalised by the NDIA and have been in the system for longer than three month awaiting a ‘reasonable and necessary’ decision for plan finalisation.

Of these requests more than half have been waiting six months or more. Participants have also shared NDIA e-mail correspondence indicating a decision on AT funding should not be expected for a further 8-12 weeks, although these timelines are regularly exceeded.

Consequently, EnableNSW has provided equipment for 567 NDIS participants who are waiting on approval of AT in their plans. While AT is now the responsibility of the NDIS, NSW Health is aware that delays in the provision of aids and equipment are adversely impacting participant’s health and has intervened to minimise the impact from these delays.

The cohort most profoundly affected by the NDIS delays is amputees who are waiting funding for prosthetic limbs. Delays in funding new limbs and socket replacements dramatically increase the risk of pressure areas and resulting wounds, and places the participant at increased risk of falls.

Other health concerns include the increased risk of preventable hospital presentations and admissions due to falls or pressure injuries, potential for carer injuries, infections and social isolation.

Specific issues raised in the terms of reference

The Terms of Reference for the Inquiry direct the Committee’s attention to specific aspects relating to the provision of AT to NDIS participants.

NSW Government provides commentary below on this Inquiry’s Terms of Reference for the Committee’s consideration.

the transition to the NDIS

EnableNSW is the peak NSW State Government funding body for and how this has impacted on speed of equipment provision Prior to the NDIS, EnableNSW provided funding and processed requests for approximately 46,000 people. In a given year 21,500 would request assistance, many individuals received funding for more than one funding request.

In the last financial year, the number of participants receiving assistance decreased to just under 19,000 and this decrease was attributed to the transition to the NDIS.

EnableNSW has worked conscientiously to ensure there are no waiting lists for requests to it for aids, equipment and/or prosthetic limbs.

In the last financial year, requests for AT were processed and funded in an average of 22 days for aids and equipment and 13 days for prosthetic limbs. In addition, 92% of repair requests were processed and placed with a repair provider within a 24 hour time frame.

EnableNSW is currently assisting approximately 18,500 individuals to ransition to the NDIS. The NDIS transition is progressing in line with expected targets excluding amputees, whose transition numbers are lower.

NSW is making a concerted effort to ensure people do not experience delays in funding due to the transition process. To assist a smooth handover, EnableNSW continues to fund equipment for individuals up to the ‘start date’ of their plans.

At the request of the NDIA, EnableNSW is working as a Registered Provider for the NDIS and assists in managing AT and repair requests for 10% of the AT spend in NSW.

As a Registered Provider, EnableNSW is aware of 990 requests that are yet to be finalised by the NDIA and have been in the system for longer than 3 months awaiting a ‘reasonable and necessary’ decision for plan finalisation. Of these requests more than half have been waiting six months or more. Participants have also shared NDIA e-mail correspondence indicating a decision on AT funding should not be expected for 8-12 weeks.

Consequently, EnableNSW has provided equipment for 567 NDIS participants who are waiting on NDIA approval of AT in their plans.

While AT is now the responsibility of the NDIS, NSW Health is aware that delays in the provision of aids and equipment are adversely impacting the health of some participants.

The cohort most profoundly affected by the NDIS delays is amputees who are waiting funding for prosthetic limbs. It should be noted that children face particular risks.

The delays in approval of child prosthetic limbs often means that the child has outgrown the prescription for the limb by the time the approval is given and the assessment and approval process must start again. EnableNSW has been providing ‘interim limbs’ for children as part of our in-kind contribution, however, this is restricted to standard limbs and does not allow for recreational or other kind of limbs or specialised fittings or attachments which are anticipated to be fundable

Under the provisions of the NDIS Act.

Health concerns related to delays include increased risk of preventable hospital presentations and admissions due to falls or pressure injuries, potential for carer injury, infections and social isolation.

b. whether the estimated NSW Health is unaware of the estimates used by the NDIA for the demand for equipment to be sourced through the The NDIS AT Strategy estimated the AT funding under the NDIS, assistive technology including home modifications, would be up to $940M per annum in full process in each roll out scheme. Based on population numbers, it would be expected that area was accurate about a third of this (or $313M) will be spent in NSW. Aggregated NDIA plan data provided to NSW highlights that approximately $150-200M of AT is funded in NSW excluding home modifications.

c. whether market based issues impact the timeliness of provision of equipment The AT market is robust with many experienced providers available across NSW providing AT equipment and services. Prosthetics and orthotics providers in rural and remote areas are the exception to this with only a single provider many rural areas. EnableNSW maintains two rural prosthetic and orthotic manufacturing units to address the demands in rural towns which would otherwise be underserviced. The data demonstrates that the majority of AT is manufactured outside Australia. Consequently, AT aids and equipment are appropriately stocked within Australia and are available in short timeframes, although complex or customised AT may take 8-12 weeks to be delivered after an order is placed.

d. the role of the NDIA in approving equipment requests It is the NDIA’s role to determine eligibility for the NDIS and to determine reasonable and necessary supports, allocate appropriate funding levels and moreover enable the participant to meet their goals. It is the role of the NDIA planner to assess whether the AT supports are reasonable and necessary and to assign appropriate funding to the participant’s plan, including ensuring that:

AT assessors assist the participant in specifying appropriate AT required to reach their goals
Specific AT items are included for delivery, assembly and training
An AT repairs budget
A consumables budget (for example, continence products)

e. the role of current state and territory programs in the assistive technology process EnableNSW was approached to work as a registered provider during the transition of the NDIS to facilitate a smooth transition and provide access to contract pricing and re-issue equipment while the NDIS developed it’s AT strategy. This assistance has been provided under an MOU in the pilot sites and then through Working Arrangements in full scheme.

Under the Working Arrangements

EnableNSW’s role includes:

Processing and co-ordinating requests for aids, equipment and equipment repairs
Providing advice regarding specific requests, including quality and safety to assist planners in applying ‘reasonable and necessary’ criteria

f. any other related matters

EnableNSW has provided individualised funding for AT for 10 years, processing approximately 75,000 requests for AT funding per annum including for equipment, repairs and consumable reorders Individualised AT funding requires discretionary case-by-case decision making supported by clinical or subject matter experts.

EnableNSW has a streamlined process for reviewing it applications, including:

Allied health staff with extensive clinical expertise in AT who train and support administrative staff
80% of requests/applications for funding are approved by administrative staff
Allied health staff also review administrative staff decisions and ensure high inter-rater reliability
Allied health staff directly approve the remaining 20% of high complexity requests and liaise with consumers and assessors regarding queries or appeals.

NSW Health operates a streamlined reconditioning, repair and re-use program that provides substantial efficiencies that extends the reach of the service to more people

NSW Health notes that savings of $161M per annum outlined in the NDIS AT Strategy will make an important contribution to Scheme sustainability. Efficiencies from tendering processes and equipment pools are estimated to contribute $121M per annum to this saving.

As EnableNSW has substantial experience in tendering, operating equipment pools, and running efficient recycling and re-use programs, those experiences may be of benefit when the NDIA is developing and implementing its AT strategy.

NSW Health continues to be willing to share the EnableNSW business expertise and intelligence about AT sourcing, approval and delivery with the NDIA.

NSW Government Submission Inquiry into Assistive Technology provision