Submission by the
Australian Physiotherapy Association
September 2018
Authorised by:
- Phil Calvert
- National President
- Australian Physiotherapy Association
- Level 1, 1175 Toorak Rd
- Camberwell VIC 3124
- Phone: (03) 9092 0888
- Fax: (03) 9092 0899
- www.physiotherapy.asn.au
Introduction
The use of physiotherapy by people with disability
Addressing timely equipment provision
Meeting demand for assistive technology equipment
Whether market based issues impact the accessibility, timeliness, diversity and availability of assistive technology
Trials of equipment by participants
Cost, price and value
The role of the NDIA in approving equipment requests
Equipment maintenance, repair and replacement
A consistent approach to assistive technology decision making
The role of current state and territory programs in the assistive technology process
Looking to the Victorian State-wide Equipment Program
Looking to other state programs
Whether the regulatory frameworks governing assistive technology are fit-for-purpose
Any other related matters
A participant-held view of their supports
Conclusion
Executive Summary
The Australian Physiotherapy Association (APA) welcomes this opportunity to make a submission on assistive technology (AT) to the Joint Standing Committee on the National Disability Insurance Scheme (the Committee) on behalf of the physiotherapy profession.
We recognise that one challenge facing modern disability services is how to ensure that quality services, including access to assistive technology (AT), are available to all Australians. We also recognise that under the National Disability Insurance Scheme (NDIS), demand for AT resources will increase, and it is important people are provided the most appropriate and high quality AT regardless of where they live and the nature of their disability.
Our members recognise that this Inquiry into AT occurs during a period of substantial change as the Scheme is rolled out nationally.
A number of the recommendations we make in our submission aim to ensure that the centrality of personal decision-making is enshrined, and appropriately balanced with a number of other legitimate issues, including the overall costs to the community.
To achieve timely equipment provision, attention must be paid to a number of precursors. Timely and high-value equipment provision requires the application of a model of ‘modern regulation’ derived from which sophisticated choices are made about the focus and degree of regulation. It requires: - a responsive market - a ‘smart’ authorising environment - streamlined administration, and - prompt monitoring and feedback loops that lead to improvements in both the authorisation and administration.
We recommend that the Committee explore ways in which AT prescription, distribution, use and obsolescence can be monitored to ensure participant demand is met.
There are a number of market-based issues that have an adverse impact on the timeliness, diversity and availability of assistive technology. Our submission focuses on two of these – the problems associated with trials of equipment by participants and the issue of value.
We recommend that the Committee explore mechanisms that would balance the needs of participants, prescribers and vendors in ensuring that equipment can be trialled.
We are concerned by ongoing reports that participants are making choices based on price, rather than value and recommend that the Committee consider ways to ensure that the level of NDIS funding provided to participants is based on the provision of safe, high quality and high value AT.
Physiotherapists, who are expert in the prescription of equipment in a wide range of circumstances because of their existing scope of practice, need to be supported through a range of delegations from the National Disability Insurance Agency (NDIA).
In line with contemporary views of cost-effective regulation
we recommend that the Committee explore mechanisms that would explicitly delegate roles in equipment (including assistive technology) prescription to physiotherapists.
Our members comment that there is inconsistent communication and uncertainty around AT requests. Thus, we recommend that the Committee explore mechanisms that have explicit, risk- based caps on the length of time that the NDIA has to make decisions, and allows participants alternative pathways to access assistive technology where the caps are unmet.
Because of its impact on the outcomes sought by participants in the NDIS, inadequate access to funding and other resources needed for the maintenance, repair and replacement of equipment/technology is a concern of our members. Where funding for maintenance, repair and replacement has not been set up in the plan, there are long delays resulting in participants using unsafe equipment. Although the case was not about equipment repair, the risks of the use of inappropriate equipment were highlighted in the inquest into the death of Melissa Standen.
We recommend that the Committee explore mechanisms that would require participant plans involving equipment, including assistive technologies, to explicitly cover the funding and other requirements for equipment/technology maintenance, repair and replacement.
We are concerned around the consistency of decision making, with AT choice made on what appears to be an ad hoc basis. One of our members commented that:
‘Decisions and wait times appear to be inconsistent and do not follow any clear pattern (or documented process) around cost of equipment, needs, outcomes or risks to the participant. There appears to be no business rules for when applications will be responded to (approved / declined). There appears to be no published risk matrix or clear information available around how to request an urgent application where health or safety risks are imminent’
We recommend that the Committee explore mechanisms that ensure that the NDIA adheres to consistent and transparent decision-making about assistive technology which includes both the participant and any prescriber.
Our members believe that there are sound precedents for the administration of equipment schemes and the reissue of some equipment. As a result, we recommend that the Committee explore mechanisms that would facilitate incentives for the reissue of suitable equipment, following its obsolescence, to another participant.
If AT is to be a central support for participants, their families and friends, then it needs to be at a ‘higher level’ – that of planning and management of their circumstances, not only instrumental in their day-to-day activities. Thus we recommend that the Committee consider ways that the NDIS will support a nationally consistent information and communications technology environment that facilitates ‘whole-of-life’ management from the participant.
We would welcome the opportunity to meet with the Joint Standing Committee on the National Disability Insurance Scheme on behalf of the physiotherapy profession. We have provided a summary of our recommendations at the end of our submission.
Introduction
The Australian Physiotherapy Association (APA) welcomes this opportunity to make a submission on AT to the Joint Standing Committee on the National Disability Insurance Scheme (the Committee) on behalf of the physiotherapy profession.
Disability reflects the interaction between the features of a person’s body (like cerebral palsy, Down syndrome or depression) and the features of society (like negative attitudes, inaccessible transportation and public buildings, and limited social supports).1 In common with the rest of the population, people with disability may have other risk factors such as smoking, high body mass, physical inactivity, poor nutrition and substance abuse.2 These elements interact, collectively creating disability and other negative outcomes for the individual.3
High-quality AT prescribed by a physiotherapist provided to people with disability has the potential to improve a person’s social, emotional and physical wellbeing and participation. It is important these gains are acknowledged, and NDIS funding resources are enhanced to support the adoption of high-value community-based options, including AT.
As a result, one challenge facing modern disability services is how to ensure that quality services, including access to assistive technology (AT), are available to all Australians.
We also recognise that under the National Disability Insurance Scheme (NDIS), demand for AT resources will increase, and it is important people are provided the most appropriate and high quality AT regardless of where they live and the nature of their disability.
Our members recognise that this Inquiry into AT occurs during a period of substantial change as the Scheme is rolled out nationally.
We support the Scheme taking a person-centred approach to care and support. Taking this approach requires the Scheme to find and fund ways that assure that NDIS participants can plan and manage their own care (including AT); and that this can do this with the support of family and friends, or formal systems where appropriate.
A number of the recommendations we make in our submission aim to ensure that the centrality of personal decision-making is enshrined, and appropriately balanced with a number of other legitimate issues, including the overall costs to the community.
2. The use of physiotherapy by people with disability
We appreciate that negative imagery and language, stereotypes, and stigma persist for people with disabilities.4 Raising awareness and challenging negative attitudes are often first steps towards creating more accessible environments for people with disabilities. As a profession, and as individual professionals, we are committed to reducing barriers to participation and inclusion that people with disability may experience.
Physiotherapy can play a substantial role in keeping people well in addition to maximising their participation in social and economic life.
Addressing timely equipment provision
We understand that the NDIA national roll-out is still underway.
Nonetheless, our members have voiced concerns about whether the NDIA is sufficiently prepared for the roll-out, as participants experience significant delays in accessing AT.
One physiotherapist recently said:
‘In the transition process, there have been long wait times for prescription and supply [of AT] as\nThe suppliers are inundated. We had children waiting 18 months for new manual wheelchairs.\nChildren have lost function (physical and social) and independence by not having access to\nstanding frames and walkers that fit them or having orthoses that cause pressure areas, resulting\nin them being unable to do standing, walking or stand transfers. This function has been difficult\nto regain.’
Another member highlighted:
‘…working in the public health sector, I have seen significant and unacceptable delays in the\nprovision of ankle-foot orthoses (AFOs) for paediatric patients who require these to enable them\nto stand and weight bear from an appropriate age. A family had an initial meeting with the NDIA’
Page 7
In October 2017, and did not receive their package until June 2018. To allow for quoting, casting, making, it was quite some time before finally fitting the child with the appropriate AT.’
Both long wait times, and uncertainty around how and when AT will be available, is challenging for NDIA participants, their carer’s and physiotherapists.
Of more concern for our members – because of its potential to impact on the lives of participants in the NDIS, their families and friends – is the perceived inability of the NDIA to be ‘agile’ and ‘nimble’. Our members foresee a demand for ongoing change in the NDIA as it responds to the challenges of changing participant expectations, technologies and social circumstances; and are concerned that the NDIA has been unable to achieve the creation of a stable ’backbone’ that delegates decision- making as close to the participant as possible and has streamlined processes, with the dynamism required to respond to change.5
To achieve timely equipment provision, attention must be paid to a number of precursors. Timely and high-value equipment provision requires the application of a model of ‘modern regulation’ under which sophisticated choices are made about the focus and degree of regulation.
It requires: - a responsive market - a ‘smart’ authorising environment - streamlined administration, and - prompt monitoring and feedback loops that lead to improvements in both the authorisation and administration.
Our submission covers issues pertaining to the market in section 5 – Whether market based issues impact the accessibility, timeliness, diversity and availability of assistive technology. Our submission addresses the issues surrounding the authorising environment in section 6 – The role of the NDIA in approving equipment requests; and it addresses the matters concerning administration of the process in section 7 – A consistent approach to assistive technology decision making.
We note that issues of monitoring and feedback are implicit, rather than explicit, in the issues raised for the Inquiry and address the matter of monitoring and feedback in section 4 – meeting demand for assistive technology equipment.
4. Meeting demand for assistive technology equipment
We have limited information on the estimated demand for equipment in each jurisdiction across Australia due to a wide variety in previous AT provision and the gradual roll out of the NDIA nationally. Due to historical underservicing, we anticipate there is an increased need for equipment, especially in a participant’s first and second plans where new or emerging opportunities for AT may be identified. As a result, it is likely that the true demand for equipment is yet to be realised nationally, as new participants join the NDIA across Australia.
However, we are aware that there is a large unmet need for equipment in Victoria, particularly for adults, due to the previous limitations on funding and gap funding requirements. We are also aware of an equipment shortage in the ACT. As a result, our members report that it is likely that shortages also exist in other jurisdictions.
Whether market based issues impact the accessibility,
timeliness, diversity and availability of assistive technology
There are a number of market-based issues that have an adverse impact on the timeliness, diversity and availability of assistive technology. This section of our submission focuses on two of these – the problems associated with trials of equipment by participants and the issue of value.
Trials of equipment by participants The nature of matching the ways that participants’ outcomes will be met with the available AT is such that trials of equipment can be a necessary part of the process. Despite this, our members report increasing difficulty in ensuring appropriate trials of equipment by participants.
In Victoria, we are aware of NDIA participants who are required to trial multiple pieces of equipment, placing both suppliers and physiotherapists under pressure.
We understand that AT suppliers are starting to charge participants for trials of equipment. Where this occurs, suppliers need to facilitate adequate time for the testing. One of our members commented that:
‘Equipment is being ordered by agencies without adequate trial time being provided, resulting in
issues such as not fitting through doorways and transfer difficulties.’
We appreciate that trials of equipment can be challenging for AT providers (as well as for participants and the professionals supporting them).
A set of nationally agreed expectations, and a self-regulated code of conduct may assist to ensure that trials occur.
Cost, price and value
We are consistently told by physiotherapists that the NDIS model precludes physiotherapists from funding activities that will provide the best long term outcome (best value) for an NDS participant. While the NDIS model of consumer choice and control is a valuable attribute, at times we receive reports of participants choosing the cheapest care, rather than what may be most appropriate. In a market-based model, such as that pursued by the NDIA, this suggests that it is quite important for the NDIA to support the provision of information about matters in addition to cost and price – for the NDIA to deliberately facilitate the provision of information about the value derived by participants from wise choices in the market.
Recommendation 3:
We recommend that the Joint Standing Committee on the National Disability Insurance Scheme consider ways to ensure that the level of NDIS funding provided to participants is based on the provision of safe, high quality and high value assistive technologies.
- The role of the NDIA in approving equipment requests
It is our position that there needs to be a substantive reconsideration of the role of the NDIA in approving equipment requests.
Physiotherapists, who are experts in the prescription of equipment in a wide range of circumstances because of their existing scope of practice, need to be supported through a range of delegations from the NDIA.
As the professional association for the physiotherapy profession, the APA would be very happy to work with the NDIA on the development of templates that balance the need for sufficient rigour to meet the fiduciary obligations of the NDIA and yet are useful to participants and physiotherapists during planning. As a member commented:
(What happens when) a child needs an AFO (decided by me in consultation with his family and rehab physician)? This is an accepted contemporary approach with no real alternatives for this case. But I find that I have to justify it and suggest possible alternatives, often without really knowing how, apart from saying – “because it is accepted international best practice”
In a scheme that aims to optimise self-management, the role of approving equipment provision by the NDIA needs to ‘residual’ and tightly focused on decisions concerning high cost equipment of where other substantial complexities arise.6 For example, a clear professional regulatory strategy needs to be articulated, in which equipment of certain characteristics (eg, type and cost) can be prescribed by professionals (eg, physiotherapists) in the same way that other therapeutic supports are; and without further intervention (other than by exception). Physiotherapists providing supports to people with disability have a range of capabilities in equipment prescription and the current system is, in effect, doubling the administrative costs by imposing a second and unnecessary layer of approval.
One of our members indicated that:
… we hear examples of … children … being declined approval for a standing frame (when it is a very well supported piece of equipment for certain cohorts), and the reason for the decline was that someone employed in an approver capacity in the NDIS (with no clinical therapy
Recommendation 4
We recommend that the Standing Committee on the National Disability Insurance Scheme explore mechanisms that would explicitly delegate roles in equipment (including assistive technology) prescription to physiotherapists.
Should the NDIA decide to intervene and not approve equipment provision, then in the interests of natural justice, the NDIA would need to provide a timely (ie, within a prescribed time limit) and expert justification for that refusal – recognising that the choice to prescribe has already been based on expert judgment.
Our Members comment that there is inconsistent communication and uncertainty around AT requests. As a result, the NDIA would need to ensure consistent information is provided. To mitigate these concerns, the NDIA would need to develop more certainty around timeframes for the provision of AT. Participants need a system that is robust, predictable and able to function effectively despite increasing demand.
Recommendation 5
We recommend that the Standing Committee on the National Disability Insurance Scheme explore mechanisms that has explicit, risk-based caps on the length of time that the National Disability Insurance Agency has to make decisions, and allows participants alternative pathways to access assistive technology where the caps are unmet.
Equipment maintenance, repair and replacement Because of its impact on the outcomes sought by participants in the NDIS, inadequate access to funding and other resources needed for the maintenance, repair and replacement of equipment/technology is a concern of our members.
Where funding for maintenance, repair and replacement has not been set up in the plan, there are long delays resulting in participants using unsafe equipment. Although the case was not about equipment repair, the risks of the use of inappropriate equipment were highlighted in the inquest into the death of Melissa Standen.7
Our members report:
“Multiple children have been unable to use their PWC due to batteries dying. This takes away
their independence and mobility. There is significant (>6months) wait time to even hear back
from LAC’s as to whether they will approve the new battery, let alone order it and get it
installed.”
“One girl with spastic quadriplegia has not had her own wheelchair (manual OR power) for 2
years now. She is independent in using a PWC. The loan chairs have not been adequate for her
postural requirements. She is unable to get transport to school on the school bus as she has no
appropriate wheelchair.”
Plans need to have financial provisions for repair and explicitly account for equipment obsolescence. Arguably, this creates a situation where the time horizon for plans needs to be more than a simple,
‘annual’ approach and include explicit consideration of future years. Where the NDIA chooses to intervene, it needs to adhere to rigorous, risk-related deadlines for decisions. Currently, there are long wait times to find out whether NDIS will fund repairs or new equipment
A model that includes clear and consistent correspondence with physiotherapists, participants and their carers will reduce participant and provider uncertainty and allow for functional and restorative improvement for participants, enhancing choice and control.
I have had a refusal relayed from a staff member in my organisation, where she was told that the
evidence given was very medical and so should be supplied by the Health sector.
When I sent off an AT application emphasizing social inclusion through standing, I was asked for
more evidence of the benefits.
It is a very frustrating situation. There is clinical evidence for paediatric supported standing
emphasizing the positive effects on bone mineral density, hip stability, range of motion of hip,
knee and ankle and spasticity.
Anecdotally standing frames also maintain standing transfer ability which greatly reduces the
burden on carers and in young children with developmental delay or low muscle tone under 2
years of age (unable to stand independently), it allows them to have the standing practice that
(anecdotally) can often lead to independent standing and walking.
Recommendation 6: We recommend that the Standing Committee on the National Disability Insurance Scheme explore mechanisms that would require participant plans involving equipment, including assistive technologies, to explicitly cover the funding and other requirements for equipment/technology maintenance, repair and replacement.
- A consistent approach to assistive technology decision making
We are concerned about the perceived inconsistency of decision making, with AT choice made on what appears to be an ad hoc basis, with a Member commenting:
‘Decisions and wait times appear to be inconsistent and do not follow any clear pattern (or
documented process) around cost of equipment, needs, outcomes or risks to the participant.
There appears to be no business rules for when applications will be responded to (approved /
declined). There appears to be no published risk matrix or clear information available around how
to request an urgent application where health or safety risks are imminent’.
AT provision (especially equipment), requires the NDIA to have a readily accessible flow-chart about the authorising environment (eg, who makes decisions and how, how to factor in servicing and repair; and provisions for growth adjustments into the participant’s plan) the administration (eg, how much documentation is required about the time needed for trials; fitting and instructions about ongoing maintenance) the monitoring (eg, what needs to be reported following provision of equipment, and when it needs to be reported).
We believe, when equipment is approved by the NDIA in a way that is different to the assessed script / quote (eg, some parts of prescription not funded) this should be discussed with prescribing therapist or documented in writing before time of order. This will allow safety issues and possible
Page 12
need for re-assessment / re-trial to be met. Additionally, clear and consistent communication will enhance service efficiency for providers and the NDIA.
We believe it is important that AT applications are considered in a consistent manner by staff who are highly trained in the field.
‘I have been refused an AT and was told that the evidence given was very medical and so should
be supplied by the Health sector. When I sent off an AT application for a standing frame
emphasising social inclusion through standing, I was asked for more evidence of the benefits.’
Recommendation 7:
We recommend that the Standing Committee on the National Disability Insurance Scheme explore mechanisms that ensure that the National Disability Insurance Agency adheres to consistent and transparent in decision-making about assistive technology which includes both the participant and any prescriber.
- The role of current state and territory programs in the assistive technology process
Looking to the Victorian State-wide Equipment Program To the degree that assistive technology decisions remain the remit of the NDIA, our members advise that it would be useful for the NDIA to review that successes of the Victorian process administered by the State-wide Equipment Program (SWEP) in Victoria. This is because: - contact procedures are clear, staff are easy to talk to on the phone (no extended waits) and clear information and communications are provided by SWEP regularly - the application process is similar to previous equipment prescription in Victoria (through a SWEP portal and information completed online so this is familiar to previous prescribers) - the SWEP holds historical files / records around previous equipment prescribed and repair history (for which is often hard for the participants to provide exact details; but very useful when new therapists working with participants want to get a replacement piece of equipment - there is a credentialing process in place and all prescribers must be registered and credentialed (levels based on experience) - the SWEP has clinical advisors that will assist prescribers review clinical reasoning on application for prescribers who do not have the required credentials for a particular piece of equipment.
We understand that Victoria has an excellent and well established re-issue system and pool of equipment with an excellent, well maintained database for re-issue. This is easy to use and provides great solutions for people with disabilities. It is a very cost effective way for this equipment that is still in working order but not able to be used for another person.
Recommendation 8:
We recommend that the Standing Committee on the National Disability Insurance Scheme explore mechanisms that would facilitate incentives for the reissue of suitable equipment, following its obsolescence, to another participant.
12 of 15
Looking to other state programs
As with a wide range of other NDIS matters, consideration needs to be given to the staff capacity/volume and capability/skill where the state/territory governments run programs at the intersection of the role of the NDIS.
As one of our members has commented“ It makes a huge difference for school therapy staff to be involved, and teachers too at times. They are hoisting children in and out of chairs multiple times per day, supporting posture and safety, and can contribute to understanding the child’s positioning when they are fresh and alert, or tired and agitated. NDIS prescribers are usually happy to collaborate with school therapy staff. It also depends largely on the parent communicating about the involvement of school therapy staff to NDIS therapists.
Another commented: Significant feedback is received that although school-based therapists are attempting to collaborate with families and prescribing therapists, suboptimal AT is being prescribed.
- Whether the regulatory frameworks governing assistive technology are fit-for-purpose
Our submission, overall, argues that the current regulatory frameworks are not fit-for-purpose and need to be substantively reviewed.
- Any other related matters
Because we take a ‘modern regulation’ approach in which the external regulator has a residual role, we take the view that the NDIA needs to consider the role it takes in surveillance of harms related to the use of AT.
Although we take the view that the rate and impact of AT-related harms is likely to be low, we believe that it would be useful for there to be a national strategy for reporting, monitoring, analysing and providing timely feedback on AT-/equipment-related harms.
A participant-held view of their supports Our members continue to express the view that the NDIS needs to increase its focus on facilitating participants gaining a ‘whole of environment’ view of their involvement with the NDIS.
Our members are keen to participate in information and communications technology architecture that provides participants with a real-time overview of their: - goals and goal attainment - past, present and future involvement with the NDIS - funding (available and already utilised) - services (both those being used and those contemplated).
Our members are keen to support a mechanism that providers participants with strategies to create appointments for services and pay for them through a single portal. 13 of 15
Recommendation
If AT is to be a central support for participants, their families and friends, then it needs to be at a ‘higher level’ – that of planning and management of their circumstances, not only instrumental in their day-to-day activities.
Recommendation 9:
We recommend that the Joint Standing Committee on the National Disability Insurance Scheme consider ways that the NDIS will support a nationally consistent information and communications technology environment that facilitates ‘whole-of-life’ management from the participant.
11. Conclusion
We are committed to ensuring people with disability in Australia have access to appropriate AT, when and where it is needed.
We would welcome the opportunity to provide evidence to the Committee and to work with the Committee and other stakeholders on the reforms that emerge.
Australian Physiotherapy Association The APA is the peak body representing the interests of Australian physiotherapists and their people they support and assist.
It is a national organisation with state and territory branches and specialty subgroups. The APA represents more than 26,000 members who conduct more than 23 million consultations each year.
The APA corporate structure is one of a company limited by guarantee. The APA is governed by a Board of Directors elected by representatives of all stakeholder groups within the Association.
14 of 15
References
1 Leonardi M et al. MHADIE Consortium The definition of disability: what is in a name? Lancet, 2006,368:1219- 1221. doi:10.1016/S0140-6736(06)69498-1 PMID:17027711 in WHO World report on disability 2011 p4
2 http://www.healthinfonet.ecu.edu.au/related-issues/disability/reviews/disability-within-the-indigenous-community accessed 7.01.2016
3 http://www.who.int/topics/disabilities/en/ accessed 6.01.2016
4 Ingstad B, Whyte SR, eds. Disability and culture. Berkley, University of California Press, 1995; Yazbeck M, McVilly K, Parmenter TR. Attitudes towards people with intellectual disabilities: an Australian perspective. Journal of Disability Policy Studies, 2004,15:97-111. doi:10.1177/10442073040150020401; People with disabilities in India: from commitments to outcomes. Washington, World Bank, 2009 in WHO World report on disability 2011 p6
5 Aghina W De Smet A Weerda K. Agility: It rhymes with stability. McKinsey Quarterly. December 2015. http://www.mckinsey.com/business-functions/organization/our-insights/agility-it-rhymes-with-stability (Accessed 1 September 2017)
6 Smith E Reeves R. Papering over the cracks? Rules, regulation and real trust. The Work Foundation. London. 2006.
7 http://www.coroners.justice.nsw.gov.au/Documents/STANDEN%20Melissa.pdf