Joint Standing Committee on the National Disability Insurance Scheme
PO Box 6100 Parliament House Canberra ACT 2600
16th December, 2022
Dear Committee Members,
The Australian Association of Psychologists incorporated (AAPi) appreciates the opportunity to provide commentary on the National Disability Insurance Agency’s capability and culture. To this end, we attach a copy of our submission made earlier this year to the Australian National Audit Office. We hope that this provides some insight into the issues that need to be addressed within the Agency.
In addition, AAPi is also very concerned about the level of training that planners and other NDIA staff have regarding disability, due to the level of decision making power that they have over plans and funded supports. We will provide further information about this to the Independent Review. We particularly stress the need for planners, who have never met participants they develop plans for, to trust the clinical decision making and opinion of Allied Health Practitioners. These practitioners have completed extensive education and training in assessing and treating clients with Disabilities and have an in-depth knowledge of the participants functioning and support needs.
AAPi represents psychologists traversing a wide range of areas of practice around the country, including working within the National Disability Insurance Scheme.
Sincerely,
Amanda Curran Chief Services Officer Australian Association of Psychologists Inc
Website www.aapi.org.au Postal Address 12-16 Parker Street Williamstown Vic 3016
AAPi Feedback Regarding the Effectiveness of the National
Disability Insurance Agency’s management of assistance with daily life supports - Australian National Audit Office (ANAO)
The Australian Association of Psychologists Incorporated
Thanks to ANAO
The Australian Association of Psychologists incorporated (AAPi) thanks the Australian National Audit Office (ANAO) for the opportunity to provide information and recommendations on the effectiveness of the National Disability Insurance Agency’s management of assistance with daily life supports.
AAPi represents psychologists traversing a wide range of areas of practice around the country, including working within the National Disability Insurance Scheme.
Sincerely,
Amanda Currun Chief Services Officer Australian Association of Psychologists Inc
Website www.aapi.org.au Postal Address: PO Box 107 North Melbourne, Vic 3015
Does the NDIA effectively support National Disability Insurance Scheme participants who require assistance with daily life?
Access
The quality and the effectiveness of the support received by participants depends on several factors such as the quality of the reports their treating practitioners have written, their own personal ability to navigate very complex systems to gain access to services and their ability to advocate or have a carer advocate for them.
Overall, the experience of our members who are psychologists working in the disability sector is that, for their clients, the process of applying for support, accessing support, and navigating the system can be traumatising and stressful and often exacerbates the impact of their disability on their life. The process itself can lead to trauma and feeling stuck for participants and this can result in providers needing to provide support to the participant to support them through the NDIS process rather than it increasing the support that is available.
The feedback we have received from participants is that there are too many people involved in the whole process - each step a ‘once-off’, with very intrusive and personal questions required to be answered. This is a large issue for those with psychosocial or neurodevelopmental disorders such as anxiety, Autism, ADHD, Intellectual Impairment etc who need time, reassurance, and gentle approaches to develop a relationship prior to personal disclosures.
Some of the restrictions on the evidence required for NDIS funding are making the application and review process more difficult than it needs to be. Accessing the right provider, to provide the right support and evidence is extremely difficult especially when providers are limited in many regions in Australia. With long wait lists to access psychologists throughout Australia, many miss out on services in their first plan due to these barriers. Upon review, this may appear that the participant does not need that level of funding to improve their functional capacity when it is simply an indication that adequate services were not accessible to the participant.
Telehealth options and internet coverage in rural, regional, and remote areas of Australia mean that not all providers are able to be accessed by telehealth and extremely long wait times are seen by participants for face-to-face services in these areas. We need to improve the workforce capacity to provide services in these regions by offering incentives, business support and utilising workforce retention strategies to retain the workforce that is available.
Getting the right assessment and evidence of disability for access or review can be incredibly challenging. When participants already have a plan in place this can be funded by the NDIS but where there is not a plan in place there are significant financial barriers to accessing this evidence. It often means providers making significant losses of income or potential participants giving up on accessing NDIS funding and support.
Funding Decisions
Decisions about funding levels depend on the Local Area Coordinator (LAC) who has completed the interview and the planner that is allocated. It is very common to see significant funding variations between almost identical participants (same disability, same functional deficits, same living situation). For example, a member provided an example of two very similar child clients where one receives $28,000 per year while the other receives $9,000 per year.
Oftentimes, allied health and specialist reports do not appear to be consulted at all in the decision-making. Some funding comes with decisions that go directly against the Act which leads to lengthy reviews or appeals to the Administrative Appeals Tribunal (AAT) and requires therapist support to assist the participant to self-advocate.
It is very difficult when the person who completes the interview is not the one who plans the funding or has any real concept of the individual’s disability due to not meeting the participant face to face or speaking with them at all. Inconsistent decision-making has resulted in clients missing out on what they need. Clients who cannot ask for their needs to be met due to their disability often miss out on services altogether or receive inadequate funding. It is common for accessibility needs to not be funded even when someone has access to the NDIS, but many cannot access support at all.
Plans that are developed are often too vague for participants to understand what they can and cannot do with their funding, leading to the underuse of funding and a resulting reduction in functional capacity due to insufficient support. There is often a great deal of misinformation given to participants from LACs about what they can use their funding for with the same result of underutilisation and reduced functional capacity. The information relayed by different parts of the system is contradictory and confusing. Interpretations from Planners, LACs, Support Coordinators, Plan Managers etc are all different so participants and providers are left very confused about the boundaries of what is acceptable and what is not.
Life-enriching equipment is often extremely difficult to get approved and purchased, with participants waiting for wheelchair upgrades, hospital-grade beds, communication supports, shower equipment or safe housing as examples, for extremely long periods of time.
Funding for Therapeutic Supports
There have been considerable issues with funding allocations for psychology providers under the NDIS with participants being told with increasing frequency that participants need to access Mental Health Treatment Plans and access 20 “free psychology sessions” before they can use their NDIS-provided funding to access psychologists. Sessions under a Mental Health Treatment Plan are not ‘free’. The Medicare system provides a rebate to the patient. Unfortunately, the rebate of $89.65 does not cover the cost of service – consider for example the NDIS Schedule Rate of $214.41. This means that in most cases the person will have a $124.76 out-of-pocket expense per session. Medicare specifies that “gaps between the rebate and the fee charged by the practitioner are not to be paid
Mental Health Treatment Plans
Mental Health Treatment Plans are for the treatment of specific psychological issues. Medicare specifically excludes diagnoses not related to one of the ICD 10 codes. Treatment for ‘Disability’ only without comorbid\psychopathology is specifically precluded. The Department of Health has directed that Mental Health Care Plans are for treating Mental Health Symptoms. NDIS therapy funding is to treat mental health symptoms that are part of the participant’s everyday life and result from the participant’s disability.
Medicare Limitations on Therapy Funding
- Treatment under Medicare is limited to 10 rebates per calendar year – this is inadequate for standard treatment, particularly with complex issues including disability. The client would be required to pay the full session fee and that is likely to impact uptake of treatment.
- Although clients can currently access up to 20 rebated sessions, sessions 11–20 cannot be provided in a home visiting capacity, there is currently no item number for this. Clients will have to use telehealth services or attend the clinic which removes choice and control over how they access services.
- There are additional restrictions on the type of therapies allowed through Medicare. Medicare restrictions on permitted therapies make the Medicare funding option inappropriate for some disabilities and the treatment goal of functional improvement.
- Assessment is specifically not permitted under a Mental Health Care Plan.
Does the NDIA effectively manage operational risks to the proper use
of resources in administering assistance with daily life supports?
There appears to be a considerable double-up in the administration of the scheme which creates the potential for significant errors when planners are not the ones getting firsthand information from participants during the planning and review stages. Often these planners are also unskilled in areas such as disability, mental health, and the impact of disability on mental health and well-being. Because of the lack of knowledge of planners in the nuance of disability and mental health, often participants are significantly underfunded or specifically not funded for the supports that they need, increasing their level of risk and vulnerability in the community. Participant safety and well-being should be predominant in decision-making.
A culture has been created such that reports from allied health practitioners are either ignored or to be effective, must be written in a specific format so that the language and information included within that report is framed in particular ways so that psychosocial disability or support for mental health is included in plans. These reports, when read by participants are distressing and do not acknowledge the strengths and abilities they have, as if this information is included, they will not be funded for reasonable and necessary supports.
The substitution of services for those the NDIA deem a cheaper therapy option is often inappropriate and causes potential risk for participants, particularly when substituting lower qualified supports such as support workers, therapy assistants or providers who are not deemed appropriate by those working with the participant. The recommendations made by current treatment providers should be accepted along with the preferences and expressed desires of the participants so that functional capacity can be improved. To make substitutions based on fiscal decision-making or “value for money” is not disability informed and as stated, increases the risk to the participant.