Culture and Capability of the National

Disability Insurance Agency

Response to consultation

deceember 2022

Recipient: The Joint Standing Committee on the National Disability Insurance Agency

Dietitians Australia contact

Name: Dr Sayne Dalton, Senior Policy Officer
Address: A Level 3, 1 Bowes Pl, Phillip ACT 2606 |
Phone: T 02 6189 1200
Email: E info@dietitiansaustralia.org.au |
Website: W dietitiansaustralia.org.au

Dietitians Association of Australia | ABN 34 008 521 480 Dietitians Australia and the associated logo is a trademark of the Dietitians Association of Australia.

About Dietitians Australia

Dietitians Australia is the national association of the dietetic profession with over 8,500 members, and branches in each state and territory. Dietitians Australia is the leading voice in nutrition and dietetics and advocates for food and nutrition for healthier people and healthier communities. The Accredited Practising Dietitian (APD) program provides an assurance of safety and quality and is the foundation of self-regulation of the dietetic profession in Australia. APDs support people with disability to meet their food, fluid and nutrition requirements, to promote optimum health, social and economic participation.[1-6]

APDs are the only profession with the knowledge, skills and training to comprehensively assess the food and nutrition requirements of people with disability.

This submission was prepared by Dietitians Australia staff following the Conflict of Interest Management Policy and process approved by the Board of Dietitians Australia.

Dietitians Australia would like to comment on the following terms of reference a: the capability and culture of the National Disability Insurance Agency (NDIA), with reference to operational processes and procedures.

Key recommendations

-   Policy and procedures to be developed, using codesign principles, to improve access and
   planning of ‘reasonable and necessary’ nutrition and dietetic supports. Policy and procedures
   should ensure:

         1.  NDIS plans have sufficient hours and funding allocated for nutrition and dietetic
           supports, to enable NDIS participants to achieve their goals
        
          2.  APD clinical decisions, evidence and recommendations are accepted by NDIS planners
            and delegates. NDIS Planners and delegates should not have the authority to
           disregard the advice of APDs or other trained allied health professionals
          
          3.  Templates, guidelines and other forms of accessible information are developed
              regarding the types of evidence required to support access and planning of nutrition
             and dietetic supports. This should include an update to the NDIS website 'types of
                 disability evidence' to include reference to the role of APDs in food and nutrition
               assessment and diagnosis practices
          
          4. NDIA provide greater transparency regarding algorithms used to make access and
            planning decisions and the outcomes of these decisions, to enable reform of these

Culture and Capability of the National Disability Insurance Agency

Pathways and Planning Decisions

e. Where need has been identified, people with disability should not be referred to mainstream services, when there are none available

f. NDIS planners and delegates should be adequately skilled to engage with the person, their supports and APD services appropriately

g. There are processes and funding for case conferencing to support multidisciplinary care

Policy and procedures should be co-designed by the NDIA, people with disability, Dietitians Australia and other relevant stakeholders.

Education and Training

Education and training to be developed to guide NDIA planners and delegates on: a. what is ‘reasonable and necessary’ regarding inclusion of APDs and nutrition support products b. the role of food, fluids, nutrition and APD services in supporting people with disability to achieve their goals and participate in the community

Education should be developed with input from Dietitians Australia and APDs working in the NDIS environment.

Internal Review Process

A more streamlined internal review process is developed that enables timely adaptation of NDIS plans, including addition of nutrition and dietetic supports. The review process should be less stressful for NDIS participants

Information Provision

Information is provided to NDIA participants on the role of different allied health professionals and the role of food, fluids and APD services in addressing participant’s functional capacity, physical, mental, social and economic participation. This information should be developed with input from the relevant professions, peak bodies and people with disability

Data Monitoring and Evaluation Framework

The NDIA to work with relevant stakeholders to codesign a data monitoring and evaluation framework to better understand access, planning, funding and utilisation of dietetic and allied health supports and services. This framework should enable transparency regarding the operation, decision-making, funding and outcomes of NDIS processes in relation to dietetic and allied health services, as well as continuous system improvement

Discussion

The National Disability Insurance Agency (NDIA) play a critical role in implementing the NDIS and we commend the agency and its staff for the work that is done to support people with disability to access the supports and services they need. However, our members continue to report problems with the operation of the scheme including inconsistencies in decision-making of NDIA Planners and delegates. These issues lead to disruption of critical dietetic services and serious impacts on the health and wellbeing of people with disability.

Below is a summary of key issues reported by our members.

3.1 NDIS access and planning processes and procedures are ineffective at connecting

people with disability to ‘reasonable and necessary’ nutrition and dietetic supports and services

NDIS access and planning processes are ineffective at connecting people with disability to ‘reasonable and necessary’ nutrition and dietetic supports and services. Our members report that requests for the inclusion of APD services and nutrition supports are frequently rejected or under-funded, despite clear evidence that these services are ‘reasonable and necessary’.

We hear from members across the country that dietetic plans are often allocated approximately 10 hours, which is grossly insufficient to meet the complex needs of many people with disability.

Several reasons for this issue are outlined below

3.1.1 NDIS planners and delegates disregard APD clinical-decisions, evidence and recommendations

NDIS planners and delegates are gatekeepers to access of nutrition supports and APD services for people with disability and are frequently cited as causing barriers to access of timely nutrition and dietetic support.

“…I’m aware of the difficulty that those individuals may have in accessing good health care, in the sense that their access may be dependent on gatekeepers who are supporting them.” (Professor Julian Troller, Royal Commission hearing, 20/02/2020)

NDIS planners and delegates frequently disregard the evidence provided by APDs and dietetic advice regarding the number of hours required to support participant needs. It is often unclear how they arrive at their decisions regarding what is ‘reasonable and necessary’.

Culture and Capability of the National Disability Insurance Agency

This is concerning, given planners and delegates lack sufficient training in health, disability, clinical decision-making, trauma-informed care or the role of dietetic or allied health professionals.

The NDIA model of delegated decision-making results in a single point of decision-making authority, which is unfair to participants and overrides professional clinical judgement. It is also unfair to planners and delegates who bear the weight of responsibility to make decisions that impact the lives of people with disability, without adequate training.

   "…I work mainly with paediatrics in Melbourne…since we’ve had the introduction of the
    health-related disability supports I have seen minimal access, I haven’t had any plans come
   through with any form of inclusion lately. It’s the self-managed and plan-managed clients
    that have goals that relate to what we are working on and we’re working side-ways and we
   are still getting push back from a lot of planners…I have talked at length about how we are
   responding in letters and advocating back to planners and what we are putting in those early
   conversations… I’m just being consistently ignored." (Accredited Practising Dietitian,
    Dietitians Australia Disability Think Tank, 23/04/2020)

APDs use clinical reasoning to understand the client’s needs, diagnose food, fluid and nutrition problems (as they relate to the functional outcomes of clients) and make evidence-informed recommendations about services and supports. APDs consider a variety of factors when making c临ical decisions to inform an NDIS participant’s plan including the person’s goals and preferences, personal and medical information, information about body functions and structures and the person’s overall functioning within their environment.

Dietetic clinical reasoning is informed by formal training (at a minimum a 4 year university degree) and experiential knowledge gained through practice. Dietetics is a self-regulated profession, overseen by Dietitians Australia, and APDs must adhere to the Code of Conduct for dietitians and nutritionists, which provides assurance of safety and quality. As part of the APD program, dietitians are also required to participate in 30 hours of continuing professional development every year.

Lack of clear templates, guidelines and information regarding the types of evidence

required to support access and planning of nutrition and dietetic supports

There are no clear guidelines and templates regarding the types of evidence and information required to support access and planning, specifically for nutrition and dietetic supports. This results in dietitians providing extensive reports.

Internal NDIS processes and information on the NDIS website may lead to misinformation. For example, the website ‘Types of disability evidence’ lists treating health professionals considered

Culture and Capability of the National Disability Insurance Agency

‘most appropriate to provide the standardised assessments that are considered “best practice” in evidence’ but the website does not include reference to APDs, who play a role in assessing and diagnosing the relationship between food and nutrition issues and the functional outcomes of people with disability.

3.1.3 Dietetics seen as a ‘health’ issue

Despite implementation of disability related health supports on 1st October 2019, NDIS planners continue to reject requests for dietetics services, arguing that dietetics should be covered by the health system. This is highly problematic as there are minimal mainstream services equipped to support people with disability and many government-funded services were closed when the NDIS was implemented. There is also a lack of alternative funding sources for people to access the supports they need through mainstream services.

  “… they don’t actually get money for dietitians… still pushed back as it’s a health issue, not a
     disability issue. Even I write in the reports, this eating has absolutely everything to do with
     their disability, give them information sheets, often from the cerebral palsy or Down
  Syndrome or whatever about the health issues, feeding issues in that disability and they still
     just say ‘nup’. Now what I do is I even put in all my qualifications and extra work that I’ve
  done and experience and all that, saying I do know what I’m talking about, I’m not someone
  who doesn’t know what I’m talking about but then they ultimately have the ultimate decision
  and they’ve got no qualifications in the field and no experience in that field but they’re the
   ones making the decisions, it’s very frustrating.” (Accredited Practising Dietitian, Dietitians
    Australia Disability Think Tank, 23/04/2020)

3.1.4 Planners rarely engage with APD services and lack of funding for case conferencing

NDIS participants often require a multi-disciplinary approach throughout the access and planning process and when engaging supports. However, NDIS Planners rarely engage with APD services unless dietitians or NDIS participants push for these services. Dietetic services appear to be underutilised and there is a lack of understanding about the role of food, fluids and nutrition care in assisting participants to achieve their goals, and social and economic outcomes. There is also poor understanding of the role and value of APD services.

There are no formal processes or funding for case conferencing to support multidisciplinary care.

   “…hardly get anyone that’s agency managed, and as [dietitian] was saying most of the time
    they’re self-managed and the carer or the person will decide that they want to use the money

Culture and Capability of the National Disability Insurance Agency

for dietitian themselves” (Accredited Practising Dietitian, Dietitians Australia Disability Think Tank, 23/04/2020)

3.2 Education and training of NDIS Planners and delegates

Many of the issues with NDIS planners and delegates, stated above, stem from the lack of education and training provided regarding the role of food, fluids, nutrition and APD services in addressing the functional, social and economic outcomes of people with disability.

We are of the view that in addition to more robust access and planning policies and procedures, education should be developed for NDIS planners and delegates that covers:

what is ‘reasonable and necessary’ regarding inclusion of APDs and nutrition support products
the role of food, fluids, nutrition and APD services in supporting people with disability

Education should be developed with input from Dietitians Australia and APDs working in the NDIS environment.

3.3 Internal review processes and planning decisions

When an NDIS participant is dissatisfied with their NDIS plan, they must request an internal review of the planning decision. Issues with this process include:

NDIS participants are hesitant to request these reviews, due to well-documented instances of participants receiving less funding for APD services following review
Internal reviews are time consuming and do not guarantee that an NDIS plan will be rectified appropriately. Several members report internal review processing times of greater than three months, which is unacceptable for a person who requires access to services related to a fundamental physiological need

3.4 Information and resources for NDIS participants

It is common for an NDIS plan to include funding for allied health services, without guidance on which therapists might be suited to support the participant. We recommend that those tasked with implementing NDIS plans (e.g. NDIS participants, their families, and Support Coordinators) are provided with information about how their budgets can be spent and the role of each allied health profession. This information should be in an accessible format and developed with input from the relevant professions, peak bodies and people with disability.

Data monitoring and evaluation

There is minimal public data available to support monitoring and evaluation related to dietetic or allied health services in the NDIS. Codesign of a data monitoring and evaluation framework and appropriate data collection is essential to build a better understanding of the constraints in the system and to identify opportunities for improvement.

References

Tracy, J., Australians with Down syndrome: health matters. Australian family physician, 2011. 40(4): p. 202.
Ptomey, L.T. and W. Wittenbrook, Position of the Academy of Nutrition and Dietetics: Nutrition services for individuals with intellectual and developmental disabilities and special health care needs. Journal of the Academy of Nutrition and Dietetics, 2015. 115(4): p. 593- 608.
Firth, J., et al., The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. The Lancet Psychiatry, 2019. 6(8): p. 675-712.
Salomon, C. and J. Troller, A scoping review of causes and contributors to deaths of people with disability in Australia. Summary of recommendations. 2019, Department of Developmental Disability Neuropsychiatry, University of New South Wales.
Dietitians Association of Australia, Health professionals, psychosocial disability and the National Disability Insurance Scheme. 2018: Canberra.
Dietitians Association of Australia, National Disability Insurance Scheme Annual Price Review 2020-21. 2020.