NDIA Accountability Project

Submission 175 — Australian Physiotherapy Association (APA) — Capability and Culture of the NDIA

‹ PrevPage 1 of 14 · Source p. 1Next ›

Joint Standing Committee on the National Disability Insurance Scheme

Submission by Australian Physiotherapy Association (APA)

December 2022

Executive Summary

Authorized by:

  • Anja Nikolic, Chief Executive Officer
  • Australian Physiotherapy Association
  • Level 1, 1175 Toorak Rd
  • Camberwell VIC 3124
  • Phone: (03) 9092 0888
  • Fax: (03) 9092 0899
  • www.australian.physio

Contents

1. Contents

2. Terms of Reference

3. Introduction

4. Preliminary comments

5. Summary of Recommendations

6. Background

7. Topic 1: Respect for physiotherapists’ clinical reasoning

8. Topic 2: Specific issues with assessments and reports for eligibility and planning

9. Topic 3: Engagement, consultation and transparency

10. Topic 4: NDIA’s workforce’s skills and capacity

11. Topic 5: Timeliness

12. Conclusion

13. About the Australian Physiotherapy Association (APA)

2. Terms of Reference

“The committee will inquire into and report on the implementation, performance, governance, administration and expenditure of the National Disability Insurance Scheme (NDIS), with particular reference to:

a. the capability and culture of the National Disability Insurance Agency (NDIA), with reference to operational processes and procedures, and nature of staff employment

b. the impacts of NDIA capability and culture on the experiences of people with disability and NDIS participants trying to access information, support and services from the Agency; and

c. any other relevant matters.”

Introduction

This document is the abridged version of the Australian Physiotherapy Association (APA)’s submission to the Joint Standing Committee (the Committee) on the National Disability Insurance Scheme (NDIS)’s consultation on the Capability and Culture of the National Disability Insurance Agency (NDIA).

The APA takes the opportunity to welcome the Committee’s reappointment and its new members.

APA members, as registered and unregistered providers, provide Therapy supports to NDIS participants. As such, they have a high degree of interaction with the National Disability Insurance Agency (NDIA). Our response to this consultation will be based on APA’s interactions with the NDIA as a peak body, as well as representing our members’ experience.

To prepare this submission we have surveyed our members belonging to our National Disability Advisory Group in October – November 2022. Quotes drawn from the survey responses were included in the submission.

It will come as no surprise to the Committee that the relationship between the APA and our members, and the NDIA has not always been optimal and we see significant room for improvement. Acknowledging the recent political reset, the renewal of the NDIA’s Board and leadership, and the recently launched NDIS Review, the present submission will focus on what our expectations are for the future.

The APA welcomes the opportunity to present further information to the Committee.

Summary of Recommendations

Overarching recommendation:

The NDIA adopts an attitude of trust and transparency in its dealings with physiotherapists and the APA, in a spirit of genuine, constructive and solutions-oriented relationship with one concern front and centre: the wellbeing of participants.

Recommendation 1:

The NDIA respects the clinical reasoning and expertise of physiotherapists, and always prioritises their judgement and advice over automated tools for decision making for eligibility and planning.

Recommendation 2:

If the NDIA chooses to use algorithmic and automated technologies to support eligibility and planning decisions:

  • participants and therapy support providers are made aware of the use of these tools;
  • participants and therapy support providers are involved in the design of any of these tools; and
  • the assumptions, parameters, and decision-making rationales are made publicly available to all interested parties.

Recommendation 3:

The NDIA:

  • implements the suggestions included in the table pages 9 to 11 of the present submission;
  • endeavours to provide clear and consistent guidelines and training programs to physiotherapists on the evidence they need to provide to the agency for eligibility and planning;
  • ensures that the guidelines are completely understood internally and disseminated across all NDIA staff consistently and in all states (including local area coordinators); and
  • adopts a policy of ‘first giving a call’ or contact by email a physiotherapist when needing clarification over evidence that was provided instead of ignoring or rejecting the evidence and the supports recommended. When relevant, and with the participant’s consent, physiotherapists could be invited to participate in planning meetings.

Recommendation 4:

The NDIA adopts a default position of trust and transparency, and engages in genuine and constructive relations with physiotherapists and the APA, to work together, with participants, towards achieving the best outcomes possible for participants and the Scheme as a whole.

Recommendation 5:

The NDIA endeavours to lead its consultation processes in a spirit of collaboration of all interested stakeholders by creating forums where everyone can engage with each other, at the same time: participants, allied health representatives, NDIA, Government, and other relevant stakeholders.

Recommendation 6

The NDIA:

  • works with therapy provider peak bodies to co-design information, education processes and content that are targeted and fit for purpose;
  • ensures that advisory groups have wide and diverse representation; and
  • contracts physiotherapists as paid consultants to provide advice on internal reviews, projects, guidelines – instead of contracting big generalist management consulting firms.

Recommendation 7

The NDIA, as a matter of emergency:

  • mandates a minimum level of education on disability and/or experience working with people with disability for all staff involved in eligibility and planning processes;
  • increases the number of new hires living with disability or having a lived experience of disability; and
  • provides continuous professional development and education to all staff, particularly on how therapy supports such as physiotherapy help participants achieve their goals.

Recommendation 8

The Commonwealth Government, Board and Management of the NIDA, each within the boundaries of their responsibility, provide the NDIA with the resources it needs to deliver on its mission, service participants, and work with therapy support providers in terms of:

  • workforce (number, qualification, training);
  • digital infrastructure;
  • internal policies and processes;
  • external technical and clinical support; and
  • any other needs.

Recommendation 9

The NDIA, in consultation with participants and therapy support providers,determines reasonable response times for its communications with participants and support providers beyond the timeframes set out for processes under the Participant Service Guarantee), puts the processes in place to respond within those times, monitors activity against those times, and publishes its performance results.

To assist with timeliness of response times, we recommend the NDIA opens a dedicated support provider point of contact (email and phone line), separate from the general enquiry ones.

The Committee will note that many of the above recommendations overlap with the Committees recommendations in their final reports into NDIS Planning and into Independent Assessments.

Background

Physiotherapy is a highly trained, Ahpra-regulated discipline with expert knowledge, skills and training in understanding how people move and learn to move, and the development of movement, specifically, as these relate to the health, wellbeing and quality of life of people of all ages. Physiotherapists are trained in the biomechanics of movement, combining knowledge of physics, physiology and anatomy to analyse movement and determine movement difficulties.

Physiotherapists are movement and participation experts in disability who provide expertise in improving function, participation and building capacity. Physiotherapists analyse an individual’s quality of movement, identify motor impairment, and investigate the interrelationship between movement and other neurological and physiological factors such as sensory perception, discomfort and pain.

Physiotherapists are committed to providing evidence-based, patient-centred, safe and high-quality supports to people with disability and contributing to an effective and equitable disability sector.

Physiotherapists promote social inclusion through optimising a person’s function and encouraging participation and inclusion in the economic and social life of the community.

Within the NDIS, a physiotherapist’s scope of practice is very broad. Physiotherapists work in multidisciplinary and transdisciplinary teams to support capacity building goals and the functional and participation outcomes for all their participants. In order to achieve participation outcomes, one of the pillars of NDIS’s insurance-based approach, these supports will often occur in natural environments such as homes, day care, work places and in the community. Often supports will require communication with both a participant’s family and their formal and informal supports. All this service provision occurs in addition to the face-to-face services that a participant receives.

Topic 1: Respect for Physiotherapists’ Clinical Reasoning

The APA is concerned about the use of algorithmic and automated technologies to make decisions that are clinical in nature and reduce human beings to a number of quantified parameters. We also have concerns around the lack of transparency of the modelling.

A participant’s physiotherapy support needs cannot be solely determined by a participant’s profile (age, disability and level of function). A physiotherapist’s clinical reasoning, based on their expertise and experience, will take into consideration a number of other factors such as the complexity of the participant’s disability(ies), and potentially other conditions, time, effort and assistance required to perform tasks, pain levels, their goals, their environment, their formal and informal support networks, and psychosocial factors.

It is our position that automatically determined plan averages and manual tweaks for individual circumstances cannot be a proxy for clinical reasoning to determine the type and volume of therapy supports a participants may need to achieve their goals.

Recommended reading:

Recommendation 1: The NDIA respects the clinical reasoning and expertise of physiotherapists, and always prioritises their judgement and advice over automated tools for decision making for eligibility and planning.

Recommendation 2: If the NDIA chooses to use algorithmic and automated technologies to support eligibility and planning decisions:

  a. Participants and therapy support providers are made aware of the use of these tools;
  b. Participants and therapy support providers are involved in the design of any of these tools; 
   and
  c. The assumptions, parameters, and decision-making rationales are made publicly available to all interested parties.

Topic 2: Specific issues with assessments and reports

for eligibility and planning

In the process of the Information Gathering for Access and Planning (IGAP) project, the APA has identified a number of practical and tangible issues related to how our members can support participants to access the Scheme and get the plans they need. This list has been communicated to the IGAP project team and suggests practical solutions to processes issues. Extracts are copied below:

Topic Issue Potential solutions

Fillable PDF forms provided by Forms are not compatible with PREFERRED: NDIA to work the NDIA (e.g. Early childhood clinic management software with major CMS providers to e – Provider report form) – (CMS). embed the forms they need interoperability with clinics’ All the data needs to be into their systems. systems. entered manually even when And / or NDIA to work to offer it’s readily available in the interoperability between CMS clinic’s systems. and NDIA online platform and NDIA online platform (export / import of data). (export / import of data)

Sharing of forms to be filled by Each Allied Health Online forms, or digital practitioners across different Professional (AHP) contributes versions that allow AHPs to businesses. to the same form, when it’s a lock the content they input fillable PDF, the AHP ‘loses before sharing with the next control’ of the content when person. the form is sent to the next practitioner.

Review of interim plans that are Currently, a focus is put on Provide support from support created for people with newly goals achievement and skills coordinators to new acquired disability. acquisition which creates a lot participants on how to of pressure on participants, navigate and use their interim and puts them in a position of plan. deficit at the time of preparing Remove obligation to succeed for the next plan. in the first plan. In the first few months after acquiring a disability and entering the scheme, a participant will have to learn how to live with their disability, learn how to navigate the

Topic

Issue

Potential solutions

scheme, learn how to use their supports.

Videos as evidence. A video footage can better explain how and why a participant would need and benefit from assistive technology or use of apps. NDIA to accept video footages as evidence submitted in assessments for planning purposes.

Objective measurement tools An appropriate tool that would cover the NDIA’s needs for assessment for eligibility and planning is not currently available. PAP to develop planning templates which include body, structure and function reporting mechanism which encompass the International Classification of Functioning, Disability and Health (ICF) framework. PAP to make recommendations / identify resources for AHPs that require training in the ICF. NDIA and NDIS QS Commission to provide AHP training modules on ICF

Use of the evidence provided to the NDIA – decision-making and planning. To provide better evidence to the NDIA for planning purposes AHPs would like to be sure that the evidence they provide will be understood, that they are providing the right level of details, and they would like to understand how the evidence will be used. The lack of clarity / guidance around the level of detail that needs to be provided to recommend supports. The lack of transparency over how the evidence and evidence and There is a lack of clarity / guidance around the level of detail that needs to be provided to recommend supports. There is lack of transparency over how the evidence and NDIA to have highly-skilled planning teams that will

Page 10

Topic

Issue

Potential solutions

| assessments provided by | AHPs are processed and analysed to produce the ‘average plan’ level, and what is taken into consideration to adapt the base plan to the personal circumstances of the participant. |

Physiotherapists report that the evidence they provide is often misunderstood and believe it’s often ignored. Eligibility is refused or supports rejected without explanation of the decision, and without the physiotherapist being contacted by the NDIA to clarify. Members tell us that often a simple phone call could have avoided an escalation to the Administrative Appeals Tribunal (AAT).

There seems to be a ‘goldilocks’ model report - not too long, not too short, not too detailed, not too vague, not too clinically specific, not too plain English – which physiotherapists are trying to achieve, without enough guidance from the NDIA. It also seems that there are variations in what is expected depending on the individual who receives the report. We don’t believe this is due to a human factor, rather we see the inconsistency as a symptom of the absence of a qualified and experienced workforce associated with a lack of strong policies and processes.

Recommendation 3: The NDIA:

  • implements the suggestions included in the table above;
  • endeavours to provide clear and consistent guidelines and training programs to physiotherapists on the evidence they need to provide to the agency for eligibility and planning;
  • ensures that the guidelines are completely understood internally and disseminated across all NDIA staff consistently and in all states (including local area coordinators); and
  • adopts a policy of ‘first giving a call’ or contact by email a physiotherapist when needing clarification over evidence that was provided instead of ignoring or rejecting the evidence and the supports recommended. When relevant, and with the participant’s consent, physiotherapists could be invited to participate in planning meetings.
  1. Topic 3: Engagement, consultation and transparency

Consultations, webinars, workshops

The APA and our members engage regularly with the NDIA in the context of consultations and information sessions via webinars, workshops or submissions.

Often the experience of this engagement is suboptimal

Issues include:

  • an experience of being ‘talked at’ with little room for conversations (often, when there’s a Q&A session it’s only for a few minutes after a lengthy slide presentation);
  • evidence provided is not trusted (this was clearly stated during the Pricing review);
  • peak bodies are brought in late in the process when there’s actually little room for input;
  • many hours of workshops (our members take time off work to be able to engage in those forums and don’t receive any remuneration for that work) with little evidence of outcomes;
  • little time to prepare with reading material being delivered late (less than one business day before a workshop);
  • at times, adversarial and undermining comments from NDIA facilitators; and
  • published outcomes from series of workshops being a watered-down version of the actual conversations that took place.

Information sharing

APA members report struggling to access the information they need from the NDIA across a number of topics. Whether it is information available on the website, in the NDIA’s documentation or via the newsletter, issues frequently reported are around: difficulty to find relevant information amongst the volume of information available / provided, inconsistency in the information available, inconsistency between the information available and what is communicated directly in one-on-one interactions, discrepancy between the information and ‘on-the-ground’ experience.

A siloed approach to stakeholder engagement

Our experience as a peak body is that the NDIA routinely adopts a very siloed approach to stakeholder engagement. Namely, it is extremely rare to be invited to a forum (e.g. workshop, webinar) at the same time as participants and participants’ representatives. In the rare occasions when participants and participants’ representatives are present, facilitators tend to contain them to a ‘witness’ position rather than active participants in the conversation.

Despite recent efforts towards co-design from the NDIA, there doesn’t seem to be much improvement in fostering proper collaboration between all relevant stakeholders.

Recommendation 4:

The NDIA adopts a default position of trust and transparency, and engages in genuine and constructive relations with physiotherapists and the APA, to work together, with participants, towards achieving the best outcomes possible for participants and the Scheme as a whole.

Recommendation 5:

The NDIA endeavours to lead its consultation processes in a spirit of collaboration of all interested stakeholders by creating forums where everyone can engage with each other, at the same time: participants, allied health representatives, NDIA, Government, and other relevant stakeholders.

Recommendation 6: The NDIA:

a. works with therapy provider peak bodies to co-design information, education processes and content that are targeted and fit for purpose; b. ensures that advisory groups have wide and diverse representation; and c. contracts physiotherapists as paid consultants to provide advice on internal reviews, projects, guidelines – instead of contracting generalist management consulting firms.

Topic 4: NDIA’s workforce’s skills and capacity

Workforce’s skills

As reported by many other allied health peak bodies which members provide therapy supports to participants, we too have numerous anecdotal accounts from our members that local area coordinators and planners (in their vast majority) have no to little knowledge of disability, therapy support provision, and how therapy supports help participants achieve their goals. APA members also report a lack of basic soft skills from participant-facing NDIA staff.

We see evidence provided by physiotherapists being disregarded or ignored – the evidence is not trusted and/or misunderstood. We also have accounts of planners engaging with participants to undermine the evidence provided by their trusted physiotherapist.

Workforce capacity and availability

In our interactions with the NDIA (including in the work recently undertaken in the Information Gathering for Access and Planning (IGAP) project) and as reported to the Joint Standing Committee by many stakeholders, we understand there is a lot of pressure on the NDIA workforce, especially in terms of workload and cost-saving objectives.

With over 500,000 participants and growing, delivering on the intent of the NDIS to deliver tailored supports to the needs of people with disability with participant’s choice and control at the centre requires that the workforce has the adequate level of skills and knowledge, capability and capacity, and that the right digital infrastructure and processes are in place. All of it seems to be dramatically lacking at the moment.

Recommendation 7: The NDIA, as a matter of emergency:

a. mandates a minimum level of education on disability and/or experience working with people with disability for all staff involved in eligibility and planning processes; b. increases the number of new hires living with disability or having a lived experience of disability; and

Topic 5: Timeliness

A symptom of the NDIA’s shortage of resources is the lack of timeliness in addressing queries and communications from participants and service providers.

For the APA, this can be illustrated by our formal request for research data on funding spent on physiotherapy dedicated price items. We have documented the details of the process in our submission to the Committee’s consultation on the Current Scheme Implementation and Forecasting for the National Disability Insurance Scheme (NDIS) (Final report) dated February 2022. Our request for data was initially submitted in June 2021 – with the view that we could use the findings to contribute to the pricing review - and we received the data in April 2022 (after multiple follow-ups).

Another example is around follow-up questions the APA sent after an industry information session regarding changing to mid-cost assistive technology. We sent our questions in writing on 24 March 2022 (the day after the webinar was held), we received a response to the questions (which requested further guidance on how to implement the changes) on 4 October 2022. On both occasions the teams apologised for the delay.

Recommendation 9: The NDIA, in consultation with participants and therapy support providers, determines reasonable response times for its communications with participants and support providers (beyond the timeframes set out for processes under the Participant Service Guarantee), puts the processes in place to respond within those times, monitors activity against those times, and publishes its performance results.

To assist with timeliness of response times, we recommend the NDIA opens a dedicated support provider point of contact (email and phone line), separate from the general enquiry ones.

At a later date, when the NDIA is properly resourced, we recommend a review of the timeframes set out under the Participant Service Guarantee to check that those timeframes remind fit for purpose.

12. Conclusion

If we had one recommendation for the NDIA moving forward, it is to adopt an attitude of trust and transparency in its dealings with physiotherapists and the APA, in a spirit of genuine, constructive and solutions-oriented relationship with one concern front and centre: the wellbeing of participants.

13. About the Australian Physiotherapy Association (APA)

The APA vision is that all Australians will have access to quality physiotherapy, when and where required, to optimise health and wellbeing, and that the community recognises the benefit of choosing physiotherapy.

The APA is the peak body representing the interests of Australian physiotherapists and their patients. It is a national organisation with state and territory branches and specialty subgroups. The APA represents more than 31,000 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.