Submission to Joint Standing Committee on the NDIS: NDIA Capability & Culture Inquiry
Oct 2022
What does the approach to functional capacity assessment say about the NDIA’s Capability and Culture?
Allied is a group of allied health professionals committed to working towards more equitable health and disability services. We welcome the opportunity to contribute to the Joint Standing Committee (JSC) on the NDIS – NDIA Capability and Culture, October 2022.
The assessment of functional capacity is a critical element of the NDIS. The NDIA’s approach to functional capacity assessment provides an insight into the capability and culture of the NDIA. The approach indicates a culture centred around a tension between cost-containment based on an NDIS financial unsustainability narrative, and funding of reasonable and necessary supports for participants. Based on this financial unsustainability narrative, the NDIS has become a system reliant on automated decision making (e.g. Typical Support Packages), with a culture of disregard for building the skill of the NDIA workforce; and a disregard for co-designed and evidence-based approaches. The processes relating to Typical Support Packages (TSPs) creates systemic incentives for planners to fund plans within TSPs rather than complying with the NDIS legislation to fund reasonable and necessary supports.
Meanwhile, the absence of a fit-for-purpose functional assessment process; alongside an ongoing systemic bias inherent in the allocation of Typical Support Packages based on primary disability, continue to create inequitable support and preventable risks for people with disability. This leads to a cascade of negative outcomes for participants - including inappropriately funded plans, and the flood of participants taking their cases to the Administrative Affairs Tribunal (AAT).
However, the NDIA’s commitment to the co-design of improvements to the National Disability Insurance Scheme, including the work related to Information Gathering for Access and Planning (IGAP) provides an opportunity for positive change. It is anticipated that cultural change and capability building within the NDIA will require sustained co-design initiatives with people with lived experience of disability, their families and supports.
Submission to Joint Standing Committee on the NDIS: NDIA Capability & Culture Inquiry
Oct 2022
Functional Capacity Assessment
The assessment of functional capacity is an essential component of the NDIS. It forms the basis of access to the Scheme, and has the potential to enable equitable allocation of support and funding. It also provides a window into the values and drivers of the NDIA. During 2021, following piloting of ‘Independent Assessments’, this Joint Standing Committee commenced a Parliamentary Inquiry into Independent Assessment. This work was summarized in a report, which again highlighted the fundamental importance of appropriate assessment of functional capacity to the allocation of supports to NDIS participants. As the Committee noted, a key reason given for the introduction of independent assessments was to address the financial suitability of the NDIS [1]. This indicates that a lens of ‘financial sustainability’ is prioritised within the NDIA.
The Committee recommended that functional assessment be completed by allied health professionals with appropriate credentials, and that functional assessment be co-designed in collaboration with people with disability and their representatives, and the disability sector. The Committee further cautioned against assessment processes that may disadvantage cohorts of people within the Scheme, and the need to tailor assessment processes. It proposed alternative approaches, including a bulk-billed Medicare model of assessment to ensure impartiality of assessment. It further recommended “The National Disability Insurance Agency implement specific, targeted strategies to ensure that particular cohorts are not disadvantaged by such a process”.
To date, co-design principles have not been applied to the development of a fit-for-purpose functional assessment or to review the TSP process. A co-designed, person-centred model of functional capacity assessment and support need identification, have potential to enhance preventative safeguards, particularly when implemented alongside a model for supported decision making for those who need it.
In recent weeks, there has been a new, quick-fix, reductionist, tick-and-flick functional capacity assessment template published by the NDIA, titled Hospital Discharge Functional Capacity Assessment template, to public health systems and hospitals in at least three States. Yet again, we have an assessment that has not been co-designed, is not evidence-based, not comprehensive enough to fully assess the functional domains as per the NDIS Act (2013) - and ultimately likely to provide inaccurate assessment of function and support needs. This latest iteration of a functional capacity assessment published by NDIA, is not a true functional assessment – but rather, it is a discharge checklist and needs to be recognized as such. Of note, there is no requirement for the participant to sign this form – an alarming oversight – as the participant is not given the opportunity to review what has been written, confirm they have undergone an assessment, or provide consent for assessment information to be sent to the NDIA to inform their future NDIS plan. This oversight raises questions around a culture of inclusion, and NDIA capability to recognize the person as an expert in their own disability.
Whilst the writers fully support the need to expediate the discharge of NDIA participants from hospital settings, this new checklist is likely to misrepresent the person’s functioning and support needs. A co-design approach incorporating lived experienced perspectives and the relevant allied health representatives, could have led to more robust, and person-centred, approach.
Most concerningly, this latest functional assessment template holds strong parallels to Independent Assessment, which were widely condemned as unfit for purpose, lacking an evidence base, and potentially harmful. In particular, the functional capacity and support needs of people with psychosocial disability cannot be appropriately assessed using this template. This example illustrates
Submission to Joint Standing Committee on the NDIS: NDIA Capability & Culture Inquiry
Oct 2022
the ongoing culture of absence to true commitment to co-design with the disability sector and participants.
There are emerging, promising pieces of work that have potential to inform a co-designed future model of functional assessment. For example, the International Classification of Functioning (ICF) Australian Interest Group have recently published a technical paper describing the potential uses of the ICF in the NDIS, with a focus on assessment models.
Typical Support Packages
Many participants and their supporting allied health professionals describe that the evidence of functional capacity and support needs provided at plan review is not considered or even read by planners; and planners have varying skill levels in interpreting the evidence provided. So even when high quality evidence of functional capacity is provided at plan review, it may not actually inform decision making around support needs.
There appears to be varied consideration given by planners, to participant-provided evidence. The Submission asks the JSC to consider the impact of TSPs on planning culture, and raises the question of the impact of complying with TSP-generation, on planning culture - including planners behaviour, attitudes, and expressed empathy. Again, the cost-containment narrative appears to prevail within the culture of planning, driven by internal incentives for planners to comply with TSPs with systemic incentives existing for planners to fund plans within the TSP. (Refer to diagram below.) It is unclear if similar systemic incentives exist that promote funding of appropriate reasonable and necessary supports that comply with the NDIS legislation.
The use of assessment scores feeding into a TSPs to inform fund allocation has been critiqued for lack of evidence supporting its validity [2]; and for lacking the required tailoring of individual support packages to meet daily living support needs. Occupational Therapy Australia has noted:
Regrettably, some of the NDIA’s own processes are a potential source of inequitable access to the scheme. The current process of assigning a ‘functional level’ through the NDIS planning process, as disclosed in the NDIA’s response to a question from Senator Jordon Steele-John, taken on notice at a meeting of the Joint Standing Committee on 18 May 2021, is a potential source of inequity. The NDIA’s response provided a table of the numerous assessment tools required by Planners for each disability type, and the score ranges (cut-off scores) determining high, medium and low levels of function that are used as an input to determine funding level, or ‘Typical Support Package’ (TSP) (NDIA, 2021).
While the assessment list was made public, the evidence base underpinning the assessments, and score ranges that determine high, medium and low functionality, were not released and continue to be a source of confusion. Based on the disclosures of 18 May, it appears that a participant’s functional ‘level’ is determined in one of two ways. Either an NDIS delegate, an administrative officer, will define a ‘level’ by asking the participant questions from the generic self-report tool used internally (presumably, the WHODAS-2), or, if the participant’s report provided by their known allied health professionals happen to include assessments matching those on the Planner’s list, those assessment scores will be used to determine functional ‘level’. Clearly, this is an inconsistent process.
Additionally, it is inequitable if certain participants are unable to afford an allied health assessment and therefore their functional ‘level’ is determined solely by the WHODAS-2. There are many assessments on the disclosed Planner assessment list, but only the WHODAS-2 is administered by NDIS Planners for the adult population. So, the system is based on the assumption that some of
Submission to Joint Standing Committee on the NDIS: NDIA Capability & Culture Inquiry
Oct 2022
Assessment scores will derive from participants’ known allied health professional reports, presumably in many cases occupational therapy functional assessments. This lack of transparency in how allied health reports and assessments are used creates risk that these reports could be used in ways that they were not intended and result in potentially unreliable or inaccurate conclusions being drawn.
OTA members have noted that the July 2021 Quarterly Report Addendum document titled ‘Analysis of reported level of function trend’ details the ‘level of function trends’, and indicates that factors such as who completed the assessment, and how they completed the assessment, are key to the determination of ‘functional level’ (2021, p. 9). It highlights a greater apparent trend towards functional decline over 5 years, when the functional level is determined by the internal, generic assessment tools (the WHODAS-2 and the PEDI-CAT). The proportion of participants assessed as ‘low’ functioning grew by 15% using the internal assessment tool administered by NDIS Planners/delegates. There was a significantly lesser trend towards functional decline over 5 years when the functional level was determined by external disability specific assessment tools (presumably, Current Scheme Implementation and Forecasting for the NDIS Submission 77 7 assessments completed externally by allied health professionals using consistent, tailored assessment strategies). The proportion of participants assessed as ‘low’ functioning grew by 4% using disability specific assessment tools (2021, p. 9).
Committee members will appreciate the considerable difference between a 15% increase in participants showing functional decline, and a 4% increase in participants showing functional decline. This discrepancy casts significant doubt on the quality and accuracy of the agency’s internal assessment process, given that the external assessments are delivered by allied health professionals with particular expertise in functional assessment. Moreover, it raises doubts as to the validity of all funding decisions informed by the same internal assessment process. The consistency, reliability and validity of the NDIA’s current system of assigning functional ‘levels’, require careful re-examination, as does the apparent trend of functional decline in NDIS participants. Such re-examination should also consider strategies to co-design a new, person-centred NDIS assessment process. Not only would this address issues around inequitable access to the scheme but would provide greater clarity for the providers who work within the scheme as to how their clients’ funding is calculated.
Submission to Joint Standing Committee on the NDIACapability & Culture Inquiry
Oct 2022
Th figure above is from the Auditor-General Report into the Decision-making Controls for NDIParticipant Plans published din 2020. The red box (added) identifies the elements of the process thatsystemically incentives delegates to fund plans within TSP’s as additional tasks, effort, interactions, coordination and time is required to fund plans deviating from the TSP.
https://www.anao.gov.au/sites/default/files/Auditor-General Report 2020-21 14.pdf [3]
References
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Parliamentary Inquiry final report Independent Assessments – Parliament of Australia (aph.gov.au) Retrieved 13/04/22
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Submission 77: Occupational Therapy Australia Submissions – Parliament of Australia (aph.gov.au)
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https://www.anao.gov.au/sites/default/files/Auditor-General Report 2020-21 14.pdf
Submission to Joint Standing Committee on the NDIS: NDIA Capability & Culture Inquiry
Oct 2022
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Submission to Joint Standing Committee on the NDIS: NDIA Capability & Culture Inquiry
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