NDIA Accountability Project

Ongoing measures to reform the scheme

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Government of Western Australia Submission to the Joint Standing Committee on the National Disability Insurance Scheme Inquiry into Current Scheme Implementation and Forecasting

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Contents

Contents ……………………………………………………………………………………………………… 2 Introduction …………………………………………………………………………………………………. 3 Comments on the Terms of Reference ……………………………………………………………. 3 A. The impact of boundaries of the NDIS and non-NDIS service provision on the demand for NDIS funding ……………………………………………………………………… 3 B. The interfaces of NDIS service provision with other non-NDIS services ……. 5 Discharge of people who are in hospital and no longer need hospital care …….. 5 Supports in Custodial Settings …………………………………………………………………. 6 Health and Justice Liaison Officers …………………………………………………………… 6 Worker screening …………………………………………………………………………………… 6 Regional Therapy Services ……………………………………………………………………… 7 C. Variations in plan funding between NDIS participants with similar needs ….. 7 Regional and remote areas ……………………………………………………………………… 7 Specialist Disability Accommodation …………………………………………………………. 8 Behaviour Supports ……………………………………………………………………… 8 D. Funding of the NDIS ……………………………………………………………………… 9 E. Financial and actuarial modelling and forecasting of the scheme …………….. 9 F. Governance and transparency measures intended to ensure the financial sustainability of the NDIS ……………………………………………………………………… 10 G. Ongoing measures to reform the scheme …………………………………………. 11

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Introduction

The State Government of Western Australia (WA) strongly supports the National Disability Insurance Scheme (NDIS). The State Government recognises that, since its inception, the NDIS has improved the lives of many participants, families and carers. For this reason, the State Government remains firmly committed to the NDIS and its key principles.

The key issues and concerns articulated in this submission include:

  • The need for continued market development and investment in innovative service delivery models in regional and remote areas, given that thin markets underly many of the current challenges with NDIS implementation. This needs to be coupled with work to develop and ensure the supply and availability of an appropriately skilled workforce.
  • The need to clarify system boundaries and improve coordination between the NDIS and mainstream services, to improve participant outcomes and reduce the lifetime cost of supports.
  • The need to pursue National Care and Support Worker Regulation reforms in collaboration with both Disability and Health Ministers.
  • The need to improve participant access to Specialist Disability Accommodation (SDA) and market supply.
  • The need for more responsive and accurate planning decisions based on engagement with the participant, family members and providers to understand the participant’s individual circumstances.
  • The crucial role of Disability Reform Ministers in the joint governance of the NDIS and the need for a transparent, collective approach from Disability Reform Ministers to safeguard the scheme’s future.

The WA Department of Communities has coordinated this submission on behalf of the Western Australian Government, with the support of the WA NDIS Interface Steering Committee and its member agencies.

Comments on the Terms of Reference

A. The impact of boundaries of the NDIS and non-NDIS service provision on the demand for NDIS funding

The State Government is committed to providing accessible and inclusive non-NDIS services for people with disability, consistent with Australia’s Disability Strategy 2021–2031, WA’s State Disability Strategy 2020–2030, and the State Government’s responsibilities under the ‘Applied Principles and Tables of Support to Determine Responsibilities of the NDIS and Other Service Systems’. The State Government’s key actions are outlined in ‘A Western Australia for Everyone: State Disability Strategy 2020–2030 Action Plan’. Ongoing work to improve the accessibility and inclusiveness of non-NDIS services is essential to give effect to the rights of people with disability and capitalise on the social and economic potential of the NDIS.

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The State Government also recognises the need to ensure that gaps at the boundary of NDIS and non-NDIS service provision do not result in a greater demand for NDIS funding. The State Government is not aware of any instances where the NDIS provides funding for services that are defined as a State responsibility under the Applied Principles and Tables of Support to Determine Responsibilities of the NDIS and Other Service System (APTOS). Further, the State Government considers that reforms to non-NDIS services may not substantially influence the demand for funding from the NDIS.

The State Government considers that there is scope to reduce long-term demand for NDIS funding through coordinated supports from mainstream service systems and the NDIS for individuals in crisis or at key transition points. Current cooperation between the State and Commonwealth governments is achieving results in this regard, but further improvements would be valuable. For example, transition supports for individuals in custody during their initial community release may decrease long-term reliance on the NDIS. The National Disability Insurance Agency (NDIA) currently provides limited support to these individuals. This is particularly evident for mentally impaired accused persons seeking Leave of Absence to begin a transition into the community. The NDIS should coordinate with the justice system to ensure appropriate NDIS funding for mentally impaired accused people to enable them to access supports in the community, so they can gain the intended benefit from their Leave of Absence and achieve a successful transition into the community.

The same principle applies to people with disability who are in hospital but no longer need hospital care, where coordinated support is essential to a successful transition into the community and reduced lifetime cost of supports. The challenges in accessing NDIS support for hospital discharge are described in the next section.

Another example is early intervention for children with Autism or child development issues. The State Government is hopeful that the NDIA’s recent Early Childhood Early Intervention reset will refocus on the needs of the child and setting them up for their best future regardless of the system responsible. This may, in turn, decrease the child’s long-term demand on NDIS funding. To build on this, it is imperative that the NDIS and health systems work together for a unified understanding of system boundaries, multi-system responsibility and coordinated approaches. Greater clarity on NDIS boundaries will ensure that children with Autism or child development issues receive sufficient early intervention support from the appropriate service system, giving them the best chance of living a full and fulfilling life.

Regarding the Information Linkages and Capacity Building (ILC) program, the State Government commends steps being taken by the Commonwealth to review and reset ILC. To improve the efficiency of the ILC program, the Commonwealth should engage broadly with state and territory human services agencies on priority areas and target funding to projects where there is a demonstrated need. This should include funding small projects that can have significant positive local impact. The Commonwealth should also ensure greater visibility of the outcomes achieved and resources developed through ILC.

B. The interfaces of NDIS service provision with other non-NDIS services

The NDIS interfaces with a range of State Government service systems to jointly support people with disability. As noted above, this coordination is critical to improving outcomes and reducing costs for all service systems, however there are significant challenges at present. The NDIA should work with the State Government and allocate resources to further strengthen the decision-making and case management approach for individuals involved with multiple service systems. This effort should align to agreed responsibilities under the APTOS.

Below are specific NDIS interface areas that carry significant risks at present. They are being addressed by the State Government through the WA NDIS Interface Steering Committee, the Western Australian Executive Steering Committee, and the Disability Reform Ministers Meeting and its underlying groups.

Discharge of people who are in hospital and no longer need hospital care

Throughout 2021, there were approximately 130 WA hospital beds occupied by patients who no longer needed hospital care and were awaiting NDIS services and appropriate accommodation. At the time of writing, the number is around 100. This situation costs the State health system around $110 million per year and impacts on hospital capacity for COVID-19 response. The system pressures that result in these patients remaining in hospital are complex and multi-factorial. However, deficits in Commonwealth programs, including challenges in securing appropriate care and accommodation for NDIS participants with complex needs and/or mental health issues, are a key factor.

The State Government is working through patient-by-patient solutions to facilitate the safe discharge of individuals who have no medical reason to remain in hospital. This includes the ‘From Hospital to Home’ project, which is piloting disability transition care services to support individuals to have their disability needs met in an appropriate community setting rather than hospital. There are also mechanisms at an operational level for State and Commonwealth governments to collaborate on a case-by-case basis to coordinate across service systems to facilitate hospital discharge.

The State Government seeks further action from the Commonwealth to facilitate hospital discharge, including:

  • Agreed timelines to complete NDIS eligibility assessment for NDIS patients in public hospitals
  • Timely and responsive planning with patients, and timely funding approval of necessary supports to enable discharge to community living for people with medium to complex needs, particularly those with psychosocial disability
  • Improved transitional funding arrangements to support individuals to move from hospital care to living in the community
  • Engaging with states and territories to address systemic issues through further collaborative policy development on the interpretation and application of the Health APTOS, the clinical governance surrounding disability related health

supports and a cohesive national approach to address persistent and widespread hospital discharge delays.

Supports in Custodial Settings

The State Government remains concerned that individuals in custodial settings lack access to appropriate support from the NDIS. This includes limited information and assistance to access the NDIS, including for people with psychosocial disability and remanded and sentenced prisoners. It also includes limited transition supports for individuals to successfully return to the community, as discussed above. This can adversely affect the individual’s eligibility for parole, access to post-release supports, and their transition or reintegration into the community. The State Government urges the NDIA to engage collaboratively with state and territory governments to increase access to supports for participants in custodial settings by ensuring operational decisions take full account of their disability needs, and clearly define responsibilities for providing information and support between the NDIA and state agencies.

Health and Justice Liaison Officers

The NDIA currently employs three Health Liaison Officers (HLO) and two Justice Liaison Officers (JLO) in WA to support access to NDIS services. HLO and JLO have assisted NDIS participants interfacing with mainstream justice and health services to access services and transition into the community. However, the supports provided by HLO and JLO are limited because this role is not participant-facing and cannot support individuals to better understand and access NDIS supports. Further, there are not enough officers appointed in these roles to meet demand, particularly across WA’s regional and remote communities. The NDIA should increase the number and geographic reach of HLO and JLO, and work with Health and Justice agencies to maximise the effectiveness of these roles. The State Government notes the NDIA has recently committed to increase the number of HLOs to 35 nationally, but it remains unclear how many positions will be in WA.

Worker screening

Work is currently being led by the Commonwealth under the National Care and Support Worker Regulation budget measure to establish worker screening for those in the aged care and veterans care sectors, building on the NDIS Worker Screening Check. The State Government understands that the Commonwealth intends to develop a single Care and Support Worker Screening Check, utilising the NDIS Worker Screening database, supported by a single Code of Conduct. The State Government notes the potential benefit for providers operating across sectors, which would contribute to the sustainability of NDIS services in regional and remote areas. The State Government also notes the potential to improve the safety of all services by preventing unsuitable workers from moving between sectors.

The State Government understands that these reforms are being led by Health Ministers through the Health Chief Executives Forum. However, they also depend on support from Disability Reform Ministers and active participation of the agencies responsible for delivering the NDIS Worker Screening Check to ensure the correct policy settings, State legislation, funding arrangements and implementation. Worker

screening reforms may depend on amendments to WA’s National Disability Insurance Scheme (Worker Screening) Act 2020, and would need to be accompanied by funding that reflects the significant resourcing requirements to expand screening to aged care and veterans care workers.

To date the Commonwealth has not engaged sufficiently with Disability Reform Ministers and their officials, nor has it established a governance structure that recognises the key policy and implementation role of all relevant agencies. This threatens to impede progress on care and support worker regulation reform. The Commonwealth should pursue worker screening reforms in collaboration with both Disability and Health Ministers, covering all aspects of policy, legislation, funding and implementation.

Regional Therapy Services

The WA Country Health Service is currently an ‘in-kind’ provider of therapy services to NDIS participants in regional and remote areas. The State Government has the aim of transitioning these services to the NDIS market, however significant challenges remain. Access to therapy services in many regional and remote areas of WA is limited or non-existent, and there are few signs of improvement. The State Government has observed a reduction in new therapy providers entering the market, reduced growth of existing providers and in some cases reduced capacity of existing providers. Further action is needed to ensure that regional therapy services transition to the NDIS and that participants can access reasonable and necessary therapy from the NDIS across WA. The Commonwealth should strengthen the NDIS therapy market in regional and remote areas and prioritise alternative commissioning models where market-based therapy services are unlikely to be sustainable.

C. Variations in plan funding between NDIS participants with similar

needs

Regional and remote areas

In 2021, the Commonwealth, states and territories commissioned Taylor Fry to review the NDIA’s cost projections and provide advice on NDIS cost drivers. The resulting ‘Review of NDIA Actuarial Forecast Model and Drivers of Scheme Costs’ provides some insight into variation by socio-economic status and geographic area in the NDIS. The report concludes that:

  • There is a small correlation between the socioeconomic status of an area and the plan funding allocated to NDIS participants in that area. This corroborates the NDIA’s report on ‘Plan Budgets and Socio-economic Status as at 30 June 2021’, which indicates a small correlation between the socioeconomic status of the participant and their plan funding.
  • The socioeconomic status of an area has a material effect on actual payments to NDIS participants in that area.

The relationship between socioeconomic status and NDIS payments is concerning given payments are closely related to participant outcomes. The effect appears to be largely due to socioeconomic status being correlated with remoteness, and disability services being less available in regional and remote areas. This contributes to the

entrenched disadvantage experienced by people with disability in regional and remote areas. Individuals in regional and remote areas have fewer opportunities to test their eligibility and develop an NDIS plan to begin with, and less choice and control given the small range of services available in remote communities. These issues significantly affect mainland WA and also apply to the Indian Ocean Territories. The Commonwealth should ensure consistent decisions, strengthen the disability market in regional and remote areas, and further develop innovative funding and service delivery models to ensure equitable access to NDIS services across Australia.

Specialist Disability Accommodation

Inconsistencies in NDIA decision-making appear to be limiting access to Specialist Disability Accommodation (SDA). This includes variations in plan funding between individuals with apparently similar needs and system issues with regards to assessment and approval of SDA funding causing delays for some individuals.

These issues have led to under-delivery of housing for participants, inhibited participant choice and control, created uncertainty of funding that limits the SDA market development and innovation, and impacted on providers required to deliver support in housing that does not meet the needs of their client.

In Western Australia, the NDIA’s ‘NDIS Specialist Disability Accommodation 2021-22 quarter 1 report’ shows 1160 participants with SDA eligibility, 92 properties enrolled as SDA, and 163 participants seeking SDA against a design category. By contrast, the Summer Foundation’s 2018 report ‘Specialist Disability Accommodation: Market Insights’ estimated that SDA, once fully implemented, would support 28,000 people nationally, and 2,980 in Western Australia. This means that, potentially, over half the SDA-eligible cohort in WA are not currently receiving SDA funding, and are unlikely to have had their level of SDA entitlement assessed.

The NDIA should act to identify people who are likely to be eligible, assess their housing needs and facilitate exploration of housing options. This should include assessing the group home cohort for their individual SDA eligibility. The NDIA should also make its systems more responsive for approvals of SDA funding. In addition, the NDIA needs to take steps to generate greater market activity and innovation, and to incentivise the development of SDA in regional areas and robust builds. Better modelling and forecasting are key to SDA market development, so the NDIA should provide clear data sets that are responsive to the needs of SDA providers. This should be based on stronger consultation with the SDA development sector to ensure the NDIA’s SDA data sets are fit for purpose.

Behaviour Supports

Based on its experience as a service provider, the State Government considers that behaviour supports are not always funded through NDIS plans in a timely or adequate way. It is recognised that there may be a number of factors that contribute to this including but not limited to Implementing Providers not taking the reasonable steps to have Behaviour Support included in a plan, Behaviour Support Practitioners not communicating the Behaviour Support need of an individual to a planner when there are funding implications and/or planners not being aware of the scope the

funding need in relation to Behaviour Support. Regardless, Behaviour support practitioners must be funded to support the full process of developing the plan to a level that fully evidences the restrictive practices use, implementing the plan and making any subsequent adjustments for changed circumstances. The challenges of limited funding for behaviour supports are compounded by a limited market, particularly for practitioners with the skills to manage the most complex cases or in regional and remote areas. There is also a need for greater clarity of funding across different line items to support participant assessment, training of staff for plan implementation, and enabling provider responsibilities and due diligence. These issues can stall the development of a behaviour support plan or even mean the process has to begin again with a new practitioner when additional funding becomes available. This has implications for the safety of the NDIS participant and increases providers’ workload in meeting reporting requirements and obligations to the NDIS Commission. The NDIA should implement processes to ensure that behaviour support funding is sufficient for the full process and is available quickly when needed in all cases. This includes enabling funding flexibility and responsiveness to participants’ behaviour needs as they are understood through assessment, planning and implementation of supports.

D. Funding of the NDIS

The State Government strongly believes the NDIS must always remain fully funded, as an uncapped scheme that guarantees reasonable and necessary disability supports for all eligible individuals. The State Government remains committed to ongoing joint funding of the NDIS with the Commonwealth.

E. Financial and actuarial modelling and forecasting of the scheme

The State Government notes the modelling and forecasting routinely undertaken by the NDIA, for which Taylor Fry’s ‘Review of NDIA Actuarial Forecast Model and Drivers of Scheme Costs’ provides further analysis. At present, the State Government is not in a position to endorse NDIS forecasts, given there are unresolved questions that create a large degree of uncertainty about the future scheme costs. These include questions regarding:

  • Whether NDIS access, capacity assessment and planning decisions are accurate and consistent.
  • The increase in the proportion of young people diagnosed with Autism or developmental delay since the introduction of the NDIS. This is a complex phenomenon involving changing diagnostic processes, NDIS implementation, and other factors.
  • The effect of recent policy and practice changes by the NDIA. The State Government notes that although average NDIS plan funding has consistently grown over recent years, in the year ending 30 September 2021, the average NDIS plan funding was reduced. The State Government understands that this reduction is at least in part due to changes to planning and funding processes for Supported Independent Living. The impact of these changes on future NDIS costs is unclear.

Disability Reform Ministers will undertake further work to understand NDIS costs in 2022, which may shed light on these questions.

A further issue is that NDIA forecasts are calculated at a national level, and projected participant numbers and costs are then allocated to jurisdictions. This limits the degree to which the NDIA model can account for local factors, which are often significantly different in Western Australia to the rest of the nation. On that basis, the State Government considers that existing forecasts are not reliable indicators of NDIS participant numbers and costs in WA.

F. Governance and transparency measures intended to ensure the

financial sustainability of the NDIS

The NDIS is jointly governed by the Commonwealth, state and territory governments. Collectively, Disability Reform Ministers are responsible for key NDIS policy decisions and approving certain categories of rules made under the National Disability Insurance Scheme Act 2013. This governance process is one of the key strengths of the scheme. Since the establishment of the NDIS, a great many participants, providers, carers and family members have brought issues to their state or territory Disability Minister as well as the Minister for the NDIS. These issues have ranged from getting the right support for an individual to fundamental questions of scheme design. Access to Ministers at both levels of government increases the accountability of the NDIS and strengthens the influence of individuals over decisions that affect them.

Disability Reform Ministers are committed to a sustainable, equitable and effective NDIS. In 2021, state and territory Ministers pushed for greater transparency and engagement from the Commonwealth on NDIS finances. The aim was to build a collective understanding of the state of the scheme and jointly develop solutions to cost pressures. In response, the NDIA Board agreed to the ongoing transparency of the Annual Financial Sustainability Report, and confidentially shared the underlying modelling used by the NDIA with state and territory governments. This enabled the further analysis by Taylor Fry referred to above, and has given the community a better understanding of the current state of the NDIS.

The State Government expects Disability Reform Ministers to build on this in 2022 through a transparent, collective approach to safeguard the scheme’s future. This should include:

  • Better understanding NDIS outcomes in addition to costs, to build a complete picture of the sustainability of the NDIS that accounts for its social and economic benefits
  • Better understanding how to build participants’ capacity and reduce the lifetime cost of supports from the NDIS
  • Developing a strategic approach to managing scheme sustainability that meets the expectations of people with disability and service providers.

Given their crucial role in scheme governance to date, the influence of Disability Reform Ministers should be maintained. On that basis, the State Government is

supportive of the proposed amendments to the National Disability Insurance Scheme Amendment (Participant Service Guarantee and Other Measures) Bill 2021 (NDIS Bill) tabled in February 2022 that would categorise new rules on financial assistance from the NDIA, plan variation and plan reassessments as Category A rules (ss 14, 47A and 48 of the NDIS Bill respectively) rather than Category D rules. These amendments would mean that the creation of, and changes to those rules would require the agreement of all states and territories. While noting that the proposed amendments are yet to be progressed, the State Government considers these changes a key factor in maintaining the collaborative role of states and territories in governing the NDIS.

G. Ongoing measures to reform the scheme

The State Government regards the following as high priority areas for NDIS reform:

  • Strengthening the disability market in regional and remote areas, including further developing innovative funding and service delivery models. This needs to be coupled with work to develop and ensure the supply and availability of an appropriately skilled workforce.
  • More responsive and accurate planning decisions based on engagement with the participant, family members and providers to understand the participant’s individual circumstances.
  • Better engagement with participants on planning decisions, including: providing transparent justification of any reduction or denial of support; time-limited supports to smooth transitions between plans; and better mechanisms to resolve disputes before they reach the Administrative Appeals Tribunal, such as mediation.
  • Implementation of the Tune Review, including improved assessment of participants’ functional capacity to ensure NDIS plans and funding meet their reasonable and necessary needs and enable social and economic participation.
  • Alignment of roles across the NDIS and other service systems to support children with Autism and developmental delay.
  • Other measures to ensure accurate, consistent and equitable decisions in NDIS access and planning.
  • Closer, more responsive and more flexible engagement between the NDIS and other service systems, particularly to facilitate discharge of people who are in hospital and no longer need hospital care.

Further, as noted above, any future reforms should be informed by a better understanding of what is currently happening in the scheme and the impact of changes the NDIA has made in recent months. Reforms should also be co-designed with people with disability and in consultation with the disability sector. The State Government supports the NDIA’s 2021 commitment to establish a partnership agreement with the disability community and holds the expectation that, under this agreement, any substantial policy changes or reforms to the NDIS will be co- designed with the community.