Submission to the

Joint Standing Committee on

the National Disability Insurance Scheme (NDIS)

Professor Caroline Hunt ACPA President president@acpa.org.au

ACPA NSW Section Chair e-mail address: nswsection@acpa.org.au

Executive Officer GPO Box 4489 Sydney NSW 2001 ABN 90 142 080 617 w: www.acpa.org.au

25th February 2022

ACPA Response 2022

Table of Contents

• Terms of Reference 2-3
• Overview 5
• Executive Summary of ACPA’s Recommendations 4-5
• Recommendations 6-16

a. The impact of boundaries of NDIS and non-NDIS service provision on the demand for NDIS funding, including:

i. the availability of support outside the NDIS for people with disability (e.g., community-based or ‘Tier 2’ supports), and

ii. the future of the Information, Linkages and Capacity Building grants program;

b. The interfaces of NDIS service provision with other non-NDIS services provided by the States, Territories and the Commonwealth,

particularly aged care, health, education and justice services;

c. The reasons for variations in plan funding between NDIS participants with similar needs, including:

i. the drivers of inequity between NDIS participants living in different parts of Australia, i. whether inconsistent decision-making by the NDIA is leading to inequitable variations in plan funding, and iii. measures that could address any inequitable variation in plan funding;

d. How the NDIS is funded, including:

i. the current and future funding sources for the NDIS, ii. the division of funding between the Commonwealth, States and Territories, and iii. the need for a pool of reserve funding;

e. Financial and actuarial modelling and forecasting of the scheme, including:

i. the role of insurance-based principles in scheme modelling, and

ii. assumptions, measures, and methodologies used to forecast and make projections about the scheme, participants, and long-term financial modelling;

f. The measures intended to ensure the financial sustainability of the NDIS (e.g., governance, oversight and administrative measures), including:

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The Australian Clinical Psychology Association ACPA Response 2022

the role of state and territory governments, and the Disability Reform Ministers Meetings, i. the arrangements for providing actuarial and prudential advice about the scheme, and ii. the way data, modelling, and forecasting is presented in public documents about the NDIS, (e.g., NDIS Quarterly Reports and Reports by the Scheme Actuary), and iii. measures to ensure transparency of data and information about the NDIS; g. The ongoing measures to reform the scheme including:

i. the new early childhood approach, including whether or how early intervention and other supports intended to improve a participant’s functional capacity could reduce their need for NDIS funding, and

ii. planning policy for personalised budgets and plan flexibility; and h. Any other related matters.

ACPA is an organisation representing over 3000 Australian Psychologists with accredited qualifications leading to endorsement in Clinical Psychology. Of these only a small proportion are currently registered as NDIS providers despite NDIS participants being amongst the most complex cases with the greatest areas of need.

ACPA has mounted a concerted campaign to attempt to increase access to clinical psychologists and other psychologists with specialist endorsements (e.g., educational, and developmental, forensic, counselling and neuropsychologists) by removing barriers to these endorsed psychologists providing services in the NDIS system. The current inquiry is directly relevant to this issue. We have reviewed the Terms of Reference and have made comments on the following pages. Thank you for considering the submission of the Australian Clinical Psychology Association.

The Australian Clinical Psychology Association

ACPA Response 2022

Executive Summary

Recommendations Section a.

• The NDIS include a specific line item for endorsed psychologists’ rate (clinical, education and developmental, forensic, counselling and neuropsychologists) including report writing and multi-disciplinary team meetings at a rate in the range of $240 to $270 p/hr.
• For the support of complex presentations, the NDIS to remove the bi-weekly psychologist service cap for clinical psychologists and other psychologists with endorsements to increase functional capacity and to help people with complex disabilities to achieve their goals.

Recommendations Section c.

• ACPA recommends an increase of billable travel hours to allow ‘provisions’ cover for home treatments for some presentations, such as OCD, where it is important to see the participant in their context (their home).
• ACPA recommends an increase of the provision of travel that is expanded to participants living in regional and rural areas and as outlined above, to participants with complex mental health conditions (home treatments).
• ACPA recommends that NDIA rethink its processes to ensure that contemporary quality training is provided to its employees.
• ACPA recommends involvement of clinical psychologists and other relevant psychology specialties as members of panels taking funding decisions to increase consistency in plan funding.
• ACPA argues for multidisciplinary teams of assessors that include knowledgeable professional groups who can determine allocation of funding for “complex presentations”.

Recommendations Section e.

• ACPA recommends reducing current barriers for endorsed psychologists by removing the NDIS registration requirement, given they are already registered through AHPRA.

ACPA Response 2022

ACPA recommends that people with disability who need ongoing psychological interventions should not have to have the burden to pay additional gap payments.

ACPA recommends that participants should not be required to have a plan review unless there is a significant change in circumstances.

Recommendations

Section g.

ACPA recommends that the NDIS avoids rigid and fixed funding blocks and make funding more flexible.

ACPA recommends psychologists are funded within the NDIS instead of Medicare to realise “true” personalised budgets and plan flexibility.

Recommendations

Section h.

ACPA recommends ‘equitable access’ which may be different in complex cases, when best practice requires psychologists to provide home treatments.

ACPA advocates for ‘quality in service delivery’

ACPA recommends a multi-disciplinary team approach over individual clinician care.

ACPA highlights the importance of investment in expert care, which is particularly important in the initial development of an effective service plan.

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The Australian Clinical Psychology Association

Recommendations. ACPA members have found that NDIS participants are being asked to obtain a referral from their GP for a mental health care plan so that consultations with a psychologist are either fully funded Ci.e., bulk- billed) or attract a rebate from Medicare for which there is a gap fee payable. ACPA is concerned about the misuse of this program because it was designed specifically for mental health presentations (e.g., limited sessions per calendar year, limited to focused psychological strategies for many psychologist practitioners). We are also concerned that shifting the burden of care from disability funding to health funding hides the true costs of supporting people with disability in the community. ACPA recommends psychologist services funding within the NDIS to ensure appropriate mental health supports for people with disability, to avoid the financial burden of GAP payments. Clinical psychologist rates can range between $240-$270 per 50 minutes. The Medicare rebate of $124.50 leaves a substantial GAP for people with disability, meaning that the financial burden of the GAP payment of $100+ per hour gives them less choices for appropriate specialist care. NDIS participants from low/mid socio demographic are particularly affected by the current approach, there is currently no equity for the access of specialist mental health care. We also suggest a more flexible approach with the removal of bi-weekly cap for clinical psychologists and other psychologists with specialist endorsements (clinical neuropsychology, educational and developmental, forensic, counselling) for the support of

The Australian Clinical Psychology Association

ACPA Response 2022

to increase functional capacity and to help people with complex disabilities to achieve their goals.

ii. the future of the Information, Linkages and Capacity Building grants program.

We have no comment on the ILC Building Grants program

b. The interfaces of NDIS service provision with other non-NDIS services provided by the States, Territories and _ the Commonwealth, particularly aged care, health, education, and justice services.

As noted already in our Recommendations 1, ACPA members have found that NDIS participants are accessing other sources of funding (i.e., Medicare) for disability-related needs. There is a concern that shifting the burden of care outside of the NDIS obscures the needs of people with disability. At the same time this puts pressure on funding streams for people with mental health conditions, such as Medicare. We don’t have any _ further recommendation to Section b.

c. The reasons for variations in plan funding between NDIS participants with similar needs, including: i. the drivers of inequity between NDIS participants living in different parts of Australia,

Recommendations. Access to providers has improved using technology (i.e., Telehealth). However, people with disabilities have complex presentations and people with intellectual disability or social communication

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disorders may have difficulty interacting via Telehealth. There is uneven access to fast, reliable internet particularly in regional and rural areas of

Australia. The NDIS has limitations on the provision of provider travel such that it is restricted to participants living in remote areas. In practice, this means that participants living in rural, regional, or even distant suburban areas (such as the NSW Blue Mountains) are not able to fund provider travel. Consequently, heir access to a provider, or their choice of the most appropriate provider is very limited. ACPA recommends an increase of billable travel hours to regional areas and for the at home treatment of people with complex presentations (e.g., severe obsessive compulsive disorder) at the hourly rate allocated for clinical psychologists and other psychologists with special

endorsement.

Our members have reported frequent inconsistencies when it comes to

funding decisions and often comes down to specific NDIS planners, local area coordinators or case managers who were not experienced, had a lack of understanding of the needs of people with disability, or whose approach

was often not person-centered.

There are existing funding formulas and in practice there can be disparities in funding based upon the use of “key words” in a funding application. We argue there is a need for multidisciplinary teams of assessors that include professionals such as a_ Clinical Psychologist, Educational and Developmental Psychologist, Clinical Neuropsychologist, Occupational Therapist, or Psychiatrist who can determine allocation of funding for

‘complex presentations’.

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This team-based approach is also relevant if a NDIS participant has protracted periods of regular professional expert support but has made only minor gains and the level of functional impairment remains largely unchanged. An assessment from a multidisciplinary team, including a clinical psychologist, would highlight whether there are underlying neurodevelopmental conditions or if some of the symptomatology mimics psychiatric conditions and if these present in an atypical manner. In such cases, there is likely to be a poor response to primary mental health interventions.

We recognise that there was a need identified previously when it was proposed the NDIS would recruit “Independent Assessors”. In a previous submission ACPA stated that it was supportive of attempts to make the funding application process more equitable, but the Independent Assessors proposal had several drawbacks, including not paying due attention to the opinion of a participants’ existing service providers.

ACPA recommends that the NDIA rethink its processes and ensure that contemporary quality training is provided to its employees. From our experience there is not good understanding of the differences between physical and neurological disability. The family members (parents, grandparents, children, spouses, siblings, cousins, aunts, uncles, etc.) of NDIS participants are often charged with procuring service providers and this too might depend on the support person’s level of understanding. The paperwork is overly complex for many and the appeal process is geared toward people who can articulate themselves. Many people instead give up

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At the first hurdle. ACPA recommends involvement of specialists such as a clinical psychologist in funding decisions to ensure more consistent plan funding.

We are acutely aware that the NDIS is not an endless pot of money. Mental illness prevention and early intervention are essential for reducing the national burden of mental illness in Australia. Clinical psychology training is broad and deep, and the accredited training of clinical psychologists ensures that they are competent to assess, diagnose, formulate, and treat across the full range of mental health disorders from mild to severe, chronic, intractable, and comorbid disorders. Clinical psychologists are skilled to treat the most at-risk people with serious, chronic, and complex mental health disorders. It is important to deliver evidence-based services within models of delivery

that are proven to be cost-effective, or public money is wasted.

We have no comments on Section d.

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The Australian

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Association ACPA Response 2022

Recommendations. ACPA is strongly supportive of the founding principles of the NDIS including the insurance principle that the scheme endeavors to fund treatment that is “reasonable and necessary.” In our previous submissions to parliamentary enquiries, ACPA has stressed that there are currently too many barriers in place for specialist psychologists who wish to provide services to NDIS participants. This includes the requirement for “+dual registration” whereby our members, who have already met high standards of training and are regulated by AHPRA and the NRAS regulatory system, are required to undertake an additional, lengthy, and costly NDIS registration process that appears to have little to do with professional standards.

We also note the principle of encouraging autonomy, quality of care and multi-level service support for participants of the scheme. The NDIS intended to create choice for participants and yet very few endorsed psychologists provide services to the NDIS which means that participants have less access and are often limited to less qualified providers. NDIS participants have fundamental human rights such as the right to contribute to society and have a meaningful life, supported through services to be their best self which is not simply an outcome of Connecting and Engaged Communities. Such aspirational principles are built into the New Zealand model and should be incorporated into the Australian model, including the need to push for the participation of those complex cases with comorbidities and high needs. These individuals should be referred to clinical psychologists or other psychologists with relevant areas of endorsed practice, and these

Mig The Australian ‘oo +. Clinical Psycholo tee ee Pd oe ACPA Response 2022

psychologists need to be members of panels to help decide the needs of participants.

Clinical psychologists and psychologists with other areas of practice endorsement complete two years of post-graduate accredited clinical training, which includes the completion of practical, hands-on supervised placements followed by two years of a supervised registrar program. It is our view that NDIS participants should have the right to choose the highest qualified provider who, because of the provider’s post-graduate training, has the relevant knowledge of their condition to provide the most appropriate intervention.

As we have argued, there is a cost that is hidden in the Medicare budget, yet there might be additional costs that are not represented in the NDIS. Psychosocial disability is a major issue, and it is unclear who has responsibility for providing psychological interventions. People with a disability who need ongoing psychological interventions should not have the burden to pay any additional gap payments. As mentioned in Section a, Clinical psychologist rates can range between $240-$270 per 50 minutes. Currently, in the more populous States, the NDIS funds $214.41 to access a clinical psychologist. There is also a financial cost to annual review plans, including the cost for reports and meetings between parties (LAC, admin, behaviour support, allied health professionals).

ACPA Response 2022

The Australian Clinical Psychology Association

Participants should not be required to have a plan review unless there is a significant change in circumstances (e.g., experiencing a transition phase in life such as entering primary school and then high school and then leaving school). However, some participants are required to undergo reviews every 1 to 2 years with little evidence of objective improvements. Less frequent reviews will improve participant wellbeing, parent wellbeing, and reduce administrative costs. Participants with high needs will be unlikely to benefit from frequent reviews.

f. The measures intended to ensure the financial sustainability of the NDIS (e.g., governance, oversight, and administrative measures), including:

• the role of state and territory governments, and the Disability Reform Ministers Meetings,
• the arrangements for providing actuarial and prudential advice about the scheme, and
• the way data, modelling, and forecasting is presented in public documents about the NDIS, (e.g., NDIS Quarterly Reports and Reports by the Scheme Actuary), and
• Measures to ensure transparency of data and information about the NDIS.

We have no comments on Section f.

ACPA Response 2022

Recommendations.

ACPA’s position is to avoid rigid and fixed funding blocks to make funding more flexible. For example, there is existing Autism Spectrum Disorder literature about early interventions to improve participants functional capacity which in turn could reduce their need for NDIS funding.

We have learned from our member feedback that once a person is deemed eligible for the NDIS and undergoes an independent assessment to develop a personal budget, the budget does not necessarily reflect their specific needs for an endorsed psychologist. When questioned about a low psychologist budget NDIS staff frequently explain that the participant has up to 20 hours of Medicare rebate under the Mental Health Plan. The current planning policy does often not allow a true personalised budget as psychologist funding for people with a disability is restricted (maximum of bi-weekly psychologist sessions) and the Medicare approach leaves many participants with a high gap payment. There is some flexibility in plans, allowing the budget which is allocated for allied health (at a rate of $193.99) to be used for a psychologist. The flexibility is positive but still leads to the difficulty of adequate access to quality, specialised psychologist services as the resulting payment gap is between $46-$76 p/hr. This means that the budget is used up earlier than the personalised need requirements and cuts

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into other allied health services funding. The personal budget is not a true personal budget if psychological services for skill development and capacity building are not funded within the NDIS but “outsourced” to Medicare, or if NDIA staff do not understand the nature of the participants disability. It makes the NDIS complex and difficult to navigate, creates unnecessary burden and frustration for the people with disability and leads to higher review applications which is a significant cost to the system.

e ‘Equitable Access’ requires a different approach for complex cases. Regarding ‘Provisions’, for some with a disability there is a need to cater for psychologist provision of home treatments. For some presentations, such as obsessive compulsive disorder, it is important to see the participant in their context (their home).

e ACPA is advocating for ‘quality in service delivery’. Some providers with generic skills (e.g., behaviour support clinicians) do not represent value for money if they do not have the required skills achieve a positive outcome in a timely fashion. We believe that the NDIS needs to be paying higher rates to attract endorsed psychologists who will be able to provide services more effectively and efficiently.

e Multi-disciplinary teams provide benefits over individual clinicians. Specialist practitioners across different areas of endorsement need to be included. For example, clinical neuropsychologists will provide specific expertise into the assessment and rehabilitation of neurological conditions, while education and developmental psychologists will provide expert

ACPA Response 2022

understanding of expected developmental trajectories for a

range of developmental problems and their management.

• Investment in expert care is particularly important in the initial

development of an effective service plan. For example, a clinical

psychologist will develop an intervention plan, parts of which

such as behavioural interventions could be implemented by less

qualified professionals at reduced cost.