Inquiry into Current Scheme Implementation and Forecasting for the NDIS

Occupational Therapy Australia submission

Date: February 2022

Australian Parliament

Joint Standing Committee on the National Disability Insurance Scheme

Occupational Therapy Australia Limited

Website: www.otaus.com.au

Executive summary

Occupational Therapy Australia (OTA) welcomes the opportunity to make a submission to the Joint Standing Committee’s Inquiry into Current Scheme Implementation and Forecasting for the NDIS.

OTA is the professional association and peak representative body for occupational therapists in Australia. As of December 2021, there were approximately 26,500 registered occupational therapists working across the government, non-government, private and community sectors in Australia. Occupational therapists are allied health professionals whose role is to enable their clients to participate in meaningful and productive activities.

Occupational therapists are dedicated to building a stronger NDIS that fulfills its promise and endures for the benefit of future generations. In order to achieve this, certain elements of the NDIS must be reviewed and developed. This submission outlines key areas in which OTA believes this change should occur. These areas include:

Improved access to housing for NDIS participants;
Clearer division of responsibilities between NDIS and external health providers particularly in the mental health space;
The assessment of functionality for potential and existing NDIS participants;
Economic calculations assessing the cost-benefit relationship of the scheme;
Stronger regulatory arrangements to protect participants, their families and carers; and
A greater role for allied health professionals in advising and providing clinical oversight for key NDIA decisions.

Summary of Recommendations

Recommendation: The committee explore opportunities to improve access to housing for those with disabilities through addressing the housing supply and the relationship between NDIS and non-NDIS housing services.

Recommendation: The committee address the lack of clarity that exists between the division of responsibilities between the NDIS and external health providers.

Recommendation: The NDIA should review the current system for assigning functional levels and measuring functional improvement or decline in NDIS participants.

Recommendation: The evidence and process behind these assessments should be made public and explained to allied health providers whose reports are contributing to this assessment.

Recommendation: The NDIA more accurately calculate the net cost of the scheme through a greater acknowledgement of the economic benefits of participant care.

Recommendation: The NDIS develop and provide preventative regulatory arrangements to minimise potential harm to clients, carers and families.

Recommendation: The inclusion of an allied health representative on the Independent Advisory Council (IAC).

Recommendation: The introduction of a committee of clinical oversight, comprising representatives of the relevant allied health professions.

Recommendation: A formal role for the Commonwealth Office of the Chief Allied Health Officer in providing clinical governance of assessment and intervention processes.

The role of occupational therapists in the NDIS

Occupational therapy is a person-centred health profession concerned with promoting health and wellbeing through participation in occupation. Occupational therapists achieve this by working with participants to enhance their ability to engage in the occupations they want, need, or are expected to do; or by modifying the occupation or the environment to better support their occupational engagement. Occupational therapists provide services across the lifespan and have a valuable role in supporting participants affected by developmental disorders; physical, intellectual, chronic and/or progressive disability; and mental health issues.

Given their expertise and area of practice, many occupational therapists deliver services funded by the NDIS. Services focus on promoting independence in activities of daily living and enablement of social and economic participation. These services may include functional capacity assessment and intervention; disability-related chronic disease management; prescription and implementation of assistive technology and/or environmental modifications; mental health interventions; positive behaviour support; driving assessments (when specifically trained to do so); and targeted, goal-focussed rehabilitation.

Significantly, occupational therapists are highly skilled in assessing the degree to which a person’s disability affects their level of function in daily tasks. Based on these assessments, occupational therapists make recommendations for, and then deliver, interventions that enhance and maintain an individual’s functional capacity.

On a closely related matter, OTA would like to take this opportunity to acknowledge the Committee’s recently published report on its Inquiry into Independent Assessments (October 2021). OTA strongly supports all 6 of the Committee’s recommendations.

Terms of Reference

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

  provided by the States, Territories and Commonwealth, particularly aged
  care, health, education and justice services.

Firstly, OTA notes and endorses the observation made by Allied Health Professions Australia (AHPA) in its submission to this inquiry:

Some of the most significant difficulties are the result of a shift from state-based services to a largely fee-for-service, market-based system, and reliance on shared responsibility across multiple governments, departments and agencies for policy, workforce development, regulation and pricing. Overlapping and at times uncertain responsibility for different aspects of the Scheme also makes it much more difficult to address issues that hamper the effectiveness of the NDIS.

While the sweeping nature of the reform process explains this confusion, it does not excuse it. Jurisdictions should work together to address this problem, as should departments within given jurisdictions. Areas where the interface is particularly blurred, resulting in a loss or deterioration of supports for people with disability, have been brought to the attention of OTA. These are discussed below.

Housing

Occupational therapists work closely with NDIS participants to allow them to access housing that is safe, appropriate and tailored to individual needs. Access to appropriate housing continues to be extremely difficult, and there continues to be substantial unaddressed housing need.

OTA members report that it is particularly difficult to have Supported Independent Living (SIL), Independent Living Options (ILO) and Specialist Disability Accommodation (SDA) funded as part of an NDIS participant’s plan, even when there is strong evidence of need and eligibility. But even with funding, there are limited housing options on the market. Many people with disability continue to live in insecure and inappropriate housing, placing them at risk of reduced social, community and economic participation, and at risk of exploitation in dubious tenancy arrangements.

OTA supports the following comments from Mental Health Australia in its submission to the committee:

There are also issues in the interface between NDIS and housing supports. Service providers working with people experiencing chronic homelessness and complex needs have pointed to a gap in support to access the NDIS. Most services are not able to provide the intensive one-on-one support required for people with complex needs, and particularly homelessness, to navigate the NDIS application process. The component of the National Community Connectors Program demonstrated an effective model for addressing this gap.

Housing and homelessness service providers have also raised concerns regarding:

extreme difficulty communicating with the NDIA – flowing onto difficulties planning participant care

having ongoing unfilled specialist disability accommodation with disconnection between NDIA and service providers

risk of homelessness for participants where they did not receive housing supports as part of their NDIS plan (which they had through programs prior to transition to the NDIS), putting their tenancy at risk.)

Furthermore, adequate housing has been found to result in decreased service use and cost over time while inadequate housing has been associated with decreased functionality in clients (Mind Australia, 2016). Providing appropriate housing for participants may reduce

some of the financial strain on the scheme through increased functionality and independence thus reducing costs for clients and providers.

The interface between health services and the NDIS

The interface with health services continues to be a challenging space to navigate for people with disability. This is particularly true of people who live with psychosocial disability.

OTA has been alerted to numerous instances of people with psychosocial disability being turned away or discharged from clinical mental health services because of their status as an NDIS participant. In these cases, the mental health services maintain that certain supports are the responsibility of the NDIS (as they relate to “disability and functional supports”), while the NDIS refuses to fund the same supports as they are deemed to be the responsibility of mental health services (as they relate to “supports that are clinical in nature”).

This problem was identified as a significant concern early in the roll out of the NDIS and while efforts have been made to address it, and clarify roles and responsibilities, the problem persists.

While OTA members welcomed many of the proposed changes to the National Disability Insurance Scheme Act 2013, including enhanced recognition of the often episodic and fluctuating nature of psychosocial disability, we remain concerned about the ambiguity of terminology used in the Proposed changes to NDIS Rules – Becoming a participant Rules (Part 2 (8)). This has the potential to blur the division of responsibility between the NDIS and clinical mental health services for people with psychosocial disability.

Additionally, there is considerable risk around ambiguity of language as it relates to proving permanence of disability. Vague references to ‘appropriate treatment’ diminish clarity around eligibility for the NDIS on the grounds of treatment history or a lack thereof. Without a clear definition of ‘appropriate treatment’, there is potential for this to delay or thwart entry to the scheme. Delayed access has the potential to compound disability or to result in an inappropriate reliance on acute, medical or clinical supports. Lack of clarity around what is meant by ‘appropriate treatment’ will lead to further tension at the ‘interface’ with clinical mental health services.

Recommendation: The committee address the lack of clarity that exists between the division of responsibilities between the NDIS and external health providers.

C. The reasons for variations in plan funding between NDIS participants

  with similar needs, including:
  ii.   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.

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OTA is on the record as supporting more equitable access to the NDIS, and renews its offer to work with the NDIA and other stakeholders as part of a co-design process to help achieve this. Central to this objective is the development of a person-centred access assessment process. OTA reminds the Committee that the assessment of functional capacity is a core skill of occupational therapists.

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 the 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,

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.

Recommendation: The NDIA should review the current system of assigning functional levels and measuring functional improvement or decline in NDIS participants.

Recommendation: The evidence and process behind these assessments should be made public and explained to allied health providers whose reports are contributing to this assessment.

F. The measures intended to ensure the financial sustainability of the NDIS

  (e.g. governance, oversight and administrative measures), including:
  iii.   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),

Given many reforms to the NDIS are justified by the Commonwealth Government on the grounds of the scheme’s financial sustainability, the NDIA should be more transparent in this space.

For example, a broader consideration of the economic benefits/impacts of the scheme would allow a more accurate picture to be painted of the sustainability and potential benefit of the NDIS. By factoring in the reduced cost on carers through potential increased independence of scheme participants and their possible return to the workforce, the scheme would not only be acknowledging the cost of eligibility, but also what can also be returned to the community and economy by allowing participants to fulfil their potential. While this will not be the case for all participants as many will experience functional decline over their lifetime, it remains a potentially important factor in determining the financial sustainability of the scheme.

Recommendation: The NDIA more accurately calculate the net cost of the scheme through a greater acknowledgement of the potential economic benefits of participant care.

Regulatory settings do not optimally support safe and quality services

The current regulatory framework does not ensure, at a systems level, that the NDIS workforce can provide safe and high-quality services. In addition to concerns around participant safety, this is a significant issue that undermines the benefits of the NDIS.

Many allied health professionals, including occupational therapists, must meet AHPRA registration standards. However, many critical supports do not require mandatory skills and experience. Essentially, anyone who thinks they can provide such important services as support coordination or NDIS recovery coaching, can provide them.

The NDIS Quality and Safeguard Commission’s Code of Conduct, which applies to all providers (registered and unregistered) can only be called upon after someone makes a complaint to the NDIS Commission. This is an unsatisfactory arrangement, given many participants, carers and family members experiencing harm from providers are likely to face significant barriers when making and following through with a complaint.

Simply put, the current regulatory framework places the burden of ensuring basic safety on participants, carers and their families rather than providing adequate preventative arrangements that minimise the possibility of significant harm in the first place.

Recommendation: The NDIS develop and provide preventative regulatory arrangements to minimise potential harm to clients, carers and families.

Conclusion

Occupational therapists are dedicated to building a stronger NDIS that fulfills its promise and endures for the benefit of future generations. We ask Committee members to consider recommending formal strategies to ensure allied health professionals are consulted in a process of genuine co-design. In addition to the above recommendations, OTA members have suggested this could be achieved by:

The inclusion of an allied health representative on the Independent Advisory Council (IAC);
The introduction of a committee of clinical oversight, comprising representatives of the relevant allied health professions; and
A formal role for the Commonwealth Office of the Chief Allied Health Officer in providing clinical governance of assessment and intervention processes.

OTA thanks the Joint Standing Committee for this opportunity to contribute to its deliberations. Representatives of OTA would be pleased to appear in person before the Committee if this were deemed to be helpful.

References

Allied Health Professions Australia. (2021). AHPA submission to the Joint Standing Committee on the NDIS – Inquiry into Current Scheme Implementation and Forecasting for the NDIS. Parliament of Australia: ACT, Canberra. Retrieved from https://www.aph.gov.au/ParliamentaryBusiness/Committees/Joint/NationalDisabilityInsuranceScheme/ImplementationForecast/Submissions.

Davidson, P., Saunders, P., Bradbury, B. and Wong, M. (2018), Poverty in Australia 2018. ACOSS/UNSW Poverty and Inequality Partnership Report No. 2, Sydney: ACOSS. Retrieved from https://www.acoss.org.au/wp-content/uploads/2018/10/ACOSSPoverty-in-Australia-ReportWeb-Final.pdf.

Joint Standing Committee on the NDIS – Independent Assessments. Parliament of Australia: ACT, Canberra. Retrieved from https://www.aph.gov.au/ParliamentaryBusiness/Committees/Joint/NationalDisabilityInsuranceScheme/IndependentAssessments/Report.

Mental Health Australia. (2021). AHPA submission to the Joint Standing Committee on the NDIS – Inquiry into Current Scheme Implementation and Forecasting for the NDIS. Parliamt of Australia: ACT, Canberra. Retrieved from https://www.aph.gov.au/ParliamentaryBusiness/Committees/Joint/NationalDisabilityInsuranceScheme/ImplementationForecast/Submissions.

Mind Australia. (2016). Effective evidence based psychosocial interventions suitable for early intervention in the National Disability Insurance Scheme (NDIS): promoting psychosocial functioning and recovery. Mind Australia: Heidelberg, Victoria. Retrieved from https://www.mindaustralia.org.au/sites/default/files/publications/Effectiveevidencebasedpsychosocialinterventionsfullreport.pdf.

National Disability Insurance Scheme. (2021). Addendum 1, NDIS Quarterly Report to disability ministers 30 June 2021. Parliament of Australia: ACT, Canberra. Retrieved from https://www.ndis.gov.au/media/3476/download?attachment.

National Disability Insurance Agency. (2021). Answers to questions on notice, 18 May 2021, received 29 June 2021. Parliament of Australia: ACT, Canberra. Retrieved from https://www.aph.gov.au/DocumentStore.ashx?id=c8d10eba-03e3-4ea4-9ff9-dbee778bfb4f.