Australian Association of Psychologists incorporated (AAPi)

NDIS General Issues Inquiry

28 June 2023

Dear Joint Standing Committee,

The Australian Association of Psychologists incorporated (AAPi) appreciates the opportunity to provide commentary to the Committee on the implementation, performance, governance, administration, and expenditure of the National Disability Insurance Scheme (NDIS). To this end, we have provided our submission to the NDIS Review. We hope that this provides some insight into the issues that need to be addressed within the NDIS.

We want to emphasise the importance of psychologists in the disability field. Limiting funding for psychologist services, which has been occurring more frequently in recent times, is inappropriate and will increase the risk to participants and limit the progression they can make toward higher levels of independence and improved functional capacity. Another more common occurrence is rejecting reports of diagnosis completed by psychologists, determining that a clinical psychologist must provide a diagnosis. This is not an informed position and must stop immediately. All psychologists, regardless of whether they have an area of practice endorsement in clinical psychology or not, are able to assess and diagnose psychological conditions and disabilities that are not predominantly physical in nature (spinal injury, for example). Rejecting the diagnoses of psychologists, which are permitted by the National Law governing health practitioners, causes harm to the disability community, increases barriers to necessary supports, and increases the cost to participants, the government and the scheme in paying for unnecessary assessments. We urge the scheme to trust the clinical decision-making and opinion of Allied Health Practitioners. These practitioners have completed extensive education and training in assessing and treating clients with Disabilities and have an in-depth knowledge of the participants functioning and support needs.

Sincerely,

Chief Services Officer

Australian Association of Psychologists Inc

Postal Address 12-16 Parker Street Williamstown Vic 3016

AAPi Feedback Regarding the NDIS Review - Building a strong, effective NDIS

23rd December 2022

Dear Independent Review Panel,

The Australian Association of Psychologists incorporated (AAPi) appreciates the opportunity to provide commentary on the review of the National Disability Insurance Scheme (NDIS). To this end, we have addressed areas that are pertinent to our members. We hope that this provides some insight into the issues that need to be addressed within the NDIS.

We particularly stress the need for planners, who have never met participants they develop plans for, to trust the clinical decision-making and opinion of Allied Health Practitioners. These practitioners have completed extensive education and training in assessing and treating clients with Disabilities and have an in-depth knowledge of the participants functioning and support needs.

AAPi represents psychologists traversing a wide range of areas of practice around the country, including working within the National Disability Insurance Scheme.

Sincerely,

Chief Services Officer
Australian Association of Psychologists Inc

Postal Address 12-16 Parker Street Williamstown Vic 3016

Terms of Reference: Building a strong, effective NDIS
Part 1: Design, operations and sustainability of the NDIS

A. The participant experience and costs of engaging with the Scheme and opportunities to rebuild trust and improve key scheme design and administration, including by examining:

The user journey, including awareness and access to the scheme, assessment, planning, review processes, and navigation of supports and key transition points;

AAPi is very concerned about the level of training of planners and other NDIA staff regarding disability, due to their decision-making power over plans and funded supports. We particularly stress the need for planners, who have never met participants they develop plans for, to trust the clinical decision-making and opinion of Allied Health Practitioners. These practitioners have completed extensive education and training in assessing and treating clients with disabilities and have an in-depth knowledge of the participants functioning and support needs.

The quality and effectiveness of the support received by participants depend on several factors, such as the quality of the reports their treating practitioners have written, their own personal ability to navigate very complex systems to gain access to services and their ability to advocate or have a carer advocate for them. Overall, the experience of our members who are psychologists working in the disability sector is that, for their clients, the process of applying for support, accessing support, and navigating the system can be traumatising and stressful and often exacerbates the impact of their disability on their life. The process itself can lead to trauma and feeling stuck for participants. This can result in providers needing to support the participant through the NDIS process rather than increasing the available support.

The feedback we have received from participants is that too many people are involved in the whole process - each step a ‘once-off’, with very intrusive and personal questions to be answered. This is a large issue for those with psychosocial or neurodevelopmental disorders such as anxiety, autism, ADHD, intellectual impairment etc., who need time, reassurance, and gentle approaches to develop a relationship prior to personal disclosures. Some of the restrictions on the evidence required for NDIS funding are making the application and review process more difficult than it needs to be.

Accessing the right provider, to provide the right support and evidence is extremely difficult, especially when providers are limited in many regions in Australia. With long wait lists to access psychologists throughout Australia, many miss out on services in their first plan due to these barriers. Upon review, it may appear that the participant does not need that level of funding to improve their functional capacity when it simply indicates that adequate services were not accessible to the participant. Telehealth options and internet coverage in rural, regional, and remote areas of Australia mean that not all providers are able to be accessed by telehealth and extremely long wait times are seen by participants for face-to-face services in these areas. We need to improve the workforce capacity to provide services in these regions by offering incentives, business support and utilising workforce retention strategies to retain the available workforce.

Getting the right assessment and evidence of disability for access or review can be incredibly challenging. When participants already have a plan in place, this can be funded by the NDIS, but where there is not a plan in place, there are significant financial barriers to accessing this evidence. It often means providers making significant losses of income or potential participants giving up on accessing NDIS funding and support.

Decisions about funding levels depend on the Local Area Coordinator (LAC) who has completed the interview and the planner that is allocated. It is very common to see significant funding variations between almost identical participants (same disability, same functional deficits, same living situation). For example, a member provided an example of two very similar child clients where one receives $28,000 per year while the other receives $9,000 per year. Often, allied health and specialist reports are not consulted in decision-making. Some funding comes with decisions that go directly against the Act, leading to lengthy reviews or appeals to the Administrative Appeals Tribunal (AAT) and requiring therapist support to assist the participant in self-advocating. It is very difficult when the person who completes the interview is not the one who plans the funding or has any real concept of the individual’s disability due to not meeting the participant in person or speaking with them at all. Inconsistent decision-making has resulted in clients missing out on what they need. Clients who cannot ask for their needs to be met due to their disability often miss out on services altogether or receive inadequate funding. It is common for accessibility needs not to be funded even when someone has access to the NDIS, but many cannot access support at all.

Plans that are developed are often too vague for participants to understand what they can and cannot do with their funding, leading to the underuse of funding and a resulting reduction in functional capacity due to insufficient support. There is often a great deal of misinformation given to participants from LACs about what they can use their funding for, with the same result of underutilisation and reduced functional capacity. The information relayed by different parts of the system is contradictory and confusing. Interpretations from Planners, LACs, Support Coordinators, Plan Managers, etc., are different, so participants and providers are left very confused about the boundaries between what is acceptable and what is not. The burden of proof/level of documentation required for access to the NDIS and for planning purposes is inappropriately high. A case study to illustrate this is a client with psychosocial disability and Autism – a professional was required to fill in two access request forms, one for each stream. However, evidence was provided on both conditions on the initial access request form as well as adaptive function assessment results. Results vary greatly depending on the LAC and the planner that is involved in the case.

If we look at Access and Planning as two separate functions, then in the case of planning, expecting disabled people to be able to navigate multiple complex systems is a perfect example of the social model of disability in action. All systems should provide wraparound care rather than disjointed services or denying services altogether.

Information re Aboriginal and Torres Strait Islander Participants

We have a number of members who identify as Aboriginal or Torres Strait Islander People or who work exclusively with this population, and they have reported significant barriers within the system for Aboriginal and Torres Strait Islander clients. We provide case studies from two psychologists who are working in Aboriginal Controlled Communities.

Psychologist 1 - The feeling from the people in the community is that the system is too complex, and they do not have the skills to navigate it nor the evidence that is required to facilitate access. They either do not have services that are operating in these areas, or the NDIS focuses on a medical and individualistic model that is not culturally appropriate and they do not understand. Most give up before an application is even made. Access needs to be supported by funded positions within the communities. Supports need to be provided in ways that are culturally appropriate. Carers are often from within the family or community,

treatment might be provided by people we would not usually see as an allied health professional, but they are the ones that are trusted and known within the community.

The biggest problem is that the system is so complex people don’t even want to try to apply. The number of reports needed really challenges many people’s disconnect and distrust of medical services - as they often need to access providers they don’t know. And that’s assuming there are available providers, and that getting a report is affordable.

I think there needs to be funded positions within Aboriginal services to assist people in getting through the process and a major review of the process so it values the reports from treating professionals. At the moment, there seems to be an assumption that the opinions of GPs and non-Clinical Psychologists is of less value - even that a treating professional would have an unreliable or biased view.

Psychologist 2 - The guts of the problem is that, ultimately we want Aboriginal-led care. We will never know the cultural protocols for each language group across Australia. Then the Western Way of Being is INDIVIDUAL COMPETITIVE AND HIERARCHICAL, leading to funding and care models based on the individual person. Whereas Aboriginal ways of being is COLLECTIVE, COLLABORATIVE AND CIRCULAR, this leads to funding and care models that reflect this.
INDIVIDUAL COMPETITIVE AND HIERARCHICAL serve a system, not human beings.

What this means for Care:

Collective - The whole family/community is the client. Whoever is in the community at the time is part of it.
Collaborative - The family decides where the care is needed. Cultural responsibilities play out.
Circular - The care needs to be circular:
- Decision making
- Carers
- Family members

General comments from a member in rural area

I am in a regional area of 60,000. It is almost impossible to get services here for things such as OT’s or speech pathologists – given these people are also required for approval of any spending – it is becoming quite

unworkable. It is also nigh on impossible to get basic service such as cleaners, assistance with food prep etc. People see their money getting used on repeated assessments and reports plus admin for support coordination and plan management – with no actions or outcomes that improves their situation. People repeatedly say they do not know who to contact at any point in the process i.e., for their plan, their Functional Capacity Assessment, to follow up with concerns or with general issues.

Ways to improve the evidence-based understanding and usage of services covered in a plan now and over time;

The importance of psychological services has seen psychologists as one of the most used therapy services that assist individuals with a disability (Dew, et al., 2016) yet it is increasingly difficult to receive psychology as a funded capacity building support within the scheme. Misinterpretation of evidence that is supplied to NDIS from professionals is a very common occurrence, with it often used as evidence that psychology services should be funded by Medicare instead, despite services focussing solely on disability and increasing functional capacity as intended by the scheme. It appears currently that information may not be written in a way that delegates understand due to the relative lack of disability and mental health training they receive.

There is a requirement for therapies, particularly psychological therapy to be focussed solely on improving functional capacity. This fails to account for the fact that some active clinical treatments will make a significant impact on the improvement of functional capacity of many people with disabling conditions (Knekt, et al., 2008). If the end result is improved functional capacity, then all form of psychological treatment, including active clinical treatment should be funded through the NDIS, if it is focussed on the participants disability and is in line with best practice when working within the disability sector. Such changes in the funding of therapies would decrease the need for other funded services and would significantly improve the quality of life of participants. Funding these services through other Government services such as Medicare, results in significant barriers to care for those with disabilities, with the cost of services being the most significant. In the recent review of Medicare Better Access, cost was cited as the number one barrier to accessing treatment (Pirkis, et al., 2022). Expecting disabled Australians, many of whom are on limited incomes, to independently afford psychology treatments through is inappropriate and not disability informed.

There have been considerable issues with funding allocations for psychology providers under the NDIS. Participants are told with increasing frequency that participants need to access Mental Health Treatment Plans and 10 “free psychology sessions” before they can use their NDIS-provided funding to access psychologists. Sessions under a Mental Health Treatment Plan are not ‘free’. The Medicare system provides a rebate to the patient. Unfortunately, the rebate of $89.65 does not cover the cost of service. Consider, for example, the NDIS Schedule Rate of $214.41. This means that in most cases, the person will have a $124.76 out-of-pocket expense per session. Medicare specifies that “gaps between the rebate and the fee charged by the practitioner are not to be paid by insurance.” Many NDIS participants are on pensions or limited income due to disability and cannot afford to pay out-of-pocket costs for psychologists. Therefore, many participants will be denied access to psychologists due to the cost.

Mental Health Treatment Plans are for the treatment of specific psychological issues. Medicare specifically excludes diagnoses not related to one of the ICD 10 codes. Treatment for ‘Disability’ only without comorbid psychopathology is specifically precluded. The Department of Health has directed that Mental Health Care Plans are for treating Mental Health Symptoms. NDIS therapy funding is to treat mental health symptoms that are part of the participant’s everyday life and result from the participant’s disability.

Treatment under Medicare will be limited to 10 rebates per calendar year in 2023. This is inadequate for standard treatment, particularly with complex issues including disability. The client would be required to pay the full session fee and that is likely to impact uptake of treatment.

There are also additional restrictions on the type of therapies allowed through Medicare. Medicare restrictions on permitted therapies make the Medicare funding option inappropriate for some disabilities and the treatment goal of functional improvement. Assessment is specifically not permitted under a Mental Health Care Plan. When psychological treatment or therapy is required to improve functional capacity for someone with a disability, it is, therefore, reasonable, and necessary for this to be funded under their NDIS plan. Participants have a right to use their NDIS therapy funding to seek support from psychologists. Declining a participant’s fully funded access to psychologists’ places participant’s mental health at-risk and violates several principles outlined under the current NDIS Act, namely choice and control. If providers comply with directions to provide

Medicare Fraud Risks

services under Medicare when participants do not meet the Medicare service eligibility requirements, the providers are at risk of committing Medicare fraud. With the onus of responsibility (financial, legal, and ethical) on the Medicare provider (psychologist), seeing a NDIS participant using Medicare funding is simply too risky.

There is also a culture of misunderstanding of the role of allied health practitioners, including psychologists in the NDIS space and confusion as to their scope of practice. We have been contacted by members and participants who have had requirements to see or have reports from endorsed clinical psychologist noted in their plans when there is no restriction of practice that requires a clinical psychologist, all psychologists would be expected to be able to assess, diagnose and treat disability and mental health. It appears that there has been a misinterpretation of the legislation or guidelines that have caused confusion around the scope of practice of psychologists. This creates barriers to care for participants that need to be removed immediately.

The substitution of services for those the NDIA deem a cheaper therapy option is often inappropriate and causes potential risk for participants, particularly when substituting lower qualified supports such as support workers, therapy assistants or providers who are not deemed appropriate by those working with the participant. The recommendations made by current treatment providers should be accepted along with the preferences and expressed desires of the participants so that functional capacity can be improved. To make substitutions based on fiscal decision-making or “value for money” is not disability informed and, as stated, increases the risk to the participant.

Ways to improve and make more timely decision making in relation to home modification, assistive technology and accommodation;

Allied health professionals working with participants are the experts in what modifications, assistive technology and accommodation is required by participants, as are participants and their carers. Failing to read reports and accept recommendations that are very clearly articulated and evidence-based and refusing to fund these is inappropriate. The documentation required in many of these cases is extremely expensive and a considerable burden to both the NDIS and the provider of services. The clinical reasoning of allied health providers needs to be respected. Where there are concerns, these should be raised with the writer of the report or request rather than denying supports and communicating

B. The effectiveness and sustainability of the NDIS

including the achievement of participant meaningful employment and lifetime outcomes and broader social and economic benefits, through the provision of reasonable and necessary supports and consider:

Ways to better ensure the delivery of value and outcomes for participants and government, including capacity building and assistive technology supports;

A culture has been created such that reports from allied health practitioners are either ignored or, to be effective, must be written in a specific format so that the language and information included within that report are framed in particular ways so that psychosocial disability or support for mental health is included in plans. When read by participants, these reports are distressing and do not acknowledge their strengths and abilities; if this information is included, they will not be funded for reasonable and necessary supports.

Scheme governance arrangements and the extent they support effective operation of the scheme, including the roles and interaction between the NDIA and NDIS Quality and Safeguards Commission and DSS, and the NDIA’s and the NDIS Quality and Safeguards Commission operational models and costs;

There appears to be a considerable double-up in the administration of the scheme, which creates the potential for significant errors when planners are not the ones getting firsthand information from participants during the planning and review stages. Often these planners are also unskilled in areas such as disability, mental health, and the impact of disability on mental health and well-being. Because of the lack of knowledge of planners in the nuance of disability and mental health, participants are often significantly underfunded or specifically not funded for the supports that they need, increasing their level of risk and vulnerability in the community. Participant safety and well-being should be predominant in decision-making.

Efficiencies within the Scheme and improving the interaction between the NDIS and other significant related policies and systems, including mainstream services delivered by the Australian Government, the states and territories, local government, and the community sector;

As raised earlier in this submission, there have been considerable issues with funding allocations for psychology providers under the NDIS, with participants being told with increasing frequency that participants need to access Mental Health Treatment Plans. The average $124.76 out-of-pocket expense per session is not affordable for those with disabilities, nor will they get the evidence-based intervention to assist with their disability if accessing a Medical System to access treatment services. There may not be the level of functional gains achieved if treatment is approached through this system, nor will it necessarily be disability informed and accessible.

Part 2: Building a more responsive and supportive market and workforce

The Independent Review Panel will make findings and recommendations to Disability Reform Ministers on reforms to:

Improve the pricing and payment system to incentivise providers to improve outcomes for participants, improve productivity, support workforce development and ensure market and system sustainability;

Psychology services are currently not funded at adequate levels to maximise participants’ outcomes. Undertreatment perpetuates the need for more services in subsequent years and reduced functional capacity. If therapies were funded at adequate levels tailored to individuals’ needs, we would see significant reductions in the supports that are required to be funded in subsequent years. There also needs to be adequate payment for the services that are provided. Those allied health providers who work within the disability sector have a specialised skill set that has taken significant training to arrive at and remuneration needs to recognise this and the complexity of the work that they do. Current mechanisms for registration as an NDIS provider do nothing to improve the quality of services and are perceived by the psychology profession as a waste of time and resources. Around two-fifths of NDIS spending goes to

unregistered providers. Unregistered providers tend to be smaller operators than registered providers and more numerous, which means they reach areas of Australia that have difficulty accessing services. Psychologists are required to be registered with a regulatory body in order to practice. Registering with another body is superfluous and will not amount to less risk to participants. Risk to the public from psychologists is very rare, with only 2% of the profession being subject to complaints in a 12-month period and 64% of these being closed with no action taken. Registration should not be required for professions that are already registered with a regulatory body. This will ensure that there is a sufficient workforce available to work within the sector.

Improve access to supports in thin markets – including cultural and regional, remote and very remote communities and service categories – and ensure participants with complex needs have continuity of support where a provider withdraws from the market;

A lack of providers, long waiting lists, or a lack of registered providers with the required expertise meant interviewees often had no choice but to use unregistered providers (Dickinson, West, & Yates, 2022). This has also been reported by psychologists working in rural and remote areas of Australia and those working within Aboriginal Controlled Communities. Please see our comments on this in the first point addressed within this submission.

Bibliography

Dew, A., Barton, R., Ragen, J., Bulkeley, K., Iljadica, A., Chedid, R., . . . Veitch, C. (2016). The development of a framework for high-quality, sustainable and accessible rural private therapy under the Australian National Disability Insurance Scheme. Disability and Rehabilitation, 38(25), 2491-2503. doi:10.3109/09638288.2015.1129452

Dickinson, H., West, R., & Yates, S. (2022, December 15). THE CONVERSATION: Unregistered NDIS providers are in the firing line – but lots of participants have good reasons for using them. Retrieved from UNSW Canberra: https://www.unsw.adfa.edu.au/newsroom/news/conversation-unregistered-ndis-providers-are-firing-line-lots-participants-have-good-reasons-using-them?mc_cid=976f0a2f69&mc_eid=29ff24f3db&utm_campaign=976f0a2f69-EMAIL_CAMPAIGN_2018_06_22_02_00_COPY_01&utm_medi

Knekt, P., Lindfors, O., Laaksonen, M., Raitasolo, R., Haaramo, P., & Jarvikoski, A. (2008, April). Helsinki Psychotherapy Study Group. Effectiveness of short-term and long-term psychotherapy on work ability and functional capacity–a randomized clinical trial on depressive and anxiety disorders. Journal of Affective Disorders, 107((1-3)), 95-106. doi:10.1016/j.jad.2007.08.005

Pirkis, J., Currier, D., Harris, M., Mihalopoulos, C., Arya, V., Banfield, B., . . . Brophy, P. (2022). Evaluation of Better Access. Melbourne: University of Melbourne.