NDIS General Issues Inquiry

Submission to

The Joint Standing Committee on the

National Disability Insurance Scheme

June 2023

Introduction …………………………………………………………………………………………………………… 3
Overview ………………………………………………………………………………………………………………. 3
Recommendations ……………………………………………………………………………………………….. 4
The NDIS Sector ………………………………………………………………………………………………….. 5
- A profile of NDIS participants ……………………………………………………………………………. 6
The NDIS as a market ………………………………………………………………………………………….. 7
The role and contribution of nurses ………………………………………………………………………. 7
- Work environment and organisation ……………………………………………………………….. 10
  - Occupational violence and aggression ……………………………………………………….. 11
Workforce Issues ………………………………………………………………………………………………… 12
- Groups requiring special care ……………………………………………………………………… 13
Regulation ………………………………………………………………………………………………………….. 13
References …………………………………………………………………………………………………………. 14

Introduction

The Queensland Nurses and Midwives’ Union (QNMU) thanks the Joint Standing Committee on the National Disability Insurance Scheme for the opportunity to comment on the NDIS General Issues Inquiry.

Nursing and midwifery is the largest occupational group in Queensland Health (QH) and one of the largest across the Queensland government. The QNMU is the principal health union in Queensland covering all classifications of workers that make up the nursing and midwifery workforce including registered nurses (RN), midwives, nurse practitioners (NP) enrolled nurses (EN) and assistants in nursing (AIN) who are employed in the public, private and not-for-profit health sectors including aged care.

Our more than 71,000 members work across a variety of settings from single person operations to large health and non-health institutions, and in a full range of classifications from entry level trainees to senior management. The vast majority of nurses and midwives in Queensland are members of the QNMU. As the Queensland state branch of the Australian Nursing and Midwifery Federation, the QNMU is the peak professional body for nurses and midwives in Queensland.

Through our submissions and other initiatives, the QNMU expresses our commitment to working in partnership with Aboriginal and Torres Strait Islander peoples to achieve health equity and ensure the voices of Aboriginal and Torres Strait Islander nurses and midwives are heard. The QNMU supports the Uluru Statement from the Heart and the call for a First Nations Voice enshrined in our Constitution. The QNMU acknowledges the lands on which we work and meet always was, and always will be, Aboriginal and Torres Strait Islander land.

Overview

Nurses and Midwives make a significant contribution to the operation of the NDIS, supporting NDIS participants through a range of areas of need. The QNMU has a number of concerns with the environment in which our members work, in particular around the high levels of violence they experience in the work environment and the insecure nature of NDIS work, and stress that these factors clearly impact on the capacity of the NDIS to attract workers. Further there are a range of issues in the organisation of the NDIS that the QNMU identifies in the outcomes that the NDIS can deliver.

The detail below details the issues behind the concerns of the QNMU, with the following recommendations summarising key areas of consideration for future improvements.

Recommendations

The QNMU recommends:

Extending definitions of activities and nursing roles (protected titles) to support nurses working to full scope of practice and thus contributing to participant outcomes.
Extending the recognition of the framework to a greater focus on the social model of disability, against the strong dependence on the current dominance of the medical model.
Strategies to manage aggression in the work environment.
Need for greater regulation of the workforce and in the care provided, recognising the limitations for coordination of specialist care by the large numbers of small operators that dominate the NDIS system and thus greater capacity for job security.

A current focus of extensive public discussions on the NDIS is around managing the rising costs of the NDIS, issues with potential fraud in the operation from service providers (ABC, 2022) and the impact such issues have on the people the system is designed to support. There are many matters in the current operation of the NDIS that need to be addressed to ensure a more cost-effective service that delivers on its objectives.

While the operation of the NDIS and the role and contribution of nurses within the system are critical issues addressed in this submission, it is vital to maintain a focus of the objective of the NDIS — the quality of life for those with disabilities inclusive of the families that care for those with disabilities.

The NDIS’s website describes the scheme as ‘social insurance, not welfare. As an insurance scheme, the NDIS takes a lifetime approach to support, investing in people with disability early to improve their outcomes later in life’ (NDIS, 2023). And it is critical that in reviewing and strengthening the scheme the focus on people and supporting them to lead quality lives is always maintained.

Nurses play an important role in the delivery of services within the NDIS. The focus of this submission is around the role and contribution that the nursing profession make to the delivery of NDIS. Does the system facilitate the most effective contribution to care? Is the nursing workforce adequate to provide the required care? And is the work environment for nurses a safe and productive one?

In this submission key features of the NDIS are initially provided to contextualise the later discussion which focuses on the role and contribution of nurses within the NDIS

system, and also on the work environment which they face – linking to specific analysis reporting on high levels of violence within the system.

The NDIS Sector

The NDIS, established in 2013, provides a single, national approach to supporting people with disability, their families and carers. The National Disability Insurance Agency (NDIA) was created around the development of a marketplace for disability services.

Ideally this concept looks to encourage “providers” to offer a diverse range of the required services at cost effective pricing levels, and the “purchasers” (the participants), after clearly articulating their immediate needs and long-term priorities, would be able to effectively operate in this marketplace. Clearly the sector hasn’t operated quite that effectively.

A feature of the current NDIS operation is one of a very large number of small operators. A feature of such a model is such operators are unlikely to be able to capture the economies of scale and thus are faced with pressures of viable operation particularly in linking levels of service needed. Ho (2021, p18) provides a summary of the distribution of providers by size of operation:

Figure 1

Profile of NDIS Providers (from Ho, 2021, p.18)

[Image not converted to Markdown – “Profile of NDIS Providers chart” – check the source PDF page for the actual content]

In the associated analysis it is noted that (p29) such small organisations face significant challenges:

smaller organisations have less access to financial resources, making the funding of health and safety systems, control measures and personnel much more difficult and uncommon. Smaller organisations also have less access to expert advice relating to the management of health and safety as well as general business management and framework planning, instead often operating via informal practices as opposed to formal procedures and rules. Generally, this has resulted in smaller organisations being less prepared to address health and safety concerns effectively in a proactive, systematic manner.

A profile of NDIS participants

In looking at the system it is useful to also understand briefly the participants that are supported.

The following figure from the NDIS summarises the key disabilities addressed (Figure

and also the funding provided across these groups (NDIS 2020, p. 33 and 48).

Figure 2

Details of the NDIS participants and also levels of payment by disability group.

[Image not converted to Markdown – “Profile of Scheme participants and total payments charts” – check the source PDF page for the actual content]

This shows firstly that the main participant groups are those with Autism (32%), Intellectual disabilities (20%) and Psychosocial disabilities (10%). Interestingly there is a clear difference between the proportion of participants and distribution of costs across disabilities. While, for example, 32% of cases are identified under autism, with Intellectual disabilities accounting for another 20%, when the relevant payment profiles are considered the highest payment level (32%) is associated with Intellectual disabilities while autism only accounts for 19%. This clearly would relate to the complexity and support levels associated with each disability.

The NDIS as a market

The construction of the NDIS is in the form of a market where participants are consumers in the marketplace (NDIS 2016, p14).

Under the previous system participants had little control over what happened to them and had limited choice of service providers. This overprotectiveness has been removed with the introduction of this consumer disability choice model. This is also balanced against the need to minimise potential conflicts of interest where many consumers may have less market power or face greater risks. Conflicts of interest rules have already been established by the Agency and will evolve over time and beyond transition.

In a comment from the UK’s National Audit Office (2012, p.6) on public service markets, it highlights some of these challenges and recognises that just the establishment of a market is unlikely in itself to be adequate.

One reason why public services markets need oversight is to ensure they function as intended. Service users need to be aware that they have a choice and to be genuinely able to exercise that choice as far as is practicable. Providers must believe that users will switch to another provider if they are not satisfied with the service.

Interestingly while the NDIS is a market where consumers are meant to make a choice, the dominance of small providers adds complexity and without clear mechanisms for users to note real choice which may also limit effective competition. And for users, with for example a very high proportion of those with intellectual disabilities, the capacity to effectively operate in such a marketplace would be difficult. Thus, many providers would recognise that they have greater power in the market than do their participants, limiting the effective operation of the NDIS as the market design.

This submission focusses on what is recognised as an ongoing area of concern to the QNMU – issues around the provision of health services provided by nurses to the disability sector.

The role and contribution of nurses

Under the NDIS, items associated with nursing services attract different levels of payment according to nursing grade, ranging from an EN, to RN, to Clinical Nurse, up to the most highly qualified Nurse Practitioners. At this juncture, the QNMU would like to raise concerns about the lack of visibility of these nursing roles within the current NDIS Practice Standards and Quality Indicators (NDIS, 2021). This document identifies some significant clinical duties that would ordinarily be provided by the registrant nursing workforce practicing pursuant to the Nursing and Midwifery Board of Australia (NMBA) Decision-Making Framework, Standards for Practice and Code of Conduct. It has been the experience of QNMU members that these duties have, insidiously, been substituted out to non-registrant care or support workers without sufficient nursing support or governance. The way this document is written places a significant burden for these care decisions onto the participant who, ordinarily, may

lack a degree of health literacy or be unable to make an informed decision either independently or with the support of advocates working separately of the provider(s).

Nurses have the capacity to make a significant contribution to the operation of the NDIS. However, operating in a narrow frame rather than providing care to their scope of practice through a holistic approach to disability care both constrains what nurses can offer and the level of care participants receive. More broadly this would limit the attractiveness of the NDIS as career choice – and most importantly does not support and help those for whom the NDIS was developed – those with disabilities.

A summary comparison of nursing line items is provided in Table 1 below (NDIS, 2022). In the full document, these roles and associated hourly rates are tabulated by times (weekdays, evening, weekends) and location per item (including by national remote and very remote). This table just provides rates for weekdays and national levels with a comparison of the costs for a carer providing assistance with self-care activities.

Table 1.

Delivery of Health Supports by NDIS workers - Weekday Daytime

Item no	Role	Hourly rate ($)
01_600_0114_1_1	Enrolled Nurse	89.17
01_606_0114_1_1	Registered Nurse	110.40
01_612_0114_1_1	Clinical Nurse	127.70
01_624_0114_1_1	Nurse Practitioner	157.90
01_011_0107_1_1	Assistance With Self-Care Activities	62.17

Clearly there is a difference in service cost – likely to be a major consideration of very small operations where short-term profitability must always be a consideration, particularly if clear role definitions required are not clear and there are limitations in resource availability.

One of the issues raised around the NDIS is its reliance in operation on the medical model of disability, which sees there is a medical issue that needs addressing for the participant rather than a more social model of disability that sees the challenge in supporting the participant to manage in society. While obviously there will be clear medical issues that a nurse can support the participant through there are many issues where the more holistic approach would be more practical and see also the nurse operating to the full scope of practice.

Pracilio et al., (2023) in an analysis of the representation of nursing in the NDIS makes focussed comments on the implications of the pricing arrangements.

The first key theme, ‘elements of nursing practice’ largely reflects the grouping and restriction of nursing within a medical model against the nodal point of the social model of disability. Two other major themes identified ‘hierarchies of nursing’ and ‘what nursing is not’, offer insight into how levels of nursing are fiscally valued against each other and coinciding professions, and what areas of practice nursing is excluded from due to its misrepresentation.

No detail is given to what such supports would look like when caring for people experiencing these conditions. Thus, the scope of practice of nursing under the NDIS is confined to medicalised/physical supports for people with disabilities. (p. 4)

concluding:

This misarticulation of nursing excludes key aspects of adaptive, therapeutic, and holistic practice which can improve health outcomes for people with disabilities. (p. 127)

Nursing is represented differently to other providers, valued at a lower fiscal rate than comparative professions and much of the nursing scope of practice is not enabled as nurses are excluded as eligible providers. (p. 132)

An impact of this approach is seen in research using an Australian based case study of a disability patient (Wilson et al., 2021) as a means of exploring the value of full roles. This study develops four scenarios around a real participant living in supported care. Scenario 1 is based on actual care under a RN, Scenario 2 includes care by RNs and advanced practice nurses, and Scenarios 3 and 4 removing nurses from the patient’s care altogether and instead relies on unregistered care workers. The focus of the analysis is on the levels of hospitalisation that are required under different care models.

The findings from this analysis highlight the issue of the difference in contribution such skills can make and also the issue of costs and who pays them. The analysis (p.12) compares costs across the scenarios, concluding:

that the financial cost saved by the disability service in Scenarios 3 and 4 is shifted to the acute health care service, through increased emergency presentations and admissions. This shift might have some benefits for the disability service, for example, by making the disability service more financially sustainable. However, shifting expenses to the acute health care sector is potentially disadvantageous to that sector, for example, in terms of patient load, and to the tax payers who fund it. Either way, the financial cost of care does not disappear, it is simply redistributed between services.

Thus, while the individual provider might be able to achieve savings employing only unregistered care workers, this ultimately won’t save on costs to the system overall. The absence of nursing care is likely to be associated with far more stress for the participant (and family) associated with less stable care coupled with the stress of unpredictable transfers for emergency care, and costs to the overall health care sector.

This highlights potential differences from different levels of quality of care and also the importance of enabling nurses to operate to the full scope of practice – thus contributing to the cost effectiveness of the operation when a more holistic approach is taken. Also under a purchaser provider model, as developed in the NDIS services, particularly under a medical view of disability, care is defined under discrete identified service items. On the other hand, a more effective approach may be seen in a more holistic approach to disability that includes the development of a relationship with providers and empowering nurses to operate within their full scope of practice (Australian Federation of Disability Organisations, 2018).

And from a more strategic perspective, particularly where the health sector generally is facing significant funding and workforce pressures, the need for the adoption of a systems view is critical. This needs to recognise that the many areas that deliver healthcare - public hospitals, private hospitals, primary health care, aboriginal and Torres Strait Islander community-controlled health services, other privately operated health services (e.g., RFDS and pharmacies) aged care, NDIS – are all related, but not interconnected, and in many cases not communicating. The extension of this perspective is in considering both the costs and outcomes of the health system – a system paid for by taxpayers and who also are the systems’ consumers. In considering reforms to the NDIS the QNMU would encourage, as a priority, the greater adoption of a wellbeing frame, one that takes a more holistic perspective of health and a more systems approach to health delivery.

Work environment and organisation

In looking more long term at the involvement of nurses within the NDIS sector a key issue is the workplace conditions. And given the significant current and emerging staff shortages in the health sector these are real considerations for staff considering work options.

Before commenting on specific issues relating to work environment it is useful to reflect on views of services providers – which is likely to also be reflective of the situations faced by nurses working in the sector. An overview of views on the operation of the disability sector was provided by the National Disability Services in their 2022 State of the Disability Sector Report (National Disability Services, 2022). Key points from respondents included:

43% agreed NDIS policy reforms are heading in the right direction.
39% confident that Quality and Safeguarding Framework supported quality of services.
36% of organisations predicting a loss in 2022-23.
11% agreed NDIS Pricing and Regulation are conducive to innovative services responding to participants needs.

83% reported problems recruiting disability support workers.

Such comments suggest a sector which is difficult in which to work, where the attraction of staff is difficult and with many small operators facing pressure on their financial viability, the specific work environment may have specific difficulties – factors reflected in a finding that 83% report difficulty in recruiting workers.

Another element of the NDIS environment, based around a large number of small providers, is in the nature of work of individual contractors and the capacity of the providers to attract adequate “resources” to operate and the nature of the operation of small businesses. At a more strategic level Baines et al. (2019) provides an overview of the system, commenting on the work environment under the NDIS thus:

In the extreme, many disability support workers end up working under especially precarious, “gig”-type arrangements: waiting to be instructed (often via digital platforms or smart phone) to attend the next client, with no continuity or stability in work, and no capacity to fully develop their professional capacities. A disability services program that organises support in the same manner as digital platforms organise fast food delivery or taxi services, is not likely to achieve the high standards of respectful, individualised support that the NDIS’s architects hoped for. And it will also be a very challenging place to earn a living. (Baines et al 2019, p5)

While not a work environment conducive to stability, this clearly also has a significant impact on those at the centre of the system – those with disabilities seeking support. And while this does not specifically relate to nurses, evidence suggest they face similar situations.

As further summarised by Baines et al. (2019) they note the new delivery model under the NDIS has been characterised by rapid casualisation of work, and fragmentation and individualisation of supports to many NDIS participants.

Such an environment is particularly difficult for the most vulnerable, in particular those with intellectual and other disabilities, and these are groups where the holistic approach normally associated with nursing practice has much to offer but is not aligned with the financial structures under which the NDIS is managed.

The comments provided here provide a focus on a difficult work environment – for both workers and also those being supported, with these insights aligning with observations the QNMU has made in representing affected members.

Occupational violence and aggression

A major issue regularly raised regarding the operation of the NDIS is that of occupational violence and aggression experienced by those working in the sector.

A report by Fiona Still (National Disability Services, 2022) includes reference to the Health and Community Services Union’s (HASCU) 2022 report on Safety in Disability with key points including:

More than half of respondents have experienced occupational violence in the last 12 months. Of those: 53.09% have experienced physical violence, 66.94% have experienced psychological harm.
Of those respondents who have experienced occupational violence in the last 12 months, the majority have experienced it multiple times.
Most incidents of occupational violence resulted in injury or illness (57%), with 76% reporting a psychological injury, and 31% reporting a physical injury. As a result of occupational violence, 45% of those impacted sought medical help from a GP, and over 20% required prescription medication.

These findings align with reports within QNMU and other research findings indicating that there is a high level of occupation violence experiences by workers in the NDIS sector. Research by Ho (2021, p 75) examining the health and safety provided details from interviews where workers identify some of the aggression relates to inappropriate understanding of the carer’s roles:

Physical and verbal aggression directed at workers from participants, often in the form of verbal abuse, being hit or scratched, spat at or having items thrown at, was noted to have increased. Interviewees explained that this change often arose from participants’ understanding and impression of the power given to participants under the person-centred care model.

And this is likely to be increasingly a problem where services are provided through small organisations, in an environment where the expectations and roles of different players are not well clarified. Further, unless there is a shift in focus it will always be difficult to provide a holistic approach when the profile of many of those receiving support (from a model) is that it expects them to operate as the purchaser of services rather than recipients of evidence-based health and supportive care.

Workforce Issues

The above issues lead to a general consideration of workforce issues. We currently face a huge health workforce strain not only in disability care but also aged care, hospital and other health services.

While nurses form a critical element of disability services, as with other service providers where they are employed around specific services under multiple small providers the capacity for stable structured positions is limited. Thus, the system requires staff to frequently work on almost a casual basis under what are quite precarious and unstable work conditions in areas faced with high levels of occupational violence.

Groups requiring special care

While those accessing disability care may well face particular challenges it is important to specifically consider groups where additional challenges, whether culturally, socially or geographically, will be faced. The nature of how the NDIS operates is likely to exacerbate these problems.

The availability for services in rural remote areas, for example, is likely to be lesser, and clearly for an approach that is operating under the concept of a market it will not be able to gain the assumed benefits of market operation where there are limitations in services provision - thus in areas such as rural remote Australia.

First Nations people, particularly where many are located in regional and remote areas will face both the difficulties of available services and the particular needs of culturally appropriate services. Given recognised issues in the provision of culturally appropriate services within the broader hospital systems the available provision of such services for disability support does need specific attention.

And finally, specialist training is always required to recognise and address the complexities of disability support – both from, the complexities that each person faces alongside their often-multiple needs or issues. In supporting all disabilities a strong consideration of the personal needs and issues of the participant is needed, those with intellectual and communication difficulties are likely to face particular challenges in negotiating the system itself hence the earlier concerns about the manner in which relevant frameworks are intended as these approaches fail to recognise that there are participants who can have that degree of ownership or empowerment on matters relating to their healthcare or support services. Even in acknowledging the care needs for many participants, the continued approach of viewing participants as purchasers of a service not only dismisses the person as an individual it devalues the legitimate care they require to ensure that person lives a life that has quality.

Regulation

The area of regulation in the NDIS covers a range of aspects. A review of regulation disability services by Hough (2012) does provide some insights into this issue. Clearly there are a range of aspects requiring some level of regulation – but also there are associated processes through which this can occur – thus the rights and interests of NDIS participants are protected by both general laws and also the NDIS regulatory system.

A first level is all providers, whether registered or unregistered are subject to NDIS Codes of Conduct. But registered providers have additional regulation through NDIS rules and practice standards.

As explained by Hough, the NDIS regulatory system combines a balance of rule and principle-based regulation. However, both approaches have strengths and weaknesses regarding the impact on the system and also the participants. The NDIS

system is also based around an extensive audit system to check the quality of service provision. Hough (2021, p 106) summarises some of the compromises between different approaches:

For example, rule-based approaches might increase precision but also increase the risk of unintentionally creating loopholes. External regulation might increase compliance by the ill- motivated provider or worker, but if applied inappropriately might result in a focus on compliance rather than on excellence. Responsive regulatory strategies might be an efficient use of resources and increase system-wide impact, but also lead to allegations that a regulator has had a weak response to the particular case.

Given the direct effect of the operation of the NDIS on the lives of those most vulnerable in society it is important that further consideration of these approaches are made, taking into account the real practical implications is a critical step. From the perspective of one professional area, nursing, that contributes to NDIS outcomes, clearly further consideration of the more effective use of such skills and the delivery of their full scope of practice through a holistic approach, has the potential to significantly contribute to positive outcomes. To this end, there are a range of professional matters that need consideration as it relates to nursing care. As previously noted, the NDIS providers already have the option of providing nursing services through the funded line items as it relates to the relevant level of classification. It is important to note that where services are provided by an EN or non-registrant care worker, the professional obligation to supervise (directly or indirectly) the care and practice of these groups is important for NDIS funding to be inclusive of the RN in this governance role which ensures participants risk is minimised and outcomes are improved.

References

ABC (2022). Service providers rorting the National Disability Insurance Scheme being targeted as a part of a new crackdown, retrieved 16/6/23 https:// ABC News - Service providers rorting the National… | Facebook

Australian Federation of Disability Organisations (2018). Medical model vs. Social model of disability, accessed 12/6/23 https:// Medical vs Social Model of Disability (afdo.org.au)

Baines, D., MacDonald, F., Stanford, J., and Moore, J. (2019). Precarity and Job Instability on the Frontlines of NDIS Support Work, The Centre for Future Work at the Australia Institute.

Ho, W. Y. C. D. (2021). Evaluating the impact of the NDIS on the health and safety of Australian workers in the disability sector, M Phil Thesis, University of Queensland.

Hough, A. (2021). Regulating disability services: the case of Australia’s National Disability Insurance Scheme quality and safeguarding system, Research and

Practice in Intellectual and Developmental Disabilities, 8:2, 99- 110, DOI: 10.1080/23297018.2021.1942176

National Audit Office (2012). Delivering public services through markets: principles for achieving value for money, National Audit Office Principles Paper, June 2012, https:// Delivering public services through markets: principles for achieving value for money (nao.org.uk)

NDIS (2016). NDIS Market Approach – Statement of Opportunity and Intent, November 2016. https:// PB Statement of Opportunity and Intent PDF.pdf

NDIS (2020). National Disability Insurance Scheme, Annual Financial Sustainability Report 2020-21.

NDIS (2021). NDIS Practice Standards and Quality Indicators, November 2021, Version 4, https// NDIS Practice Standards and Quality Indicators (ndiscommission.gov.au)

NDIS (2022). Pricing arrangements and price limits, 2022-23, Version: 1.1.

NDIS (2023). Australia’s national disability insurance scheme (NDIS) Act, retrieved 16/6/23 https://Australia’sNationalDisabilityInsuranceScheme(NDIS)Act-PeoplewithDisabilityAustralia(pwd.org.au)

NDS (2022). State of the Disability Sector Report 2022, Factsheet. https:// SoTDS_Factsheet_2022.pdf (nds.org.au)

National Disability Services (2022). Addressing Occupational Violence in the Victorian Disability Sector: An overview https:// Addressing Occupational Violence in the Victorian Disability Sector: An overview (nds.org.au)

Pracilio, A., Wilson, N. J., Kersten, M., Troller, J., N. & Cashin, A. (2023). A discourse analysis of the representation of nursing in the National Disability Insurance Scheme pricing guide and eligibility criteria, Collegian, 30 127 -133.

Wilson, N. J., Reeve, R., Lin, Z., & Lewis, P. (2021). The Financial Costs of Registered Nurse-Led Relationship-Centred Care: A Single-Case Australian Feasibility Study, Disabilities, 1, 331-346.

NDIS General Issues Inquiry

The Joint Standing Committee on the

National Disability Insurance Scheme