NDIA Accountability Project

Challenges to NDIS participant plan adequacy and consistency

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23rd October 2019

Illawarra Forum Inc. ABN 95 589 148 519 PO Box 158 Oak Flats NSW 2529

Joint Standing Committee on the National Disability Insurance Scheme P: (02) 4256 4333 PO Box 6100 Parliament House Canberra ACT 2600

E: ndis.sen@aph.gov.au

Inquiry - General issues around the implementation and performance

of the NDIS

The Illawarra Disability Alliance (IDA) is pleased to provide a submission to the Joint Standing Committee on the National Disability Insurance Scheme in regard to general issues around the implementation and performance of the NDIS.

About Illawarra Disability Alliance

The Illawarra Disability Alliance is a group of Not for Profit disability specific providers working together collegially and collaboratively to deliver better outcomes for people with disability in the local community.

Background

We preface our comments about the overall success of the implementation of the NDIS in our region with a statement of utmost support for the NDIS in delivering choice and control for people with disability.

While we, as not for profit registered NDIS service providers, strive to deliver the reasonable and necessary supports to enable people with disability to lead great lives, we face key challenges in the areas of Plans, Pricing Structure, Portal, Workforce and Policy.

For many NDIS participants and disability service providers, the barriers that prevent the successful implementation of the NDIS relate to quality, consistency and flexibility. Quality and consistency in plan content, plan decision making and plan funding allocation; and flexibility in acknowledging that people with disability, particularly those with complex care and support needs may regularly require additional funding for each NDIS plan to provide for emergency or unforeseen crisis situations.

In addition, we have identified that many carers supporting people with a disability have limited capacity to manage an NDIS plan, or in some cases even ensure that the NDIS participant is actively engaged. Carers need more frequent and higher levels of support in understanding, advocating for,

Illawarradisabilityalliance.org

engaging in and assisting in developing and implementing NDIS participant plans. Currently disability service providers are spending unfunded and unremunerated time and resources to provide education and support to carers, and to assist carers and PWD to seek plan reviews and upgrades.

Participant Plans

The requirement to enter into service agreements every year, or even two years, significantly increases the administrative burden and costs for disability service organisations and puts strain on participants and carers as they gather, generate and input information into the process. The benefit of these regular plan reviews for NDIS participants is still unclear, indeed such short term planning inhibits individual capacity building. One year is not long enough, in most cases, to reach a goal, but then plans are reviewed and new goals are set for the next plan.

IDA members do not, however, support the 2 or 3 year plans which NDIA has been introducing. Evidence demonstrates that where people have gone from a 1 year plan to longer plans, the overall amount of supports in the plan has been reduced. For example, a participant with a 1 year plan worth $55,000 may only be given a new 2 year plan totalling $90,000 for the whole 2 years. Instead, we propose the Core Plan model as detailed model below.

The Core Plan model will also address another key issue with the implementation of the NDIS, the unfunded work undertaken to educate and support participants, communicate with planners, follow up on plan gaps, quote for services, and work with participants to individualise a wide suite of services, determine budget affordability, draft service specification and have each service agreement signed off.

Core Plans would also address the impact of the “churn” in plan reviews which often results in claiming errors. Gaps in plans and overlapping plan dates contribute to a high rate of errors and loss of revenue for providers. The cycle of manually claiming for smaller amounts often more costly for providers to navigate than it is to simply write the debts off, this provision of unremunerated services, however, cannot be sustained.

Plan inadequacy and lack of consistency continues to be a problem, with some participants finding that key components have been omitted from plans, resulting in immediate plan reviews and even more “churn”. The lack of cross checking for errors such as plan gaps and omissions of key aspects adds to the administrative burden for service providers, as plans are sent back for review early and the provider is required to start again in setting up billing and rostering systems in line with the reviewed plan.

The 12 month time frame also fails to allow for the development of quality systems for structured participant capacity building and outcome measurement. For instance, capacity building is often established to meet goals in Year 1 plans but removed in Year 2 even if progress is being documented. The impact of this is a system that provides more “care and support” options and less opportunity to deliver on the promises of the Productivity Commission around increased social and workforce participation. In the same manner, the reduced focus on employment during planning processes also hinders the realisation of the scheme’s promise.

Recommendations

  • Adoption of 5 year Core Plans which include annual indexation.

  • Increased training of LACS and agency planners to;

    • deliver quality plans that demonstrate consistency amongst a similar participant cohort;
    • eliminate errors such as gaps in plan dates and non-intentional omissions;
    • ensure that core supports are considered holistically alongside the consideration of SIL quotes so that shortfalls don’t arise requiring immediate reviews
    • provide for better assessment of participants’ capacity building needs and employment goals.

  • NDIA agency planners to complete plans for all new or complex participants to remove the ‘intermediary effect’.

Recommendation – Core Plans

The IDA proposes that participants should receive a properly constructed Core Plan which is based on 12 months of support. To ensure the credibility of the Core Plan, it should be subject to various appeals (if necessary). Any funding for capital expenditure with would not form part of a participant’s Core Plan but would be reviewed as their needs change.

Once the Core Plan is finalised, it should be indexed and rolled over every year. The Core Plan would simply be rolled over each year at its anniversary with indexation. If at the anniversary less than 20% remains unspent, the unspent funds would be rolled over into the next year’s plan. If, there is more than 20% of the plan unspent, the NDIA could review the plan to determine whether to:

  • Reduce the surplus because it is unlikely the participant will use it,
  • Permit the full surplus to be rolled over because the participant is likely to use it, or
  • Create a new plan with more realistic supports.

The Core Plan should be subject to review every 5 years, or if requested by the participant due to significant changes in circumstances.

The benefits of a Core Plan

  • Anecdotal evidence indicates that a transition from annual plan reviews to the stability of five year plans would be overwhelmingly welcomed by participants and their carers who report they find the current arrangements time consuming and bureaucratic.

  • Indexing all plans annually to cover indexation, TTP or other support price increases will provide stability and certainty for both participants and providers, and ensure neither are disadvantaged.

  • Reduces administration overheads for providers because they will not have to change service agreements with participants unless requested by the participant.

  • Less resource-intensive for Local Area Coordinators (LACs) and the NDIA, and overall savings for the NDIS due to reduced administrative burden. Releases LACs to take on more community development initiatives.

Plans - Transport

Transport, particularly in rural and regional areas, is essential to ensure participants are able to access the services and activities which are included in NDIS plans. The NDIS Price Guide 2019-20 has major gaps in the provision of transport supports. NDIS participants are expected to fund transport costs from Category 2 funding, provided they have it in their NDIS plan. Where there are no Category 2 or insufficient Category 2 funds are available they will not be able to access services or activities unless they can meet transport needs from their own personal finances. In rural and regional areas, where participants need to travel large distances, this cost would be prohibitive.

The current Price guide directly opposes advice from senior people within the NDIA over a number of years that individuals were able to use their plans flexibly across core supports in relation to transport. This same message of permitting, if not encouraging, flexible use of core supports has been reinforced to participants in planning meetings with NDIA staff and LACs.

This change in policy has resulted in significant repercussions from disappointed clients whose ability to access parts of their plan such as community supports is compromised when transport becomes unavailable or unaffordable. The inflexible consumption of Core Supports and the low value of the Transport Allowance will inadvertently lead to participants unable to reach the goals and outcomes of their NDIS plan. Many participants will simply be unable to get to services that were otherwise deemed reasonable and necessary.

A significant percentage of people with a disability do not have the personal finances necessary to independently travel to access the services they need, especially in rural and regional areas. The lack of alternative transport infrastructure and long distances make the costs of travel to access services preclusive. In regional and rural Australia, other costs to provide services are also higher making cross-subsidisation by providers untenable and potentially leading to further market failure in parts or all of the service system. Withdrawal of services will further exacerbate inadequate access to the supports necessary for participants in these communities to reach their reasonable and necessary goals.

The lack of capacity of a significant group of participants to pay for additional transport will have flow on effects on providers. Providers who offer transport to participants are likely to be exposed to higher rates of unrecoverable bad debts. Where providers continue to offer transport, back office systems currently positioned to support NDIS billing, including portal, plan and self-managed services, will need to be further resourced to support a new billing and cost recovery system dedicated entirely to transport.

This decision will also lead to further competitive advantage for unregistered providers. Participants who self-manage their funds enjoy a greater degree of flexibility, including the option of using unregistered providers to deliver core supports. In these cases participants are able to directly negotiate hourly rates (inclusive of transport costs) with unregistered providers and utilise their core supports to do so. This could potentially accelerate free market pricing for Core Supports and lead to a pricing gap between unregistered providers and registered providers, and expose vulnerable people to a greater degree of risk.

Recommendations

  • NDIA reverse its policy decision with respect to transport so that participants are able to utilise their plans flexibly to meet their reasonable and necessary needs.

  • Participants are permitted to charge both carer time and additional kilometres to core supports.

Price & Market

IDA members continue to be concerned about the inadequacy of the price point for one-on-one supports. The price point is particularly problematic for in-home personal care supports which are generally rostered in shorter shifts, contributing to the transactional costs of rostering and billing. Many providers are seeking to exit the personal care market over time or are reducing their exposure to the non-profitable elements of the rate card, which leaves participants who have high support needs opting for less desirable alternatives. While the IDA recognises that there is place in the market for cheaper platform-based systems of connecting carers and individual staff, we strongly reject the idea that platform-based systems offer the necessary protections or commitment to staff training and safety concerns that is required by more vulnerable people or those with high and complex care needs.

The other compounding factor in individual supports is that they often represent small monetary values that can be claimed for each shift. Claims errors continue to be a normal part of business, due to NDIA error or portal issues, providers tend to chase payment for larger amounts as their first priority. Significant amounts of accrued income due to hundreds of smaller claims errors are therefore often written off. The expense of rectifying large numbers of small value errors is often higher than the amount that can be retrieved. Non-payment for services provided is not sustainable, and the lack of a consistently applied approach to claims errors and payment represents a very real cost of doing business with the NDIS.

The issue of pricing is even more fraught in rural areas. The NDIA have implemented a price increase in acknowledgement of the challenges of rural service provision. The implementation of the price increase, however, adds even further to transactional complexity. Rather than increasing the base price per hour by a percentage amount to allow for a higher unit cost in rural areas, the new arrangement permits providers to dig into participant plans to enable a greater part of each individual shift to be billed for transport and travel time. For personal care, where shifts are already often too short, these now need to be “chopped up” further into different billable rates and items. This increases the number of transactions, requires further rostering, adds complexity to the business model that sits behind our billing system, and increases the already heavy administrative load.

A further area of concern is the intersection between rural rates and complexity rates which arises as a worker can be only graded at one level of the Award (usually the higher) despite needing to work across multiple parts of the rate card. In a regional or rural environment with limited workforce availability, further splitting the workforce into two grades of workers is not possible.

Issues with pricing are being exacerbated in some instances, by poor quality plan management. In some cases, plan managers appear not to recognise that their role is more than being data entry and payment clerks. The are not quarantining funds to pay for services in agreements, and when service providers seek payment for services provided, are being told there is no more money in the plan.

Recommendations

  • Increase the price point for one on one supports to a rate that reflects a viable service system for more vulnerable participants, based on level 2.4 of the SCHADS award for general disability support workers, and level 3.4 for one-on-one support for participants with complex behaviours and/or physical needs.

  • Rural rate increased through an adjustment to base price rather than adding transactional complexity by splitting already short billable units into two different rates for service shift and travel.

  • Rural rates reflect the need to provide complex care to a small number of participants.

Competitive Advantage for Unregistered Providers

As the NDIS continues to roll out across each state, there appears to be two distinctly different marketplaces emerging, one marketplace which is highly regulated and compliance driven, and another which is much more market driven with minimal regulation. Unregistered providers experience a competitive advantage as they do not need to account for costs of implementing quality systems or paying for the conduct of external audits.

Registered providers often have decades of experience supporting people with disability, and are used to working within a compliance driven environment. Operating as a registered provider within the NDIS environment, however, is like trying to operate with one hand tied behind your back. Registered providers are:

  • constrained by the limits contained in the NDIS Price Guide.
  • unable to deliver services other than those approved as part of the registration process;
  • required to meet very high levels of compliance in accordance with the Quality and Safeguarding Framework including practice standards, reportable incidents, code of conduct, worker screening, and complaints processes;
  • subject to the NDIS Quality and Safeguarding Certification or Verification audits – full audit every three years and light touch audits annually in between;
  • expected to have skilled and experienced staff who can deliver supports that meet the new quality and safeguarding standards (despite having insufficient funding available for ongoing training); and
  • obliged to use a portal which is flawed in design, problematic to use, and which has no flexibility to accommodate claims affected by NDIA or participant driven changes (change in Plan end dates for example).

Unregistered providers are part of an open market, and are able to operate much more freely. These providers are able to provide services (other than high risk or complex services) to NDIS Participants who self-manage all or part of their NDIS Plan. Unregistered providers who provide these services do so with:

  • no pricing constraints – the NDIS Price Guide does not apply to unregistered providers;
  • low compliance obligations – worker screening only where a participant requests it, a complaints management process, and compliance with the Code of Conduct.

Although unregistered providers are required to meet these minimal compliance obligations, the only way the NDIS Quality & Safeguarding Commission (the Commission) would know that the provider even exists is when they have received a complaint about that provider or their services. Unlike registered providers who are highly regulated, the Commission has no clear way to monitor unregistered providers other than by responding to those complaints. The Commission does not have the ability at present to measure the standard and quality of services being delivered by unregistered providers.

Recommendation

  • The Commission captures unregistered provider details by reviewing invoices and receipts from self-managing participants (ongoing).

  • As the Commission registers the details of unregistered providers in their system, they schedule an audit to:

    • Review whether the provider has a suitable Complaints Process in place;
    • View their National Police Check clearance (or) request one, with a copy of the results to be sent to the Commission;
    • View their Working with Children Check (where applicable) or request one, with a copy of the results to be sent to the Commission;
    • Complete and assessment to ensure the provider is compliant with the Code of Conduct; and
    • Have a process in place to notify participants where an unregistered provider has a high risk non-compliance.

Portal

Service providers have invested heavily in IT systems and resources in order to operate within the NDIA. Leveraging applications and software for rostering and claiming can deliver efficiencies, however the inadequacies within the portal, combined with the upgrading and constant changes to the portal have produced the reverse. The current system has created an uncontrolled environment and therefore, an inefficient system. It is now common for service providers to employ fulltime staff just to manage portal claim errors.

An analysis by a local Illawarra provider across around 500,000 NDIS shifts demonstrated that of all errors, 36% are due to service bookings being stripped out or prorated prior to claiming and 52% are due to service bookings being ended and not communicated. Additionally, there is an emerging trend to release plans prior to their natural end date, independent of a requested review. While this is an advancement over the previous situation which left gaps in plans, this nevertheless causes claiming errors as providers are unaware new plans have been released. Participants are also still learning the system and are not always aware of an obligation to notify the provider. By ending plans early, the

NDIA are also denying the participant the ability to fully utilise the funds associated with their reasonable and necessary supports.

It is not uncommon for clients to have ‘gaps’ in their plans. For example, a plan may end on July 1st but the new plan released on August 15th. The period from July 2nd to August 14th is therefore unfunded due to gaps in plans. To receive payment, providers must then work through the Provider Payment Team, which is a highly manual process. The Provider Payment Team equivocates in its advice between requests for manual invoicing and advice to await amendment in the portal at their end. While advice needs to be consistent, a more efficient arrangement is urgently required which would establish a system to prevent such gaps in plans from occurring.

Changes are made to the MyPlace Portal without prior communication to providers or associated software vendors, and changes are often made without rigorous testing, so something often ‘breaks’.

Providers are also unable to access a report of all their service bookings, their status, and the amount remaining. Having such a report would allow providers to be proactive around service booking revisions (stripping or ending) to avoid claiming errors. Providers could also make contact with participants in a timelier manner to follow-up on new plans. An automated notification system advising of service booking changes would also be welcomed.

Equally, providers currently have no ability to generate an ‘exceptions report’ showing where the NDIA has adjusted (pro-rated) service booking amounts, or has cancelled future service bookings for example. It is not realistic to rely on participants to notify providers of changes to service bookings or plan date changes, particularly as they are often unaware of the changes including unplanned earlier end dates themselves.

In addition to the direct challenge to providers of extracting useful reports for operating their own business models, it would seem that LACS and NDIA staff themselves are unable to generate historical reports of what has been provided to a participant. This means that providers are being asked to provide detailed reports from their own CRMs to take to plan reviews. In a market model where the provider has no assurance of ongoing business, this activity is both unfunded and with no assurance of any subsequent return. Assisting the NDIA and participant in this manner places ongoing burdens on providers and is contrary to a “participant facing” system.

The biggest improvement to the portal would come in the form of appropriate reports and the activation of web services or API technology that would facilitate live linkages to disability service providers’ CRMs. There is an effective precedent for such a system; the childcare management system (CCMS) that links to Centrelink has the capability to feed directly into software like qikkids and hubworks, making for a far more efficient billing process. In that environment the provider logs into the CRM to see changes to billing, not the portal, which is a simpler and more streamlined option.

It is important to note that non-registered providers who provide supports to self-managing participants are at a competitive advantage, not only because they are not bound by the same compliance obligations, but also because they deal directly with the participant. This means they do not need to access the portal, and are therefore not constrained by the NDIA portal system and process issues faced by registered providers, and they are generally not requested to provide reports to support participant ongoing plans.

Agency-managed participants, especially those with intellectual disability and those with older carers or from CALD backgrounds, have found the transition to the NDIS confusing and confronting. The

most common concern raised by ageing carers is the level of uncertainty they now feel. Many not only struggle with ICT infrastructure, but also their roles and responsibilities in the NDIS environment, and the future for their child. Opportunity costs for participants and their families may include a reduction in supports as they try to navigate an unfamiliar and complex system. Many people from a CALD background also require additional support through the process including managing portal interactions. Uncertainty about future supports and services and complexity of processes is particularly concerning for ageing carers.

The IDA expects that a similar opportunity cost has emerged for the NDIA itself, as the immediacy of problem solving issues such as those resulting from portal inadequacies have hindered investment in policy development and enhanced communication.

Providers incur significant monetary costs with the implementation of every ICT change. The costs of internal and external resources to generate, test and deploy changes in internal NDIS related systems should not be underestimated. Where systems are integrated, changes need to be tested against user stories across all platforms. This requires vendor input and generates costs in testing and implementation.

Many organisations leverage a best-of-breed rostering and claiming solution. Disappointingly, there appears a lack of collaboration between the NDIA and software vendors who deliver NDIS solutions. Vendors claim the NDIA are unable to share with them the MyPlace platform roadmap and therefore are unable to ‘future proof’ their software. As changes are released by the NDIA, service providers are required to develop ‘work-arounds’ until the software vendors can adapt their NDIS solutions. The general consensus is that there is not an overall plan for the MyPlace Portal, given the consistent change and lack of communication.

Transition to the NDIS has represented a complex period of change for service providers who multiple demands at the same time. These include providing quality participant experience, assisting long term participants to understand and navigate the new system, responding to new policy frameworks, recruiting, training and equipping an increasing workforce, and developing and refining their own internal business systems. Beyond this there is a need to be paid for NDIS work undertaken for participants and the issues in the portal which result in providers being forced to chase money rather than value adding in more meaningful ways. The diversion of key resources to support ICT systems and processes also means that providers are unable to focus on innovation and growth strategies within a highly competitive environment.

Recommendations

  • Enhance portal functionality to provide alerts when plans are ended prior to their intended expiration date.

  • Sufficient funds to be left in expired plans for legitimate claiming to be completed within the allowable 60 day period.

  • Improvement to portal functionality to either not permit gaps in plans or to provide alerts to NDIA staff entering non-adjacent plan start and end dates. In the short term it is recommended that NDIA staff are trained to more closely monitor start and end dates.

  • Implementation of a ticketing system to manage technical enquiries and record and respond to provider or participant support needs in a timely manner.

  • That a test environment be established for providers to test their systems interface when upgrading or changing their own software.

  • Portal functionality be developed for the generation of useful reports by providers, LAC and NDIA staff, thus removing the burden of continual extraction of data from provider CRMs.

  • Development of web services or API technology that would facilitate live linkages to disability service providers’ CRM.

  • Plan management only be proposed when the participant has requested it and where there is a legitimate need to access supports from non-registered providers.

  • Collaboration and consultation with software providers to find ways to make the NDIA Portal work more efficiently and effectively.

  • That the NDIA considers transactional complexity when designing business solutions and implementing changes that are intended to be favourable.

People and Workforce

The success of the implementation of NDIS is dependent on a number of market factors being stable and secure, such as the supply of a steady and sustained workforce to service NDIS participants and their various needs and service requirements, together with the need for disability support staff to be experienced and to be sufficiently trained.

The establishment and sustainability of a skilled and trained workforce within the disability services sector impacts the implementation of NDIS across our region, affecting both demand and supply complexities, and impacting disability service providers who now find themselves operating in an insecure funding environment (in terms of variations in year to year individual funding) which builds further constraints around workforce planning and spending. Many of our regional disability service providers are providing necessary but unremunerated support coordination to clients who are not funded for support coordination, which is clearly unsustainable and which further stretches an under-resourced workforce.

Workforce issues have a major influence on the quality and standard of support provided to NDIS participants. The pricing formula which applies Level 2.3 of the SCHADS Award is inadequate as it does not account for progression, and assumes a high level of staff turnover with organisations employing greater numbers of entry level staff. Clearly neither of these options is desirable for workplace culture and stability, or for quality service provision.

The impact of the poor pricing formula and incompatibility with the SCHADS award will be even more impactful with penalty rates. Especially for casual employees.

The disability sector is already being forced into an increased use of casual employees as we try to match workforce availability with participant needs. A highly casualised workforce will put at risk quality outcomes, particularly where service providers prioritise investment of their scarce resources into training permanent employees over potentially more transient casual employees.

Promotion of plan self-management for NDIS participants will also lead to a partial deregulation of the labour market as workers either

  • become self-employed contractors working for themselves;
  • are engaged by labour hire companies; or
  • are employed directly by the participant.

These arrangements will heighten the risk of exploitation of either NDIS participants by workers who are unregistered, or of support workers themselves, if there are not adequate safeguards introduced during the full NDIS rollout.

The disability sector needs to be able to offer good quality employment opportunities, not precarious employment, if it is to attract a stable workforce to support the NDIS. Senior and middle managers are finding themselves constantly under pressure and dealing with continual changes. Pain points are becoming business as usual as managers now finding themselves expecting to be working with pain and change. There is a high turnover in these roles and a reluctance from staff to take up higher roles because the pay increase is not worth the additional stress.

Recommendations

  • NDIA should establish a high level NDIS Workforce Forum made up of representatives from the NDS, Jobs Australia, ACCI, ASU, HSU and United Voice to develop strategies for building a skilled and adaptive workforce that meets the needs of participants within the system.

Policy

Current policy lacks often clarity, making additional work for staff who need to seek clarification. This, coupled with a reluctance in NDIA staff around putting anything in writing, means that issues are often open to individual interpretation.

Supported employment

The newly announced pricing model for employment support will, unless sufficiently changed, cause job losses amongst many Australian Disability Enterprises (ADEs) and put the most vulnerable people disabilities out of work.

Larger ADE’s in the Illawarra region have examined the new proposal and, based on their existing employees choosing to remain at their ADE, will have a loss of funding of over 20%. If this is the case the ability for these organisations to maintain current employment levels will be impossible.

The NDIA-announced funding model indicates that employment support pricing would be aligned to community support pricing. At the time of writing the report this was simply not the case. Applying an NDIS hourly rate will impact financial viability as a consequence of funding not being available when a supported employee is on annual leave, long service leave, public holidays, and in some cases sick leave. The community support pricing is higher and therefore compensates organisations when participants are off.

We believe the proposal needs to be reviewed to ensure its objective of sustaining and improving outcomes for people with disabilities in employment does not have the reverse affect.

Recommendations

  • NDIA does not proceed with a new pricing model until such time that the new model can guarantee employees of ADEs will not lose their jobs as a result of the new model.

  • Recognition that employment is a significant part of living a normal life and that this takes many forms including supported employment.

  • Implementation of an “Employment First” approach for all NDIS participants of working age by prioritising employment for all people with a disability who have been assessed and are capable of work. This could be achieved via an ‘opt out’ employment approach in plans, thus enabling people with a disability to commence work immediately or at any time during their plan instead of waiting for plans to be amended.

  • Targets set for employment in plans similar to the current level of social and civic plan activities.

  • Choice of employment options include and acknowledge supported employment via recognised ADE’s and that the NDIA and LACs encourage participants to take up supported employment.

  • Employment is identified as a valuable outcome and Australians Disability Enterprises are incentivised to transition participants from supported employment to open employment.

Undefined or poor intersection of state and federal responsibilities

For NDIS participants with complex care and support needs, the overlap between disability support, clinical support and nursing care is often intrinsically linked, and cannot be separated, particularly in relation to the undertaking and funding of daily self-care tasks, or to medical emergencies or mental health related crisis.

The inflexible nature of an individual’s NDIS plan which is capped for a 12-month period, and cannot have a ‘crisis’ funding component that can be utilised in such situations, not only places PWD in a vulnerable and high-risk care position, but also increases strain on the public health and hospital systems. In some cases, disability service providers are required to keep a PWD hospitalised until sufficient clinical support and nursing care can be guaranteed upon discharge, with either the disability service provider absorbing the cost, or the PWD receiving less supports later in the 12- month NDIS plan period due to funding being expended at a faster rate to cover the increased clinical and nursing care needs. Reports of NDIA review processes to recoup such funds indicate reviews have not occurred in a timely or conducive manner for the PWD and the disability service provider. This scenario creates an increased level of risk and uncertainty when providing NDIS services and supports to people with complex care and support needs.

Disability service providers across our region have a strong history of successfully managing the needs of people with complex care and support needs. This is exemplified through the historical management of the contract for delivery of weekend emergency and crisis care for people with disability who have complex care and support needs. Local disability service providers have expressed strong commitment to the continuation of such service provision, but this commitment must be matched by the necessary funding to deliver such specialised care. Such funding may take the shape of increased resourcing within individual NDIS plans, or be provided for through a State government funding model for which crises expenses are recouped through a rapid claims system.

In addition to high care and clinical support scenarios, people with complex care and support requirements may in some cases exhibit behaviours of concern. In this circumstance, they may become suspended from school or a place of accommodation (such as a group home) or employment. In such a scenario, the person with disability to support worker ratio is likely to increase in order to provide a higher level of support, with the aim for the PWD to re-enter school, accommodation, employment, etc. In most cases, the individual NDIS plan does not provide for an increase in supports throughout the 12-month plan life, and the PWD cannot gain access to the increased level of behavioural support, case management and supports that are necessary and required to rejoin and participate in their daily activities, until their plan is reviewed, which can take months.

There are many areas where individuals can ‘fall through the gaps’ between state-run services and the supports available through the NDIA. In particular, there needs to be agreement between the States and Commonwealth regarding responsibility for health care supports, particularly as related to complex disability non-medical treatment. For example, a child was suspended from school and obviously required services and supervision, but the NDIS refused to cover care as the child should have been in school. These situations are bound to be repeated as the child has behavioural issues which require additional support, but the NDIS isn’t funding additional supports in schools. The current situation leaves providers managing unacceptable levels of risk without assurances of adequate resourcing from Commonwealth or State.

The intersection with mental health services and the justice system, is also complex and requires a special focus. People with disability who exhibit extreme behaviours often find themselves dealing with police, and in many cases, are incarcerated when their behaviours would have been dealt with more successfully in the disability service system. Similarly, PWD who experience episodic mental health crises or suicidality, often end up in mental health services.

As previously highlighted, managing the intersections between disability support and state funded care and protection is particularly challenging for younger people requiring residential care to support the management of disability needs. The interaction of these young people with the statutory out of home care system places strain on the system, but most importantly, on families and young people.

Finally, touch points between state operated transport and education systems and the NDIS require clarity. More publically available advice is needed for providers and participants caught in the middle of disputed accountabilities.

Plan Management

Increasingly LACs and NDIA staff appear to be recommending to participants that they nominate Plan Management even when all services are being delivered by registered providers. This increases the administrative burden on all parts of the system as providers must generate invoices for Plan Managers, who then review invoices and claim to the NDIA Portal. Invoices are typically sent via email, manually interpreted and keyed into a bulk upload format or entered online. NDIS-registered providers should be able to leverage efficiencies in their software and upload claims to the NDIA Portal whereby a Plan Manager can review/approve these claims, rather than generating invoices for mailing/emailing.

Providers are also concerned with the number of participants who have plan managed plans without requesting a plan manager at their review meeting or requiring one to manage supports or to make purchases from non-registered providers.

As outlined previously, issues can be exacerbated when plan managers fail to quarantine funds to pay for services contained in service agreements.

Recommendations

  • More efficient systems for plan management are developed to review and approve claims “invoices” in the portal when participants are purchasing from an already registered providers.

  • Plan management is only proposed when the participant has requested it and where there is a legitimate need to access supports from non-registered providers.

Quality and Safeguarding

The disability sector welcomes the establishment of a Quality and Safeguarding Commission for the protection of human rights and the enhancement of quality participant experiences within the NDIS. To be successful in its quality and safeguarding role however, the Quality and Safeguarding Commission needs to engage with providers to understand the breadth of supports being delivered. The significant compliance impost on registered providers is yet to be considered. As an example, the use of chemical restraints (PRN) is not permitted unless endorsed in a behaviour support plan. This has meant that a child who uses a mild PRN under medical advice in the family home is unable to attend an upcoming sport and recreation camp with their peers over a long weekend. Removal of any medication at short notice is not an option nor is gaining a behaviour support plan when funding for this isn’t included in the child’s NDIS plan and when there is limited availability of specialists to undertake this form of work. Short term and limited duration activities such as short term accommodation (STA) require as much work and the same level of evidence including a full behavioural support plan (BSP) as does a SIL placement. This raises the likelihood of exclusion of people from vitally needed services that would otherwise, in the long term, facilitate their better inclusion in the life of the community.

Maintaining a quality management system is expensive and resource intensive and annual surveillance audits add to the cost. Most disability agencies employ specialist teams to collect and manage quality data, manage risks and complaints and to build rigorous reporting and monitoring systems internally. Non registered providers do not have to meet such an expense.

Currently the language and tone of the quality and safeguarding initiatives is punitive and there is a lack of proposals to build and support quality and embed best practice within the market. While the new Quality and Safeguarding requirements place a lot of the onus on providers to “comply” with the new framework there is a less well articulated piece of work around how participants are going to be empowered to choose a “good provider”. Given that we are creating a market based approach to services, there is more that can be done to support vulnerable participants to become knowledgeable about purchasing supports particularly in unregulated parts of the market.

Recommendations

  • Participant Plans have sufficient resourcing for behaviour support to allow the Quality and Safeguarding framework to be implemented.

  • Price point for services delivered by registered providers recognise the cost of operating within the requirements and the cost of auditing and compliance activities.

  • NDIA and the Quality and Safeguarding Commission recognise the need to support positive developments that enable quality services, the importance of building ethical cultures within the sector, and the support required for vulnerable participants to safely self-manage in a market environment.

  • That the Quality and Safeguarding Commission urgently address the vulnerability of participants and families that are self-managing in an environment with unregistered providers.

  • That independent mechanisms are in pace for monitoring and scrutiny of unregistered providers.

The Illawarra Disability Alliance thanks the Joint Standing Committee on the National Disability Insurance Scheme for the opportunity to raise the above-mentioned issues and concerns, and look forward to engaging with the Committee in the further discussion of and resolution of these issues. Should you require further information on any of the points raised in this submission please contact me on redacted or email at redacted

Sincerely,

Nicky Sloan On behalf of Illawarra Disability Alliance