Joint Standing Committee on the National Disability Insurance Scheme

PO Box 6100, Parliament House, Canberra ACT 2600.

23 September 2020

SUBMISSION: GENERAL ISSUES AROUND IMPLEMENTATION & PERFORMANCE OF THE NDIS

This Submission asks the Committee to consider:

Is the National Disability Insurance Authority’s proposed Independent Assessment Panel (IAP) model the best model to assess eligibility for the NDIS, in terms of cost effectiveness, evidence-base and reasonable outcomes for Australians with a disability?
Does the proposed eligibility screening process provide quality, safe and accurate assessment provided by suitably qualified assessors, that can guarantee matching funds to reasonable and necessary needs for Australians with a disability?
Does the proposed IAP model introduce potential for harm or adverse outcomes for NDIS applicants and participants, particularly those experiencing psychosocial disability?

This submission is written from an occupational therapist and mental health professional perspective. Occupational therapists offer a key contribution to NDIS participants through our focus on the person’s function in daily life and on the outcomes of social and economic participation (Occupational Therapy Australia, 2017). Our professional training includes focusing specifically on functional capacity assessment and functional assessment. Our work is aligned with the World Health Organization International Classification of Functioning, Disability and Health (WHO ICF) and is highly compatible with the social model of disability as it is articulated in the NDIS Act 2013.

BACKGROUND

The proposed IAP model was announced by the Minister for the NDIS on August 28th, 2020. The IAPs are panels of NDIA-contracted assessors whose role is to facilitate the provision of assessment services. These assessors use standardised assessment tools, delivered in a single assessment session, without input from existing service providers. They determine eligibility for the NDIS for Australians who are seeking to become participants and for those individuals who are already participants, including on an ongoing basis as their life circumstances change. These assessments will not include recommendations for reasonable and necessary supports for Australians with a disability.

Occupational Therapy Australia (OTA), the national peak body representing occupational therapists made a statement at the OTA Virtual Exchange 2020, September 7th, highlighting concerns around the relevance and scope of the proposed eligibility screen, the lived experience impacts on consumers, the process for determining eligibility and the effectiveness of the tools being used to determine eligibility. While OTA has been reassured that it is an eligibility screening process and not a functional assessment, the NDIA continues to use terminology pertaining to functional assessment, a practice that misleads all stakeholders.

OTA was not consulted on the development of the proposed IAP model.

Where is the cost-analysis for the proposed IAP model?

The cost-analysis for the proposed IAP model relative to other comparative models of assessing eligibility for the NDIS, or other approaches to streamline functional assessment, if completed, has not been made publicly available. The proposed IAP model involves funding a new national service infrastructure, a costly exercise, particularly in the absence of evidence such an approach will meet the needs of the NDIS or Australians with a disability.

Where is the evidence for the proposed IAP model?

The proposed IAP model has not been researched in the Australian context or internationally. A trial of IAPs began in late 2018. Participants of this voluntary pilot complete a functional assessment with an independent assessor using standardised assessment tools. The pilot program was discontinued in March 2020 due to covid-19 (NDIS, 2020). No final report has been distributed or communicated to stakeholders. Of the pilot scheme participants, only a small number of individuals (40) had a psychosocial disability. These were volunteers and self-selected, therefore they are unlikely to be a representative sample of the broader group of people with psychosocial disability, many of whom have difficulties with self-advocacy; navigating systemic processes independently; and have complex needs.

Why were people with disabilities and other stakeholders not consulted?

There has been an absence of consultation with people with disabilities and other stakeholders in the development of the IAP model. This approach is contrary to the ethos of the United Nations Convention on the Rights of the Person with Disability (UNCRPD), which Australia signed in 2007; and contrary to the ethos of the National Disability Strategy 2010- 2020 (2010), both of which emphasise the inclusion of people with disabilities in decision- making, and active participation in designing systems that support them.

Mental health occupational therapists value the person’s perspective in designing, planning, delivering and evaluating services; and they support co-production principles. Co-production validates and utilises strengths of the person with lived experience of psychosocial disability (Roper, Grey and Cadogan, 2018), and is closely aligned with a recovery orientated practice framework (Department of Health, 2011).

How was the IAP model conceptualised?

The rationale for developing the current proposed IAP model above other comparative models of assessing eligibility for the NDIS, or other approaches to streamline functional assessment, has not been made publicly available. Statements indicating that the IAP model was recommended by the Productivity Commission (2011) or the Tune Review (2019) are misleading. The Productivity Commission (2011), recommended ‘needs based assessment’ which included recommendations for funded supports; and the Tune Review (2020) recommended improved planning processes. Significantly, neither of these documents recommmended or prescribed the IAP model as the preferred approach to eligibility assessment or functional assessment.

IS THE PROPOSED IAP MODEL APPROPRIATE AND FIT FOR PURPOSE?

2.1 Does the IAP model hold potential risk of harm to people with disabilities?

Should the eligibility assessment process outlined in the IAP model be rolled out nationally, it would need to be a parallel process to screen for harmful impacts. There is precedence for potential harm associated with large-scale benefit-eligibility assessment delivered through checklist-based assessment.

For example, in England between 2010 and 2013, just over one million recipients of disability benefit had their eligibility reassessed using a new functional checklist. A research study concluded that the program of reassessing people on disability benefits using the checklist was independently associated with an increase in suicides, self-reported mental health problems and antidepressant prescribing. The reassessment process was associated with the greatest increases in these adverse mental health outcomes in the most deprived areas of the country, widening health inequalities (Barr et al, 2015). In addition to potential harm, thi sstudy highlights the potential of such a program to widen existing health inequality. Thi sstudy’s authors recommend that health professionals advocate for a well-designed trial to clarify the benefits and harms of these disability assessment policies (Barr et al, 2015). Pote ntial for harm for people with psychosocial disabilit yis outline dini section 3.1. below.

2.2 Is the assessme ntprocess fit for purpose?

As described above, the proposed mandated IAP assessments in their current form do not constitute a complete functiona lass essment or functio nal capacity ass es smen t.The p roposed I AP as sess ment proce ss will have limited utility beyond eligibilit yas ses sme nta , as it does no tinclude recommendations fo rsupports . As th efinalised suite o fchosen asses sments has not yet been confirmed by the National Disabili tyInsurance Agency, their suitability for assessing eligibility for the NDIS as i ti sd efined b yt heNDIS Act (2013) cannot be addressed in this document. However, no curren tevid en ceex iststo confirm tha td isability canbe measuredor assessedby a suiteof pre-selected,m an dated asses sment tools,inthe absenceo fh ealth professional interpretation,absence of historicaland developmental contextanda bsenc eof input fromcurrent support providers.

Functional cap acity assessment requires the exercising of the occupational therapist’sprofessional judgement to choose assessment tool sand interpretassessment findings and make recommendatio ns,i nth ec ontext oftheperson’ slife journeyande pisodic fluctuationsinfunction.Itn eeds toi ncorporate the perspectiveofthe personando those offtheir family,c arersan dclinical ano ther care-providers.Acomprehensive approachto functionalcapacity assessmen tlead stotailored recommendation soutlining reasonablea ndnecessary suppor tn eed s–thereb ysuring supp ort plans arenot over or under-funded.

2.3 Is there potentialfor unnecessary and costly duplication of ass ess ment?

The proposed IAP assessment process will have limited utility beyond eligibilit yassessme nt, as it does not include recommendations for tailored supports.The participantwill needadditional as sessm entandin putfrom allied health professionals to identify anda ttai lort ailorsupports toe nable themtoreach their goals.Therefore,the introduction o ftheI AP is likely tob et ime-consuming ,costly a ndpotentially distressingduplicationofas ses smen tfor th ep articipant.

Can the assessment process guarantee reasonable and necessary supports are funded accurately?

It is unclear how the independent assessment will interface with decision making processes informing the participant’s funding. Full transparency on these processes would enable more comprehensive analysis of the IAP model as a whole. If the aim of independent assessment is to reduce disability to a single number or algorithm for administrative purposes, then it may be fit for purpose in its proposed form. However, this is not a functional assessment and does not provide tailored recommendations that match the person’s essential disability support needs to reasonable and necessary supports.

Will the IAP assessments be delivered by suitably qualified assessors with disability-specific expertise?

Assessments need to be delivered by skilled and experienced assessors with disability-specific expertise. It is essential that assessors are skilled health professionals, who are very clear on the understanding of functional capacity as outlined in the NDIS Act 2013 and who have the ability to assess fully the impacts on self-care, communication, social interaction, learning, mobility and self-management.

Is the proposed IAP model trauma-informed?

Trauma-informed approaches to service delivery emphasise the physical, psychological and emotional safety of the person, and they recognise that past trauma impacts the person’s ability to engage. The expectation that a person with a disability meet with a mandated assessor, a stranger, to complete a series of standardised tools to assess the impact of disability, for the purpose of making decisions around access to essential supports, has the potential to be a highly stressful and even traumatic experience.

Occupational therapists recognise the impact of trauma on the individual, group and community, and its impact upon mental health. A trauma-informed approach places emphasis on recognising trauma within vulnerable populations and the impact of trauma of occupational, social and economic participation (Edgelow et al, 2019).

Are there concerns regarding the timing of rollout of the proposed IAP model?

Currently, people with disabilities are grappling with the significant impact of COVID-19 on their lives and support systems. This is particularly the case in Victoria. People with psychosocial disability are disproportionately affected by social isolation and disconnection due to COVID-19 social distancing and restrictions. Introducing change to NDIS processes in the current climate adds to the challenges already experienced by this group and further increases the risk of adverse mental health outcomes.

3 MAJOR CONCERNS FOR PEOPLE WITH PSYCHOSOCIAL DISABILITY

A proportion of people who experience significant mental health difficulty also experience ongoing, and sometimes permanent, barriers to occupational, social and economic participation. This is termed psychosocial disability. People with psychosocial disability currently represent approximately 12 per cent of participants accessing the NDIS.

3.1 Risk of harm

As described in section 2.1 above, international studies evidence the potential for harmful outcomes, when disability assessment is conducted via point-in-time standardised checklist by a mandated assessor. These harmful outcomes include increased rates of suicide, increased mental health impacts and increased reliance on prescribed medication (Barr et al, 2015). These outcomes are likely to be amplified in the cohort of people with psychosocial disability, who are frequently vulnerable to mental health decline, have increased need for prescribed medication and increased risk of suicide.

Further evidence of harmful outcome in the Australian context would be an increased reliance on the acute mental health system through crisis or hospitalisation, as a result of distress and mental health decline triggered by engagement in a mandated assessment process, or by inadequately funded psychosocial disability supports. Inadequately funded psychosocial disability supports can result in mental health decline leading to unnecessary, costly and distressing hospitalisations or crisis-service engagement. The introduction of the proposed IAP model, or any significant change to existing processes to formal assessment for NDIS eligibility purposes, would require close surveillance at the population level, and monitoring at an individual participant level, to ensure risk of harm is understood and minimised. Further, the interface between NDIS supports and clinical or acute mental health services requires scrutiny and cost-analysis, to fully understand the implications of changes to NDIS eligibility and funding structures.

3.2 Risk of mandated assessment becoming a barrier to accessing the NDIS

As described above, the assessment process has the potential to be a stressful or even traumatic experience. Assessment processes that focus on deficits and impairments can be inherently triggering or distressing for people living with psychosocial disability. Assessors will require skill in risk assessment and have a duty of care to provide advice, support, and adequate follow-up for people undergoing the assessment process. In addition, many people with psychosocial disability have histories of involuntary treatment or involuntary hospitalisation, or experiences with assessments that have resulted in loss of freedom or dignity. This group is particularly vulnerable within the proposed IAP model, and requires a more tailored, trauma-informed, person-centred approach, ideally delivered by known and trusted providers. Without this in place, they may withdraw from, or have difficulty engaging with, assessment to determine eligibility for the NDIS. In this instance, the assessment process becomes a barrier to accessing the scheme and places them at risk of mental health decline and adverse health outcomes. Research is required to explore the impacts of mandated assessments on access and engagement pathways for people with psychosocial disability and other complex and hard to reach groups.

3.2 The need for best-practice functional assessment processes

The proposed IAP assessment process will have limited utility beyond eligibility assessment.

People with psychosocial disability require access to functional capacity assessment processes built on a foundation of quality, safety and accuracy. This approach ensures functional assessment results in a set of clear, reasonable and necessary recommendations for support.

People who live with severe and enduring mental health conditions frequently experience fluctuations in their functional capacity. Many need strong support factors in place to stay well and maintain optimal functioning. A range of factors can influence this balance and impact on functional capacity. Assessment processes need to capture these factors, once again there are risks for serious decline in mental health and functioning. Functional capacity reports need to include detailed, tailored recommendations, and accordingly, NDIS support plans need to have flexibility and be highly tailored to individual needs.

Standardised measures are important, however the use of professional judgement to choose the appropriate tools to accurately highlight these fluctuations in individual circumstances is imperative. A broad spectrum of practice frameworks and practice tools, including therapeutic interventions and assessments, are at the disposal of the mental health occupational therapist, enabling the therapist to tailor and individualise an approach with each client, unique to the client’s functional and occupational needs. Tailoring intervention and assessment strategies reflects professional judgement and client need and may include a combination of observation-based, interview based and performance/task-based tools.

People who experience significant and substantial mental health difficulty and functional capacity frequently require collaborative care, with many professions and services required to work together to provide optimal care. The Australian Occupational Therapy Competency Standards (2018) identify collaborative care approaches as a key competency for all occupational therapists. Occupational therapists value partnership with the person, and working towards the person’s self-identified goals, to support the person on their recovery (Fontaine, 2019).

3.3 The need for appropriately skilled and experienced assessors

Assessors are required to be skilled mental health professionals, who are very clear on the understanding of functional capacity as outlined in the NDIS Act 2013 and who have the ability to assess fully the impacts on self-care, communication, social interaction, learning, mobility and self-management for the person with psychosocial disability. For comparison, to provide services under Medicare Better Access to Mental Health Scheme (BAMH), qualified occupational therapists are required to have a minimum of two years’ experience in a supervised mental health setting before applying to be endorsed to provide care under a Mental Health Care Plan. If this is the benchmark for Medicare-funded mental health programs, similar standards are surely needed for NDIS participants.

The Australian Occupational Therapy Competency Standards (2018) identify the recognition of power imbalances in the client-therapist relationship as core practice competencies for all occupational therapists. Development and benefits of a therapeutic relationship must not

CONCLUSION

In light of the articulated concerns regarding the proposed IAP model and the mandated eligibility assessment, and the substantial concerns for people with psychosocial disability, including risk of harm, mental health occupational therapists seek that the NDIA review its plans to roll out the model nationally and ask for further consultation on model alternatives or adaptations.

One alternative model is the development of a functional assessor endorsement program that appropriately skilled and experienced allied health professionals could choose to undertake, to qualify them to offer functional assessment compatible with NDIS needs, while retaining their professional judgement in the completion of individual participant assessments. The model would not require costly establishment of a new national service infrastructure, as it would use the existing provider base. This would ensure functional assessments are completed by experienced allied health professionals, including mental health professionals for people with psychosocial disability. An assessor endorsement program would meet the NDIS requirements of a more consistent approach to assessment, while enabling participants and applicants to retain choice and control of provider. This model would prevent costly duplication of assessment process, as the functional assessment would include tailored, needs-specific recommendations for supports. Conflict of interest concerns could be mitigated by the assessor being prohibited from therapeutic support or services in the proceeding term of the NDIS-participant support plan.

WRITTEN BY: Muriel Cummins, AHPRA-registered Mental Health Occupational Therapist NDIS-registered provider of therapeutic support

NOTE: This submission also summarises the perspectives of a large cohort of mental health occupational therapists.

REFERENCES

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