Occupational -

Thera PY austratia

Australian Parliament

Joint Standing Committee on the National Disability Insurance Scheme

Inquiry into general issues around the implementation and performance of the NDIS

Occupational Therapy Australia supplementary submission

June 2021

Occupational Therapy Australia Limited

www.otaus.com.au

Introduction

Occupational Therapy Australia (OTA) welcomes the opportunity to make a supplementary submission to the Joint Standing Committee’s Inquiry into general issues around the implementation and performance of the NDIS.

OTA is the professional association and peak representative body for occupational therapists in Australia. As of March 2021, there were more than 24,600 registered occupational therapists working across the government, non-government, private and community sectors in Australia. Occupational therapists are allied health professionals whose role is to enable their clients to participate in meaningful and productive activities.

Occupational therapists provide services such as physical and mental health therapy, vocational rehabilitation, chronic disease management, assessments for assistive technology and home modifications, and key disability supports and services. As such, many occupational therapists provide services to National Disability Insurance Scheme (NDIS) participants.

The role of occupational therapists in the NDIS

Occupational therapists work with people with a disability and their families to maximise outcomes in their life domains, including daily living, social and community participation, work, learning and relationships. Occupational therapists are highly skilled in assessing the degree to which a person’s disability affects their level of function in daily tasks. Based on these assessments, occupational therapists make recommendations for, and then deliver, interventions that enhance and maintain an individual’s functional capacity.

Given their expertise and area of practice, many occupational therapists deliver NDIS funded services to participants. These services include, but are not limited to, functional capacity assessments, interventions to promote participation in daily living skills and independence, minor as well as complex home modifications, prescribing assistive technology and providing positive behaviour support.

OTA would like to draw the attention of the Committee to two issues of great concern to occupational therapists working with NDIS participants.

The NDIA’s use of assessment tools

Members of the Committee would be aware that OTA and the peak body representing allied health professionals in Australia, Allied Health Professionals Australia (AHPA), have documented their professional concerns regarding the inability of the proposed NDIS Independent Assessments to assess the functional capacity of people with disabilities (OTA 2021a; OTA 2021b; public hearing of 23 April 2021). In addition, in response to a question taken on notice, OTA has documented in detail why the Independent Assessment process lacks capacity to reliably inform funding decisions in participant plans (OTA 2021c).

It now transpires that long before the controversy around Independent Assessments, the National Disability Insurance Agency (NDIA) was utilising clinically flawed assessment tools

to determine participant plan budgets and, because of the agency’s culture of secrecy, allied health professionals were unable to alert the agency to this problem.

This came to light as a result of a question from Senator Steele-John, taken on notice by the NDIA on 18 May of this year (Reference IQ21-000015). The NDIA’s response was published on the Committee’s website on 22 June.

In this response, the NDIA for the first time publicly discloses the existing system for determining functional ‘level’ to inform the budget planning process. It lists the assessment tools required by planners for each disability type, and the cut-off scores for determining high, medium and low levels of function. These scores determine funding amounts by generating Typical Support Packages.

Significantly, this is the first time the NDIA has disclosed the existence of a list of assessment tools required by NDIS planners and delegates for planning purposes. Previous assessment lists were published on the NDIS website for NDIS application purposes, not planning purposes, and those lists do not match the newly-disclosed list required by planners.

The disclosure has profound implications. Under existing arrangements, occupational therapists provide evidence to inform needs-based planning for NDIS participants, including functional capacity assessments. OTA asks what has occurred to date when the occupational therapist has provided a detailed report, including clinically relevant assessment scores, that did not happen to match the planner’s assessment list? Was this report ignored, and a planner-delivered self-report assessment used instead?

Withholding the list of required assessment tools from allied health professionals has likely denied many NDIS participants the most appropriate plan and budget, compromising their ability to achieve identified goals. There can be no doubt that withholding an essential list of assessments and, crucially, the weighting attributed to these tools, has contributed to the inconsistent NDIS decision making of which allied health professionals have complained for years and to resultant inequities in the current planning process. Much greater weight should have been attributed to the detailed, best practice functional capacity assessment administered by a qualified allied health professional.

Participants exercise choice and control and engage therapists in good faith; and therapists exercise best practice in their assessment practices, in good faith. Under existing arrangements, it is unclear if the detailed and well informed functional capacity assessments participants have undergone with qualified clinicians have even contributed to the NDIA’s decision making. Moreover, there would have been substantial costs to many participants as a result of additional clinical assessments required to resolve issues arising from inadequately informed plans.

Because occupational therapists, and other providers, were unaware of required assessment lists, they were unable to provide fully informed functional assessments based on the assimilation of their clinical assessment and interpretation of assessment scores. So, the NDIA has been funding assessments that could have been better and, even then, has subordinated these to assessment tools that are clinically inappropriate and, worse, hidden.

In many instances, the NDIS-listed assessments themselves are not regarded as clinical best-practice assessment for particular disability groups (e.g. Life Skills Profile -16 for psychosocial disability), and hence therapists have quite reasonably not included them in assessment reports. So, therapists exercised clinical judgement and provided the best available assessment tools and evidence for individual participants, only to have these assessment reports subordinated by the planner/NDIA delegate to a secret, prescribed list of required assessments.

The WHODAS-2 appears the only assessment tool on the assessment list actually delivered by planners – indicating that the reports of occupational therapists and other allied health professionals are relied upon to contribute additional listed assessments which enable planners to assign functional ‘levels’. In short, as a result of deliberate policy, allied health professionals have been kept in the dark around which assessment tools contribute to planning decisions, and this has likely contributed to seriously suboptimal planning decisions.

OTA, and individual therapists, have repeatedly asked the NDIA how therapy reports can support the participant planning process. No guidance has been provided. Instead, OTA and disability peak bodies such as VALID and Summer Foundation, have developed training and resources to acquaint allied health professionals with the language and concepts of the NDIS. OTA, since 2019, has also offered to help develop training modules for planners to better understand functional capacity. This offer has never been taken up by the NDIA.

It should be clearly understood that there is no existing evidence in the disability literature to support the implementation of functional ‘levels’ as per the current NDIS planner rating system. There is no evidence to suggest the NDIA’s cut-off scores, which determine funding amounts by generating Typical Support Packages, hold any clinical validity. The NDIA has not disclosed how they developed this current system of functional ‘levels’, with arbitrary cut- off scores on assessments not designed for this purpose; nor even when this system commenced.

The absence of any clinical evidence to support the current NDIS-planning functional ‘levels’, mirrors the absence of evidence for the proposed Independent Assessments, and the automated system, or algorithm, that will determine future participant plan funding. Both systems are clinically flawed.

Significantly, what protects the current system from complete failure is human input from a number of sources. Currently, participants and carers, and known and trusted providers who understand the participant’s supports needs, can identify and highlight these needs by way of the planning meeting, enabling some tailoring of the plan-budget.

Support-needs focused input at planning meetings from participants and providers, demonised as driving inconsistency in NDIS population-level macro-analysis, is in fact a crucial safeguard at the individual participant level. Without this human input, the current NDIS planning process and its reliance on planner-determined functional ‘levels’, would be at best unsafe. With the IA and automated or ‘roboplanning’ in place, this safety net is removed.

Accordingly, the Committee is asked to consider alternative models to the IA and robo- planning reforms. There needs to be an evidence-based process to assess the functional capacity of people with disabilities, to inform plan-funding decisions, which is bespoke and tailored to the needs of the individual. Key features of this process should include participant co-design, and allied health input. Without this, we risk lurching from flawed planning process to flawed planning process.

OTA has proposed an alternative model for consideration, the National Endorsed Assessor Team (NEAT) which can be further developed with participant co-design (OTA 2021a). It includes a focus on incorporating participants’ and existing providers’ input into the assessment process. This model has the potential to be a cost-effective and reliable alternative to IAs.

Committee members will not be surprised to learn that OTA is dismayed by the existence of a secret list of required assessments, which has been withheld from the occupational therapy workforce – which provides the majority of functional capacity assessments. This has not made the task of supporting participants any easier but it does go some of the way to explaining the inconsistency of the NDIA’s decision making. It is particularly galling, therefore, that the NDIA attributes this inconsistency to sympathy bias on the part of the allied health professional.

This disclosure, combined with leaked NDIA marketing documents framing allied health peak bodies as risks to be managed (Harris 2021), the demonstrated lack of integrity of the proposed functional assessment processes, and the diminishing value placed on evidence- based practice in current NDIA policy direction, is ensuring that the NDIS is slipping rapidly down the list of career avenues of choice for allied health professionals. If this trend continues, it will have a devastating impact on choice and control, and quality of care, for people with disability in Australia.

The Design of an Early Childhood Assistive Technology Approach (ECATA)

The NDIA recently indicated that it is committed to changing the way Assistive Technology (AT) is provided for children younger than 7 so that participants have timely access to AT that represents value for money. This includes giving participants more options for sourcing and/or accessing AT, such as trial before buying and access to equipment loan pools.

The NDIA has sought input from providers that have established or emerging capabilities that can help deliver these new ways of sourcing and/or accessing assistive technology in early childhood.

While the NDIA has sought the views of such providers, it has again undertaken a process of consultation which is at best inadequate, and at worst cynical.

For example, the agency’s Request for Information (RFI) to inform the design of a new Early Childhood Assistive Technology Approach (ECATA) makes it clear that the approach is a fait acaccompli (1.1.2), and that the feedback sought “may” be used by the agency (1.1.4) – the implication being that it may just as easily be ignored.

The RFI involves answering just seven questions online, questions that some OTA members report as being confusing. And the period of time in which these questions are to be considered and answered is unreasonably short.

Most disturbing, this inadequate consultation process is supposed to inform not just a new approach to the provision of AT to children but, over time, to older cohorts (RFI 2.1). Given the centrality of AT to the achievement of goals by hundreds of thousands of NDIS participants, this consultation process should have been much more thorough and should have involved genuine co-design.

Once again, the NDIA appears to view consultation with stakeholders as one of the final steps – if not the final step – in the process of service design. It should, of course, be the very first step.

While the outcomes of the consultation process are not known at this stage, OTA takes this opportunity to alert Committee members to two emerging dangers.

First, while AT can and should be made more easily accessible, occupational therapists cannot be expected to sign off on requests for an item of AT, and then be held professionally liable for the safety and efficacy of that item, without a thorough clinical assessment of the item’s appropriateness. Any expectation that they summarily approve equipment, and then answer for its effectiveness, would contravene best practice and OTA’s code of conduct. It would likely lead providers to walk away from the NDIS, further eroding participants’ choice and control.

Second, OTA notes the concerns of the AT industry and draws the Committee’s attention to emailed correspondence from Assistive Technology Suppliers Australia (ATSA) to OTA, dated 30 June 2021:

It is very disappointing that the NDIA has elected to pursue a new policy of supply for assistive technology in a climate where the complexity of scripting and approval is resulting in delays to access AT. We are puzzled that the NDIA wishes to introduce an additional supply pathway of AT, by way of a product exchange programme, rather than first focusing on the simplification of the current systems and processes.

The recently released RFI – Designing an Early Childhood Assistive Technology (AT) Approach, has raised a number of concerns across the industry, due in part to the short timeframe to respond and the prescriptive nature of the RFI. The concept of loan and exchange has merit, however it is not a simple activity and requires a genuine investigation to identify the risks and pitfalls in order to avoid failure. The RFI has assumed the concept will work, and will provide a cost effective solution to access AT in a timely manner without consideration of all the practical commercial aspects (supply/demand/ incentive to purchase the second hand equipment/prescribing complexities). It is anticipated that this approach will diminish choice and control, due to the likely limits of what would be available to allow for the system to work. In turn, it places the prescribing allied health professional in

circumstances where they are expected to fit the child to the equipment supplied rather than aligning them with the best clinical outcome.

ATSA is concerned, based on early review of the RFI, that the approach as outlined will in fact reduce access to AT due to the costs of supporting the proposal as set out. It may also lead to market distortion and a reduction in what can be supplied to the Australian market. ATSA along with OTA strongly believes this approach needs significant investigation to identify the best solution for timely access to AT.

Conclusion

OTA thanks members of the Joint Standing Committee for this opportunity to raise matters of great concern to our members working in the NDIS, their clients, and their carers.

We would be pleased to appear before the Committee to expand on the observations made in this submission, were Committee members to deem this useful.

References

Harris, R. (2021). Secret NDIS report warns of backlash unless government is ‘seen’ to have listened. The Sydney Morning Herald. Retrieved from https://www.smh.com.au/politics/federal/secret-ndis-report-warns-of-backlash-unless-government-is-seen-to-have-listened-20210603-p57xsl.html

Joint Standing Committee on the National Disability Insurance Scheme, Public Hearing, Friday, 23 April 2021. Independent Assessments Proof. Retrieved from https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id%3A%22committees%2Fcommjnt%2Fc84a18cc-272b-46c0-83a4-8cb1ae6034a8%2F0000%22

National Disability Insurance Agency. (2021). Answers to questions on notice, 4 May 2021, received 18 May 2021. Parliament of Australia. Retrieved from https://www.aph.gov.au/ParliamentaryBusiness/Committees/Joint/NationalDisabilityInsuranceScheme/IndependentAssessments/AdditionalDocuments?docType=Answer%20to%20Question%20on%20Notice

Occupational Therapy Australia. (2021a). NDIA Access and Eligibility Policy with Independent Assessments: Occupational Therapy Australia submission February 2021. Retrieved from https://otaus.com.au/publicassets/701ad0dc-457a-eb11-943a-005056be13b5/OTA%20submission%20to%20NDIA%20-%20Access%20Policy.pdf

Occupational Therapy Australia. (2021b). Joint Standing Committee on the NDIS Inquiry into Independent Assessments under the NDIS: Occupational Therapy Australia submission April 2021. Parliament of Australia. Retrieved from https://www.aph.gov.au/DocuemtnStore.ashx?id=24b9598c-6926-440c-997a-6030a16eb486&subId=706476

Occupational Therapy Australia. (2021c). Answer to a question on notice, 6 May 2021, received 21 May 2021. Parliament of Australia. Retrieved from https://www.aph.gov.au/ParliamentaryBusiness/Committees/Joint/NationalDisabilityInsuranceScheme/IndependentAssessments/AdditionalDocuments?docType=Answer%20to%20Question%20on%20Notice