Queensland Nurses & Midwives’ Union
Submission to Joint Standing Committee on the National Disability Insurance Scheme
Date: June 2021
Contact Information:
- Address: 106 Victoria St, West End Q 4101
- Postal Address: GPO Box 1289, Brisbane Q 4001
- Phone Numbers: (07) 3840 1444 and (07) 3844 9387
- Website: www.qnmu.org.au
General issues around the implementation and performance of the NDIS Submission 73
Contents
Introduction ……………………………………………………………………………………………….. 3
Recommendations ……………………………………………………………………………………… 3
Employment of nurses by NDIS providers or as sole practitioners ……………………. 4
Specialist clinical workforce ................................................................................. 5
Comparable standards of care and access to nursing to the health sector ......... 6
Incentives for the employment of nurses ............................................................. 7
Regulation and minimum qualifications of workforce ………………………………………. 7
General comments …………………………………………………………………………………….. 9
References ……………………………………………………………………………………………….. 9
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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 General issues around the implementation and performance of the NDIS.
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 (RM), 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 and disability care.
Our 66,000 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 in Queensland are members of the QNMU.
The QNMU will provide a comment regarding the employment of nurses in the NDIS system, the regulation of the NDIS workforce, and general concerns regarding financial transparency.
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Development and implementation of a national disability pricing authority to ensure that service providers are funded at an efficient price.
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Public costs reporting from service providers, including the percentage of operational costs and administrative fees.
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Consistency around award entitlements, appropriate financial remuneration and job security for the NDIS workforce
Employment of nurses by NDIS providers or as sole practitioners
The role of registered nurses in the disability sector is supported by the Nursing and Midwifery Board of Australia (NMBA). The introduction to the NMBA’s Registered Nurse Standards for Practice states that (bold emphasis added):
Registered nurse (RN) practice is person-centred and evidence-based with preventative, curative, formative, supportive, restorative and palliative elements. RNs work in therapeutic and professional relationships with individuals, as well as with families, groups and communities. These people may be healthy and with a range of abilities or have health issues related to physical or mental illness and/or health challenges. These challenges may be posed by physical, psychiatric, developmental and/or intellectual disabilities.
(Nursing and Midwifery Board of Australia, 2016)
Disability nursing is a specialty area of nursing that requires a high level of expertise, knowledge and skills to deliver interventions that aim to improve the quality of life for people with a disability and their carers. This is also acknowledged in the NDIS Price Guide by the introduction of Items for services that can only be provided by a registered nurse or an enrolled nurse.
Nurses are further embedded in the NDIS system beyond Support Items that explicitly require the practitioners to be a nurse. For example, registered nurses may be Specialist Support Coordinators (National Disability Insurance Agency, 2020) or Behaviour Support Practitioners (Commonwealth of Australia, 2018), which emphasises the broad scope within which nurses practice and the vast range of specialised skills that nurses possess.
It is therefore disappointing that the critical role of registered and enrolled nurses has been overlooked in the 2020 General Issues Report (Commonwealth of Australia, 2020). In recognition of the important role that nurses can play within the disability sector, the NDIS must enable nurses to work to their full scope of practice by recognising and promoting the specialised and vital role of nurses in the assessment,
Specialist Clinical Workforce
There is an urgent need of a specialist clinical workforce with the skills, training and education to manage specific types of disability. The absence of such a workforce may be a contributing factor to the ongoing NDIS Accommodation issues.
The Queensland Government, in their submission to the Inquiry into the NDIS Market in Queensland, stated that (bold emphasis added): “The quality of providers in the market is not able to meet the complex needs of many patients being discharged from hospital. They often do not have a sufficiently skilled workforce to accept referrals immediately or to sustain the levels of care that are required within the community.” This is further problematic as NDIS participants may become inappropriately held in the acute hospital sector due to lack of disability support options post-discharge. As an example, the QNMU presents the following case study:
Case Study 1 — Rehabilitation Unit
A random workload monitoring audit by the QNMU of a single day ina specialised rehabilitation unit in a tertiary hospital revealed that on that day, there were at least 15 patients who were experiencing delayed discharges from hospital due to the lack of appropriate NDIS community-based services. Sourcing adequate in-house clinical care was Challenging for the level of disability support and assistance required.
QNMU members have also raised concerns regarding delays in discharging patients to NDIS-funded accommodation, citing the scarcity of facilities who employ a specialist clinical workforce capable of meeting the complex support needs of patients with specific disabilities. Cases recently brought to the attention of the QNMU include:
Case Study 2 — Medical Unit
A young woman receiving NDIS support was admitted to an acute care medical ward, where she was successfully treated for a medical issue. However, the lack of appropriate post-discharge accommodation options suitable for her disability needs resulted in an inappropriately long length of stay on the ward, effectively “trapping” her in the acute care sector. The experience on an acute ward led to significant distress and agitation for the patient. Additional nursing staff were required to be rostered on to manage the increased acuity of the ward as a result.
Case study 3 — Mental health unit
A young man with a severe disability was admitted to a mental health unit for over 12 months despite no mental health diagnosis or history, due to his complex challenging behaviours related to his disability. The treating team concluded that he required 24/7 care from experienced clinicians with a specialist qualification in his area of disability. While he has an NDIS package, it was insufficient to cover the cost of providing specialist home support services for the management of his behaviours.
These examples suggest there are significant delays and barriers keeping NDIS participants from receiving care and support that is appropriate for their level of clinical need. Such highly specialised level of care cannot be provided by disability support workers. However, nurses have the skills and training required to provide specialist clinical care and support in the disability sector.
To avoid similar endemic problems as those caused by inappropriate skill and staff- mix in the aged care sector, the QNMU urges the Committee to consider the impact of an insuffi ciently capable workforce on client outcomes, quality of care and safety.
Comparable standards of care and access to nursing to the health sector
People who receive NDIS support should be able to expect the same standards of care as would be provided in the acute health sector, especially with regard to having appropriately qualified people providing care. Given the broad overlap between the disability, health and aged care sectors, nurses are well placed to lead the disability workforce due to the professional expertise that nursing brings across all three sectors, especially in terms of case management and case co-ordination.
There is a complex relationship between disability care and nursing care that must be acknowledged and promoted; a specialist disability nurse has the training and expertise to identify health-related issues quickly, coordinate care in a manner that supports continuity and advocacy, and reduce the risk of fragmented service. Moreover, any medication management would benefit from being overseen by registered nurses, who undergo extensive training in pharmacology.
However, the QNMU is concerned that participants receiving NDIS support are restricted by financial and provider-bound barriers to accessing appropriate nursing care.
Any person with a disability who is eligible for NDIS support of any kind must have comparable access to nursing care as in the acute health care sector, that is, have access to funding for nursing care under the NDIS and have access to providers of nursing care. NDIS participants must not be disadvantaged compared to the rest of
General issues around the implementation and performance of the NDIS Submission 73
the general population simply because they have a disability that is funded at the exclusion of nursing care. If the participant requires care that otherwise would have been provided by a nurse if the participant did not have a disability, then they must receive care that is at minimum supervised by a registered nurse.
Incentives for the employment of nurses
The QNMU urges the Committee to work with the Royal Commission to grow the nursing workforce in disability services to ensure an appropriate level of expertise supports people with complex disability care needs. This would include:
- Sustainable funding of incentives for providers to employ nurses and promoting nursing care.
- Diversification of nursing roles, such as nurse-led training and education, or nurse navigator-style models of care.
Regulation and minimum qualifications of workforce
The NDIS workforce is comprised primarily of personal care workers and assistants- in-nursing (Commonwealth of Australia, 2020), which are currently unregulated and unregistered. As the qualifications (or lack of qualifications) required to be employed as a personal care worker are set by the employer (Eddy, 2020), there is a significant degree of variation across the sector of the qualification and skill level required. It follows that the level of education and training of the workforce is likewise inconsistent. This must be addressed through appropriate regulation, minimum qualification standards, and clear lines of delegation and governance.
While the Royal Commission into Aged Care Quality and Safety highlighted how concerning this matter is in the Aged Care sector, the QNMU contends that this is an even greater concern in the disability care sector. This is because disability care, being largely community-based care (Australian Institute of Health and Welfare, 2020), is often delivered in an absence of direct supervision or clear lines of governance.
The QNMU therefore strongly recommends the introduction of baseline qualifications for personal care workers who are employed in the disability sector and urges the Committee to draw upon the lessons learned from the Royal Commission into Aged Care Quality and Safety, in particular, the recommendations regarding the workforce.
Firstly, the following recommendation from the Royal Commission into Aged Care Quality and Safety suggests that there is a strong expectation of crossover in the training and skills of the personal care workforce in the aged care and disability sectors. Personal care workers who are employed in the disability sector should therefore be held to the same standards as in the aged care sector at a minimum.
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Recommendation 76: Aged Care Workforce Industry Council Limited.
- From 1 July 2022, the Aged Care Workforce Industry Council Limited should map career pathways for the aged care sector. These career pathways should:
b. facilitate personal care workers having opportunities to move laterally across aged care, disability care, community care and primary health care and vertically in aged care by advancing into nursing, specialist care roles and supervisory or managerial roles
(Royal Commission into Aged Care Quality and Safety, 2021)
Secondly, we draw the Committee’s attention to the Royal Commission’s call to register and regulate the personal care workforce:
Recommendation 77: National registration scheme.
By 1 July 2023, the Australian Government should request that the National Cabinet Health Council determine whether to regulate the occupation of ‘personal care worker (health)’ or ‘assistant in nursing’ under the National Registration and Accreditation Scheme, established and governed under the Health Practitioner Regulation National Law.
Recommendation 78: Mandatory minimum qualification for personal care workers.
- A Certificate IIl should be the mandatory minimum qualification required for personal care workers performing paid work in aged care.
We note here that maintaining, improving, restoring or managing people’s wellbeing is defined in Queensland under the Health Ombudsman Act 2013 (Qld) as a health service. Therefore, most NDIS workers will be captured as “health service providers” under that Act and subject to a National Code of Conduct for Unregulated Healthcare Workers. Unfortunately, no regulatory entity provides guidance or direction on how to comply with that Code. This is just one of the reasons why we recommend that NDIS workers have appropriate accredited training in safe, ethical care and appropriate professional conduct in the provision of that care.
The QNMU builds on the above recommendations to argue that the minimum qualification to be employed as a personal care worker in disability should be a Certificate III in Individual Support (Disability), and that the occupation of personal care worker and assistant in nursing (across all sectors, not only disability and aged care) should be regulated under the Ahpra framework.
General issues around the implementation and performance of the NDIS Submission 73
General comments
As a publicly funded institution that supports some of the most vulnerable people within our community, the NDIS must be open to public scrutiny and regulatory oversight and administration. The QNMU is concerned that self-regulation of the market has clearly failed in the case of the aged care sector; it appears that the disability sector may be falling prey to some of the same predatory business practices that take advantage of a complex, confusing NDIS system to financially exploit participants. As it currently stands, the NDIS is provider-driven and not consumer-driven. This approach must change. Support provision must be responsive to the needs of the person accessing it and acknowledge that the participant is the expert on their needs.
To support a more open, transparent, and equitable NDIS, the QNMU requests that the Committee considers:
- Development and implementation of a national disability pricing authority to ensure that service providers are funded at an efficient price.
- Public costs reporting from service providers, including the percentage of operational costs and administrative fees.
- Consistency around award entitlements, appropriate financial remuneration and job security for the NDIS workforce
References
Australian Institute of Health and Welfare. (2020). People with disability in Australia. Canberra: Australian Government. doi:https://www.aihw.gov.au/getmedia/ee5ee3c2-152d-4b5f-9901- 71d483b47f03/aihw-dis-72.pdf.aspx
Commonwealth of Australia. (2018). Behaviour Support Competency. Retrieved from NDIS Quality and Safeguards Commission: https://www.nds.org.au/images/resources/NDIS Behaviour Support Compet ency Framework Draft 30 May 2018.pdf
Commonwealth of Australia. (2020). Joint Standing Committee on the National Disability Insurance Scheme: General issues. Canberra: Senate Printing Unit. Retrieved from https://parlinfo.aph.gov.au/parlInfo/download/committees/reportjnt/024349/toc pdf/Generalissues.pdf
Eddy, M. (2020). How to Become a Disability Support Worker. Retrieved from TAFE Courses: https://www.tafecourses.com.au/resources/disability-support-worker/
National Disability Insurance Agency. (2019). NDIS. Retrieved from Review of Therapy Pricing Arrangements: https://www.ndis.gov.au/media/1662/download 9
General issues around the implementation and performance of the NDIS Submission 73
National Disability Insurance Agency. (2020). NDIS Price Guide. Retrieved from NDIS: https://www.ndis.gov.au/media/2213/download
Nursing and Midwifery Board of Australia. (2016). Registered nurse standards of practice. Retrieved from Nursing and Midwifery Board Ahpra: https://www.nursingmidwiferyboard.gov.au/codes-guidelines- statements/professional-standards/registered-nurse-standards-for- practice.aspx
Royal Commission into Aged Care Quality and Safety. (2021). Final Report: Care, Dignity and Respect. Canberra: Commonwealth of Australia. Retrieved from https://agedcare.royalcommission.gov.au/publications/final-report
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