Joint Standing Committee on the National

Disability Insurance Scheme

Occupational Therapy Australia submission

November 2021

Occupational Therapy Australia Limited ABN 27 025 075 008 | ACN 127 396 945 5 / 340 Gore St. Fitzroy VIC 3065 Ph 1300 682 878 | Email policy@otaus.com.au | Website www.otaus.com.au

Introduction

Occupational Therapy Australia (OTA) welcomes the opportunity to provide the Joint Standing Committee on the National Disability Insurance Scheme (NDIS) with a supplementary submission regarding issues and challenges facing our members who operate within the scheme.

OTA is the professional association and peak representative body for occupational therapists in Australia. As of September 2021, there were more than 25,300 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 engage in meaningful and productive activities.

Occupational therapists provide physical and mental health therapy, vocational rehabilitation, chronic disease management, assistive technology prescription, home modifications and key disability supports and services. As such, many occupational therapists provide services to NDIS participants.

This submission outlines some of the challenges facing occupational therapists as they work within the NDIS, as reported by our members. It also proposes potential solutions to these challenges.

Issues in assistive technology approvals process

Lack of communication

A number of issues arise from the lack of effective communication between the NDIA and the scheme’s participants and service providers. This leads to inefficient processes and delays in the provision of vital assistive technologies to participants.

Inconsistent receipt and processing time of requests

It is important for service providers to be able to track the progress of assistive technology applications in order to complete a thorough clinical process in line with best practice, and to best support participants while they are waiting. This can also help providers manage participant expectations.

OTA members report that there is no consistent process whereby the receipt of assistive technology applications is acknowledged. Often, planners do not confirm receipt of such requests and when a reply is received, it is often delayed by months.

While OTA acknowledges the high demand for assistive technology and various supply side issues, an acknowledgement of the receipt of an application must be a fundamental step in the process. It gives clients and care providers the assurance that their requests for assistive technology are being processed. A receipt number would give them a paper trail with which to pursue any follow up requests or queries. Our members report a lack of notification as to when orders are placed as well as delays in response to more general queries. If any

confirmation is received, it is often received a month after the initial request, with it then taking even longer to be processed and actioned.

Our members have also raised concerns about the time it is taking to process and deliver requests. Timeframes have lengthened from weeks to months, and care providers are left with no assurances that the needs of their clients will be met in a timely manner. Additionally, urgent requests are facing the same issues despite their time critical nature.

Finally, there are occasions when the prescribing therapist is unaware that equipment has been delivered. This gives rise to obvious risks to participant safety, as the equipment may be incorrectly installed or participants may not be trained in its use.

There are also professional liability risks for service providers, if they are unaware equipment has been delivered and are therefore unable to complete the clinical process.

NDIA not honouring participant consent for communication

Our members continue to encounter great difficulties when communicating with the NDIA on behalf of their client. Occupational therapists are often informed they do not have their client’s consent to discuss the client’s case directly with the NDIA despite participants providing their explicit consent. While there appears to be an option to allow for this representation on the participant portal and on the new request form, it appears this is not always honoured.

This raises some challenges for occupational therapists when attempting to advocate for their patients’ needs. This issue is particularly problematic when the service provider is taking over from an original prescriber. Current solutions involving communicating with the NDIA while on a home visit with the client are not suitable, as communication is often required more frequently than home visits may occur.

Additionally, while the assistive technology request form asks for extensive clinical reasoning behind decisions, occupational therapists are afforded very little opportunity to make a clinical case or further discuss cases directly with any person at the agency when further information is required. This can lead to neither party being satisfied with certain decisions and the reasoning behind them if direct communication between them is not allowed despite consent being given.

Escalation system

No escalation point exists in the system for either outstanding or critical assistive technology requests beyond lodging a complaint and then waiting 30 days for a potential outcome. This process is onerous and time consuming, and directly affects participant outcomes as our members are unable to escalate the issue any further and alert the NDIA to urgent participant needs.

Lack of justification for decisions

While OTA appreciates the volume of requests and applications the NDIA receives, our members report that their requests are often rejected without appropriate justification. Again, while OTA acknowledges the need for critical assessment of assistive technology requests against the necessary criteria, a failure to provide clear justification for decisions only heightens the likelihood of unsuitable requests being repeated. Clear and consistent reasoning on why claims are rejected would allow occupational therapists to do their work more effectively and efficiently, to the advantage of all concerned. This would reduce the workload for NDIA case managers as well as occupational therapists, and allow the timelier approval and implementation of assistive technologies for participants.

Moreover, clear and consistent reasoning behind the rejection of claims by the NDIA would help to manage participant expectations and facilitate the development of alternative solutions.

Administrative issues

Our members report other issues stemming from various administrative requirements of the assistive technology request process.

Length and clarity of new request form

The new assistive technology request form is increasingly time consuming and is eating into time that could be better spent on behalf of scheme participants. Repetitive and unclear questions in a confusing order result in wasted time for prescribing therapists. While OTA understands that clinical reasoning and addressing necessary criteria is vital for the appropriate provision of assistive technology, our member feedback suggests this reasoning is asked for in “bits and pieces” rather than in a clear and logical sequence thus not allowing therapists to clearly explain their clinical reasoning.

A simplification of the form’s design, with direct input from those who are required to fill it out, might alleviate some of these problems. Ideally, it would provide easier to follow clinical justification for delegates, and would represent better use of scheme funds by making better use of service provider time.

NDIA employees working outside of scope

Increasingly, our members are reporting that assistive technology requests are being declined without valid or appropriate justification. While OTA and our members again appreciate the need for high standards in assistive technology requests, it often appears that the clinical decisions of highly trained allied health professionals are not being judged against the reasonable and necessary criteria but are being overridden by those without the required clinical expertise to decide what is appropriate for the participant. Often these decisions are made by someone who has never met the client and is not an occupational therapist.

Some examples of clinical decisions being made by unqualified employees following assistive technology requests include:

Assistive technology being declined on grounds it duplicates therapy supports provided by speech pathologists when the speech pathologist is not currently working on those skills;
Excessive requests to trial equipment when this had already been justified in the report; and
An electronic wheelchair being approved but without the required battery pack.

These decisions all require clinical assessment from a qualified professional, in this case an occupational therapist. Assistive technology recommendations must be made with extensive clinical reasoning in order to achieve their goal and best address the needs of the participant.

Additionally, there appears to be an increase in assistive technology requests being declined based on value for money regardless of the justification or appropriateness of the therapy requested. This justification may even include demonstration that the costs of alternative supports would be greater than what is being asked. Once again, greater communication between the NDIA and the prescribing therapist would allow a solution to be agreed on that best meets the participants goals.

Misuse of allied health assistants

OTA has received reports of members being asked to “sign off” on plans either created by students or allied health assistants (AHAs) or to create plans for students and AHAs to implement without the required supervision. Clearly, this is an unacceptable practice that places participants at risk.

Key issues that might be contributing to this practice include:

Confusion around supervisory and professional indemnity requirements;
Perception of AHAs as a cheaper option than a registered allied health practitioner;
Lack of regulation by the NDIA or the Australian Health Practitioner Regulation Agency (AHPRA); and
Inadequate funds in NDIS plans for the engagement of qualified allied health professionals.

OTA is on the record as supporting AHAs, when properly qualified, appropriately deployed and responsibly supervised by a qualified professional. Indeed, they are crucial to ensuring that fully qualified allied health professionals have capacity to work to top of scope. Under no circumstances, however, and regardless of workforce shortages, should AHAs be undertaking occupational therapy-related tasks for which they are not properly trained or without the supervision of a registered occupational therapist. For more information, the Committee is invited to review our position paper, The role of allied health assistants in supporting occupational therapy practice (OTA, 2015).

Recommendation 1:

The NDIA, along with AHPRA and other regulatory bodies, should revisit and reiterate the regulations surrounding AHAs and their place within the allied health system and the NDIS. Additionally, the NDIA should ensure that plans involving the improper use of AHAs are not being approved.

Lack of protection for small businesses

OTA strongly supports the principle of participant choice and control within the NDIS. We believe it is a central tenet of the scheme and something that must be upheld in all policy decision making.

However, we are aware of growing concerns among members regarding the process by which participant complaints are managed within the scheme. Our members report that it is becoming increasingly challenging and costly for small businesses and sole traders to respond to complaints by participants.

While it seems the weight and resources of the agency are available to scheme participants, service providers are left to fend for themselves.

While the NDIS represents a welcome move to client directed care, the scheme will ultimately fail its clients if the rights of participants are not balanced by an appreciation of the rights of service providers. There need to be protections and assurances in place to ensure small businesses and sole traders are not subject to unreasonable or vexatious complaints.

A clearer system for addressing complaints would provide greater certainty to both participants and providers within the NDIS.

Recommendation 2:

There should be a clear and fair process for the management of complaints made against service providers by scheme participants. The process should ensure both participants and service providers are aware of their rights and responsibilities.

Professional liability

The NDIA has noted that if consumer law is breached in relation to advice or prescription of assistive technology, pursuit of replacement or refund of costs via the assistive technology advisor’s professional indemnity insurance may be made.

There is a growing number of examples of this occurring in practice and OTA has accordingly alerted members to the importance of maintaining impeccable documentation of all cases, particularly when a client has exercised their right to choice and control, and overruled an occupational therapist’s clinical recommendations around assistive technology.

While OTA has no objection to the application of consumer law by the NDIA, we remind Committee members and the NDIA that the needs of many participants change over time, and that consequently prescribed technology may at some point become outdated and inadequate.

Conclusion

OTA thanks the Joint Standing Committee for the opportunity to make this submission. Please note that representatives of OTA would gladly meet with committee to expand on any of the matters we have raised.

References

Occupational Therapy Australia. (2015). Position Paper: The role of allied health assistants in supporting occupational therapy practice. OTA: VIC, Melbourne.