The Australian Clinical Psychology Association

Submission to the

Joint Standing Committee on the NDIS

Independent Assessments Inquiry

The Australian Clinical Psychology Association (ACPA) has many members who provide services to people with disabilities who are participants in the National Disability Insurance Scheme (NDIS).

ACPA notes that the parliamentary Joint Standing Committee on the NDIS has called for submissions regarding the proposed introduction of Independent Assessments (IAs). ACPA has considered the Terms of Reference of the inquiry and has responded to each in turn, below:

Terms of reference

As part of the committee’s role to inquire into the implementation, performance and governance of the National Disability Insurance Scheme (NDIS), the committee will inquire into and report on independent assessments, with particular reference to: a. the development, modelling, reasons and justifications for the introduction of independent assessments into the NDIS;

ACPA understands that the NDIS Act Review of 2019 identified problems with the rollout of the NDIS and that some participants had found the transition to the NDIS “confusing and frustrating”⁇ On 28 August 2020 the Minister for the NDIS, the Hon Stuart Robert MP, announced reforms to the NDIS that would include Independent Assessments.

ACPA has reviewed the information available on the NDIS website› We agree there is a valid argument that Independent Assessments (IAs) funded by the NDIS could improve equitable access and the fairness of access into the NDS. We support the process being made less onerous because families do need a lot of time to attend appointments to enter the NDIS and review their NDIS plans, and there is often significant cost involved in arranging and facilitating such appointments. We also agree that reviews at life stage transitions make sense and cut down on work for all. Yearly reviews are stressful, and participants worry that funding will get cut from year-to-year despite no change in their functioning. Furthermore, there is a disincentive to increase capacity and become more independent if it means that essential services that support that independence might not be funded.

ACPA is concerned about the process for participants to appeal an IA. There is little information on the NDIS website about how this would work and it simply states, “Participants can request a review or appeal decisions made by the NDIA, if they feel a decision made about them is wrong.” We note that currently participants can appeal to the Administrative Appeals Tribunal (AAT), however we are concerned that participants will no longer have access to appeal the decision outside of the NDIS itself.

b.

the impact of similar policies in other jurisdictions and in the provision of other government services;

We are concerned about changes to eligibility and review processes because of the lack of understanding of people with complex conditions and interactions with mental health conditions. By way of comparison, the process of applying for the Disability Support Pension is very difficult for people with complex needs and multiple disabilities. Standard assessments can fail to adequately capture the difficulties the person faces and therefore people with complex disabilities might struggle to put forward a valid case to be a participant of the NDIS and to have support commensurate with their needs.

the human and financial resources needed to effectively implement independent assessments;

ACPA has noted that the NDIS has called for tenders to conduct IAs. Because of the nature of this work and the resources involved it would appear that the primary bidders will be large NGOs. We are concerned that small providers will be effectively shut out of this process. We note that small providers, such as clinical psychologists, have had difficulty being involved with the NDIS because of the onerous demands of NDIS-registration. We are concerned that the tender process for conducting IAs further limits the appeal of operating within the NDIS for experienced clinical psychologists who currently run established practices. We believe that the tender process is geared towards commercially orientated enterprises who will make money from the NDIS by putting in low bids and employing newly qualified or less qualified workers who they can pay at lower rates. This thereby reduces the quality of service that is provided.

There is also a concern that the tender process will put a standard fee on providing an IA and therefore assessors will be motivated to conduct an IA as quickly as possible and/or not take the extra time to understand a participant with a complex presentation. For many NDIS participants they need the assessor to take time to build rapport and make them feel at ease.

ACPA is concerned that there is a lack of detail about oversight of the IA process. Will there be any audit of providers conducting IAs and by whom?

the independence, qualifications, training, expertise and quality assurance of assessors;

ACPA is concerned about the independence, qualification, training, expertise and quality assurance of assessors. As discussed above, we are concerned about the tender process leading to underfunding of assessments such that there is an incentive for the assessments to be completed as quickly as possible and by assessors who are less qualified and/or experienced,

Concerns Regarding Independent Assessments (IAs) Under NDIS

compromising the quality of clinical decision-making. As discussed below, we are also concerned about the reliance on a limited selection of standardised assessment tools.

We are concerned that the IAs will be conducted by an assessor not otherwise familiar to the participant and that might compromise the quality of the information provided. For instance, some participants will tend to minimise problems that they have and present themselves as somewhat more capable than they actually are. Therefore, they might be assessed, inaccurately, as high functioning, and therefore miss out on services as a result.

We note that the NDIS is introducing IAs in order to improve the consistency of eligibility and review decisions, however it is not clear how the NDIS will ensure consistency between organisations providing IAs. There is also potential for conflict of interest with organisations conducting assessments who also deliver service provision to NDIS participants.

ACPA believes that if standardised assessment measures are going to be applied then a National Standardised battery per disability should be listed on the NDIS website for conducting IAs. This is essential to ensure equity amongst all Australians. In addition, an Aboriginal and Torres-Strait Islander battery and Culturally and Linguistically Diverse battery should be developed.

We are concerned about the implications of IAs for participants living in rural and regional areas. In such small communities it is difficult to get service providers and we are concerned that this might lead to problems accessing IAs. We note that since the beginning of the COVID-19 pandemic service providers have become more used to working via online platforms, however this is no substitute for in situ assessment of people with disabilities whose impairments might be reflected differently in person rather than online.

e. the appropriateness of the assessment tools selected for use in independent assessments to determine plan funding;

ACPA would support IAs if it means that funding decisions will be based on functional impairment levels rather than a specific diagnosis. However, we are concerned that use of standardised measures might miss important factors related to individual circumstances. We are also concerned about the reliance on standardised measures and that assessors might lack appropriate interviewing skills to capture the full range of a person’s impairments.

ACPA notes that the measures listed in the IA Toolkit, such as the Vineland, rely on respondents who might not know what the participant is capable of, or they might not have picked up on the problems they have. For instance, participants might not notice their own social skills deficits, but the assessor might not notice that they don’t have any friends. The items in the toolkit measures rely on the participants’ and informants’ experience, so for instance, where the Vineland asks about money handling, this could be something that participants have never had the opportunity to do. In that instance a proper assessment would require trialling particular skills in naturalistic or contrived situations. So, if there is uncertainty about money handling then the assessment should include an exercise using money to buy goods in a real-life situation. It is difficult to see how this would fit within a standardised assessment conducted in a three-hour timeframe.

ACPA Submission

ACPA notes the comments of Professor Bruce Bonyhady’s submission to the parliamentary committee. We echo his concern that standardised assessments open up the possibility for further exploitation of the system by well-informed and resourced participants to respond to the standardised assessments in a way that ensures they attain more funding. The measures currently chosen for the toolkit contain no validity scales to pick up on exaggeration or minimisation of issues by participants. It is therefore hard to see how IAs could assess this possibility in a 3 hour time frame. We are also concerned that the approach to IAs is very much focused on deficit and doesn’t ask what the person with a disability is capable of and how their strengths can be utilised.

f. the implications of independent assessments for access to and eligibility for the NDIS;

Aside from the comments above, in which we have discussed our concern about the accuracy of self- or others-reports when understanding standardised measures, ACPA has other concerns. We are particularly concerned with participants who have mental health issues. People with disabilities are not immune to mental illness and in fact are at increased risk according to the Australian Institute of Health and Welfare^3. It is possible that underlying mental health problems such as psychosis might not be present at the time of the IA but could affect the person’s functional capacity at another time during their NDIS plan. The material available on the NDIS website does not indicate how IAs will account for fluctuations in functional capacity.

ACPA is concerned that participants and their families might not know what options are available to them in terms of treatment and therefore might not flag a particular need. In the context of a typical assessment, an assessor might make suggestions for service delivery that would expand the participant’s capabilities. However if the IAs are limited to prescribed areas and standardised measures this might not happen. The outcomes of the IAs might be affected by the expertise and profession of the assessor. In particular, there might be an assessment conducted by an allied health professional who is not familiar with what clinical psychologists can offer and thereby not make a recommendation that is necessary for the participant.

ACPA is concerned the IAs might not take into account the individual’s context and how their needs change depending on what supports they have. Further, we have a concern that there’s a

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lack of incentive to identify services through the IA process that would push the individual closer to their true potential.

h.  the circumstances in which a person may not be required to complete an independent
   assessment;

ACPA believes that a person should not be subject to an assessment when they are not able to speak for themselves and where they do not have a competent adult who knows them sufficiently to attest to their profile of strengths and weaknesses. We are aware of adults with disabilities who live with elderly parents who have always managed all aspects of their care. The parents of NDIS applicants or participants might not be aware of their adult child’s potential or skills and this could affect the accuracy of any IA.

ACPA is also concerned that where an IA might rely on telehealth, that the person with a disability might not have capacity to use this platform effectively, thereby cutting off this avenue for their assessment.

  i.  opportunities to review or challenge the outcomes of independent assessments;

If a client of a clinical psychologist or other provider was to challenge an IA it is likely that they would want their provider to assist in challenging an assessment. There is a lack of clarity about the role of providers were a participant to request an IA be reviewed. This should be agreed upon and further clarified by the NDIS.

  j.  the appropriateness of independent assessments for particular cohorts of people with
     disability, including Aboriginal and Torres Strait Islander peoples, people from
    regional, rural and remote areas, and people from culturally and linguistically diverse
   backgrounds;

Standardised assessments have to be proven valid for particular populations. It comes back to clinical opinion and sometimes these assessment measures are not applicable to particular cohorts within the Australian context. Additional measures should be put in place to assist with ATSI participants, for example, an Aboriginal Health Officer, an Indigenous Psychologist, Elder e tc. to help with the assessment and how their disability impacts their functioning in their cultural context.

k.  the appropriateness of independent assessments for people with particular disability

types, including psychosocial disability; and

We maintain that this sort of an assessment requires professionals who understand how psychosocial disability affects functional capacity. This might not be apparent to a discipline not specifically trained for mental health. There is a concern that having one assessor, who may come from a discipline focused on physical function, might miss the impacts of psycho-social disability. For example, some mental health conditions are associated with fluctuating functional ability and this might be missed at the time of the assessment, particularly if the participant is “well” at the time. These assessments should be conducted by psychologists or another mental- hhealth specific discipline (e.g. psychiatrist).

   l.  any other related matters

The supports that our clients get often keep them at a level where they are functioning well but if those supports are taken away they would not function well. An IA might find that the participant is functioning well at the time of the assessment and therefore classify the participant’s need as lower, leading to the removal/reduction of support that renders them less capable. Because the proposal is to only review participants at a time of lifestyle change then it is possible that participants will get locked into too low a level of funding support for years, as opposed to under the current system where this is reviewed annually.