Australian Association of Psychologists opposes mandatory Independent Assessments

Australian Association of Psychologists incorporated (AAPi)

AAPi AUSTRA LIAN ASSOC IAT ION

Submission to the Joint Standing Committee on the NDIS-

March 2021

Introduction

The Australian Association of Psychologists incorporated (AAPi) thanks the Joint Standing Committee on the National Disability Insurance Scheme for the opportunity to provide information and recommendations regarding Independent Assessments under the NDIS.

AAPi represents psychologists traversing a wide range of areas of practice around the country, including working within the National Disability Insurance Scheme, who are on the front line of dealing with the increasingly important mental health needs of Australians.

Using these insights, we would urge the Committee to strongly consider our recommendations regarding this issue. AAPi is strongly opposed to the commencement of mandatory Independent Assessment.

Sincerely,

Tegan Carrison Executive Director Australian Association of Psychologists Inc

Website www.aapi.org.au

About AAPi

The AAPi is the leading not-for-profit peak body representing all psychologists Australia- wide. Our members include psychologists from all areas of endorsement as well as those who have chosen not to pursue endorsement, from graduates through to university lecturers and leaders in their field.

A group of passionate psychologists formed our organisation in 2010 to:

Represent a united voice for psychologists to government and funding bodies
Promote the recognition, professionalism, skills, and expertise of psychologists
Improve access and equity to psychological services in Australia by removing barriers to effective treatment
Advocate for the removal of the two-tier funding system and reinstate one Medicare rebate for the clients of all psychologists
Uphold the value of all psychological expertise and pathways to registration
Serve the professional needs of all psychologists by providing members with quality professional development opportunities, expert support, and guidance

By advocating for equality for psychologists, the AAPi is also fighting for equitable access to mental health services for all Australians.

AAPi represents the interests and integrity of all psychologists regardless of endorsement status, with members in all States and Territories of Australia.

Response to the terms of reference within scope of

AAPi

The development, modelling, reasons and justifications for the

introduction of independent assessments into the NDIS

The move toward NDIS led access assessments brings a series of concerns to those who are working in the sector, those who advocate on behalf of people with disabilities and people with disabilities across Australia. While the opportunity for commonwealth funded assessment is welcome for those who are financially disadvantaged and unable to fund their own assessment it reduces the opportunity to have specific needs addressed in depth, potentially restricting the amount of necessary funding allocated to those with a disability.

Many participants will see a restriction of funding due to the limited approved assessments being performed. These limited approved assessment reduces the ability to identify individual strengths and difficulties outside of functional assessment. There is significant concern that the assessors will not be able to recommend treatment or make further comments other than the reduced scope of the results of the limited assessments. It is a reductionist approach to the complex and unique nature of participants disabilities, potentially resulting in suboptimal levels of care and support to those most in need.

This type of assessment also fails to pick up those who respond to assessments in socially desirable ways such as females with autism or those with intellectual impairment who overestimate their abilities.

Also of concern is the limited assessors that will be available, especially in rural and remote regions. Assessments should be conducted in person with face to face observation, which may cause significant wait times or travel commitments for those who live outside of metro areas.

AAPi, along with the majority of peak bodies and professional groups who are experts in the field, view the imposition of mandatory Independent Assessments as a gatekeeping exercise, limiting adequate partcipant funding. This makes navigating the system even more difficult for consumers with disabilities who, as a population, are often not able to advocate for themselves. We believe those who will be most impacted will be indidviduals with Autism Spectrum Disorders, those with Intellectual Disabilies and those with Psychosocial Disabilities.

The NDIS assessor model states that reassessments would occur at review to guide funding for the next plan period. NDIS states that the purpose of the assessors is to make funding more uniform/standardised across the NDIS. This fails to take into account the unique needs of participants.

There is not enough information in the report from the pilot study to make any real comparisons about the appropriateness of this for participants. The decision to implement Independent Assessments has been rushed, without adequate evidence, and without adequate testing to determine its viability and whether it disadvantages participants. Failures of Independent Assessment are being noted more frequently across the media, with many needing to lodge an Admisitrative Appeal. The fact that participants have already been negatively affected is unacceptable.

Allied health professionals understand that it takes a considerable amount of time to understand an individual’s specific disability and support needs. Practitioners take the time to build rapport and trust with participants before discussing personal issues and their complex disability-related needs. Other issues such as communication difficulties and sensory differences can also impact on the quality of the assessment process.

The position of AAPi is that the power to decide whether to engage in this process should lie with the participant. Participants should be given the choice to either undergo the ‘independent assessment’ process or use reports from their preferred allied health providers. Alternately, if there are assessment measures or processes that the NDIA requires, these need to communicated clearly to providers, in consultation with peak bodies so that they can be incorporated into reports. This would negate the need for independent assessors.

AAPi does not believe that independent assessment using a specific battery of tools is appropriate. We believe this takes away the participants right to have a tailored assessment and treatment program to improve their function and achieve goals of their choice. Other allied health membership organisations share our concerns about the effect to their members and the participants they work with. Experienced allied health practitioners who are familiar with the most evidence-based interventions available are best placed to recommend the type and frequency of treatment required to meet the participant’s needs.

Likely impacts for people with a disability:

Being forced to undergo review of eligibility each year and the disruption and stress this will cause
Being forced to explain their situation/history/needs to an unfamiliar ‘independent assessor’ each year and when a review is required for change of circumstance
Facing the review without their allied health team’s involvement or recommendations. This is particularly concerning for people with rarer diseases and syndromes
For people with social, cultural and language barriers as well as those with complex communication or sensory needs, unfamiliar ‘independent assessors’ are unlikely to be able to understand and assess their needs appropriately
Higher likelihood of being denied access or having a reduction in funding due to the standardised ‘tick and flick’ one-size-fits-all approach being adopted by the NDIA
The proposed assessment instruments are unlikely to capture the complex and diverse needs of all people with disabilities
Participants could lose access to the long-term professional supports who have completed tailored plans and treatments for them. Therapeutic relationship is

paramount in any therapy, and even more so with people with disabilities who may have histories of abuse, neglect, or rapid and unexplained changeover of support staff

The impact of similar policies in other jurisdictions and in the

provision of other government services

The current assessment against disability impairment tables for those needing access to the Disability Support Pension (DSP)and the use of Independent Medical Examiners assessment in WorkCover are example where the use of independent assessors by government services has been detrimental to the health and wellbeing of the community. Even where the treating team has made a recommendation regarding the impact of workplace injury or disability, these are often ignored. Independent assessments are also used within Income Protection to determine work capacity and/or assess for Total and Permanent Disability insurance payments. The primary criticism of all of these assessments is the standardised approach which does not account for individual factors or variation. They also undermine the expertise of treating practitioners and imply that treating parties are unable to remain impartial when assessing, diagnosing, and treating individuals under their care.

Potential impacts of these types of assessments include:

All are considered a “snap shot” in time of the individual’s medical and functional capacity. They assess the individual on the basis of presentation during the assessment interview and while they may take into account medical reports from treating practitioners, these tend to be used to inform diagnosis and treatment history as opposed to current functioning
Recommendations made through such assessments, tend to be based on “best case scenario” for the diagnosed condition(s). Similar to the disability tables used in assessment of DSP applicants, the Workers’ Compensation systems have injury and impairment tables which outline the expected recovery outcomes for each accepted condition. As such, Independent Assessments start to become more about what is considered a normal prognosis and trajectory for the condition and less about the individual’s specific circumstances
DSP assessments are typically concerned with medical diagnoses and reports completed within a 2 year timeframe. They do not account for conditions which have been diagnosed and are stable (with few treatment options) and where the individual may no longer be under the care of a specialist. This can make the process of obtaining relevant medical information arduous for the individual. It also de-values the role of the GP in managing a stable, long-term condition
Independent assessments in Workers’ Compensation and Income Protection do have an inherently negative implication as they are usually used when a claim is being challenged or when the claim is due for review. As such, they can be used to deny or close claims leaving individuals without needed support for their ongoing condition(s). This often pushes people into the Centrelink system and increases applications for support through DSP

The independence, qualifications, training, expertise and quality

assurance of assessors

We do not support the mandatory aspect of Independent Assessments. Allied health professionals appreciate that it takes a considerable amount of time to understand an individual’s specific disability and support needs. These practitioners have taken the time to build rapport and trust with participants before discussing personal issues and their complex disability-related needs. The requirement that all participants (current and prospective) will be assessed through this new process, fundamentally removes choice and control from participants (a central tenet of the NDIS). Under the new process, the allied health professionals who are known to participants will have little input (if any) into the participant’s eligibility determination, plan development and reviews. NDIA appointed ‘Independent Assessors’ will not have the depth or breadth of knowledge about a range of disabilities, particularly uncommon disabilities, to be able to adequately understand the complexity of participant needs. Assessment by unfamiliar assessors will likely be traumatic for participants and their families, and the use of one-size-fits-all assessment tools, will likely result in people with complex disabilities not being assessed properly. Poor assessments are likely to lead to people being denied access to the Scheme and for those deemed eligible, they are likely to be granted inadequate funding. This will disadvantage participants, their families and support teams, as well as the thousands of allied health providers currently providing assessments and reports for NDIS reviews and working with participants to meet their goals.

The blunt application of a tool without the professional experience of the treating practitioner is insufficient to interpret an assessment instrument adequately. There are many contextual factors, information about treatment responsiveness, knowledge of the individuals circumstance and diagnostic implications involved in adequate assessment of functioning. An ethical practitioner would not apply a tool and undertake a brief evaluation and consider they have the full picture of an individuals functioning. Practitioners working with participants may have been doing so for a considerable amount of time, enabling them to gain an expert opinion on what is required to assist the participant to significantly improve their functioning. What the NDIS is seeing as “Sympathy bias” is simply an adequate conceptualisation of the participants support needs and requirements, built in a professional relationship of trust and openness. It is disgraceful and defamatory that the NDIS has framed it as anything other than professional and ethical.

The assessments provided by Independent Assessors will be invalid at best, due to the way that these assessments are being implemented and grossly inaccurate, due to the lack of background information and knowledge of contextual information available to Independent Assessors.

The appropriateness of the assessment tools selected for use in

independent assessments to determine plan funding.

The assessment tools were chosen to be “diagnosis neutral.” This is inappropriate in many ways. Different disabilities affect individuals in many different ways. Having a broad

brushstroke assessment will have limited to no success in picking up the individual differences that are apparent in the disability sector. Some disabilities have effects that are not covered by the assessments that have been chosen but these individuals will not be able to live an independent life because of their disability. Disabilities involving chronic pain, vision impairment, hearing impairment and psychosocial disabilities for example will not be adequately assessed using these assessment tools. The qualifier regarding Independent Assessments was that the assessment would be based on “what is the best a person can do at a given time in a given place with and without ance.” Basing an assessment on the best functioning an individual has would lead to a gross underfunding of their supports and fails to account for how much of the time they are functioning at their worst. Many disabilities cause varied fluctuation in functional capacity. These need to be accounted for when allocating funding and treatment budgets. It could also mean that function may not be improved over the course of a plan period. The aim of the NDIS is to improve the functioning of the person with disability but this will not be met if we only focus on the best a participant can function. If adequate funding is provided then the participant can gain significant functional improvement, leading to less intervention needing to be provided later on in subsequent plans. The assessment tools chosen are not adequate when provided by a unfamiliar personto the participant, considering the nature of many disabilities that include a lack of ability to self-monitor and mask disability to people that are not familiar. Asking someone with a moderate or severe intellectual impairment whether they are able to perform tasks without assistance will not garner an accurate measure of their ability to do so on a regular basis. In the case of Neurodivergent individuals (Autistic, Intellectually Disabled, ADHD etc) the drive to behave and respond in socially desirable ways and mask their disability is often an overriding factor that would prevent their open disclosure of deficits to a stranger, regardless of their profession.

NDIA appointed independent assessors will not have the depth or breadth of knowledge across a range of disabilities, particularly uncommon disabilities, to be able to adequately understand the complexity of various participant needs.

It is the position of AAPi that functional and access assessments should be undertaken by providers who are specialists in the disability being assessed, and have experience in treatment of that disability. The most appropriate assessor may indeed be the treatment provider as they have an in-depth view of the functional capacity of the individual, they have been providing therapeutic support to and would have an existing professional relationship, thereby reducing stress for participants and their carers’. We disagree with the viewpoint that there is inherent compassion bias and challenge the validity of this concept in its entirety. The term compassion-bias appears to be pejorative and is used to undermine effective and efficient assessment and treatment. It appears to be utliised by people who do not understand the benefits of compassion and connection as part of the assessment process, and who believe that lack of humanity is somehow more actuarial and economically astute. Compassion is the ability to be present (highly attentive) and listen deeply. Compassion bias appears to be confused with unprofessional sentimentality. Psychologists and other professions providing therapeutic supports are bound by their registration to be ethical and evidence-based in their decision-making processes particularly around treatment choice and efficacy. It would be unethical and psychologists would not remain registered if they were inappropriately inflating treatment needs of clients.

The implications of independent assessments for access to and

eligibility for the NDIS

It is of great concern that the allied health professionals who are known to participants will have little input (if any) into the participant’s eligibility determination, plan development and reviews.

Simplistic assessment by unfamiliar assessors will likely be traumatic for participants and their families, as will the use of one-size-fits-all assessment tools, will most likely result in people with complex disabilities not being assessed properly. Poor assessments are likely to lead to people being denied access to the Scheme and for those deemed eligible, they are likely to be granted inadequate funding.

The implications of independent assessments for NDIS planning,

supports

These assessments will not provide adequate information that would allow for funding decisions to be made regarding the plans of participants. The assessment tools themselves will not pick up many disability related needs.

For illustrative purposes we ran a few real life examples through the framework that has been provided to determine what, if any impact Independent Assessment would have on a participants funded supports.

One example was a participant with multiple comorbid diagnoses that scores in the first percentile across all adaptive function areas and who has no informal supports. Another was a participant who also has multiple comorbid diagnoses that scores in the first percentile across all adaptive function areas and who has no informal supports. Provision of supports would be larger depending on the expression of that disability in the community over time.

One individual with that level of function who isolates in their home and has no behavioural issues received a package that allowed for support work a few times a week and some allied health support on a fortnightly basis. They can remain relatively stable in the community. Yet the other case, who receives the same scores would be significantly underfunded. They have a history of escalating rapidly in the community, requiring multiple hospital admissions, emergency service attendances and tertiary interventions each year. The independent assessor would not know this information as the individual does not have insight into their impairment and does not have any support people from their personal network to assist them to communicate this information. If the assessor consulted with the treatment team they would recommend SIL level of support is required with weekly allied health intervention from multiple providers. This individuals plan, based on independent assessment would be deficient in the realm of hundreds of thousands of dollars, which instead would expand to millions paid by the public health system and state emergency services in avoidable

emergency interventions. This underfunded participant who was assessed incorrectly would rapidly exceed their community supports, leading to a high changeover of support workers and allied health providers, increasing the stress on the participant and requiring more support. If the participant was stabilised adequately in the community and appropriate funding provided this would result in a significant financial saving and relieve the burden on public health and state based services.

Another example is individuals with psychosocial disabilities such as schizophrenia, who commonly deny having any mental health diagnoses. If an Independent Assessor was to ask them about their disability and take their responses at face value, without reviewing reports from their relevant service providers, they would most likely lose access to funding. Without their regular psychological and social supports, these individuals will likely end up deteriorating quite rapidly and requiring intense supports/hospitalisation/police involvement.

The circumstances in which a person may not be required to complete

an independent assessment

These assessments will be stressful for the majority of participants. Even the current planning meetings with NDIS community partners that are known to the participant, elicit strong stress reactions for participants. Some escalate in their symptoms in the lead up, and those with profound disabilities who are required to participate generally become very distressed as they do not understand what is happening and why they must participate in these meetings, terrified that they will lose the supports they rely on to function.

That the NDIS would knowingly introduce a policy, known to be increasing the distress of 400 000 participants is disturbing and ill-conceived.

We strongly advocate that independent assessment, as optional rather than mandatory, with participants being afforded the opportunity to decline and instead provide documentation and assessments from their current treating team to inform their planning and budgeted supports.

It is particularly important that those with complex disabilities, disabilities that affect personal insight or ability to communicate, rare disabilities or multiple disabilities be assessed by professionals who are known to them and understand the expression of their disability and what supports are required to enable them to live an “ordinary life” in the community. It is in these situations that they should not be required to participate in Independent Assessment as it would be grossly inaccurate and detrimental to the wellbeing of the participant.

Opportunities to review or challenge the outcomes of independent

assessments

There is increasing anxiety around not being able to access or challenge Independent Assessments. Clients need to be informed of their rights to appeal and what this process will involve.

Some of the disabilities identified on the previous access lists are disabilities that require high level supports, and waiting long periods of time for access to NDIS or being denied access based on inaccurate assessment will create decline in their function and create health emergencies or increase risk of harm for some individuals.

In every other service, particularly health and disability services, the client has the right to access their records unless doing so would be harmful to their health and well-being. This should also apply to assessment results. If the assessor considers that the participant or applicant needs to be supported to understand their results they should be provided with that support in a timely manner and with the support that they request.

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

Participants with communication difficulties will likely need access to assistive technology during the assessment process. For some individuals, they may be unable to participate meaningfully in the assessment process. This needs to be interpreted as an inability to participate rather than a refusal to participate, although it may look like the latter if the individual is distressed by the process. This requires a high level of disability specific knowledge and experience to navigate from an assessment perspective. An individual’s treatment provider may need to be present during the assessment to assist the process and even then, the individual may not be able to participate.

Participants should be given the power to choose to either undergo the ‘Independent Assessment’ process or use reports from their trusted allied health providers. People living with disabilities are often subjected to the prejudice and quick judgement of others, as well as loss of control and choice (a central tenet of the NDIS). This change cements that experience for participants. It takes away the participant’s right to have a tailored assessment and treatment program to improve their function and achieve goals of their choice.

Assessors of their own choice or from their own cultural group; interpreters present during assessment; and/or an allowance for a support person from their own cultural group being present during assessment, would be the most respectful option in these cases. Some disability types may have their own identified community (e.g. deaf community and autistic community) and prefer their inclusion in this process.

The NDIS has an opportunity to contribute to closing the health gap for Aboriginal and Torres Strait Islander people. The proposed assessments are limited and not directed in a way that will adequately provide for Indigenous Australians. Trust and cultural safety can be increased when services are provided using culturally relevant approaches and in more appropriate settings. For Indigenous Australians this can be supported by allowing the assessment to be provided by their provider of choice, in a setting that they are familiar and

comfortable with and using assessment tools that are culturally appropriate. The current assessment tools are not. If Independent Assessments must be provided then there needs to be funding provision for partnerships with Aboriginal Health Workers so that they can be utilised alongside assessors to promote cultural safety.

Assessment tools used with Indigenous Australians would also need to be significantly expanded so that culturally appropriate assessment could be provided. There would need to be lengthy consultation with groups representing Indigenous Australians to inform the assessments that would be used and determine how plans would be led by these assessments. Culturally Responsive practice with Aboriginal and Torres Strait Islander people requires of the practitioner to work within a holistic framework that should also incorporate a social and emotional wellbeing therapy paradigm and understanding the determinants of mental health. This is an important skill area and should not be overlooked. We would ask for Independent Assessors to be provided education to ensure that there are more culturally safe assessment options available for Indigenous Australians.

The appropriateness of independent assessments for people with

particular disability types, including psychosocial disability

The pilot study into Independent Assessments is reported to include categories of disabilities applicable to 64% of NDIS participants. There is no clarity on how appropriate the results of this pilot study would be to the other 36% of participants in the scheme. There was also an inadequate sample size. 513 out of 400 000 is equivalent to 0.13 percent of the NDIS population being involved in the trial. These results are not representative of enough participants to draw any conclusions about the utility of Independent Assessments. We have no robust data from this trial about the utility of the Independent Assessment framework for it to be rolled out to the whole scheme. There is also a lack of data around the participants in the pilot study who did not complete all requirements. There was a non-completion rate of over 70%. This takes the sample size down to 145, representing 0.04% of participants. Clearly this does not equate with adequate representation of the participants receiving NDIS supports. Additionally 28% reported that the assessor was not adequately familiar with their disability. In the NDIS scheme this would mean that hundreds of thousands of participants would not be assessed by someone who was familiar with their disability. This is unacceptable. How could participants needs be adequately assessed by someone who was not familiar with their disability, the trajectory or treatment needs as well as the support needs could not be adequately assessed by someone who did not have a working knowledge of their disability.

Being able to choose whether you participate in the assessment or not and being able to choose a provider of your choice would be the most respectful, appropriate and accessible option. Being able to choose where the assessment is to take place is also important. For some participants the requirement to participate in an Independent Assessment will cause extremely high levels of distress. Many will not be able to participate fully in the assessment process due to their distress. Some participants with health vulnerabilities will not be safe to meet with unknown assessors due to the current COVID-19 pandemic. Many with such

vulnerabilities are choosing to engage in therapeutic supports via telehealth and this needs to be an available option as well.

Summary

There is insufficient evidence that Independent Assessments are required. Their design and implementation in the NDIS has been illconceived and without adequate consultation with providers or the participants themselves. Independent Assessment rollout needs to be immediately ceased and full consulation undertaken to address the issues within the NDIS and the difficulties accessessing the scheme.

AAPi opposes the introduction of mandatory Independent Assessments. If there are additional assessment measures that the NDIA requires, these need to be communicated with providers, after thorough consultation with peak bodies so these can be included in reports. This negates the need for independent assessors. The Independent Assessment system has the potential to negatively affect hundreds of thousands of disabled Australians and as such a high level of evidence is required before such a change is implemented. We do not believe this high level of evidence has been established nor the negative rampifcations fully understood, thus any plans to implement mandatory Independent Assessments should cease immediately.