Implications of independent assessments for NDIS planning and supports | External submission

PHYSIOTHERAPY ASSOCIATION

Joint Standing Committee Inquiry into independent assessments under the NDIS

Submission by the

Australian Physiotherapy Association

March 2021

PHYSIOTHERAPY ASSOCIATION

Table of Contents

Executive Summary …………………………………………………………………………………………………………… 3

APA Position on Independent Assessments ………………………………………………………………………………………. 3

APA Recommendations……………………………………………………………………………………………………… 3

Introduction ………………………………………………………………………………………………………………………. 7

Terms of Reference ......................................................................................................................................... 7

Detailed response ……………………………………………………………………………………………………………… 7

Terms of Reference (a): The development, modelling, reasons and justifications for the introduction of
independent assessments into the NDIS ......................................................................................................... 7

Terms of Reference (b): The impact of similar policies in other jurisdictions and in the provision of other
government services ........................................................................................................................................ 8

Terms of Reference (c): The human and financial resources needed to effectively implement independent
assessments .................................................................................................................................................   9

Terms of Reference (d): The independence, qualifications, training, expertise and quality assurance of
assessors ....................................................................................................................................................... 10

Terms of Reference (e): The appropriateness of the assessment tools selected for use in independent
assessments to determine plan funding ......................................................................................................... 10

Terms of Reference (f): The implications of independent assessments for access to and eligibility for the NDIS
      ....................................................................................................................................................................... 11

Terms of Reference (g): The implications of independent assessments for NDIS planning, including decisions
 related to funding reasonable and necessary supports .................................................................................. 12

Terms of Reference (h): The circumstances in which a person may not be required to complete an independent
assessment .................................................................................................................................................   12

Terms of Reference (i): The opportunities to review or challenge the outcomes of independent assessments
      ....................................................................................................................................................................... 13

Terms of Reference (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 ................................................................. 13

Terms of Reference (k): The appropriateness of independent assessments for people with particular disability
 types, including psychosocial disability .......................................................................................................... 14

Terms of Reference (l): Any other related matters ......................................................................................... 14

About the Australian Physiotherapy Association ……………………………………………………….. 15

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PHYSIOTHERAPY ASSOCIATION Executive Summary

The Australian Physiotherapy Association (APA) welcomes the opportunity to provide feedback on independent assessments under the NDIS to the Joint Standing Committee on the National Disability Insurance Scheme (NDIS/the Scheme).

The APA acknowledges the challenges and complexities in designing services to suit the diverse range of needs of people with disability. The reform is unprecedented in scale and scope and while the full operation of the NDIS represents a major milestone, this is not the Scheme that was promised to Australians to ensure access to the support they need.

The NDIS promised to help many Australians living with disabilities – delivering disability services differently with more choice and control for participants towards using individualised funding and self- directed supports. It is clear from the significant shifts of the past few years – under the guise of reform – that the Scheme has fallen well short on its promise.

The most recent move by the National Disability Insurance Agency (NDIA) in proceeding to an Independent Assessment (IA) model, as confirmed by Government just days out of a consultation process, undermines choice and control and risks diminishing trust and confidence in the Scheme.

APA Position on Independent Assessments

The APA has significant concerns regarding the proposed introduction of independent assessments.

The proposed model will not create consistency and equity. The policy promise to provide people with true choice over the design and delivery of their supports cannot be fulfilled through such a blunt instrument. This is an approach that locks out the required clinical expertise in making assessments, with potential for trauma for the individual applicant.

The model lacks empathy in policy design. It does not value people with disability as partners in shared dialogue. It weakens hard-earned trust by excluding existing providers. It disempowers and removes choice and control for the individual and leaves no room for appeal. This will only serve to create inequalities between groups of people with disability.

APA Recommendations

The APA offers the following recommendations in relation to the Terms of Reference (ToR) set out by the Joint Standing Committee.

Introduction of IAs into the NDIS, ToR (a)-(b)

The APA calls on the Australian Government to take the necessary steps to uphold the values of the NDIS, as promised. This change represents significant reform by reducing choice and control, with potential for harm. More evidence is required to justify its introduction.

The NDIA has failed to meaningfully engage with people with disabilities, participants, their families and carers, and the wider disability sector.

This proposal will have far-reaching consequences for the almost 450,000 people participating in the NDIS. It represents the largest change to the Scheme since its introduction, and therefore warrants closer policy attention to the lessons learnt elsewhere, particularly where similar policy experiments have failed. There is a need to evaluate a range of solutions before proceeding.

The APA recommends that the Government immediately pauses the implementation of IA until a valid and independent study can be carried out to assess the risks of such measures.

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The APA recommends that the Government directs the NDIA to work in partnership with people with disability and move to a co-design approach from the outset in developing reforms.
The APA recommends that the Government directs the NDIS to look to past lessons to avoid unintended policy harm and in pre-empting future challenges (relates to recommendation 1 above).

Cost impacts, ToR (c)

The proposed model is a harsh deficit-based approach that will not lead to consistency in decisions or individualised planning.

There is a need for multiple sources of knowledge about a person and their context-specific challenges. The cost impacts will be realised through the model’s failure in capturing these requirements. The need to include expert reports as part of assessments, and particularly from those who have worked with the individual, must be prioritised.

It is important to note that the policy failings and costs will be realised over time. The proposed model that involves time-limited observation by an independent assessor – not known or chosen by the individual – using standardised tools that remain untested will result in policy failure.

While the social costs are impossible to determine and may not be borne immediately by the independent assessor model, they will most certainly be realised over time. We will see a crisis unfold one person at a time. It will result in an upstream of applications to the Administrative Appeals Tribunal (AAT) with a heavy social toll on people with disability.

It is our view that efficiencies and improvements can be found through some simple policy fixes. The APA considers a more viable and less costly policy solution to the NDIS employing their own “independent assessors” to complete standardised assessment would be to appropriately support existing processes that prioritise the required expertise. Further, options to change existing models must always align with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) and be undertaken through a co-design process with people with disability.

The APA recommends that the Government directs the NDIA to explore more viable policy options to its costly mandatory contracted assessor model.

Devaluing expertise, ToR (d)

The APA questions the clinical competency and independence of the assessors sourced from a pool of NDIS-appointed healthcare professionals using standardised tools.

There are inherent risks in an approach that sees sole assessor practitioners making assessments on physical functioning without specific disability knowledge or experience. The current requirement for allied health professionals to be qualified and to have a minimum of 12 months full-time clinical experience is grossly inadequate and cannot possibly ensure assessors hold adequate experience or the depth of clinical expertise required.

The APA supports the need for providers in the Scheme to have rigorous quality control and governance mechanisms implemented within their practice. This is vital to ensure that professional standards are maintained, risks for providers and participants are identified and reduced, and that sustainable and ethical mechanisms underpin the management of the Scheme.

This requirement would extend to the implementation of Independent Assessors. The Government must ensure that, should an independent assessment process be implemented, that assessors are required to be appropriately skilled to complete the assessments, have identified experience within the sector, and have quality and governance mechanisms in place specifically aimed at reducing risk

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to participants. As a minimum, they should be required to meet the practice standards of registration, as controlled by the NDIS Quality and Safeguards Commission (NQSC).

The APA categorically and unanimously rejects the assertion that these proposed assessments can be implemented safely regardless of whom is completing them. The APA calls on the Government to halt their implementation and consider an alternative model. The APA welcomes the opportunity to engage with the NDIA on a reworked evidence-based assessment and assessor framework that is co-designed with people with disability.

Recommendations 1-3 above.

Determining plan funding, ToR (e)

Independent assessments should not be mandatory nor should they be the primary basis for an individual’s funding. The proposed model in assessing functional disability has limitations, it places a single time lens on assessment and therefore unable to capture capacity and fluctuations over time.

The tools selected are not valid for the purpose of the NDIS and are certainly not designed to discern funding or funding level. This aspect is untested and unproven in the literature making it a policy experiment that deviates from accepted approaches used elsewhere in other disability systems.

There is no evidence base that supports the use of the functional impairment tools as proposed to inform funding estimates across impairments/disability types. There are other more appropriate tools for this cohort that could be utilised. A key caveat would be to extend the model design to leverage the skills of multidisciplinary teams across a range of settings and towards uncapped assessments based on need or complexity of need.

Recommendations 1-3.

Access impacts, ToR (f)

Access remains key as these changes will impose significant barriers for some, particularly in terms of pre-access where there are shifts in eligibility. Assessments used decisions for “access” and “planning” should be considered separately as they are separate pathways. This approach can only lead to adverse outcomes for people with disability. The mandatory element is most troubling whereby a participant without exemption who refuses to undergo an IA will automatically be locked out of the Scheme.

Recommendations 1-3 above. In addition, the APA recommends that the Government directs the NDIA to ensure that choice is factored in future policy design.

Funding reasonable and necessary supports, ToR (g)

The APA is concerned that the IA model does not recognise future gains, prognosis and capacity building potential. It also does not capture deteriorating conditions or requirements to monitor and track changes. We see capacity building, in building independence and skills, is where opportunities lie and where significant gains can be found through the right allied health inputs. This will have direct implications on funding reasonable and necessary supports.

Recommendation 1-3 above.

Exemptions ToR (h)

The APA strongly believes that participants should have the right to choose which access path they would like to undertake. In upholding choice, the IA should be optional for access to the NDIS and not mandatory. This choice, either for IA or provision of evidence from their regular providers, must also be made clear to the applicant.

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The APA recommends that a detailed assessment be made available in enabling both choice and in ensuring applicants are not worse off.

Right to appeal (i)

The IA model as outlined cannot capture the complexity of support needs required and will lock individuals out, with no room for appeal. In considering reforms of this nature, the APA urges the Government to ensure that there is an appeals mechanism built into the process and that applicants must be made aware of their rights to review.

The APA recommends that an appeal mechanism be built into the process and ensures applicants have the right to a review before a matter proceeds to the Administration Appeals Tribunal (AAT).

Impacts on specific cohorts (j) and disability types (k)

The APA is very concerned about the impacts on applicants from specific cohorts and that NDIS- appointed assessors will not hold the expertise to make assessment across a range of disabilities and impairments. There is no evidence to support the suite of assessments in the toolkit to provide the standardised assessment.

The APA recommends that further research is required to prioritise a population impact study and to explore the relationships between disability types against functions and outcomes.

Any other related matters, ToR (l)

In looking to the future and towards more viable policy solutions, the APA recommends that the Committee carefully considers the alternative model put forward by Professor Bruce Bonyhady AM in his Submission to the NDIA Consultation. Professor Bonyhady’s proposed model – An Alternative Fair Way Forward1, provides the policy essentials to ensure a valid, equitable and consistent assessment model that is more in keeping to the original Scheme design. This model would ensure the Government delivers the NDIS as promised to Australians with disability.

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Introduction

The Independent Assessment (IA) proposal will have far-reaching consequences for the almost 450,000 people participating in the NDIS. The APA shares the growing sector-wide concerns that the proposed mandatory IA model will create stress and trauma for people with disability and that this instrument will be of little utility in terms of understanding a person’s support needs. Further, the APA shares concerns that the model will not address process issues and system failures and is being rolled out without effective consultation and engagement.

Terms of Reference

In our submission, we have focused on the key impacts brought about by this change. In doing so, we have emphasised the core principles of dignity, safety and inclusion. The new assessment process will be traumatic and limit access to the Scheme. The APA has significant concerns about the impacts on the individual from a model that involves time-limited observation by an independent assessor not known or chosen by them using standardised tools that remain untested.

We have not addressed fully all of the Terms of Reference set out by the Joint Standing Committee but offer experts that can provide further input to these issues.

The APA would welcome an opportunity to present to the Joint Standing Committee on the NDIS should it pursue public hearings on the matter. This would help bring an important focus on the impacts of this change in terms of enabling appropriate access to physiotherapy services and supports for people with disability.

Detailed response

Terms of Reference (a): The development, modelling, reasons and justifications for the introduction of independent assessments into the NDIS

APA Position | There can be no justification for enforcing such a significant shift without an evidence- base. The evidence for making such a major change is not substantive. We recommend that the Government immediately pauses the implementation of IA until a valid and independent study can be carried out to fully assess the risks of such measures.

Justification for the changes

Evidence-based policymaking is informed by available evidence, rigorous analysis of policy solutions and ensures key perspectives are included. It should not be guided by evaluation of two pilot programs conducted in 2018-19 and 2019-20, and particularly while the results of which remain concealed. This reform stemmed from a Tune Review recommendation but with a clear condition that it was dependent on close consultation with people with disabilities. This has not occurred.

From what we know of the pilot results, the NDIA reported 90 per cent of participants were either very satisfied or satisfied by their experience. However, these results were not deemed reliable.

During Senate Estimates on 29 October 2020, it was clear that they were based on a small survey sample. It is important to highlight that the survey itself was not a validated survey, thereby further weakening the pilot. Of the 512 participants in the first pilot, 145 completed a survey (or 28 per cent). This moved Senator Steele-John to ask the question: “What level of participant dissatisfaction would cause the government to pause the introduction of assessments?” Other details about around the

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second pilot program also suggests limited validity in evaluation approach: of the 99 assessments undertaken in the second pilot, 27 completed a survey (27 per cent). In the context of policy change that will impact almost 450,000 individuals, reliance on small sample surveys to validate such significant reform is grossly inadequate.

Process and accountability

APA Position | It is clear that the NDIA was going ahead with this significant change regardless of the consultation process and the outcomes of this Inquiry. The NDIA has failed to meaningfully engage with people with disabilities, participants, their families and carers and the wider disability sector. We recommend that the Government directs the NDIA to work in partnership with people with disability and move to a co-design model in developing reforms.

The APA made a submission to the NDIS Consultation 1, Access and Eligibility Policy for independent assessments on the due date, 23 February 2021. Later that day, Minister Colbeck presented the government’s response to final report of the Joint Standing Committee on the National Disability Insurance Scheme on its inquiry into NDIS planning.

The APA is concerned about the Government’s response to the Joint Standing Committee, and in particular how these responses relate to this inquiry’s Terms of Reference (a) the development, modelling, reasons and justifications for the introduction of independent assessments into the NDIS (specifically).

The Government’s position appears to be that IAs will be introduced, irrespective of the feedback from the NDIS consultation process and this Joint Standing Committee Inquiry. It is obviously not a question of ‘if’ but ‘when’ and ‘how’ these assessments will be used. This does give the appearance that the NDIS consultation process was inadequate, or to put it colloquially, they paid ‘lip-service’ to the consultation process.

Terms of Reference (b): The impact of similar policies in other jurisdictions and in the provision of other government services

APA Position | There is much to be learned from experience in other jurisdictions, particularly where similar policy experiments have failed. In implementing major complex national reforms, there is a need to look to past lessons to avoid unintended policy harm and in preempting future challenges. We recommend that the Government ensures this focus is captured through the independent study recommended against ToR (a) above.

Policy lessons

Given the accelerated rollout of the NDIS, there was always risk of settling on Scheme design elements without proof of concept. Closer policy attention was required in examining the strengths and limitations of disability policy reform in the UK and elsewhere. In particular, the findings from a recent study (Barr et al. 2106) that found functional capacity assessments have potential to cause significant harm should have been considered.2

The UK’s Work Capability Assessment provided key lessons on imposing a blunt instrument onto a vulnerable cohort. In this study, the authors found that for those areas most exposed to the reassessment process that the functional assessment approach led to a greater increase in three adverse mental health outcomes – suicides, self-reported mental health problems and antidepressant prescribing. This research warns of the potential impacts of these ‘real-life policy experiments’ imposed on individuals without their explicit consent stating that the health impact of alternative disability assessment policies should be established through well-designed trials before they are implemented universally. 3

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Policy process

A further concern is that the NDIA has proceeded towards implementation of IAs without due policy process. It is clear that the reform focus in this case is misguided. Mandatory IAs will not address inconsistencies in the NDIS access and planning process. In advancing the required reforms, there is a need for an independent focus on the policy problems, a further focus on those best equipped to design effective change as well as a commitment to independent evaluation of tested initiatives. The pilot evaluations carried out by the NDIA were clearly underdone as detailed in our response to ToR (a).

Terms of Reference (c): The human and financial resources needed to effectively implement

APA Position | The introduction of mandatory IAs represents a significant departure from the values and original vision of the NDIS. The APA calls on the Committee to ensure the NDIA upholds these values based on individual needs, control and choice.

The APA considers a more viable and less costly policy solution to the NDIS employing their own “independent assessors” to complete standardised assessment would be to appropriately support existing processes that prioritise the required expertise. We recommend that the Government directs the NDIA to explore more viable policy options to a costly contracted assessor model.

The proposed model represents a harsh deficit-based approach that locks out the required expertise in making assessments, with potential for trauma for the individual applicant. There is a need for multiple sources of knowledge about a person and their context-specific challenges.

The APA would only support a model that encompasses choice. Therefore, it may form a pathway for an individual applying to be a participant for the Scheme should they select this option or pathway. The policy solution needs to be agile enough to capture complexity in disability leveraging the required specialised expertise. A key feature would include the use of expert reports as part of assessments to supplement the areas not covered by the assessor and/or in response to their skill deficits. The model must be redesigned to allow for additional ‘inputs’ to harness the required expertise encompassing diverse skillsets across multi-disciplinary teams.

A simple policy shift to provide a definition for “functional capacity” and guidance about making these judgements would help to address inconsistencies and issues of perceived or real bias. The NDIA should provide clear guidance to the market regarding the inclusion of a minimum data set of standardised assessments, without devaluing the essential relationship between a participant and their allied health professional, which is fundamental to contextualise the impact of disability for an individual. Improvements can also be made through the redesign of templates to ensure ample space for an appropriately detailed response and the provision of clear guidance on what is required.

More broadly, rather than explore the human and financial resources needed to effectively implement the flawed IA model, it is the broader cost impacts and social costs that need more focus. The social costs of this policy experiment cannot be underestimated. These impacts will be realised over time as the model fails. The consequence will be an upstream of applications to the AAT. The social toll is much harder to quantify but this is a harmful measure that will have a marked effect on people’s wellbeing.

The very discussion about the need for the IAs in the first place reflects the lack of guidance by the NDIA to the market about the required information needed to facilitate appropriate plan development. Therefore, this represents regulation of the wrong end of the system. The misguided policy solution (for IAs) only demonstrates that the decision makers (Planners) are ill equipped to make appropriate determinations based on the information provided. Further clarification of the information provided to the Agency through the existing mechanisms would certainly mitigate some of this issue. However,

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the need for a review of the systems used to support the decision makers is where the policy focus is needed. Additionally, the cost of regulation and compliance for providers is high. Further threats and challenges to the market will only enhance the difficulty of the market in meeting this requirement.

Terms of Reference (d): The independence, qualifications, training, expertise and quality assurance of assessors

APA Position | The APA questions the clinical competency and independence of the assessors sourced from a pool of NDIS-appointed healthcare professionals using standardised tools.

There are inherent risks in an approach that sees sole assessor practitioners using simplified assessment tools within the context of complex disabilities. This policy should not be pursued.

Physiotherapists are movement and participation experts in disability who specialise in improving function and building capacity. Physiotherapists are committed to providing expert, evidence-based, safe and high-quality care to people with disability and contributing to an effective and equitable disability sector.

Ensuring the required expertise in making assessments and the ability to further leverage that expertise beyond the initial assessment is important. We note that the NDIA has stated that the IA will be completed by a qualified allied health professional with a minimum of 12 months’ full-time clinical experience. This level, as set, is grossly inadequate and cannot possibly ensure assessors hold adequate experience or the depth of clinical expertise required.

It is important to emphasise that, given the framework of the proposed assessments, we feel that no mechanism would exist that would reduce the risk posed by these assessments to the participant. To discuss characteristics of an assessor that would mitigate risk and improve outcomes would only distract from the fundamental inadequacy of the assessment framework. The APA categorically and unanimously rejects the assertion that these proposed assessments can be implemented safely, regardless of whom is completing them. Therefore, we advise the Government to halt their implementation and consider an alternative model.

Providers in the Scheme must have rigorous quality control and governance mechanisms implemented within their practice. This requirement would need to extend to independent assessors. While still acknowledging this proposal is fundamentally flawed, for the purpose of responding to ToR (d) above, we offer the following policy parameters. The Government must ensure that, should an independent assessment process be implemented, that assessors are required to be appropriately skilled to complete the assessments. That they have identified experience within the sector and have quality and governance mechanisms in place specifically aimed at reducing risk to participants. As a minimum, they should be required to meet the practice standards of registration, as controlled by the NDIS Quality and Safeguards Commission (NQSC).

Terms of Reference (e): The appropriateness of the assessment tools selected for use in independent assessments to determine plan funding

APA Position | The APA remains concerned about the tools selected for assessment of such a vulnerable population. The strong policy basis for person-centred approaches to care is lost with the implementation of IAs. The use of standardised assessments within a heterogenous participant population will not adequately identify the personal impact of a participant’s disability.

Independent assessments should not be mandatory nor should they be the primary determinant of an individual’s funding. We recommend that the Government directs the NDIA to explore more viable policy options to its costly mandatory contracted assessor model.

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Individuals who require support under the NDIS experience a range of sensory, physical, cognitive, socio-emotional/behavioural and/or speech and language disabilities that impact significantly on their daily functioning and self-care skills. These context-specific challenges need to be prioritised in policy to reflect the complexity, and changing and evolving nature of a person’s functional impacts from their disability.

A key issue is that the NDIA has not indicated how functional capacity, as just one measure used as a predictor of everyday function, will be measured and how other important factors will be captured. This is an assessment that is not indicative of function over time, of disability history or nuanced to address fluctuations in daily needs. It is important to acknowledge the limitations of tools to measure functional capacity in a disability. There is no evidence to support the suite of assessments in the toolkit to provide the standardised assessment. Further, the tools recommended by the Productivity Commission to be considered as part of a toolkit (I-CAN, I-CAP and SIS) are not captured.

The use of standardised assessments via the IAs assumes the nature of the disability is static for the assessed period. This will result in the development of inadequate plans and unsuitable levels of support that will increase the number of participants at risk of harm. The use of standardised tools will not adequately “predict” functional change. The need to “anticipate” the impact of disability and its progressive nature is paramount in many populations supported by the NDIS. This is crucial in degenerative diseases in particular, and arguably some of the most vulnerable participants within the Scheme.

Terms of Reference (f): The implications of independent assessments for access to and eligibility for the NDIS

APA Position | Access remains key as these changes will impose significant barriers for some, particularly in terms of pre-access where there are shifts in eligibility. Assessments used for decisions about “access” and “planning” should be considered separately. The mandatory element is most troubling whereby a participant without exemption who refuses to undergo an IA will automatically be locked out of the Scheme. There is confusion about appeals with the NDIA indicating that results will not be a ‘reviewable decision’.

We recommend that the Government directs the NDIA to ensure that choice is factored in future policy design through a co-design approach.

The APA is concerned that the haste in implementing IAs is contributing to increased distress and anxiety. As the APA noted to the NDIS, having a stranger make decisions while locking out the trusted physiotherapist who may have an on-going relationship of care can be traumatic for a person with disability. We also question decision-making processes that may involve inappropriately qualified assessors. To be eligible for the NDIS, participants have already been through extensive assessments by qualified health and medical experts.

We consider the disruption imposed as significant for the individual. People with disability and their families/carers need to continue to be treated and managed by their trusted health professional. This toolkit will allow a stranger, unknown to the person and their family, to take over, locking out their practitioner of choice. Challenging behaviours can be dangerous for new providers, as well as cause unnecessary anxiety and stress for those in the Scheme.

In its attempt to provide “equitable” access to the Scheme, the implementation of the IAs will in fact further polarise the population of people living with a disability within Australia. The rigidity of the approach (IAs) and its limited ability to stratify the impacts of disability will result in those individuals already struggling for access being further disenfranchised.

It is reasonable to suggest that those individuals who struggle to voice the impact of their disability may be obstructed from accessing the Scheme as a result of the impact of the IAs. Therefore reinforcing and compounding the current difficulties with access within the current framework

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for this population. In contrast, those participants who may be able to adequately quantify the impact of their disability, through the announced reforms, are likely already well supported through existing mechanisms.

Terms of Reference (g): The implications of independent assessments for NDIS planning, including decisions related to funding reasonable and necessary supports

APA Position | The APA is concerned that the IA model does not recognise future gains, prognosis and capacity-building potential. We see capacity building, in building independence and skills, is where opportunities lie and where significant gains can be found through the right allied health supports.

The NDIS funding across a range of supports and services including education, employment, social participation, independence, living arrangements and health and wellbeing is a vital component of the Scheme. The IA approach lacks sensitivity to a participant’s potential and threatens the funding of the supports that would allow its pursuit. There is further need to ensure a strong degree of social participation for people with disabilities and for giving them greater capacity to exert choice and control. This power will be significantly diminished by the implementation of the proposed measures.

This model only serves to transfer choice and control from individuals to the NDIS. The further need to ensure a strong degree of social participation for people with disabilities and for giving them much greater capacity to exert power has been significantly diminished.

Terms of Reference (h): The circumstances in which a person may not be required to complete an independent assessment

APA Position | The APA strongly believes that participants should have the right to choose which access path they would like to undertake. To ensure applicants are not disadvantaged under the current arrangements, we recommend that a detailed assessment pathway is made available in lieu of the IA.

From a policy principle standpoint of upholding choice, the IA should be optional for access to the NDIS and not mandatory. The choice for IA or provision of evidence from their regular providers must be made clear. Further, where participants have had strong relationships and evidence of quality outcomes in the past with regular providers, then these assessments should be considered as an alternative to an assessment.

The IA should not be mandatory, and alternative pathways must be available to individuals both applying for access to the scheme and participants already accepted in the scheme.

We consider that if the assessor has the appropriate skillset, there shouldn’t be many circumstances that a person will not be able to complete the full assessment. However, there are a number of scenarios where an individual should not be required to undergo an independent assessment for access. For a person with a psychosocial disability, an IA may further cause significant burden/stress to the person and may be unable to be completed.

The NDIA needs to conduct more research to better aide participants with progressive neurological diseases and for those who are undergoing significant life change and at transition points their life and where the proposed IA process would cause significant burden and stress.

Case example 1 | Motor Neurone Disease

Motor Neurone Disease is a hugely heterogeneous condition. The assessment required would need to differentiate between a participant who would immediately need high level and specific supports from another participant who may not. However, the system would equally need to be agile enough to allow for a rapid response in the event of a change in the rate of progression of condition,

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which is common. Based on our understanding of the working model of the IA, this is highly unlikely to be achieved. This will result in significant difficulty in implementing appropriate supports for the participant and will lead to unnecessarily suffering for the participant and their informal support networks.

Of even more concern is the fact that we have not been provided clarity about how an individual may seek reassessment. If an individual were to receive their IA shortly after diagnosis, they may not yet have experienced the functional decline to support access to the Scheme. Should they be denied reassessment for even a short period, there is a huge risk that an individual in this circumstance would unnecessarily be at risk with no supports. It may, in turn, delay participants accessing the Scheme until they feel they are experiencing significant enough decline in order to meet the unclear access arrangements.

Case example 2 | Cerebral Palsy

A participant with Cerebral Palsy, GMFS V, with high medical needs as a result of their disability (for example, epilepsy, PEG and catheter management and challenging behaviours) will have extensive care needs and require intensive allied health supports. However, their living arrangements will play a major factor in the level of their NDIS-funded supports. One participant may reside in Specialist Disability Accommodation with 24-hour care and two staff available for all required transfers with active overnight supports. Their informal support networks and family burnt out a long time ago. The same person who remains living in the family home with family persisting in supporting them and are nursed in bed. Both would score 0 in most assessment scales. What will differentiate these participants to determine their funding needs and differences?

Terms of Reference (i): The opportunities to review or challenge the outcomes of independent assessments

APA Position | The APA urges the Government to ensure that there is an appeals mechanism built into the process and that there is transparent criteria about the right to review or challenge decisions. The process must be clarification and ensure that appeals can be undertaken before a matter proceeds to the Administrative Appeals Tribunal (AAT).

This process as outlined cannot capture the complexity of support needs required and will lock individuals out with no room for appeal. In considering reforms of this nature, the experience of people with disabilities needs much more policy attention than currently being afforded.

We share concerns raised by others that cost cutting is behind some of the rush to implement IAs. Independent assessments may be used to remove participants from the Scheme by finding them ineligible. Of most concern is that the NDIS has not outlined any process about how they will decide who will be exempt.

Terms of Reference (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

APA Position | The APA is concerned about the impacts on applicants from Aboriginal and Torres Strait Islanders, and those from diverse cultural backgrounds and/or disadvantaged population groups will be further impacted. There is a need for model validation to be carried out across multiple functional assessments/disability types as well as across population and most at-risk cohorts. Accurate translation and culturally appropriate processes will need to be embedded into the policy supports. There has been limited discussion about how distance or rurality will be addressed to ensure equity of access. A priority study is required to work through the key barriers for these priority cohorts.

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Terms of Reference (k): The appropriateness of independent assessments for people with particular disability types, including psychosocial disability

APA Position | The APA is concerned that NDIS-appointed assessors will not hold the expertise to make assessment across a range of disabilities and impairments. Further, we are concerned that the tools as selected are not fit for purpose. Therefore, even an expert would not necessarily be able to adequately capture the impact of disability if they are constrained to using the very limited resources contained within the toolkit.

As we have maintained throughout, there is no evidence to support the suite of assessments in the toolkit to provide the standardised assessment. Further research is required to explore the relationships between disability types against functions and outcomes. The model as proposed will not lead to more valid and equitable outcomes. We are concerned that this will only serve to create inequalities between groups of people with disability.

Terms of Reference (l): Any other related matters

APA Position | Broader implications

The workforce implications are significant. The current provider market is “thin”, meaning that the IA workforce will likely be recruiting from an under-skilled market. This will leave gaps in workforce cover in all locations, especially rural, regional and very remote.

In order to provide a meaningful assessment and information to NDIA delegates the IA will need to have extensive experience working with people with similar type of disability in the community and be familiar with common functional issues. As there are a wide range of disability types, it will be difficult to build a comprehensive workforce to meet this need in the geographical area.

This workforce would compromise already thin markets and providers available to support people with their actual needs. This new system will undoubtedly take away from available therapists to support people with disability. Therefore, the implementation of the IAs will create a competitive workforce to the existing provider market.

If the Government and NDIA is committed to implementing mechanisms that support the maturity of the market, ensure access and the development of robust quality systems, then the implementation of a process that will compete with these mechanisms is counter intuitive.

Early Childhood Early Intervention (ECEI) pathway

The APA supports the policy objective to create a distinct ECEI implementation model, differentiated from the adult-centric Scheme. We support the core aim to ensure the right level and mix of support at the right time (including more pre-access assistance and transition support) through a family- centred approach aligned with best practice. While we support the exclusive use of registered providers to facilitate access to ECEI services, we believe significant reform will be needed to remove the current policy barriers. This includes supporting the current workforce by removing excessive red tape impacting on provider participation and ultimately market growth.

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About the Australian Physiotherapy Association

The APA’s vision is that all Australians will have access to quality physiotherapy, when and where required, to optimise health and wellbeing. The APA is the peak body representing the interests of Australian physiotherapists and their patients. It is a national organisation with state and territory branches and specialty subgroups. The APA represents more than 29,000 members who conduct more than 23 million consultations each year. The APA corporate structure is one of a company limited by guarantee. The APA is governed by a Board of Directors elected by representatives of all stakeholder groups within the Association.

References

1 Bonyhady B. ‘An analysis of the NDIA’s proposed approach to Independent Assessments. A response to the NDIA Consultation. The University of Melbourne. Melbourne Disability Institute. February 2021. Available at: https://disability.unimelb.edu.au/__data/assets/pdf_file/0011/3623987/Independent-Functional-Assessment- An-Analysis-of-the-Proposed-Approach-by-the-NDIA-Final-22-February-2021.pdf

2 Barr B, Taylor-Robinson D, Stuckler D, et al. ‘First, do no harm’: are disability assessments associated with adverse trends in mental health? A longitudinal ecological study. J Epidemiol Community Health 2016;70:339- 345.

3 Ibid.