SUBMISSION:
March 2021
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AUDIOLOGY AUSTRALIA Suite 101, 13 Cremorne Street, Cremorne, VIC. 3121 P: 03 9940 3900 | E: info@audiology.asn.au W: www.audiology.asn.au
Introduction
Audiology Australia (AudA) welcomes the opportunity to respond to the Joint Parliamentary Inquiry into the NDIS Inquiry into Independent Assessments. AudA is the peak professional body for the health profession of audiology, representing over 3,000 audiologists across Australia.
Audiologists are hearing health practitioners who help their clients preserve, manage, and improve their hearing and balance and their ability to process and understand sounds. They provide hearing services to a wide range of clients, including to National Disability Insurance Scheme (NDIS) participants. Currently, there are 21,079 NDIS participants with a hearing impairment in Australia (NDIA 2020).
Our submission addresses relevant terms of reference of the Inquiry as outlined below.
(a) the development, modelling, reasons and justifications for the introduction of independent assessments into the NDIS
Independent assessments (IA) are an assessment of a person’s functional capacity including their environmental and individual circumstances that will be undertaken by qualified health care professionals for the purposes of NDIS decision making. They will be free for participants and people with disability applying to access the NDIS.
Functional capacity is a major part of decision-making in the NDIS, however, under current arrangements, it can be a complex, costly and inconsistent process with participants sometimes spending thousands of dollars obtaining assessments to show their level of functional capacity.
We acknowledge the National Disability Insurance Agency’s (Agency) stated objectives behind IA’s introduction - that everybody, regardless of their situation, will have access to internationally recognised, evidence-based assessments and an up-to-date and complete assessment of their functional capacity. By making IA free, the Agency is also seeking to remove the financial burden of evidence gathering, to access and use the NDIS, and making sure participants have the right assessments to assist in the planning or review process.
AudA recognises that it is unfair that some people have to pay a significant amount for their assessments to access the NDIS and that some potential participants are disadvantaged because they cannot access health professionals who have the appropriate skills and knowledge to submit the kinds of evidence that is required.
A major focus of the IA process is to have consistent decision making for functional assessments to make sure the NDIS is fair and consistent for all participants. Lack of
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consistency has been a major problem for NDIS participants with hearing loss with similar functional assessments. AudA members frequently report to us that the resulting NDIS funded supports and budgets have wildly varied depending on where a person lives, who their local area coordinator or planner is and their knowledge and understanding of the impact of hearing loss.
However, AudA is concerned that the current IA proposal will not meet these objectives and, in fact, will disadvantage NDIS participants, including those with hearing loss in terms of goal setting, their resulting NDIS plan and plan budget.
Independent Assessment pilots
As a general comment, AudA is concerned about the speed of the rollout of IAs and the lack of evaluation across the different disability areas of the NDIS. The first IA pilot in late 2018 sought to demonstrate whether sourcing independent functional capacity assessments improved consistency, accuracy and reliability of Agency decisions. It included 513 opt-in IAs in nine metropolitan service delivery areas in NSW and covered NDIS applicants and participants with autism spectrum disorder, intellectual or psychosocial disabilities. The first pilot provided evidence that the use of standardised assessments can support better decision-making by the Agency and participants were generally satisfied with the process but, crucially, the summary report of the pilot’s results did not include any information about the links between IAs and the resulting participant’s support budgets.
We note the second pilot for IAs recently recommenced after it was delayed due to COVID- 19. While we support the second trial as it will cover participants from a wider variety of backgrounds, we believe that it needs to be concluded and evaluated before the IA process can be introduced. It appears that the IA process will be implemented in mid-2021 regardless of the second pilot’s outcomes.
(d) the independence, qualifications, training, expertise and quality assurance of assessors
Role of health professionals
Under the proposal, a person will need to have their IA done by one of the appointed assessors who will work separately to the Agency rather than having a functional capacity assessment done by their treating health professional/s.
The consultation paper states that independent assessors will be health care professionals, including occupational therapists, physiotherapists, speech pathologists, clinical and registered psychologists, rehabilitation counsellors and social workers.
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While AudA is pleased that the proposed assessors are to be trained health professionals, it is important to have assessors with at least a couple of years of clinical experience and who have provided services to people with a range of health conditions and backgrounds and not just recent university graduates who will not have yet fully developed these skills.
We note the Department of Social Services and the Agency’s submission to the Inquiry states that assessors will “have the right skills, experience and training to support a person’s disability needs”.
However, AudA questions how IAs will address the needs of people with hearing loss. In all the material that has been produced on the proposed IA process, there has been nothing to address this issue, which is of significant concern.
Responding to functional impact questions from independent assessors will likely be challenging for potential new NDIS participants with substantial hearing loss. It is common for people with hearing loss to wait on average seven to ten years before acknowledging difficulties with their hearing and seeking help for their hearing loss. Many people tend to delay treatment until they cannot communicate even in the best of listening situations.
This means that new potential participants may struggle to understand the questions being asked of them due to their hearing loss and/or have difficulty completing and fully participating in the IA process given that they do not have hearing AT or the appropriate kind for their needs. It is also possible that potential NDIS participants may inadvertently overstate their abilities and functional capacity in everyday life in response to the IA standardised questionnaires, which may not elicit the full extent and support that a person with hearing loss may need to complete everyday tasks. We are therefore concerned that the IA tools will not give people a full and accurate picture of the true needs of this group of participants.
On this basis, we strongly recommend that – if the IA process does proceed - audiologists form part of the pool of independent assessors. We note that – of all the independent assessor companies appointed by the NDIA – none appears to refer to audiologists as independent assessors or health professionals who have experience with hearing loss on their websites.
AudA understands that one of the Agency’s reasons to use independent assessors is to remove any potential ‘sympathy bias’ – the idea that a treating health professional who is familiar with an existing person may be inclined to give a sympathetic portrayal of that person and overstate their need for NDIS funding. However, we also note that health professionals are trained to provide objective assessments based on their clinical assessment of a person’s health care needs and, as noted, a person’s treating health professional will
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remain part of the NDIS application process in any case in terms of providing evidence of a person’s disability, which may include insights into their functional capacity.
(f) the implications of independent assessments for access to and eligibility for the NDIS
The introduction of IAs means significant changes to the current operation of the NDIS, including a new NDIS Access and Eligibility Policy.
This will replace existing processes, including the NDIS access lists, which set out a number of health conditions that automatically met the disability or early intervention requirements of the NDIS. One of these conditions was permanent bilateral hearing loss > 90 decibels in the better ear (pure tone average of 500Hz, 1000Hz, 2000Hz and 4000Hz).
Now, it is proposed that all participants will need to provide evidence of their disability. This will include advice from their treating health professional as to whether their impairment is likely to be permanent and whether, in their health professional’s clinical judgement, a person’s disability or disabilities are attributable to one or more cognitive, neurological, sensory or physical impairments. Health professionals will also be required to provide information about what interventions or supports have been considered and/or administered to the potential participant.
Based on information provided by the Agency, it appears that potential participants will not be funded to gather evidence of their disability and so will still need to spend considerable time, effort and cost to obtain this information if they have not already done so (as is often currently the case now).
Currently, the Agency accepts evidence of a person’s hearing loss as illustrated through an audiogram (or other relevant testing) combined with an assessment from their treating audiologist of that person’s functional capacity or the impact that hearing loss has on that person’s ability to participate in everyday life and their individual circumstances.
As the extent and nature of a person’s hearing loss is not going to be demonstrated through a functional capacity test, this means that potential participants will still need to self-fund the cost themselves to demonstrate their eligibility for the NDIS with a “hearing impairment”.
We submit that the Agency needs to put measures in place to enable NDIS participants to deal with the costs of these assessments. One idea could be to have a gated assessment process with funding available once a certain stage in the process is passed or funding could be made available for a designated portion of the assessment costs over a certain amount.
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This also makes clarifying how the Agency will consider pre-existing assessments as part of the IA process crucial to save potential participants time, effort and cost. This is particularly important for people with hearing loss who – by the time they apply for access to the NDIS - have usually already expended some time and funds to ascertain whether they have a hearing loss, the extent of that loss and recommended intervention strategies. It is AudA’s opinion that this cohort should not have to undergo new testing or a requirement to tell people their circumstances repeatedly to meet different bureaucratic requirements.
We also query how the IA process will increase access and equity for underrepresented groups such as people from culturally and linguistically diverse or Aboriginal and Torres Strait Islander backgrounds to access the scheme with these requirements in place.
An additional problem is how these IAs will impact on participants with hearing loss who may have similar functional requirements and therefore who may be expected to have a similar IA profile. Under the IA proposal, they would also be expected to have a similar plan budget.
Yet, such participants may have very different goals. The latest NDIA figures show that the current 21,079 NDIS participants with hearing loss have between them 66,953 goals in several different areas, including choice and control over their daily lives, health and wellbeing, relationships and social and community activities (NDIS, 2020). Given this, AudA queries how standardised IA findings will impact the resulting plan budgets for participants with hearing loss when participants have such a variety of needs and individual life circumstances. We are concerned that the IA process will mean that standardised assessments will in turn result in standardised budgets for NDIS participants with hearing loss, limiting their outcomes and opportunities if the NDIS plan budget is not adequate for their needs.
(i) opportunities to review or challenge the outcomes of independent assessments
AudA is concerned that there will be no opportunity to review or challenge the outcomes of IAs given that decisions made by independent assessors cannot be reviewed or appealed.
As highlighted by the Administrative Appeals Tribunal (AAT) in the recent case of Ray v National Disability Insurance Agency [2020] AATA 3452, there is a vast difference between the evidence that can be provided by a person’s treating health professional and an independent assessor who has only just met the person they are assessing. In this case, Mrs Ray who was seeking to access the scheme provided evidence from several health professionals she had seen over the past ten years against which the NDIS provided the evidence of an independent assessor who had seen Mrs Ray once. The AAT considered the observations made by her treating health professionals as more reliable than those made by
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the independent assessor – noting that they had seen her multiple times over many years, including outside of the comfort and familiarity of her home environment, whereas the independent assessor had only seen Mrs Ray once for a period of three hours in her home environment.
AudA is also concerned that assessors appear not to be subject to any level of oversight. Registered NDIS providers are subject to the NDIS Quality and Safeguards Commission but there seems to be no such requirement here for assessors.
We understand that some organisations who have been appointed to the IA panel by the NDIA are now seeking to engage subcontractors in order to fulfil their contractual requirements.
While each assessor will be subject to the ethical and professional requirements of their individual health professions, we are concerned that independent assessors – who are in effect private contractors or subcontractors - may be subject to pressure from their employers to meet IA targets within a certain time frame and there will be a temptation to “speed up” the IA process in order to achieve these targets, leading to poor decision making about a person’s functionality capacity and undermining the process of what the IA and overall NDIS system is intended to achieve.
Given these concerns, AudA is seeking:
- separation of IAs for the purpose of access and eligibility from the purpose of making NDIS plan budgets;
- the Agency to release the evaluation of the second IA pilot; and
- a delay or hold on the rollout of IAs until these critical issues are addressed.
References
National Disability Insurance Agency. (2020). NDIS Quarterly Report to disability ministers 30 December 2020. https://www.ndis.gov.au/about-us/publications/quarterly-reports
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