NDIA Accountability Project

Inquiry into Independent Assessments under NDIS

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Submission 253

Inquiry into Independent Assessments

under NDIS

Submission to the Joint Standing Committee AUTHORISED BY: on the NDIS Connie Digolis Chief Executive Officer March 2021

                                                                                                      Supported by the Tasmanian
                                                                                              Government through the
                                                                                                  Department of Health

Contents

About Us ………………………………………………………………………………………………………………………… 3

Introduction ……………………………………………………………………………………………………………………. 3

Recommendations …………………………………………………………………………………………………………… 4

Response to Terms of Reference ……………………………………………………………………………………….. 5

  1. The independence, qualifications, training, expertise, and quality assurance of assessors. … 5
 1.1 Independence of selected organisations ........................................................................... 5

 1.2 Limited access to Skilled Independent Assessors .............................................................. 5

 1.3 Validity of telehealth for independent assessments ......................................................... 7

2. The implications of independent assessments for access to and eligibility for the NDIS; ……. 8

  1. The circumstances in which a person may not be required to complete an independent assessment. ………………………………………………………………………………………………………………… 9

  2. The appropriateness of independent assessments for people with particular disability types, including psychosocial disability …………………………………………………………………………………… 10

    Efficacy of Independent Assessments for people with Psychosocial Disability ………………… 10

Further information ……………………………………………………………………………………………………….. 11

References ……………………………………………………………………………………………………………………. 12

Submission to the Joint Standing Committee 2

About Us

The Mental Health Council of Tasmania (MHCT) is the peak body for community managed mental health services in Tasmania. We represent and promote the interests of our members and work closely with government and agencies to ensure sectoral input into public policies and programs. We advocate for reform and improvement within the Tasmanian mental health system. Our purpose is to strengthen and advocate for our communities and service providers to support the mental health and wellbeing of all Tasmanians, and our vision is that every Tasmanian has access to the resources and support needed for good mental health and wellbeing.

Introduction

MHCT welcomes the opportunity to respond to the Joint Standing Committee’s Inquiry into Independent Assessments under the NDIS. MHCT’s response is informed by our existing policy positions and literature related to NDIS Independent Assessments including the Independent Assessments: Pilot Learnings and Ongoing Evaluation Plan and Removing Barriers to Testing for the NDIS

This submission is structured on the Joint Standing Committee’s Terms of Reference for their Inquiry into Independent Assessments with responses provided to:

  • the independence, qualifications, training, expertise and quality assurance of assessors;
  • the implications of independent assessments for access to and eligibility for the NDIS;
  • the circumstances in which a person may not be required to complete an independent assessment;
  • the appropriateness of independent assessments for people with disability types, including psychosocial disability

MHCTs submission focuses specifically on the impact of Independent Assessments for people with psychosocial disability. The submission highlights several key concerns regarding the implementation of Independent Assessments including:

  • The limited workforce to support the implementation of Independent Assessments in Tasmania
  • The limited evidence base to support telehealth assessments
  • The limited evidence base to support Independent assessments for people with psychosocial disability
  • The time intensiveness for NDIS participants in accessing the NDIS and receiving a plan

MHCT recommends that the efficacy of Independent Assessments for people with psychosocial disability and the validity of telehealth assessments must be evidenced prior to the implementation of mandatory NDIS Independent Assessments. Additionally, consideration must be made to the capacity for Independent Assessments to be administered given allied health workforce limitations in outer regional to remote areas of Tasmania.

Submission to the Joint Standing Committee 3

Recommendations

Recommendation 1

NDIA should develop policies and processes to maintain impartiality of independent assessment organisations.

Recommendation 2

NDIA should investigate the implementation of Independent Assessments for participants living in regional to remote areas and ensure that participants are able to access face-to-face, in person Independent Assessments.

Recommendation 3

NDIA should ensure that all Independent Assessors working with participants with psychosocial disability must have appropriate qualifications, skills and experience.

Recommendation 4

The validity and efficacy of telehealth assessments for people with psychosocial disability must be researched and best practice guidelines implemented prior to telehealth assessments being offered to NDIS participants with psychosocial disability

Recommendation 5

NDIA should ensure a choice of either face-to-face in person assessments or telehealth assessments, based on the preferences of the NDIS participant.

Recommendation 6

Consideration must be made to ensure appropriate and timely access to Independent Assessors. Additionally, consideration must be made to develop a streamlined process for people with Psychosocial disability to access the NDIS and receive a plan.

Recommendation 7

Definitions of exemption criteria should be clearly defined. With specific consideration provided on how exemption criteria apply to people with psychosocial disability and those in outer regional to remote areas.

Recommendation 8

The efficacy of independent assessments for people with psychosocial disabilities must be determined prior to NDIS Independent Assessments becoming mandatory.

Submission to the Joint Standing Committee 4

Response to Terms of Reference

1. The independence, qualifications, training, expertise, and quality assurance of assessors.

1.1 Independence of selected organisations

The National Disability Insurance Agency (NDIA) official webpage indicates that it has “gone through a formal process to find the right organisations to provide independent assessments.”1 Subsequently, NDIA has selected eight organisations based on their, experience, understanding, availability of right staffing mix and level of professional expertise to deliver independent assessments.2 MHCT does not challenge NDIA’s decision to nominate these organisations as independent assessment organisations or their suitability to carry out and administer independent assessments. However, as the organisations are funded by the NDIA, MHCT questions if this may cause a level of ‘political dependence’.

MHCT notes that political dependence can occur when organisations are fundamentally reliant on funding resources to maintain viability.3 The nomination, appointment, and funding of the independent assessment organisations by the NDIA increases dependence of these organisations and may lead to political dependence rather than the intended outcome of independent bodies with the authority and capacity to make impartial decisions.

Recommendation 1

NDIA should develop policies and processes to maintain impartiality of independent assessment organisations.

1.2 Limited access to Skilled Independent Assessors

MHCT recognises the importance of selecting highly qualified, skilled and experienced professionals to undertake Independent Assessments, however, MHCT is concerned that it may well be impractical to recruit such professionals in outer regional, rural and remote areas of the state. Additionally, MHCT is concerned that the number of Independent Assessment organisations operating in Tasmania reduces in outer regional and remote areas of Tasmania.

Since NDIA announced their intention to implement Independent Assessments, MHCT has raised concerns regarding the limited allied health workforce available to provide independent assessments in Tasmania. Outer regional to remote areas of the state, particularly the North west, and west coast of Tasmania have a very limited pool of allied health professionals4. Tasmania’s consistent health workforce challenges are echoed in the Tasmanian Department of Health’s Our Healthcare Future – Immediate Actions and Consultation Paper 2020 which highlights that, “recruitment of health professionals in some professions and to regional and rural areas remains difficult for Tasmania”.

Submission to the Joint Standing Committee 5

With a limited workforce, MHCT has concerns regarding the capacity for Independent Assessment organisations to provide quality face to face assessments for people with psychosocial disability. Figure 1 indicates the operation of the organisations in 29 local government areas in Tasmania. As the map clearly demonstrates, there are only five Independent Assessment organisations that intend to operate in the North West region. MHCT suggests that further investigation and understanding must be undertaken by the NDIA to ensure equitable access to face-to-face, in person assessments in outer regional to remote areas.

Figure 1: Independent assessment organisation operational areas

Additionally, MHCT is concerned that Independent Assessors may not have the skills and expertise required to undertake an Independent Assessment for people with psychosocial disability. MHCT’s Removing Barriers to Testing report highlights the importance of all professionals and NDIA staff in working under a recovery focus and trauma informed lens. To add to this MHCT is of the view that Independent Assessors working with people with psychosocial disability must have a thorough working knowledge and expertise in understanding mental illness, including the episodic nature of mental illness and the impacts on a person’s functional capacity.

Recommendation 2

NDIA should investigate the implementation of Independent Assessments for participants living in regional to remote areas and ensure that participants are able to access face-to-face, in person Independent Assessments.

Recommendation 3

NDIA should ensure that all Independent Assessors working with participants with psychosocial disability must have appropriate qualifications, skills and experience.

Submission to the Joint Standing Committee 6

1.3 Validity of telehealth for independent assessments

With a limited skilled workforce with capacity to provide face-to-face, in person Independent Assessments, MHCT has heard that telehealth independent assessments may be an alternative option. However, to MHCT’s knowledge, there is no empirical research or evidence-based analysis that validates the effectiveness of telehealth functional assessments for people with psychosocial disability. Additionally, the Independent Assessment pilot study conducted by NDIA was delivered face to face to NDIS participants, further providing no evidence of the efficacy of telehealth in the provision of independent assessments for people with psychosocial disability.

As part of MHCT’s response to the COVID19 pandemic, MHCT conducted a survey with clients of mental health service providers to understand the benefits and preferences for use of telehealth in service provision post pandemic. 62% of survey respondents preferred face to face supports with 22% indicating a preference for phone and 12% via video conferencing. Consistently, MHCT has heard from consumer and carer representative groups that there must be a choice provided to consumers in the preferences of service delivery (whether that may be face-to-face or telehealth).

Survey participants provided the following comments in relation to preferences in service delivery methods:

  • ‘I only like face-to-face sessions. It’s far too easy to get distracted and avoid everything when online or on phone’.
  • ‘Online didn’t work near as well as face to face’.
  • ‘Video link and phone felt very impersonal, and links keep dropping out’

Mental Health Council of Tasmania COVID-19 Data Collection Project – Client Survey August 2020

In addition to concerns regarding telehealth raised by consumers and carers, there is also reservations among practitioners concerning the establishment of a quality therapeutic relationship between the client and practitioner. Practitioners have also identified concerns regarding the capacity to exercise professional judgement in interactions with clients in the absence of visual cues5.

For the reasons stated above, MHCT recommends that the use of telehealth in assessments for people with psychosocial disability is evidenced prior to implementation. Additionally, MHCT is concerned that due to the difficulty of deploying suitable assessors in regional and rural areas, telehealth may become the only option. MHCT recommends that NDIS participants are provided with a choice of options for undertaking telehealth assessments including face-to-face in person assessments and telehealth assessments.

Recommendation 4

The validity and efficacy of telehealth assessments for people with psychosocial disability must be researched and best practice guidelines implemented prior to telehealth being offered to NDIS participants with psychosocial disability.

Recommendation 5

NDIA should ensure a choice of either face-to-face in person assessments or telehealth assessments, based on the preferences of the NDIS participant.

Submission to the Joint Standing Committee 7

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

MHCT notes that testing eligibility for the NDIS is a complicated and time intensive process for people living with severe and complex mental health difficulties. MHCT’s report, ‘Barriers to Testing for the NDIS’6, provides a detailed analysis of the most pertinent barriers to making an access request to the NDIS. MHCT is concerned that these barriers may well be exacerbated with the addition of an Independent Assessment process.

Unlike other government services, the NDIS process is not straightforward, and the recipients must go through several complex procedures. For instance, the process involving other government benefits like Disability Support Pension is reasonably clear and straightforward. However, testing eligibility for the NDIS requires the person to go through several stages including seeking approval to receive an application, completion of documents by the applicant, along with completion of documents from authorised professionals such as GPs, social workers and psychologists, however, MHCT has heard that it is difficult to access health professionals to support the NDIS application process. All of these processes require a high level of functional capacity to begin with, let alone the costs, time and emotional distress involved in retelling the persons story several times. MHCT has heard from mental health consumers that the overall NDIS application process is ‘triggering, overwhelming, time consuming and costly.’ 7

MHCT emphasises that the introduction of Independent Assessments would not help in resolving this complexity. Rather, the independent assessments would add another layer to an already complex and lengthy process, potentially significantly increasing the length of time to gain an NDIS plan. As explained in section one of this submission, Tasmania has a limited allied health workforce which in turn limits the number of professionals with the capability to administer Independent Assessments8. With limited access to Independent Assessors, people with psychosocial disability may experience longer than appropriate wait times, thus impacting on the time taken to receive an NDIS plan.

Recommendation 6

Consideration must be made to ensure appropriate and timely access to Independent Assessors. Additionally, consideration must be made to develop a streamlined process for people with Psychosocial disability to access the NDIS and receive a plan.

Submission to the Joint Standing Committee 8

3. The circumstances in which a person may not be required to complete an independent assessment.

MHCT welcomes the NDIA’s consideration to the provision of an exemption policy for Independent Assessments. The current NDIA exemption policy indicates that, where there is a risk to safety, or an assessment is deemed inaccessible or invalid, NDIA may decide that an applicant is not required to complete an independent assessment. However, MHCT is concerned that the policy does not provide adequate clarity on the exemption criteria, particularly for people with psychosocial disability.

MHCT suggests that exemption criteria related to ‘risk and safety’ in the context of people with psychosocial disability must include the impact of re-traumatisation on people retelling their story to yet another health professional9. Additionally, exemption criteria related to ‘inaccessibility’ must be clarified. MHCT suggests that this term relates to firstly the inability for a participant to access an assessment via their preferred method (for example, face to face). Additionally, MHCT questions if inaccessibility also relates to the length of time to access and complete an independent assessment. If the timeframe to complete an Independent Assessment is lengthy, this will impact on the participant receiving a plan, leaving the person to wait for an inappropriate length of time before receiving supports.

Lastly, the exemption criteria of ‘invalid’ must clarify firstly the validity of telehealth assessments and secondly the validity of Independent Assessments for people with episodic symptoms of mental ill-health. This presents a significant issue for people with psychosocial disability as the often episodic nature of mental illness can impact the validity of the assessment, for example, on a relatively good day, a person may present with minimal functional impacts, but on a not so good day these impacts may be significant.

Recommendation 7

Definitions of exemption criteria should be clearly defined. With specific consideration provided on how exemption criteria apply to people with psychosocial disability and those in regional to remote areas (which includes all of Tasmania).

Submission to the Joint Standing Committee 9

4. The appropriateness of independent assessments for people with particular disability types, including psychosocial disability

Efficacy of Independent Assessments for people with Psychosocial Disability

MHCT is concerned with the standardised nature of Independent Assessments, whilst there is merit in a uniform approach that treats everyone equally, MHCT questions whether Independent Assessments have the capacity to take into consideration the complex and diverse needs of each NDIS participant.

MHCT is particularly concerned that people with psychosocial disability may not receive a valid assessment given the episodic nature of their condition as stated in section 3.1 of this submission. With the fluctuating nature of mental illness, a participant assessed in a stable condition is more to receive an assessment outcome that is not reflective of the true impacts of their condition, resulting in a plan and budget that does not align with their needs.

MHCT has also noted that the process involving Independent Assessments would not provide sufficient time to identify the functional needs of the NDIS participant. This is clear from the September 2020 decision made by the Administrative Appeals Tribunal in Ray v National Disability Insurance Agency. This decision indicates that the independent assessor’s understanding was mistaken for the purposes of the diagnosis. It further reads that the client has “lost the confidence that the Independent Assessor’s opinions were based on an accurate understanding.”

Ray v National Disability Insurance Agency

In a recent decision the Administrative Appeals Tribunal has commented on the NDIA’s use of an independent assessor, stating “this type of therapist is not appropriately qualified” (for the purposes of disgnosis) and that the assessor’s understanding was mistaken.

The Tribunal compared the evidence of the independent assessor and Mrs Ray’s treating psychologist Teana Barry, stating: “The Tribunal considers the observations made by Ms Barry are more reliable than those made by (the independent assessor), as Ms Barry has seen Mrs Ray on approximately 50 to 60 occasions, including out 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.”

The Tribunal noted that the opinions of the Independent Assessor were at odds with those allied health professionals who knew Mrs Ray and had carried out multiple assessments over an extended period.

AAT Rejects NDIS Independent Assessments - Joint Media Release Villamanta Disability Rights Legal Service Inc. and Gippsland Disability Advocacy Incorporated

In understanding the efficacy of Independent Assessments for people with psychosocial disability, NDIA has conducted a pilot study that included people with autism, intellectual disability and psychosocial disability.10 513 participants participated in the first pilot program, however, NDIA does not state the number of participants that participated in the study with psychosocial disability. MHCT is concerned that the specific outcomes of the pilot program does

Submission to the Joint Standing Committee 10

not provide a sufficient understanding of the efficacy and validity of Independent Assessments for people with psychosocial disability.

Given limitations in understanding the efficacy of Independent Assessments for people with psychosocial disability, MHCT recommends that specific research must be undertaken to determine the suitability and best practice needs for administering Independent Assessments for people with psychosocial disability. This research must take place before any decision is made on the implementation of mandatory Independent Assessments for people with psychosocial disability.

Recommendation 8

The efficacy of independent assessments for the people with psychosocial disabilities must be determined prior to Independent Assessments becoming mandatory.

Further information

MHCT welcomes further discussion to support reforms related to the mental health and wellbeing of Tasmanians. MHCT invites government and community stakeholders, MHCT members and other interested stakeholders to contact us to discuss our feedback to this submission.

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References

1 NDIS Independent Assessments https://www.ndis.gov.au/participants/independent-assessments/independent-assessors 2 Ibid 3 Resource Dependence, Uncertainty and the Allocation of Corporate Political Activity across Multiple Jurisdictions, Academy of Management Journal (2021), Trey Sutton, Richard Devine, Bruce Lamont and Michael Holmes 4 Tasmanian Department of Health, 2020, Our Healthcare Future consultation paper, https://health.tas.gov.au/ourhealthcarefuture 5 Are there interactional differences between telephone and face-to-face psychological therapy? A systematic review of comparative studies, Journal of Affective Disorders Annie Irvine et al 2020 6 MHCT, 2019, Removing barriers to Testing for the NDIS, https://mhct.org/wp-content/uploads/2020/02/MHCT-Removing-Barriers-to-Testing-for-the-NDIS-31012020.pdf 7 Ibid 8 Tasmanian Department of Health, 2020, Our Healthcare Future consultation paper, https://health.tas.gov.au/ourhealthcarefuture 9 MHCT, 2019, Removing barriers to Testing for the NDIS, https://mhct.org/wp-content/uploads/2020/02/MHCT-Removing-Barriers-to-Testing-for-the-NDIS-31012020.pdf 10 NDIS, Independent Assessments: Pilot leanings and ongoing evaluation plan, September 2020

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