130 Rose Terrace T 08 8273 7100
Wayville SA 5034 E enquiries@baptistcaresa.org.au
ABN 81 257 754 846 baptistcaresa.org.au
TO: Joint Standing Committee on the National Disability Insurance Scheme
FROM: Baptist Care SA
DATE: 30 March 2021
RE: Inquiry into Independent Assessments
Baptist Care SA welcome the opportunity to provide feedback to the Joint Standing Committee (JSC) on the implementation, performance and governance of the NDIS, in particular the introduction of Independent Assessments (IA). We welcome any further enquiries to our experience working with the NDIS, as a registered service provider for numerous supports.
We have outlined below some of our concerns regarding implementation of the Independent Assessment process, as well as some suggestions as to how it may be implemented to alleviate those concerns. We welcome any further questions or opportunity to discuss with the Joint Standing Committee our concerns regarding the new Independent Assessment process as well as general concerns regarding the implementation and operation of the NDIS.
Development, modelling, reasons and justifications for the introduction of IA into the
NDIS
It is our understanding the IA was introduced to ensure a consistent, transparent and equitable way to capture information about a person’s functional capacity to be able to make a fairer decision about a person’s access to NDIS funding. IA are also supposed to alleviate the need for participants to pay for costly assessments to access the scheme and receive the funding required to live as independently as possible.
Having a consistent approach using IA, if applied appropriately and outside the influence of the NDIS, may reduce unsubstantiated variation of planning decisions and associated funding for people within the scheme. In addition, the use of standardized assessment tools, which are based on objective data and are not influenced by NDIS financial pressures, will support identification of the need for the specific, necessary supports required for each individual to support them to achieve their goals and improve their lives. How the assessments and associated funding allocations are determined must be open, transparent, support participant choice and control and not be controlled by the organisation who is also administering the scheme and who may make decisions based on financial pressure rather than client need.
Although IA appear, in theory, to be a reasonable approach to ensuring an equitable way to assess an individual’s functional capacity, we have concerns that it may just do the opposite. Rather than making it a fairer process, it may actually disadvantage potential and current participants, particularly if the NDIS puts expectations in place that funding is kept low and justification for higher levels of funding requires large amounts of specific evidence. The evidence required is often unspecified by current NDIS
processes and which clients and guardians are unlikely to be able to supply. We can see this process already in place within the SIL space where in an effort to reduce costs, planning decisions often seem to be made outside of the reality of what is actually required to support the client safely and effectively. Any request for review or further information as to why certain decisions are being made is met with complete silence from the NDIS SIL and Enquiries teams or just a “not enough evidence” response without clarity on what evidence is actually required. This leaves clients and support organisations at risk from both a people and financial perspective.
It is our understanding that one of the reasons for introducing IA was to remove the need for participants to provide evidence of their disability to access the scheme. Assessments are expensive and hard to get for those who don’t have the means or the capacity to organise, meaning that people of low means often would not have the required evidence to access the scheme. IA are supposed to alleviate this issue, however, the process that has been outlined by the NDIS means that people first have to show eligibility, meaning that they have to get doctors and Allied health or psychology / psychiatric reports first to make themselves eligible. Only then will they be allocated an IA. Rather than alleviating the need for people to pay for their own assessments and reports to access the scheme, this process simply adds another layer of complexity for participants. Depending on a variety of circumstances, including qualifications and experience of the assessor, the particular tool being used in the assessment, and any pressure placed on assessors by the NDIA, this process is still unlikely to ensure that funding is determined appropriately.
Another major concern is that we believe it will be difficult to gain an accurate picture of a person’s functioning from a single interview or conversations and a practitioner choosing only one assessment tool based on their ability and knowledge. The assessor can choose one of a number of potential standard assessments to use which may be inadequate to fully understand a participants needs, particularly where participants have multiple disabilities and complex contributing health conditions. Participants under and over report their capacity and functioning regularly, depending on how they may feel or present at any given time, for a variety of reasons. Feedback that we have received from a variety of sources, including participants who have undertaken the trial independent assessment, is that the questions asked were inadequate to fully understand their needs, the assessors had no knowledge of the type/s of disability and health conditions that impacted their ability to function, and that any attempts by them to explain circumstances were ignored and they were asked to provide only a yes/no answer.
We further believe that the introduction of IA will remove personal decision making related to plan funding, rather placing this responsibility on an assessment. Although some individuals may benefit from this assessment style, unfortunately we believe that some individuals will have adverse funding limitations as a result. Another concern we have, particularly for individuals we support, is that in the assessment style, there is a denial of the other aspects of a person’s life that is impacted by their disability, i.e. related to their vulnerability and there is therefore no support for this. For example parents with low capacity who experience difficulty caring for their numerous children with disability, an IA will not allow for support coordination for their children. Another example is young people with psychosocial disability and drug use, as there are conflicts/high risk behaviors in community that also require supports in addition to their capacity building. Other service systems such as housing or support services have no capacity or funding to provide for the additional needs of people with disability and do
not know how or want to provide support. This support requirement won’t be reflected in an IA and is a barrier to effective plan use, engagement and implementation
Impact of similar policies in other jurisdictions and in the provision of other
government services
A similar policy introduced within the disability sector, was the computer tool for assessment (JSCI) within the Disability Employment Services (DES). The government introduced JSCI as well as supposed face to face assessments to determine access and level of support (funding) for all job seekers. It is our experience that neither of these processes ever worked well and there were clients who consistently ended up in the wrong funding streams for their level of disability. This was well known within the industry and a review of the process was supposed to be undertaken but is yet to occur. The assessors are inconsistent in their approach, depending on their qualifications and how knowledgeable they actually are on the disabilities of the clients that they were assessing. Assessors also complete phone assessments for regional and remote areas as well as for many metropolitan participants due to lack of time and ability of assessors to complete proper face to face assessments for the number of clients required. Due to incorrect assessment results for clients, organising a review on behalf of clients is assisted by providers in many cases, to ensure that a participant is provided with the right level of servicing for their need. This process means further evidence gathering in the form of doctor and health professional’s reports which is additional cost, time and effort for the participant and the provider plus additional administrative burden for providers, to ensure that their clients can be provided with appropriate services for their needs.
This is a big concern for the new IA – how are the NDIA going to ensure that people in regional and remote locations, as well as all clients in metropolitan areas, receive the required face to face assessments? How will the NDIA ensure that appropriately qualified assessors, who will understand often complex and comorbid diagnosis with associated health conditions and family or environmental dynamics, are allocated to each individual, in order to apply the correct assessment tools and determine appropriate funding for reasonable and necessary support required.
Workers Compensation is another example of a policy released in this environment with similar impact. Workers Compensation uses a one off assessment to review capacity (looking at function). The assessment looks at what a person can do on a given day, simulating repetition of daily life. This gives an indication and can be useful and accurate in some situations, but it does not give a clear reading for daily life, day in day out. This was used to identify what alternate jobs a person could consider doing with their permanent impairment and also then what they could be paid for their payout. Workers Compensation requirements are adversarial, NDIS was not intended to be adversarial, the Insurance model for NDIS has principles regarding Human Rights and quality of life, which is not so compatible with reducing costs from a one off 3 hour assessment (it is inadequate) – especially as they do not commit to reading treating practitioner’s reports and recommendations, who’s expertise and knowledge of the client will far outweigh the information provided from one assessment alone.
Resources needed to effectively implement IA
It is our understanding that IA will be delivered by 8 external providers to the NDIS. Although this concept is positive to ensure a non-bias assessment, if this responsibility sits with only 8 providers, we have concerns about the capacity, skill set and responsibility of these vital assessments sitting with such a limited number of providers. It is our opinion that this responsibility needs to sit with a variety of providers, who can specialise in their selected expertise, e.g. an Aboriginal organisation could focus on IA for ATSI, CALD organisations could provide culturally specific service, etc. In addition to selected expertise, we have significant concerns regarding coverage of regional and remote areas.
It is our understanding that several of the providers who have been chosen to deliver IA are subsidiaries of organisations which provide NDIS services to participants. This is in direct contradiction to the tender criteria for the Independent Assessments tender process and creates a huge conflict of interest and potential issues for clients regarding transparency and choice and control. These organisations are likely to promote their own parent organisation as part of the process therefore removing participant choice and control. We believe that the tender process needs to be investigated and that the organisations who are providing NDIS services should be removed from this process.
Assessor’s qualifications, training, expertise and quality assurance
Assessors completing IA need to be approachable, relatable, have a thorough understanding of a broad range of Disabilities, including psychosocial and what that might mean for participants, including impact, barriers, etc. They will need to ensure individuals feel comfortable with their presence and ensure they are not putting people ‘in a box’ due to their disability status, as we know all individuals will experience their disability differently, according to a variety of factors including comorbidity, level of disability, diagnosis, etc. Assessors need to have demonstrated ability to complete similar assessments and report writing skills, to ensure they are capturing all relevant information in the first instance. We believe to hold all of these essential skills, assessors should hold a relevant Allied Health qualification, including access to psychologists as assessors. Their experience and qualifications could also determine the disability types they assess, as not all Allied Health professionals understand all types of disability. Comorbidity is also a factor here, for example, a person with Autism may also have a psychosocial disability such as Bi-Polar, anxiety or depression. This will have a large impact on their capacity to function but may not be recognised or understood by an assessor who only understands Autism. Similarly if the tool used does not appropriately consider psychosocial disability impacts, it will not achieve a correct result and therefore funding package for the client.
The monitoring of Independent Assessments will be vital in ensuring the implementation of Individual Assessments, and the ongoing IA process, is meeting participant’s expectations and achieving the required outcomes. This could be done via regular feedback and surveys of participants, as well as the providers who are supporting them on a daily basis.
Having the right assessors (experience, diversity, etc.) will help ensure quality. Depending on qualifications, assessors must also be regulated by their own professional frameworks and requirements, particularly allied health professionals.
We believe that no matter who controls the independent assessment process, an external auditor should be implemented to monitor this process. This will ensure that plan funding and utilisation is consistent across assessors, and that funding decisions are made dependant on the true capacity and need of the participant, which provides the required
reasonable and necessary supports to meet participant goals. The process should not be influenced by any need for cost cutting driven by the NDIS.
Having appropriate engagement and a continuous quality improvement plan in place, listening to participants about their expectations, feedback on their experience of their assessment, etc. will ensure participant satisfaction – listening to the client’s voice.
Appropriateness of the assessment tools selected for use for IA to determine funding
Although there needs to be a specialised tool, Independent Assessments need to be extremely flexible in their nature, ensuring they understand individual needs of the participant. For example, be flexible enough to understand if there is an appointment booked but the participant does not feel up to it, then it can be rescheduled. Other flexibility, such as being able to split the allocated 3 hours across days / locations is vital in ensuring a thorough and accurate assessment. In addition, some individuals won’t have the capacity or knowledge to complete certain questions within an assessment, or may over or under estimate their ability to complete a task, how will this be compensated for within the IA process – this could lead to many participants being underfunded or not receiving funding at all if they cannot answer the questions put to them.
Being able to utilise informal supports where appropriate would allow assessors to gain an accurate understanding of an individual’s circumstances, especially those who are non- verbal or do not have the capacity to communicate their needs, although we understand there will be additional flexibility for high and complex needs.
NDIS was not originally designed to include psychosocial disability. This cohort is yet to be fully integrated into the scheme and any assessments used will need to be able to effectively assess capacity for participants experiencing psychosocial disability, not just physical and intellectual capacity.
Diversity (gender, cultural background, disability knowledge, etc.) in assessors will ensure that assessors can tailor their assessment to the individual they are assessing. Ensuring there are assessors in regional and remote areas will also be vital in ensuring accessibility of IA. This may require specific incentives for regional assessor, as we believe IA must be face to face, not over the phone. The participant’s surrounding environments, including the barriers related to living in the region, need to be included in the assessment. Assessors also need to be well resourced to ensure IA are completed thoroughly and accurately.
Information provided to us at this stage advised that there will be a two day turnaround time for a participant to be contacted by an assessor; however, a timeframe between contact made and actual assessment starting has not been outlined. This needs to be made clear, to ensure participants have clear expectations and to hold assessors accountable. To be accessible, it needs to be quick and easy.
If IA is to go ahead, NDIS access eligibility assessments should be less rigid, a simple letter from a GP stating that a person has an ongoing disability may be enough, however this does however not address the eligibility question fully. For a GP to write a letter or complete a form confirming that a participant has a permanent and ongoing disability, they will likely need evidence in the form of previous assessments and reports from other professionals. Particularly in the case of participants with a psychosocial disability, to obtain a diagnosis, multiple psychology and / or psychiatrist visits over a lengthy period of six months or more
are required to confirm a diagnosis. These visits must be paid for by the participant or their family and can only partially be covered by Medicare, therefore the IA will not remove the need for potential participants to gain evidence, often at great time and cost, to be made eligible for NDIS funding.
Another strategy that could assist in IA being successful is allowing potential participants the power to choose their IA provider, rather than being ‘allocated’ one. This allows choice and control, in line with NDIS principles.
The allocation of 3 hours for an IA is a concern, as some individuals will require additional time to complete a thorough assessment. Allowing the time allocated for IA to be spread across different sessions and locations (home, phone, office, etc.) and allowing input from an individual’s support network will allow for a more accurate and thorough assessment. Allowing professionals already supporting an individual to provide information/ reports to be considered alongside the IA would further ensure an accurate IA. We don’t believe that a one off assessment is going to accurately reflect how a person’s disability affects their day to day lives and therefore have the ability to fully inform the funding required for that participant to be supported to live as independently as possible.
Implications of IA for NDIS planning
It is our understanding that the people who participated in the pilot for IA did not have to be concerned about their plan funding being impacted, as it was more of an objective assessment of their function. Unfortunately, this appears to have changed now the pilot has ended. The scheme is best set up for people with physical disability and no other significant issues; people who have stable family and strong advocates have managed well over all; however, people without strong relationships and who are not articulate themselves are disadvantaged. Compliance and a desire to please create a significant vulnerability for people with an intellectual disability or psychosocial disability. Children, also, who are reliant on their parents to have capacity to engage, articulate needs, organise supports are also disadvantaged with IA. In addition, for those who do not wish to engage, for a variety of reasons, including finding the process intimidating, have high anxiety in combination with their disability, IA will be very difficult to complete, as an assessor will not be able to gather accurate information from them. In many situations the person with disability may be excluded from the process unintentionally due to the time pressure for the assessor to gather the information. This in turn will result in poor planning for vulnerable individuals who greatly need the support from NDIS.
Circumstances in which a person may not be required to complete an IA
There needs to be special consideration given to those individuals experiencing high and complex needs and those with multiple diagnosed disabilities and health conditions which impact their capacity. These participants may not have the capacity to engage in an Independent Assessment, or the advocacy supports in place to assist in the process. In addition, if there is risk and safety concerns, as highlighted in the NDIS IA consultation paper1. An assessment still needs to be developed to meet these individual’s needs, to not
1 National Disability Insurance Scheme, Consultation paper: Access and Eligibility Policy with independent assessments, November 2020 | Version 1.0, ndis.gov.au
disadvantage them further. This is particularly relevant for participants who have psychosocial disability as a primary or secondary diagnosis alongside other disabilities as assessing the impact of psychosocial disability is not easily determined in a one off assessment.
Consideration needs to be given to applicants who decide not to complete their scheduled assessment, for example if they are experiencing other challenges in life, the assessment may not be a priority. There needs to be flexibility for an applicant with high and complex needs to ‘pause’ their assessment if needed, so they don’t have their funding application withdrawn. Engagement with support networks will be vital in some circumstances, as there will be individuals who verbalise they don’t want funding, or to engage in an Independent Assessment; however, in reality do need the funding and support.
Opportunities to review or challenge the outcomes of IA
Assessment results should have the flexibility to be provided in a variety of forms, including electronic, hard copy, easy-read versions, and potentially in participant’s first language. It should be the responsibility of the assessor to ensure the most appropriate format is provided to individuals.
It is our understanding that individuals will only receive a summary of their assessment. Sharing the entire IA with the individual, or guardian where suitable, when complete, would allow individuals/guardians insight in to their eligibility for NDIS payments and support requirements. Individuals should have the right to challenge the result of their IA. Providing access to the IA and allowing an effective and timely review process if the individual is unhappy with the assessment or the IA contains inaccurate information, will empower individuals to advocate for appropriate funding and support.
NDIS Planners need to be thoroughly educated about IA’s to ensure they have enough information to make an informed decision about plan value to meet goals. If IA is inadequate, the Planner needs the power to re-assess or delegation of authority for funding.
Appropriateness of IA for particular cohorts of people with disability, including ATSI,
CALD, and people living in rural and remote areas
Ensuring all assessors complete cultural competency training should be mandatory, for CALD and ATSI backgrounds. Ensuring assessors are of a variety of age, genders and cultural backgrounds will allow assessors to best meet the needs of the participants. Upon booking the initial assessment, asking if the participant has a preference of gender/age/cultural background would ensure comfort when completing the assessment. As mentioned previously, we have concerns regarding how all people in regional and remote areas will access independent assessments.
Appropriateness of IA for people with particular disability types, including
psychosocial disability
Particular disability types and groups of people need to be specifically considered, these include people with psychosocial disability, people with disability who experience homelessness and those who experience high and complex needs who may not have the capacity to engage in an IA. Through our experience these two particular groups are hard to reach and face additional barriers to understand and apply for funding/supports. These
groups also tend to be hard to reach and transient, adding additional barriers. IA need to be flexible enough to engage with these cohorts, whether that be over numerous sessions, by consulting the persons support networks, and the flexibility that completing an IA for some of this cohort may not be appropriate.
Additional concerns regarding the NDIS and predicted issues with IA
- The Access Lists, which we understand will be no longer with IA in place, allowed a clear understanding for potential participants on the types of disability that can access the scheme. Removing the lists will cause confusion among potential participants. IA are only completed once individuals have met NDIS eligibility, so removing the Access Lists is not necessary in our opinion.
- It is a Health Care Professional’s responsibility to evidence if a person’s disability is, or is likely to be permanent and lifelong. It is our understanding that the NDIS is seeking information on how to clarify the evidence required. A toolkit to assist clarifying requirements would be beneficial to alleviate confusion. Adding Allied Health professionals to the Health Professional list would allow for a broader range of professionals determining disability impact and provide a better understanding of disability, outside of GP, Dentists and Nurses. A list of preferred Health Professionals who thoroughly understand the NDIS Access Request requirements may assist individuals to get an appropriate eligibility assessment.
- To ensure there is a clear distinction between disability and chronic, acute or palliative health conditions, we suggest developing a mutual understanding between NDIA and Health Departments. As this would assist in clarifying the distinction between disability and health conditions. There will, at times, be areas where these two overlap, so there needs to be an agreed understanding and commitment to supporting individuals at this point of their life, rather than red tape preventing individuals receiving adequate supports. Unfortunately this is something we have experienced on numerous occasions, for example when an individual is discharged from hospital and require supports in their home, there is commonly disagreement about whether SA Health or NDIS should fund this support, when in reality it should be the responsibility of both parties.
- We believe that IA should aim to remove the barriers associated with the cost of gaining access to NDIS payments; however, it appears that this is not the case, as an individual still needs to pay to confirm their eligibility, through the engagement of health professionals. It appears that the IA is not actually to help individuals become engaged in the scheme, rather is in place once individuals have met eligibility requirements and although on the surface designed to ensure that fair funding decisions are made, we believe that pressure and additional criteria applied by the NDIS will ensure that funding is set as low as possible without the participant and / or providers providing significant and detailed evidence to support funding which is actually required to support the participant.
- With the introduction of IA, the NDIS need to ensure the information provided to people who apply for NDIS funding is clear and concise about the process on ‘how to’ receive NDIS payments, including the steps involved, e.g. make contact with Local Area Coordinator (LAC), complete Access Request, confirm Eligibility at own cost, then if approved have an Independent Assessment complete. It is our experience that this information has not been made clear enough for potential participants, resulting in confusion in the application process.
Information specifically related to IA needs also to be detailed, to ensure it provides potential NDIS participants a clear understanding of the expectations, the flexibility, timeframes, payments, etc. The information needs to be transparent to alleviate any distrust individuals and organisations have in the scheme. Lack of transparency by the NDIA also creates mistrust by participants of providers who need to adhere to NDIS rules but without the NDIA explaining to participants what this actually means to the participant.
- An issue we have experienced is that the NDIS communicate with individuals and their families (as their nominated person), as they should; however, families do not necessarily pass relevant information on to providers to ensure / enforce the information to achieve positive outcomes for individuals. Families often do not know more detailed requirements of costs and requirements to actually support their loved ones. The NDIS leaves providers completely out of the process of consultation on supports that they will be providing therefore creating miscommunication and mistrust by participants and their families with the provider. Providers are left to try to educate and inform participants and their families at significant additional time and effort (resourcing) which is not factored into the cost of provision of services and pricing caps set by the NDIA. We have also seen instances occur more than once where the NDIS has updated a plan without any evidence being provided by either the guardian’s / family or supporting provider and approving plans with no input from either party and no indication that this had been done other than a new plan appearing on the portal. Doing this without input from participants, families and providers creates confusion for all and leads to inadequate plans and significant additional follow up and work needing to be done by providers on the behalf of participants and their families to seek a review and update required funding.
Definitions:
IA – Independent Assessments
NDIS – National Disability Insurance Scheme
NDIA – National Disability Insurance Agency
JSC – Joint Standing Committee
LAC – Local Area Coordinator
CALD – Culturally and Linguistically Diverse
ATSI – Aboriginal and Torres Strait Islander
References:
- National Disability Insurance Scheme, Consultation paper: Access and Eligibility Policy with independent assessments, November 2020 | Version 1.0, ndis.gov.au
- Joint standing committee on the NDIS, New inquiry into Independent Assessments, Terms of Reference included in letter to Baptist Care SA, dated December 2020