About NACCHO
NACCHO is the national peak body representing 143 Aboriginal Community Controlled Health Organisations (ACCHOs) Australia wide on Aboriginal and Torres Strait Islander health and wellbeing issues. NACCHO’s work is focused on liaising with governments, its membership, and other organisations on health and wellbeing policy and planning issues and advocacy relating to health service delivery, health information, research, public health, health financing and health programs. Our members provide about three million episodes of care per year for about 350,000 people across Australia, including about one million episodes of care in very remote regions.
Sector Support Organisations, also known as affiliates, are State based and represent ACCHOs offering a wide range of support services and Aboriginal and Torres Strait Islander health programs to their members including advocacy, governance and the delivery of state, territory and national primary health care policies.
ACCHOs range from large multi-functional services employing several medical practitioners and providing a wide range of services, to small services which rely on Aboriginal Health Workers/Practitioners and/or nurses to provide the bulk of primary health care services, often with a preventive, health education focus. Our 143 ACCHOs operate approximately 700 facilities, including about 450 clinics. ACCHOs and their facilities and clinics contribute to improving Aboriginal and Torres Strait Islander health and wellbeing through the provision of comprehensive holistic primary health care, and by integrating and coordinating care and services. Many provide home and site visits; medical, public health and health promotion services; allied health; nursing services; assistance with making appointments and transport; help accessing childcare or dealing with the justice system; drug and alcohol services; and help with income support.
Collectively, we employ about 6,000 staff, 56 per cent of whom are Indigenous, making us the second largest employer of Aboriginal and Torres Strait Islander people in the country.
Any enquiries about this submission should be directed to:
NACCHO
Level 5, 2 Constitution Avenue
Canberra City ACT 2601
Telephone: redacted
Website: naccho.org.au
Introduction
This submission will look at four specific areas outlined in the Joint Standing Committee’s Terms of Reference:
- the development, modelling, reasons and justifications for the introduction of Independent Assessments into the NDIS
- the appropriateness of the assessment tools selected for use in independent assessments to determine plan funding
- the implications of Independent Assessments for access to and eligibility for the NDIS
- 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
This submission is written by NACCHO with valued input from the Victorian Aboriginal Community Controlled Health Organisation (VACCHO), The Aboriginal Council of South Australia (AHCSA), the South Australian West Coast ACCHO Network (SAWCAN) and the Aboriginal Health Council of Western Australia (AHCWA).
Aboriginal and Torres Strait Islander people are twice as likely to experience a disability than other Australians (9% have a severe or profound disability compared to 4% for non-Indigenous people1). This is compounded with higher rates of chronic illness2 in Aboriginal and Torres Strait Islander people compared to other Australians, higher rates of poverty3, numerous barriers to accessing services4 and racism from different sources5. Aboriginal and Torres Strait Islander people also have many other compounding factors such as remote locations, English as a second/third language, and specific cultural elements and traditions that can often be overlooked and can affect the experience of disability.
The Introduction of Independent Assessments
The lack of consultation or engagement with Aboriginal and Torres Strait Islander people, communities and organisations by the NDIA on the current reforms shows the lack of understanding of the needs of our communities. None of the documentation to date discusses the cultural considerations for Aboriginal and Torres Strait Islander people, the complexities of delivering services in communities and the systemic challenges faced before accessing the NDIS.
This is considered a substantial failure of NDIA and it is not consistent with the National Agreement on Closing the Gap (the National Agreement). The National Agreement demonstrates a commitment from all levels of government to changing the way policies and
1 Aboriginal and Torres Strait Islander Health Performance Framework 2020 report, section 1.14 Disability.
2 AIHW. (2016) Australian Burden of Disease Study: impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011.
3 ACOSS and UNSW (2018). Poverty in Australia 2018
4 Disabled People’s Organisations Australia (2019). CRPD Shadow Report consultation survey results
5 Marwick et al. (2019). Experiences of racism among Aboriginal and Torres Strait Islander adults living in the Australian state of Victoria: a cross-sectional population-based study.
programs affecting Aboriginal and Torres Strait Islander people are developed and delivered6. Shared decision making between Aboriginal and Torres Strait Islander people and government, strengthening the community-controlled sector, improving mainstream institutions, and improving collection and access to Aboriginal and Torres Strait Islander data are the priority reforms that underpin the National Agreement. Disability is a key focus of the National Agreement, including the call for partnership actions to strengthen the community-controlled sector in providing disability programs and policy. This presents an opportunity to work together in genuine partnership that recognises the needs and rights of Aboriginal Torres Strait Islander people with a disability.
If implemented correctly, Independent Assessments have the capacity to ensure transparency and equity in the NDIS application process and will better capture a person’s functional capacity and unique circumstances. Independent Assessments that are appropriately designed should lead to further inclusion of Aboriginal and Torres Strait Islander communities in the NDIS by ensuring that cultural safety is paramount to assessments of Aboriginal and Torres Strait Islander people nationally.
However, the current policy for Independent Assessments is likely to cause communities to further disengage with the NDIS and leave Aboriginal and Torres Strait Islander people living with disability without the support they urgently need and deserve.
The appropriateness of the assessment tools
Currently, there is no tool that that exists to provide a functional assessment on every person that has a disability that aligns with the NDIS. NACCHO is concerned that any mainstream tool that is currently in use will further disadvantage Aboriginal and Torres Strait Islander people.
Measures that have benchmark norms against mainstream populations (including Australia) are culturally biased and do not take into consideration the needs of Aboriginal and Torres Strait Islander people.
Using these tools will create bias when assessing and providing access for Aboriginal and Torres Strait Islander participants. NACCHO advocates for NDIA to develop a tool that considers the holistic view of Aboriginal and Torres Strait Islander health and disability, and acknowledge the complex environments these assessments are undertaken including:
- Culturally appropriate tools
- Culturally appropriate methods
- Culturally appropriate people, staff and/or health professionals to undertake the assessments.
Current models of NDIS focus on a deficit rather than a strength-based approach that Aboriginal and Torres Strait Islander people view health. If the functional assessment tools
6 Coalition of Peaks (2020). National Agreement on Closing the Gap.
continue down this path this will continue to undercut the budgets provided to Aboriginal and Torres Strait Islander participants.
The implications of Independent Assessments for access to and eligibility
Navigating the health and human services system can be difficult for anyone. Prior to colonisation, there was no word for ‘disability’ in traditional Indigenous languages, rather disability was understood as part of the human experience7 with evidence suggesting that Aboriginal and Torres Strait Islander people with disability were treated the same as non-impaired people8. Accordingly, a large proportion of Aboriginal and Torres Strait Islander peoples who currently live with disability are not aware of the pathways to support. This lack of understanding is partly evidenced by the proportionally poor take-up of the NDIS by Aboriginal and Torres Strait Islander people to date.
There is a clear preference for Aboriginal and Torres Strait Islander people to access community controlled services in disability, health or otherwise and will bypass mainstream services to access one where they are confident their cultural safety is guaranteed. More concerning is that Aboriginal and Torres Strait Islander people will not access a service (or at least put off accessing a service) if they perceive that or have an experience where their cultural safety is compromised9. For this reason, Aboriginal Community Controlled Organisations (ACCOs), including ACCHOs, are critical to the successful uptake and delivery of the NDIS to Aboriginal and Torres Strait Islander people.
Aboriginal and Torres Strait Islander people have issues with the NDIS across all points of the spectrum. The limited participation of Aboriginal and Torres Strait Islander peoples in the NDIS originates at the pre-access stage to the Scheme and continues through all points of NDIS service provision whether this be through ACCO or mainstream services.
Research has shown that ACCHOs are best placed to overcome the social and cultural determinants of health which can hinder Aboriginal and Torres Strait Islander people accessing the health care they need.
By introducing the Independent Assessments, you have added an additional step, or potential barrier into an already complex system. ACCHOs are best placed to support Aboriginal and Torres Strait Islander participants in accessing and staying on the NDIS so should be included in the Independent Assessment Pathways for all urban, regional and remote Aboriginal and Torres Strait Islander participants.
7 Productivity Commission, ‘Disability within the Indigenous community’, in Productivity Commission Disability care and support: draft report, Canberra, 2011, viewed at http://www.pc.gov.au/__data/assets/pdf_file/0018/111285/14-disability-support-chapter11.pdf
8 Louis Ariotti, ‘Social Construction of Anangu Disability’, Australian Journal of Rural Health, vol.7(4), 1999.
9 Aspin., C. et al., Strategic approaches to enhanced health service delivery for Aboriginal and Torres Strait Islander people with chronic illness: a qualitative study. BMC health Services Research., 12: 143.
The appropriateness of Independent Assessments for Aboriginal and Torres Strait Islander people
In the current system, assessments require subjective judgments from NDIS staff. This means that non-Aboriginal staff make judgments based on their own experiences and background, and do not consider the specific needs of Aboriginal and Torres Strait Islander people due to unconscious bias and institutional racism. This continues to perpetuate racism, and often ignore impacts of intergenerational trauma and systemic racism as leading factors in influencing Aboriginal and Torres Strait Islander social and emotional wellbeing. It is evident from the poor uptake of the Scheme by Aboriginal and Torres Strait Islander people that there are a number of barriers that lead to a lack of cultural safety and cultural appropriateness of the NDIS.
The Independence Assessment issues paper and framework makes mention of Allied health professionals undertaking the assessment on participants. How will the cultural safety of Aboriginal and Torres Strait Islander participants be maintained through this process?
NACCHO would advocate for Aboriginal Health Practitioners leading the assessment processes for all Aboriginal and Torres Strait Islander participants. If this is not guaranteed, there is a lack of cultural safety that can lead to bias in the assessment process and consequently planning and budget setting for all participants.
NACCHO also questions the need for Independent Assessment as many Aboriginal participants with disability, especially those with psychosocial disabilities, might find an assessment with someone that they haven’t been able to form a relationship and trust with, distressing and traumatic.
It will also be very hard to locate appropriate independent assessors in regional and remote areas who have the capacity to complete assessments with Aboriginal and Torres Strait Islander people with disability in a timely and culturally appropriate manner.
There are currently gaps in service provision for the NDIS, particularly in areas of thin-markets and Aboriginal and Torres Strait Islander communities. With the current gap in this service provision, will Allied health professionals who opt to undertake Independent Assessments be taken away from the delivery of NDIS supports for those participants on plans? How will this gap of service provision then be filled? This is a major concern of NACCHO where disability service provision is already patchy and introducing this new process will ensure an additional barrier for Aboriginal and Torres Strait Islander NDIS participants utilising their plans.
The current disability system is not accessible to Aboriginal and Torres Strait Islander people with a disability for numerous reasons. The needs, situation and culture of Aboriginal and Torres Strait Islander people were not taken into consideration when developing the NDIS, creating a system that creates accessibility and service gaps at best and exploitation for Aboriginal and Torres Strait Islander people at worst. Current systems must better respond to Aboriginal and Torres Strait Islander people with disability to prevent experiences of
violence, abuse, neglect and exploitation and gain access to the disability support services they deserve.
Aboriginal and Torres Strait Islander people focus on the strengths and differences of an individual, not on the “deficits”. This can be a struggle for Aboriginal and Torres Strait Islander people who are applying for NDIS funding because applicants are asked to articulate their deficits and not their opportunities or strengths. Before colonisation there was no word for disability, consequently many Aboriginal and Torres Strait Islander communities will abstain from using terminology like ‘disability’ or ‘disabled’.
The World Health Organisation (WHO) International Classification of Functioning, Disability and Health10 recognizes the need to consider other parts of an individual in context of their disability. It provides a framework to consider the dynamic between body, health, environment and personal factors, including culture11. This focus on the social model that captures and promotes the holistic view of a person is central to Aboriginal and Torres Strait Islander culture so needs to be a key element in the Independent Assessment model.
The social model of disability distinguishes between impairment and disability and notes that it is not the impairment or diagnosis that disadvantages them, it is society12 . This is supported by the Aboriginal and Torres Strait Islander view of health as holistic encompassing, physical, cultural, and spiritual components of health and wellbeing.
Conclusion
As the peak body of ACCHOs, NACCHO looks forward to further consultation with, and to work closely with NDIA, in developing a culturally appropriate and safe assessment process for Aboriginal and Torres Strait Islander people. If we work collaboratively, in genuine partnership as outlined in the National Agreement in Closing the Gap, the Independent Assessment process can improve transparency and equity in the NDIS for Aboriginal and Torres Strait Islander people.
10 WHO. (2001). International Classification of Functioning, Disability and Health.
11 WHO. (2001). Ibid.
12 Goering, S. (2015). Rethinking disability: the social model of disability and chronic disease. Current Musculoskeletal Medicine. 8(2).