Recommendations for Improving NDIS Independent Assessment Process | External submission

Exercise & Sports Science Australia Submission

Inquiry into Independent Assessments

Joint Standing Committee on the National Disability Insurance Scheme

31 March 2021 1A Locked Bag 4102, Ascot OLD 4007

1.0 About Exercise & Sports Science Australia

Exercise & Sports Science Australia (ESSA) is the peak professional association for exercise and sports professionals in Australia, representing over 9,000 members, including university qualified Accredited Exercise Scientists (AESs), Accredited Exercise Physiologists (AEPs), Accredited Sports Scientists (ASpSs) and Accredited High-Performance Managers (AHPMs).

AEPs are recognised allied health professionals (AHPs), with 4 years of university training and provide clinical exercise interventions aimed at primary and secondary prevention; managing acute, sub-acute and chronic disease or injury; and assist in restoring optimal physical function, health and wellness to people living with disability. Exercise physiology is a recognised and funded profession under compensable schemes such as Medicare Benefit Services (MBS), Department of Veteran Affairs (DVA), the National Disability Insurance Scheme (NDIS), private health insurance, and state and territory-based workers’ compensation schemes. AEPs typically register with the NDIS Quality and Safeguards Commission under the ‘Exercise Physiology and Personal Well Being Activities’ and ‘Therapeutic Supports’ registration groups and deliver supports in both the ‘Improved Health and Wellbeing’ and ‘Improved Daily Living’ categories of participant plans.

AESs apply the science of exercise to design and deliver physical activity and exercise-based interventions to improve health, fitness, well-being, performance and assist in the prevention of injury and chronic conditions. They coach and motivate to promote self-management of physical activity, exercise and healthy lifestyles and work in the National Disability Insurance Scheme (NDIS) as personal trainers and allied health assistants (AHAs), in fitness businesses, for sporting bodies, in corporate health and as AHAs for exercise physiologists and other allied health professionals. AESs are three year trained university professionals.

ESSA’s response to the Inquiry into Independent Assessment has been prepared in consultation with ESSA members and responds to the topics most relevant to the experiences of AEPs and AESs engaging with participants under the NDIS. ESSA welcomes the opportunity to respond to this inquiry and can appear before the Committee if invited. 2A Locked Bag 4102, Ascot OLD 4007

2.0 Summary of Recommendations

Recommendation 1: That AEPs, and other appropriate allied health professions, be included in the independent assessment workforce and added to the list of allied health professions published on the NDIS website that are able to conduct independent assessments, to mitigate the risk of an inadequate assessment workforce.

Recommendation 2: That the NDIA allows participants and their families to exercise choice and control over which allied health professional(s) conduct the independent assessment, i.e. participant’s regular allied health professional, or a specified allied health professional from the panel of independent assessors, or group of specified allied health professionals which may include the participant’s regular allied health professional.

Recommendation 3: That the NDIA considers reports on the participant’s disability and functional capacity from their regular healthcare providers when making access, eligibility and funding decisions in relation to the participant.

Recommendation 4: That the NDIA produce a policy outlining the extent to which regular healthcare provider reports are considered when making access, eligibility and funding decisions in relation to a participant.

Recommendation 5: That a competency module be created in relation to independent assessments, specifically in relation to working with people with a disability, and be delivered to all employees conducting independent assessments and their supervisors.

Recommendation 6: That an Allied Health Expert Advisory group be created to contribute to the codesign of the assessment process and oversee the implementation and evaluation of the independent assessments.

Recommendation 7: That additional assessment tools, such as the Rivermead Mobility Index, be considered for inclusion in the independent assessment toolkit to address some of the gaps currently identified.

Recommendation 8: That assessors be required to utilise observation of activities in at least the home setting and one community setting (e.g. work, school) as part of assessing functional capacity.

Recommendation 9: That the independent assessment process include recognition of individual goals to ensure funding allocated to each category (e.g. capacity building or core supports) is reasonable and necessary to support the participant to achieve their individual goals.

Recommendation 10: That there is an opportunity to vary budgets until after a participant has had the opportunity to refine goals and discuss reasonable and necessary supports that best suit them to live a meaningful life.

Recommendation 11: That people diagnosed with degenerative conditions be deemed automatically eligible to receive support from the NDIS to prevent or delay deterioration.

Recommendation 12: That the NDIA considers how independent assessments will impact participants with Aboriginal and Torres Strait Islander and CALD backgrounds and instigating safeguards to ensure these issues are addressed prior to implementation.

Recommendation 13: That the NDIA consider further involvement of Aboriginal and Torres Strait Islander peoples prior to the implementation of independent assessment, including further consultation with First Nation’s communities and increasing representation in the assessment workforce. 3A Locked Bag 4102, Ascot OLD 4007

Recommendation 14: That the NDIA consider setting up a unit to assist Aboriginal and Torres Strait Islander Peoples access the NDIS, and that this unit design, develop and deliver a different assessment process that is culturally specific to this group.

Recommendation 15: That the NDIA engage ESSA to implement the Exercise is Medicine© program for NDIS planners and support workers to augment workforce knowledge and health literacy to better support NDIS participants.

Recommendation 16: That the NDIA employ planners that have qualifications and/or experience in health or human services and support planners to develop a strong understanding of the complex needs associated with participants’ disabilities.

Recommendation 17: That the NDIA employ an exercise physiology advisor that can educate and provide guidance to NDIS planners.

Recommendation 18: That the outcomes of independent assessments be made a reviewable decision, allowing participants to appeal a decision made by the delegate as a result of an independent assessment.

Recommendation 19: That the NDIA take health professional advice, including from AEPs, into account if considering reducing participant funds due to improved functional capacity.

Recommendation 20: That the recommendations in this submission be piloted prior to the implementation of independent assessment and that all pilot results be released prior to implementation and commencement of mandated independent assessments. 4A Locked Bag 4102, Ascot OLD 4007

3.0 Introduction and Summary of Issues

ESSA’s submission is based on feedback from AEPs delivering services under the National Disability Insurance Scheme (NDIS), and provides responses to the following provider topics:

independent assessment workforce, including independence and expertise;
assessment tool gaps;
recognition of participant goals;
access and eligibility implications;
planning and budgeting;
appeals process; and
other matters.

4.0 Independent assessment workforce

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

4.1 Meeting workforce demand

The National Disability Insurance Agency (NDIA) has suggested that independent assessments will remove a number of access barriers for NDIS participants. One of these involves long waiting times due to the need to book appointments with various health professionals, including allied health clinicians, doctors and specialists, to gain evidence of the impact of their condition.

ESSA cautions that participants facing long wait times will continue and increase where the assessor workforce is insufficient to meet the demand for independent assessments. This will particularly be the case in thin markets. For this reason, ESSA is concerned that the NDIA has limited the independent assessor workforce to only six allied health professions, as promoted on the NDIS website.

AEPs meet the Pearson level B qualification requirements. They possess the skills and clinical expertise required to conduct independent assessments using the proposed assessment tools. AEPs are university qualified allied health professionals that complete a minimum of four years of study in an ESSA accredited course (either all four years undergraduate or a combination of undergraduate and postgraduate). Further, AEP Practice Standards prescribes accredited course graduate outcomes, including the ability to choose and apply guidelines and measurement tools/techniques to measure and assess clients’ clinical and functional status. AEPs have transferable knowledge and skills to screen and assess capacity and function for activities of daily living and activities in the workplace.

Further, ESSA notes that, of the eight organisations selected by the NDIA to conduct independent assessments, at least five already employ AEPs, making AEPs appropriately placed to effortlessly be included in the independent assessor workforce. ESSA also notes that given the independent assessment process will be delivered using standardised tools, discriminate calls as to which qualified professionals that apply those tools is inappropriate and inaccurate.

ESSA is concerned that AEPs have not been included on the published list of allied health professionals selected to conduct independent assessments. While the NDIA may imply that the list of allied health professions is not exhaustive, many AEPs have interpreted this list to determine that they are not eligible to be included in the 5A Locked Bag 4102, Ascot OLD 4007

independent assessor workforce. Further, one of the organisations that has been identified to provide NDIS independent assessments is currently recruiting for allied health professionals to join their NDIS assessor team. Such advertising has only referred to the allied health professions listed by the NDIA, despite AEPs being perfectly placed to contribute to this workforce. This demonstrates that the current NDIS list of allied health professionals relevant to provide independent assessments is limiting.

4.2 Independence

ESSA notes that some of the organisations that will make up the Independent Assessment Panel selected by the NDIA during their open tender process are existing Local Area Coordinators (LACs) and already receive funding by the NDIS to provide services.

For assessments to be truly independent, existing services that receive funds from the NDIA should not have also been considered for employment as independent assessors. ESSA members are concerned that LACs are already involved in the planning process and execution of NDIS participant plans, may be regarded as a conflict of interest when conducting independent assessments.

4.3 Quality Assurance

4.3.1 Assessor workforce expertise

Of the remaining organisations, the primary focus of their service is in areas outside of disability. For example, aged care, employment and workplace safety. While these organisations may have had some experience in disability due to the overlap between sectors, our members have expressed concern that the independent assessment workforce will be one that is lacking in skills and expertise required to support people with disability under the NDIS. These organisations simply do not have sufficient experience to determine the impact of a disability and the needs of the individual. ESSA members suggest that even 12 months of working with NDIS participants is not sufficient to gain the appropriate skills and understanding with regards to participant conditions.

AEPs who have analysed the proposed assessment tools have confirmed that there is a certain level of clinical competency required to complete the assessment forms and accurately assess functional capacity. ESSA is aware that not all Early Childhood partners employ allied health professionals and, therefore, will not have the clinical expertise required to conduct independent assessments for children under seven years. ESSA members are confident that the child’s existing allied health professional is best placed to administer independent assessments to children, based on the clinical nature of the assessments and history with the child.

ESSA notes that some allied health professions will be better placed to assess certain conditions than others. For example, a psychologist will be best placed to assess a participant with a psychosocial disability. In contrast, an AEP would be better placed to assess a participant with a physical disability. The NDIA has suggested that participants may have choice and control over which of the eight organisations may conduct their independent assessment. However, ESSA notes that each of the eight organisations employ numerous types of allied health professionals that can conduct independent assessments, therefore, selecting an organisation on the assessor panel does not guarantee the desired allied health professional conducting the participant’s independent assessment. Further, 6A Locked Bag 4102, Ascot OLD 4007

there has been no indication from the NDIA that a participant may select which type of the allied health professional may conduct their assessment. If an allied health professional is assigned to assess a participant who does not have sufficient experience with their condition, they may not fully understand or accurately depict, the impact of the condition on the participant’s functional capacity. Since the NDIA has indicated that participants will be assigned funding based on their function capacity scores, there is the risk that the participant will not receive the appropriate funds to achieve their goals.

4.3.2 Existing health professionals’ expertise

ESSA is concerned that a participant’s regular healthcare professional is not able to conduct the independent assessment nor be involved in the access process, apart from when requested by the NDIA delegate.

ESSA notes the importance of establishing trust and confidence when working with participants, particularly for some types of disability. An example of this includes the autism spectrum disorder (ASD). Diagnosis assessment of ASD typically takes time and collaboration with a clinical psychologist, paediatrician and a range of allied health professionals, including exercise physiologists, speech pathologists and occupational therapists. This allied health team supports the child, builds rapport with both the child and family, and observes/supports the child at home and in other settings, such as pre-school. When this family seeks support from the NDIA, this multidisciplinary team will provide strong insight into the child’s needs, current behaviours in different environments and recommendations for ongoing support. Exclusion of this vital information would be to the detriment of the child and his/her family.

Additionally, ESSA members have outlined that participants and their families already have a major burden of attending multiple therapies to demonstrate the impact that their condition has on their functional capacity. This process is time consuming and emotional for participants and their families. The ability to use familiar practitioners who already know the participant and their condition for assessment to access the NDIS, or for ongoing assessment in the case of reviews, will alleviate this burden. This is a current process for NDIS reviews and has worked well for participants accessing AEP services. AEPs working with NDIS participants suggest that this approach minimises stress when accessing the scheme. The focus on addressing their needs, which will likely result in better participant health outcomes and overall service experience within the scheme.

ESSA acknowledges that the NDIA has expressed concern about existing healthcare professionals exhibiting sympathy bias when conducting assessments for their clients to access the NDIS. However, many allied health professionals are required to operate under regulated codes of conduct in order to obtain accreditation with the relevant professional body. For example, AEPs are required to practice under ESSA’s Code of Professional Conduct and Ethical Practice, which outlines that AEPs must practice with honesty, integrity and transparency. Therefore, ESSA advocates that this addresses the issue of sympathy bias.

There is also concern among ESSA members and other allied health organisations that independent assessments risk excluding or underfunding participants that experience a “good day” at the time of independent assessment. ESSA notes that the NDIA has made statements relating to the consideration of reports from the applicant’s usual treating health professional. However, this only seems to be the case when the NDIA delegate has requested additional information. The Independent Assessment Framework is unclear about how the usual treating health professional’s reports will be considered in the assessment, even when reports are requested by the delegate, simply stating:

‘There are times when it will be necessary for delegates to scrutinise specific assessment items, to ask more questions, to source extra information from parents, carers, significant others and health professionals as 7A Locked Bag 4102, Ascot OLD 4007

needed. However, the way this supplementary information is included in the assessment process will be different to the current state.’ (page 25)vi

Participants’ regular healthcare professionals have a deeper understanding of the participant’s condition, including current therapy and therapy limitations, and should be considered by the delegate if they have been provided, regardless of whether they were requested by the delegate.

4.3.3 Training and supervision of assessors

To promote quality assurance of independent assessments and positive participant experience, ESSA suggests that the organisations responsible for recruiting and conducting independent assessors should ensure staff are appropriately trained and supervised. This is especially critical due to the lack of disability specific experience of the current tender winners, as mentioned above. Without proper training and supervision, assessors will not likely have the skills and expertise required to appropriately support NDIS participants through the assessment process.

4.3.4 Regulation of assessors

ESSA notes that the organisations that have been selected to conduct independent assessments have been exempt from requiring registration with the NDIS Quality and Safeguard Commission (the Commission). This means that the Commission will not regulate independent assessors working under these organisations.

ESSA is concerned that these organisations may prioritise meeting key performance indicators over ensuring quality of the assessment process. This, in addition to the lack of regulation of organisations conducting independent assessments, may result in inaccurate assessment outcomes, followed by inadequate supports for participants to achieve their goals.

When considering the potential impact that the independent assessment process is likely to have on all NDIS participants, both during the assessment and the funding allocation as determined by the assessment, quality and safety oversight should be of utmost importance. Given that assessors will be allied health professionals, it would be most appropriate for oversight to come from expert allied health professionals that are representative of the independent assessment workforce and highly experienced in disability. Such a group of experts would be 8A Locked Bag 4102, Ascot OLD 4007

appropriately placed to monitor progress on the implementation of the independent assessment process and make suggestions for continuous improvement.

5.0 Assessment tool gaps

The appropriateness of the assessment tools selected for use in independent assessments to determine plan funding

ESSA members and other allied health professionals have identified several gaps in the proposed assessment tools to be used for independent assessments. If these gaps are not addressed, the independent assessment cannot provide an accurate depiction of a participant’s functional capacity.

AEPs have assessed the proposed assessment tools and identified the following gaps:

Lack of review of functional needs relating to upper limb function.
Lack of focus on adult participants with complex movement disorders and reduced mobility when reviewing lower limb capacity.
Functional balance is not sufficiently covered.
Insufficient focus on pain, mental health or emotional health.
Non-existent questioning about physical activity (structured vs unstructured) for participants aged over 18 years.

AEPs have noted that many of these gaps are linked to numerous domains contained in participant goals. For example, upper limb function is linked to numerous activities of daily living that are typical for participant goals, including mobility and self-care.

Case Study A:

A 24 year old male suffered a spinal cord injury from a rugby tackle 18 months ago. He is classified as a C6/7 complete quadriplegia. Prior to his injury, he was living out of home, on university campus where he was in the second year of his law degree. He has just been approved to move into an accessible apartment where he will be living with two close friends. Although there will be a continuation of carer supports in his new abode, the participant realises that there will be things he will need to do independently when these supports are not around, with a big emphasis on being able to empty his catheter bag independently. Currently he does not have the upper limb strength nor core stability to be able to hold himself in a safe position to perform this task. He is also hoping to return to university to continue his Bachelor of Law. This will require him to attend campus and move independently between classes. Although able to propel himself in his manual wheelchair for short distances, he does not have the fitness, muscular endurance or stamina to do so for longer distances.

Assessment of the individual in Case Study A using the proposed assessment tools for participants over 18 years does not capture mobility of the upper limbs, which will be required for pushing his manual wheelchair. Without an assessment of upper limb function and consideration of his ability to push his wheelchair, these assessments will not provide the valuable insight required to enable this participant to achieve his goals. 9A Locked Bag 4102, Ascot OLD 4007

ESSA is concerned that these gaps will result in participants receiving inaccurate scores for their functional capacity. This will translate to either the refusal to access the NDIS or undervalued funding packages for participants. AEPs have suggested a tool similar to the Rivermead Mobility Index would better examine functional capacity related to mobility.

Further, ESSA is concerned that the use of assessment tools alone is insufficient in obtaining thorough information relating to a person’s level of functional capacity. AEPs rely on observations and self-reporting of the participant, and those close to them, to be able to form a holistic view of their capacity and subsequent support needs. The independent assessment design does not allow for this, and as such, relevant, pertinent information will be missed leading to undervalued funding packages for participants.

Recommendation 8: That assessors be required to utilise observation of activities in at least the home setting and one community setting (e.g. work, school) as part of assessing functional capacity.

6.0 Recognition of participant goals

The appropriateness of the assessment tools selected for use in independent assessments to determine plan funding (cont.)

ESSA and other allied health organisations recognise that participants with the same functional capacity will have very different goals, resulting in varying levels of funding required. The proposed assessment tools are not comprehensive enough to capture participant goals.

For example, consider three participants with a visual impairment. One has the goal to join the workforce, another has the goal to learn to use a guide dog and a third wishes to improve physical capacity to ambulate safely following a fall that occurred due to their impaired vision. All three participants will require different supports, all supports requiring different funding to achieve their goals.

The NDIA has not outlined in detail how independent assessment outcomes will translate to draft budgets. However, the NDIA’s Planning Policy for Personalised Budgets and Plan Flexibility consultation paper indicated that draft budgets will be determined by the NDIA delegate prior to the participant’s first planning meeting and that draft budgets will only be adjusted if a participant has extensive and/or complex support needs or if additional high-cost supports relating to accommodation, assistive technology or home modifications are identified at the planning meeting. As independent assessments do not currently consider individual participant goals, and this is the only interaction between the participant and the NDIS prior to the first planning meeting, the approach currently described by the NDIA does not allow for varying funding requirements based on the participant’s goals.

ESSA suggests that consideration of participants’ goals in determining the appropriate level of funding directly reflects the object prescribed in section 3(1)(e) of the National Disability Insurance Scheme Act 2013 (the Act), which states that an object of the Act is to “enable people to exercise choice and control in the pursuit of their goals and the planning and delivery of their supports.” Further, section 6 of the Act provides that the NDIA may provide financial support to participants in relation to meet obligations under the Act, i.e. pursuit of goals, as prescribed in section 3(1)(e).

For the NDIA to allocate a truly personalised budget, goals must be considered when allocating and finalising personalised budgets. ESSA suggests that if the NDIA propose to include individual’s environmental circumstances, 10A Locked Bag 4102, Ascot OLD 4007

including informal supports available to clients, as part of the independent assessment process to determine draft budgets, then it should also consider individual participant goals prior to determining draft budgets. Goals are an important component of what makes each participant individual.

7.0 Access and eligibility implications

The implications of independent assessments for access to and eligibility for the NDIS; and the appropriateness of independent assessments for people with particular disability types, including psychosocial disability.

7.1 Access for people with degenerative conditions

Independent assessments will pose an additional barrier to entry into the scheme for people living with degenerative conditions, such as Parkinson’s Disease and Multiple Sclerosis. At present people living with progressive neurological conditions face significant barriers to entry despite there being comprehensive evidence to suggest that early intensive therapy supports delay the progression of symptomsi-iv, enabling the person to have higher functional capacity for longer. ESSA members have seen numerous examples where people recently diagnosed with Parkinson’s Disease have been deemed ineligible for support from the NDIS due to the fact they are still too high functioning, despite evidence their symptoms are having a significant impact on their capacity to complete typical activities of daily living. Early intensive therapy would support delaying the progression of symptoms. As discussed earlier, ESSA members have identified significant gaps in the proposed standardised assessment tools relating to assessing mobility and community participation outcomes, resulting in further negative impacts on access by people with these degenerative conditions.

Recommendation 11: That people diagnosed with degenerative conditions be deemed automatically eligible to receive support from the NDIS to prevent or delay deterioration.

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.

7.2 Access for people from culturally and linguistically diverse backgrounds

It is important to consider how independent assessments may impact people from Culturally and Linguistically Diverse (CALD) backgrounds, as these populations already experience significant barriers to accessing the NDIS. A report produced by the NDIA in 2019 stated that the proportion of CALD participants had been less than expected across all age groupsv.

It is broadly understood that CALD participants and their families can have difficulty communicating their unique needs. ESSA cautions that the independent assessment process may further communication difficulties for CALD 11A Locked Bag 4102, Ascot OLD 4007

participants. This is of particular concern due to the interview nature of the assessment tools, with only limited assessor observation based on a single setting, which will not appropriately capture the needs of the participant. There is potential for misinterpretation of assessment questions by a CALD participant or their family member, which will result in inaccurate assessment results and reduced access to the NDIS by people from CALD backgrounds.

For example, an ESSA member described the interaction between their client and the NDIS. The client had a CALD background and experienced a stroke that had resulted in permanent and significant disability. She had struggled to explain her situation to the NDIS and a variety of health professionals to be able to gain evidence of her condition and access into the scheme. She has been deemed ineligible to access NDIS funding by the NDIA four times and, as a result, has ceased attempting to access NDIS funds and is not able to live independently.

7.3 Access for Aboriginal and Torres Strait Islander peoples

Around 6 per cent of ESSA members work with Aboriginal and Torres Strait Islander people. ESSA members have expressed concern that independent assessments will have a negative impact on accessibility of Aboriginal and Torres Strait Islander peoples, specifically those in rural and remote areas.

Ensuring Aboriginal and Torres Strait Islander peoples with disability have timely and culturally appropriate access to supports aligns with six out of the 16 targets identified in the National Agreement on Closing the Gapvi. These six targets relate to improving the health and wellbeing of Indigenous Australians, ensuring children from Indigenous backgrounds are not left behind and enabling economic participation of all Indigenous Australians. While the participation of Indigenous Australians in specialist disability support services has been reported to have increased in recent yearsvii, it should be noted that such data may not be accurate, due to the reliance on self-identification of Indigenous status and typical underreportingviii.

Aboriginal communities have indicated that they will not accept any model of care without adequate consultation. ESSA members have suggested that, in order to enable access to the NDIS by Aboriginal and Torres Strait Islander participants, the NDIA need to consider thorough consultation with Indigenous communities prior to the implementation of independent assessment. If this has not been adequately considered, the NDIA risks further inhibiting access to the NDIS from Aboriginal and Torres Strait Islander participants.

Other programs that have successfully engaged Aboriginal and Torres Strait Islander communities have included the use of Aboriginal and Torres Strait islander workforces to support Aboriginal people. For example, the NSW health model of using Aboriginal Liaison Officers to offer additional cultural support.

8.0 Planning and budgeting

The implications of independent assessments for NDIS planning, including decisions related to funding reasonable and necessary supports.

ESSA is concerned that NDIS planners do not have the clinical expertise to interpret independent assessment results, and subsequently recommend reasonable and necessary supports for participants.

ESSA advocates that the best way to support participant decision making is to ensure NDIS planners and Local Area Coordinators (LACs) are appropriately trained and educated in relation to the reasonable and necessary supports available for participants. This will enable planners and LACs to recommend services that are most appropriate to each NDIS participant based on the individual’s disability, functional capacity and goals.

AEPs have expressed concern about inconsistencies in planning decisions, noting that some participants receive a generous plan with adequate funding allocation for therapy, whilst others with similar conditions and circumstances receive very little funding allocated for the same therapies and large amounts of funding allocated to supports that are not the preference of the participant. Such concerns are reflected in the recent Tune Review of the National Disability Insurance Scheme Act 2013i. This is currently one of the most significant issues that AEPs report in relation to their NDIS clients. With the proposed plan flexibilities, ESSA maintains that planners require greater access to education and support when it comes to proposing reasonable and necessary services in allied health.

Under the current planning arrangements, there are several factors that can lead to the inappropriate allocation of funding for therapy:

Planners have insufficient knowledge or lack the qualifications or experience to determine the allied health needs of a participant and make appropriate plan recommendations.
Planners lack understanding of the role, scope of practice and value of various allied health professions and often look to identify lower value alternatives which can be to the detriment of the client’s health outcomes. For example, ESSA members have reported that it is common for planners to assume that personal trainers or disability support workers can deliver the same supports as university qualified exercise physiologists.
Participants are required to develop their own goals and justify to planners/LACs why they need the support of an exercise physiologist or exercise scientists. There are significant discrepancies in the quality and detail of goals from plan to plan. Subsequently, there is inequitable variation in the funding people receive purely on the terminology used in the development and justification of goals.
Participants can struggle to articulate their goals and requests using the desired terminology.

As a result of inadequate funding allocation to therapy, AEPs are reporting that they are either:

supporting new participants to prepare and justify their NDIS goals (often without being funded for the support provided)
supporting participants to request plan reviews and developing evidence reports to justify why participants need exercise physiology services
redesigning exercise interventions so that the participant can have maximum engagement within the limited funds available (refer to case study B)
delegating low risk interventions to disability support workers and accepting the fact that high risks interventions will have to be applied less frequently. 13A Locked Bag 4102, Ascot OLD 4007

Several AEPs noted that some participants’ goals cannot be achieved within the allocated funding and have expressed concern that this may reflect poorly on the health outcomes, service quality and impact on the provision of therapy in the participant’s future NDIS plans. An example of this has been described in case study B.

Case study B

A participant who has psychosis, autism, mutism, and is overweight has engaged an AEP to assist with achieving a weight loss goal of 8kg. The participant’s planner has only made provisions in their budget for one 1-hour exercise physiology session a week for 10 weeks. The AEP has expressed concerns that it is difficult to achieve behavior management for weight loss when the therapy sessions are so infrequent, particularly when the participant has multiple and complex conditions. To ensure the participant has a greater chance of achieving the goal, the AEP has had to schedule two 30-minute sessions a week and charged at a reduced rate.

ESSA would welcome the opportunity to inform planners and LACs by providing education and resources on the evidence-based benefits of exercise treatments for NDIS participants as well as the role and value of exercise physiology services. Collaboration and shared understanding will enhance the outcomes and service experience of NDIS participants, by ensuring choice and control of the participant.

ESSA operates Exercise is Medicine© (EIM©) Australia, which is a bespoke education program facilitated by local AEPs and can be delivered via face-to-face and online. EIM sessions are currently designed to increase primary healthcare provider’s literacy on the role that physical activity plays in health, wellbeing, inclusion, self-efficacy and the prevention and treatment of chronic disease. However, ESSA would be delighted to work with the NDIA and EIM to modify and tailor the content of our current EIM program specifically to suit NDIS planners, LACs and carers.

ESSA also understands that the NDIA employs advisors for other allied health professions and suggests that access to an exercise physiology advisor would facilitate a greater understanding of the profession and support planners’ capability in selecting services and allocating funding within a personalised budget to best suit the participant’s unique situation. ESSA notes that the appointment of exercise physiology advisors in other compensable schemes, such as the Department of Veteran Affairs (DVA) and some Private Health Insurers, has generated better outcomes and service equality for beneficiaries as well as the compensable schemes.

Recommendation 17: That the NDIA employ an exercise physiology advisor that can educate and provide guidance to NDIS planners.

9.0 Appeals process

Opportunities to review or challenge the outcomes of independent assessments. 14A Locked Bag 4102, Ascot OLD 4007

ESSA members are concerned that an individual will not be able to appeal the result of an independent assessment if they disagree with assessment results and are denied access to the scheme. Given the significant impact the result of an independent assessment will have on access, eligibility, budgeting and planning, ESSA suggests that it is important for participants to be allowed the opportunity to have any decisions in relation to their independent assessment results reviewed.

10.0 Other Matters

10.1 Improved functional capacity

ESSA suggests that the NDIA ensures participants retain a certain level of funding even if functional capacity improves. Improvements in functional capacity are a likely result of therapy supports and indicate that the therapy is generating positive outcomes in assisting participants to achieve their goals. The NDIA should be aware that if funding for therapy supports is reduced because functional capacity improves, the participant’s functional capacity is at risk and may decline as a result.

Recommendation 19: That the NDIA take health professional advice, including from AEPs, into account if considering reducing participant funds due to improved functional capacity.

10.2 Further research required

Given the issues outlined in this submission, including those related to the assessor workforce, assessment tools and lack of consideration of goals, further research into the independent assessment process is required by the NDIA. ESSA suggests that these issues need to be addressed prior to the implementation of mandated independent assessments. Further, any proposed solutions to issues will need to undergo appropriate testing to ensure they adequately address the issues and meet the needs of participants.

References

i Klingels, K., Feys, H., Molenaers, G., Verbeke, G., Van Daele, S., Hoskens, J., Desloovere, K., & De Cock, P. (2013). Randomized Trial of Modified Constraint-Induced Movement Therapy With and Without an Intensive Therapy Program in Children With Unilateral Cerebral Palsy. Neurorehabilitation and Neural Repair, 27(9), 799–807. https://doi.org/10.1177/1545968313496322

ii Synofzik, M., Ilg, W., Maffiuletti, N. (2014). Motor Training in Degenerative Spinocerebellar Disease: Ataxia-Specific Improvements by Intensive Physiotherapy and Exergames. BioMed Research International, 2014, 583507. https://doi.org/10.1155/2014/583507

iii Trahan, J., Malouin, F. (2007). Intermittent intensive physiotherapy in children with cerebral palsy: a pilot study, Developmental Medicine & Child Neurology, 44(4), 233-239. https://doi.org/10.1111/j.1469-8749.2002.tb00798.x

iv Warren, Z., McPheeters, M., Sathe, N., Foss-Feig, J., Glasser, A., Veenstra-VanderWeele, J. (2011). A Systematic Review of Early Intensive Intervention for Autism Spectrum Disorders. Pediatrics, 127(5), e1303-e1311. https://doi.org/10.1542/peds.2011-0426

v National Disability Insurance Agency (NDIA). Culturally and Linguistically Diverse participants. [Internet]. NDIA;2019 [cited 26 Mar2021]. Available from: https://data.ndis.gov.au/media/1946/download

vi Australian Government. National Agreement on Closing the Gap. [Internet]. July 2020 [cited 26 Mar 2021]. Available from: https://www.closingthegap.gov.au/sites/default/files/2021-03/national-agreement-ctg-mar-21_0.pdf

vii Austalian Bureau of Statistics (ABS). Sources of data for Aboriginal and Torres Strait Islander peoples with disability, 2012-2016. [Internet]. 2019 [cited 26 Mar 2021]. Available from: https://www.abs.gov.au/ausstats/abs@.nsf/mf/4431.0.55.004?OpenDocument

viii Griffiths, K. Coleman, C. Al-Yaman, F. Cuningham, J. Garvey, G. Whop, L. Pulver, L. Ring, I. Madden, R. (2019). The identification o fAboriginal and Torres Strait Islander people in official statistics and other data: Critical issues of international significance. Statistical Journal of the IAOS, 35(1), 91-106. DOI: 10.3233/SJI-180491.

ix Tune D. Review of the National Disability Insurance Scheme Act 2013: Removing red tape and implementing the NDIS participant service guarantee [Internet]. 2020 December [cited 2020 Jan 23]. https://www.dss.gov.au/sites/default/files/documents/01_2020/ndis-act-review-final-accessibility-and-prepared-publishing1.pdf 16A Locked Bag 4102, Ascot OLD 4007