Submission to the Inquiry into the Integrity of the National Disability Insurance Scheme

Introduction

1.1

Minda is the largest not-for-proﬁt provider of support to people with intellectual disability in South Australia. Minda was created 128 years ago in 1898 to provide support to 22 children with intellectual disability. Over the years Minda has grown into a body supporting over 1000 adults with intellectual disability through a range of services including Supported Independent Living, Day Programs, Mentoring, Supported Employment and Allied Health. Today Minda’s only children services are for children with intellectual disability who are under the guardianship of the Minister for Child Protection. Minda is a registered NDIS provider.

1.2

Like many of the large not-for-proﬁt disability providers across the country Minda struggled to make the transition from the world of government ‘block contract’ funding to individualised NDIS funding arrangements. This resulted in the near ﬁnancial collapse of the organisation four years ago. In response to this the governing body brought in new executive leadership to take the organisation through a signiﬁcant recovery program. This resulted in substantial change to the model of support provided such that it was more consistent with participant needs, changes to underlying processes to reduce overhead expenditure and signiﬁcant investment in quality assurance to place greater emphasis on enabling individual participants to achieve their identiﬁed outcomes. The culmination of these changes has led to the ﬁnancial recovery of the organisation and an increase in participants choosing Minda as their support provider. As a result, Minda is one of the few large not-for-proﬁt providers nationally to now be making a small, but necessary, surplus for the last two ﬁnancial years. This is enabling investment in technology and the development of workforce which will bring about further improvements in how Minda operates.

1.3

This submission draws upon the experience of Minda and the participants it supports. Minda does have a clear methodology for engaging with those people who choose to use its services, including a self-titled consultative group, the Minda Soldiers, supported through independent advocacy. Minda also has separate consultation mechanisms for engaging with the families/support networks of its clients.

1.4

As a result, this submission relates to the experience of people with intellectual disability, albeit that some of those people also have a degree of physical disability, rather than those people with physical disability alone. It is important to recognise this given that the majority response to much consultation regarding the NDIS comes from those participants with a physical disability and the voice of those with intellectual disability, particularly complex intellectual disability, is less well heard.

Market Stewardship

The submission addresses the terms of reference of the Committee by focusing upon four key areas.

2.1

The NDIA has no visible Market Stewardship framework and therefore no clear visibility of who providers are, let alone their capability, quality and integrity. Given the ability of participants to take up Plan Manager and Self-Managed options for implementing their plans the NDIA may also have a limited view on who payments are being made to. In addition, there is minimal control in place as to who calls themselves a provider. Over recent years Minda has seen staff under investigation for poor practice leave the organisation to establish their own provider business or be employed by another provider undertaking no reference checks. This creates an environment in which non-compliance, fraud and sharp practices can thrive.

2.2

Whilst the recent decision to introduce mandatory registration for SIL and Platform providers is a step in the right direction the detail of how this is going to operate is very unclear. Even this limited form of registration is challenged by some participants, particularly those with physical disability, who see the use of a registered provider as a restriction on their right to ‘choice and control’. This might be acceptable in the terms of some types of supports but can impact signiﬁcantly on quality, placing participants at risk, if the supports required are complex and more clinical in nature.

2.3

Unregistered providers do not carry the overhead costs of being registered and undertaking all that that entails and therefore achieve a much higher margin compared to registered providers. This creates the potential for ‘sharp practices’. For example, Minda has lost SIL participants to private unregistered SIL providers who have offered ‘incentives’ to those participants. These range from small gifts, through free internet services to providing ‘free’ cars. This latter example became a signiﬁcant incentive when the NDIA tightened up on the rules for using NDIS funds on transport. These unregistered providers can provide these incentives because of the size of proﬁt they are making.

2.4

Of even more concern is those providers, both registered and unregistered, who are prepared to agree to support regimes that the family might want for a person with intellectual disability that that person with the disability might not want, or indeed, could be harmful to them. In recent months Minda has experienced two such examples. The ﬁrst relates to a family who wanted PRN sedation medication issued routinely each morning at breakfast to their step-son in a SIL service. Minda refused to do this given it

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is a misuse of PRN medication and against the interests of the participant. As a consequence the family within 24 hours removed the step-son from Minda to another provider who had agreed to this sedation regime. The second example is that of a SIL participant with signiﬁcant capacity who identiﬁed as a transwoman. Their family disagreed with this and instructed Minda staff to only use a male name and remove any feminine items from their home daily. Minda refused to do this in respect of the participants human rights. This resulted in the family moving the participant to another SIL provider who had agreed to do as they instructed. Minda reported both incidents to the NDS Quality & Safeguards Commission given the implications for the respective participants. In both case Minda was informed that the Commission had spoken with both families, and they had no issues with their new providers therefore no action was being taken.

These examples illustrate the need to not only introduce appropriate mandatory registration of all providers but also elevate a more consistent understanding of concepts such as ‘choice and control’ as part of good practice activities. This is particularly important regarding people with intellectual disability where ‘supported decision making’ is not well understood and implemented by some providers and families. A recent survey of families undertaken by Minda indicated over 30% of families believed ‘choice and control’ belonged to them and not the participant.

Pricing

The NDIA’s pricing regime does not support a market model. The annual Price Guide produced by the NDIA is seen as the price providers can legitimately charge without regard to their actual cost or quality rather than the ‘price cap’ it is intended to be. Therefore, all providers, including the single-handers self-employed with an ABN charge the same Price Guide amount for a particular support. This creates a huge proﬁt margin for small or self-employed providers compared those large providers, like Minda, who are registered and have signiﬁcant costs associated with compliance requirements and achieving quality outcomes. Simply, there is no incentive for providers to determine their own price below the published price cap.

This is different to Aged Care where there is a framework surrounding what providers can and cannot charge for but essentially each provider sets their own prices. The aged care consumer can then make an informed choice in terms of who their Home Care Package provider is, based upon price and their perception of quality of service offered.

There are already recommendations from the NDIS Review about the pricing regime being moved to an independent body with a greater focus on linking pricing to quality of outcomes for the participant. Minda supports these recommendations but would like them to go further in moving away from the ‘price cap’ model to incentivise providers to competitively price their services.

Quality

Minda’s Service Excellence Framework

Minda has undertaken significant work in developing a Service Excellence Framework. This has involved considerable engagement with participants and their families as well as looking at the international evidence base to determine appropriate quality outcomes measures for people with intellectual disability.

A key finding, reflected in Minda’s framework, is the different, but overlapping views, as to what quality is from the perspective of the participant versus the family. From a participant perspective, quality outcomes related to overall physical and psycho-social health and achievement of specific life goals, e.g. developing and maintaining friendships. These were recognised by some families, but they placed much greater emphasis on ‘customer satisfaction’ measures, e.g. timeliness of service delivery, consistency of staffing, appropriate communication with them, etc. Both perspectives are important and Minda’s Service Excellence Framework recognises the two with appropriate and measurable headline indicators.

Complexity of ‘Quality’ within NDIS Context

Minda has raised this as part of its submission to the committee to illustrate the complexity of the notion of ‘quality’ within the context of the NDIS. Much of the reform agenda outlined by the NDIA increasingly refers to the importance of quality in terms of market stewardship and pricing and yet the notion of what quality is appears very undeveloped.

Minda is a participant in the SIL Quality Supports Project established by the NDIA but this is really looking at costing the inputs that might lead to good quality rather than trying to look at costing quality outcomes. This work is certainly not addressing the issue of whose perception of quality is being looked at. Likewise, the NDIS Quality & Safeguards Commission is currently heavily occupied by compliance matters and basic safeguarding. Whilst this is critical and necessary it is not fostering the debate about what quality outcomes are for participants, particularly those with complex intellectual disability.

Diversity Within Disability

The NDIS is a ‘one size fits all’ system that has difficulty in adapting to the needs of people with very different types of disability. At a high level, as illustrated elsewhere in this submission, people with physical disabilities and people with intellectual disabilities have potentially different needs that require different solutions. The current system struggles to accommodate these differences.

For example, when the recent changes were made to meeting the costs of transport Minda tested the option for three consenting housemates to ‘pool’ their transport funds. This would enable them to lease a car for their house so that it is available to them 24/7. This was going to be better for them in terms of being more spontaneous in maintaining friendships and more cost effective for the NDIS than each of them using transport on a per km basis in line with the current funding rules. Despite NDIA officers understanding this concept and thinking it sensible they have also said that the system cannot deal

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with this type of variation even though it may yield better outcomes for participants with intellectual disability and a better deal for the taxpayer. This is a small example but there are many other examples where the nature of the supports provided could be more beneﬁcial to the participants if the rules allowed them to be tailored more speciﬁcally to the needs and circumstances of those with intellectual disability.

5.2 The system recognising this diversity is going to be more important as the new

assessment and plan management approach is introduced from the 1st July 2026. Whilst the ICANv6 assessment tool may allow greater understanding of the needs of people with intellectual disability to be addressed compared to the existing methodology the ‘rules’ around the new plan format with its Stated Service and Flexible elements may make it even more difficult to provide the appropriate supports. With the recent budgetary-driven perspective on what the NDIS should and should not fund assumptions are potentially being made about the social capital or ‘in-kind’ should be available to people with a disability by friends and family. The experience at Minda is that approximately 35% of our clients have no family contact and are under the guardianship of the Public Advocate which is an administrative process. Equally, for most of our clients their only income is the Disability Support Pension. Therefore, they are in a very different position to a person with physical disability with full-time employment.

Summary

Minda is supportive of the reforms required to ensure that the NDIS system remains viable, more adequately meets the needs of people with intellectual disability and closes down the opportunities for fraud, non-compliance and sharp practices. To ensure this happens effectively Minda believes the four areas of Market Stewardship, Pricing, Quality and Diversity within Disability needs to be addressed. This last issue of Diversity is particularly of concern as there is a danger that if the needs and circumstances of people with intellectual disability get overlooked in any future reforms, they will be further disadvantaged.

David Panter Chief Executive Minda