Joint Standing Committee on the National Disability Insurance Scheme (NDIS) inquiry into market readiness

Queensland Government submission

Table of contents ………………………………………………………………………………………………………. 2 Introduction ……………………………………………………………………………………………………………… 3 a. The transition to a market based system for service providers …………………………………… 3 Taxi Subsidy Scheme ………………………………………………………………………………………………… 3 Specialist School Transport ………………………………………………………………………………………… 4 Health and Mental Health Services ……………………………………………………………………………… 4 Advocacy ………………………………………………………………………………………………………………… 4 b. Participant readiness to navigate new markets ………………………………………………………… 5 c. The development of the disability workforce to support the emerging market ……………….. 5 d. The impact of pricing on the development of the market …………………………………………… 6 e. The role of the NDIA as a market steward ………………………………………………………………. 7 f. Market intervention options to address thin markets, including in remote Indigenous communities ………………………………………………………………………………………………………. 8 Aboriginal and Torres Strait Islander peoples ……………………………………………………….. 8 People living in rural and remote areas ………………………………………………………………………… 9 People from culturally and linguistically diverse (CALD) backgrounds ……………………………….. 9 g. The provision of housing options for people with disability, with particular reference to the impact of Specialist Disability Accommodation (SDA) supports on the disability housing market …………………………………………………………………………………………………………….. 10 h. The impact of the Quality and Safeguarding Framework on the development of the market …………………………………………………………………………………………………………….. 11 i. Provider of last resort arrangements, including for crisis accommodation …………………… 11 j. Any other matters – Nil ………………………………………………………………………………………. 12 Conclusion …………………………………………………………………………………………………………….. 12

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Introduction

The Queensland Government submission to the Joint Standing Committee on the National Disability Insurance Scheme (NDIS) inquiry into market readiness (the inquiry) will outline opportunities to improve the scheme based on the state’s experience to date.

a. The transition to a market based system for service providers

Queensland key message for Term of Reference ‘a’

Queensland Service Providers have identified a number of challenges in transitioning to a market based system. These fall into two key categories:

Uncertainty of the market

Disincentives through NDIA processes

Uncertainty of the market

Market size

In Queensland providers are starting to question how many Queensland participants there will be and this creates uncertainty in the market.

Under the terms of Queensland’s NDIS Bilateral Agreement, 60,000 Queenslanders with disability are estimated to transition to the NDIS in the final year, 2018-19. The NDIA has only been able to achieve around half of the estimated numbers at the end of the first year (2016- 17).

The NDIA will need to significantly boost the number of people entering the scheme to meet the estimates in the bilateral, which could strain the capacity of the market to meet any sudden increase in demand.

Interface with mainstream service provision

The interface between mainstream state service delivery and NDIA funded supports for a number of issues has been problematic for some service providers transferring to a market based system in Queensland.

The areas where interface issues have arisen include:

transport assistance - Taxi Subsidy Scheme
transport assistance - specialist school transport
health and mental health, and
advocacy.

Without a clear decision about whether the NDIS will fund the above types of support service providers do not have the certainty required to move into these markets.

The following provides a summary of these interface issues.

Taxi Subsidy Scheme

The Queensland Government announced on 15 July 2017 that it would continue to provide for the Taxi Subsidy Scheme (TSS) for NDIS participants through an in-kind arrangement through the transition period. This included reinstating any cancelled TSS memberships.

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Negotiations with the Commonwealth Government for TSS to be recognised as a formal in- kind contribution to the NDIS have not been resolved, nor has funding been returned to the State to cover these increased costs.

Specialist School Transport

Specialist school transport for state and non-state schools is being delivered by the Department of Education (DoE) as an in-kind contribution to the NDIS until 31 December 2019, six months into full Scheme. This will enable the NDIA to develop a national model and potentially fund this service through an approach that allows NDIS participants choice and control over who provides this service.

The National Disability Insurance Agency (NDIA) is working with jurisdictions to undertake consultation on a possible national model of specialist school transport under the NDIS. A report to the Disability Reform Council (DRC) based on the outcomes of the consultation will be provided for its consideration later in the year.

Results of consultation on a potential model for school transport and broader provider readiness issues must influence decisions on the future operation of school transport and ensure service provision is viable in thin markets.

Health and Mental Health Services

Queensland Health (QH) continues to support clients via cashed out services in NDIS regions who, according to the roll-out schedules, should have transitioned to the NDIS.

Given community uncertainty about the NDIS, some potential participants are also deferring their NDIS applications, preferring to remain with Queensland Health services, and in the case of the Medical Aids Subsidy Scheme (MASS), bringing their MASS applications forward in advance of NDIS implementation.

Advocacy

The long-term provision of advocacy supports is an ongoing concern for NDIS participants, other people with disability, and service providers. The Commonwealth Government will only provide advocacy-type supports through its Information, Linkages and Capacity Building program, including LACs.

The Queensland Government is continuing to fund disability and community care advocacy organisations for a further two years from 2019-20.

Disincentives through NDIA processes

Providers are experiencing delays between when a participant receives their plan and when that plan is activated (i.e. the person commences receiving supports). In the quarter to 30 September 2017, 53 per cent of plans were activated within 30 days, however 20 per cent took up to 90 days to be activated, and no payments were made in the quarter for 25 per cent of plans.

Costs associated with establishing new business models, adapting to NDIA administrative requirements, and technical difficulties with the provider portal, have acted as disincentives to providers entering, or remaining in, the market. These costs are inadequately recognised in the pricing structure. Queensland acknowledges the NDIA is now undertaking work to improve the provider experience, including improvements to the provider portal.

Queensland has found Aboriginal and Torres Strait Islander businesses need additional support, including investment and expert advice, to help with transition to the NDIS.

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b. Participant readiness to navigate new markets

Queensland key message for Term of Reference ‘b’

Delays to LACs in Queensland have directly impacted on participant readiness to navigate the new markets.

With the exception of Bundaberg, no LAC has been in place in any phasing area six months in advance as required in Queensland’s NDIS Bilateral Agreement. This has been of significant concern to Queensland and has been raised numerous times at multiple levels.

The NDIA’s failure to announce partner agencies for the areas due to phase from 1 July 2018 will further impact the ability of participants to navigate the new market.

Partner agencies should have established and recruited to LAC positions before 1 January 2018.

LACs need to be established on time and to full capacity so that participants are able to reap the full benefits of contact with and support from a LAC.

c. The development of the disability workforce to support the emerging market

Queensland key message for Term of Reference ‘c’

Queensland has worked hard to develop the workforce and requires access to better data to inform future activities.

More attention needs to be placed on a plan to attract and retain Aboriginal and Torres Strait Islander people into the workforce.

There needs to be work done on potential gaps on workforce development for clients with complex needs.

Queensland has actively pursued strategies to ready the workforce, initially investing $1.03 million in 2015-16 to establish a consortium[1] to create the Queensland NDIS Workforce Strategy (WorkAbility Qld), build workforce supply and capability to meet demand under the NDIS. This work continued in 2016-17 and 2017-18 with $2.8 million under the Commonwealth’s SDF.

Given that Queensland is only just entering its largest stage of transition and there is a lack of data about the disability workforce it is challenging to monitor how the workforce is changing in response to the NDIS.

Aboriginal and Torres Strait Islander peoples in the workforce

Queensland considers specific workforce strategies are required to attract and retain Aboriginal and Torres Strait Islander people in the NDIA and disability workforce. Such strategies could include consideration of enabling community members in Aboriginal and

[1] Links to information about the WorkAbility strategy are provided for reference: http://workabilitityqld.org.au/about; and http://workabilityqld.org.au/wp-content/uploads/2016/04/Fact-Sheet-NDIS-NGO-Workforce-Strategy.pdf.

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Torres Strait Islander communities to provide supports prior to gaining full disability support worker qualifications.

Potential gaps in the delivery of support for people with complex needs

In some regions there are few allied health providers with relevant capability to deliver higher risk clinical supports, such as mealtime support and paediatric feeding, complex equipment and positioning prescription, and Positive Behaviour Support Plan development (both providers to write the plan and allied health professionals to undertake functional assessments to contribute to positive behaviour support planning).

Market gaps in support for people with complex needs will increase if providers (including small sole traders) choose not to upskill in these areas due to the cost of professional development. There is also a risk that providers who have not undertaken professional development may deliver supports that are not consistent with the current evidence base or good practice. Queensland is particularly concerned risks may arise for people with complex needs in the absence of clinical expertise in the NDIS system.

While the NDIS Senior Practitioner will provide clinical leadership in the area of positive behaviour support and restrictive practices, this role does not extend to, nor is there is a similar position for, other high risk clinical supports.

d. The impact of pricing on the development of the market

Queensland key message for Term of Reference ‘d’

Queensland supports the publication of the McKinsey and Company Report and the NDIS response.

The NDIA must ensure prices are sufficient to encourage the required supply of supports while maximising value for participants.

The NDIA commissioned an independent review of pricing in response to concerns expressed by participant and provider groups, and in the PC’s Study Report. The report by McKinsey and Company[2], together with the NDIA’s response, were published on 2 March 2018 on the NDIS website. Queensland welcomes the publication of the independent report as a step towards greater transparency in the NDIA’s price setting.

The McKinsey and Co report made recommendations related to service delivery in rural and remote areas enabling providers to quote for services in isolated areas rather than being bound by a set price and enabling therapists to charge and support workers to charge up to 45 minutes in travel time in rural areas. Given Queensland’s dispersed population and geography, these changes to pricing will enhance viability for providers delivering services to participants in rural and remote locations.

Providers expressed concerns NDIS pricing does not cover actual costs. Gaps in service provision may be created if pricing is insufficient to retain providers in the market and attract new entrants. The NDIA has accepted recommendations from the McKinsey and Co report to increase loadings for service delivery to people with complex needs, change therapy prices to better reflect different therapy types, introduce a second tier of pricing for therapy assistants; and enable providers to charge up to 90 per cent of service costs for late cancellation of a

[2] Independent Pricing Review: National Disability Insurance Agency Final Report, February 2018, McKinsey and Company https://ndis.gov.au/medias/documents/ipr-final-report-mckinsey/20180213-IPR-FinalReport.pdf

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service booking. These steps will go some way to improving providers’ capacity to tailor service provision to participant needs and recover costs, minimising the impact of pricing on the delivery of allied health and therapy services in rural and remote areas.

Queensland expressed support for the PC’s recommendation[3] for price regulation to be conducted by a body independent of the NDIA to avoid a potential conflict of interest arising when the NDIA is both setting prices and being responsible for the financial sustainability of the scheme. Queensland supports a transparent level of price setting along with independent review and monitoring of prices.

The NDIA will face tensions between pressure from providers to increase prices to cover service delivery, administration costs, and workforce issues (such as supervision, training) and the NDIA’s responsibility to ensure scheme sustainability. The NDIA must ensure prices are sufficient to encourage the required supply of supports while maximising value for participants. If prices are set too low, providers may choose not to deliver some services leading to gaps in the market[4].

At the end of December 2017, 2,388 providers were registered in Queensland. Of these, 54 per cent were not yet active. This may be due to some providers registering before the NDIS has commenced in their location, or providers registering for many types of support but finding there is not demand for all the types for which they have registered. It is too early to tell if the low percentage of active providers in Queensland is leading to gaps in the market. Queensland will continue to monitor this situation.

e. The role of the NDIA as a market steward

Queensland key message for Term of Reference ‘e’

Queensland supports the NDIA’s publication of more information about provider and workforce data.

The NDIA’s Corporate Plan 2017-21 and NDIS Market Approach: Statement of Opportunity and Intent, November 2016, set out the NDIA’s role as a joint market steward[5], alongside the Commonwealth Department of Social Services and state and territory governments.

The NDIA’s market steward functions include monitoring the marketplace to assess whether the desired outcomes are being achieved; facilitating actions that directly and indirectly influence demand and functioning of the marketplace (such as information provision and price- setting); and direct commissioning of supports if required.

The PC’s Study Report found there was an urgent need to publish better, forward looking market information, including provider and workforce data, to create a better evidence base to inform better market stewardship[6]. Queensland considers the NDIA’s role should also include the implementation of the eMarketPlace, publication of market information, including market analytics and benchmarking.

[3] Queensland Government submission to Productivity Commission Position Paper: NDIS Scheme Costs, June 2017 [4] Study Report into NDIS Costs, Productivity Commission, October 2017, page 33 [5] NDIA Corporate Plan 2017-2021, p 10 https://ndis.gov.au/about-us/information-publications-and-reports/corporate-plan and NDIS Market Approach: Statement of Opportunity and Intent, November 2016, p18 https://ndis.gov.au/medias/documents/h08/h2e/8799510396958/Statement-of-Opportunity-and-Intent-PDF-1.02MB-.pdf [6] ibid

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A Market Position Statement for Queensland was published in 2016; no further statements specific to Queensland have yet been published. As the NDIS commences in new geographic areas, providers need more contemporary market intelligence to support decisions about the types of services in demand and the location of demand.

Queensland, the Commonwealth and the NDIA have agreed working arrangements for market readiness and an action plan linked to national market readiness key performance indicators. The action plan covers priority areas such as growing the NDIS market, ensuring the full suite of services can be provided, supporting existing providers, mapping thin markets including in rural and remote areas, and ensuring comprehensive strategies are available to respond to service disruption and crisis. The action plan also covers building the capability of the workforce, and ensuring a sufficient workforce for specialist providers. All actions for which Queensland has responsibility have commenced or been completed.

f. Market intervention options to address thin markets, including in remote Indigenous communities

Queensland key message for Term of Reference ‘f’

There are specific challenges to be met in relation to thin markets to service the needs of Aboriginal and Torres Strait Islanders, people in rural and remote communities and people with CALD backgrounds.

Aboriginal and Torres Strait Islander peoples

Queensland’s participant readiness initiatives, augmented by SDF, have increased the rate of participation of Aboriginal and Torres Strait Islander peoples. Aboriginal and Torres Strait Islander peoples represent 4.2 per cent of Queensland’s population[7] and now represent 8.8 per cent of Queensland NDIS participants[8].

Historically, access to allied health services in remote Aboriginal and Torres Strait Islander communities has been limited. Connections Inc. is engaged to deliver provider readiness activities in Cherbourg, Woorabinda, Thursday Island, Cairns, Mossman, Yarrabah and Gordonvale, Caboolture, and Wujul Wujul and Cooktown. The Connections Inc. project team has expressed concerns regarding the lack of allied health professionals in some remote locations, reporting that many are fly-in-fly-out workers on rotation, and may work one or two days per week in rural locations.

Connections Inc. has established an Indigenous mentor (project team) in each community with strong connections to their communities. The mentors use their existing networks and relationships to engage with existing and prospective service providers, and the general community. The mentors not only deliver workshops and information sessions, but facilitate relationship-building between community members, service providers and health professionals. They have found that building relationships with the local elders, who are well- known and well-respected, and having them ‘champion’ the project, encourages locals to get more engaged.

The organisation has also assisted a Cairns doctors’ surgery to become an NDIS-registered provider and facilitated the creation of a new position ‘Aboriginal and Torres Strait Island plan manager’ in this surgery. An Indigenous Health Worker has taken up this role and provides

[7] 3238.0.55.001 - Estimates of Aboriginal and Torres Strait Islander Australians, June 2011 Australian Bureau of Statistics, June 2011 [8] National Disability Insurance Scheme COAG Disability Reform Council Quarterly Report, Table E11, page 101, National Disability Insurance Agency December 2017

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support to local service providers, GPs and allied health professionals as well as supporting participants to access the NDIS.

Connections Inc also identified there are no culturally appropriate communication resources for Indigenous communities, and organised for a number of NDIS resources to be translated into local languages and re-designed in a culturally appropriate way for the intended audience. This has resulted in a more engaged community in the Torres Strait locations.

In these communities, close relationships with existing, trusted services are essential for successful engagement with potential clients and to support their participation in NDIS. Thin markets of locally based NDIS service provision compromise choice and control for participants, and there is a need to ensure culturally safe services are in place.

People living in rural and remote areas

People with complex needs in rural and remote communities have difficulty accessing qualified and experienced clinicians able to, for example, prescribe specialised adaptation to aids and equipment, or advise on paediatric feeding, and behaviour support.

Queensland is concerned people in rural and remote locations may be disadvantaged by not having ready or timely access to face to face support for NDIS engagement and planning opportunities. Participants may not be willing or able to travel or have difficulty engaging via telephone, potentially compromising their plan and support outcomes. In addition, there are limited advocacy supports available to assist vulnerable people to engage with existing services.

People from culturally and linguistically diverse (CALD) backgrounds

The proportion of people born in non-English speaking countries who are accessing disability services[9] is much lower than their representation in the community[10]. People from CALD communities may experience language and cultural barriers in accessing services or information. Queensland notes that the NDIA’s CALD Strategy, which has been anticipated for some time, is yet to be finalised. The delay risks the continued underrepresentation of people from CALD backgrounds in the NDIS.

Access to interpreter services is crucial to enabling participants with limited English proficiency to engage with the scheme, exercise choice and control and access services. Queensland understands the NDIA is considering this issue with a view to provide NDIS participants with access to interpreters to assist them to implement their plans.

As an interim arrangement, the Queensland Government is varying the contract with SWITC to enable Queensland participants as well as existing clients to access interpreting and translation services via SWITC. Funds for language support in plans, where appropriate, would greatly empower and benefit CALD participants. Information on new language support arrangements must be appropriately communicated to relevant stakeholders, including service providers who support people from CALD backgrounds, people with disability, families and carers who require language support.

[9] Australian Institute of Health and Welfare, 2017, Disability support services: services provided under the National Disability Agreement 2015-16. http://www.aihw.gov.au/publication-detail/?id=60129559747&tab=2 [10] Australian Bureau of Statistics, 2016, 4430.0 - Disability, Ageing and Carers, Australia: Summary of Findings, 2015, www.abs.gov.au/ausstats/abs@.nsf/mf/4430.0

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g. The provision of housing options for people with disability, with particular reference to the impact of Specialist Disability Accommodation (SDA) supports on the disability housing market

Queensland Government key message for Term of Reference ‘g’

The sector needs more data and communication to understand the opportunities and limitations of the SDA. This information should be designed to help stimulate entry into the disability housing market by potential providers.

The separation of the provision of housing from other support types is an important safeguard for people living in shared housing and individual accommodation. The NDIA has stated its commitment to this principle. Market intelligence and price signalling is needed to stimulate investment in SDA type housing by organisations other than those delivering disability supports.

SDA is not yet well-understood by the disability sector. There is a risk some providers may develop properties which do not meet SDA conditions, or are unsuitable for the SDA needs of participants in that area. More market intelligence is needed to guide and encourage industry to develop SDA and prepare the housing sector for a market-led environment. There remains a lack of certainty about the ability of the SDA payment to stimulate the market, particularly outside of metropolitan areas.

In response to a request from DRC in November 2017, the NDIA intends to provide further information to the market and to consider mechanisms through which private investment in SDA could be encouraged. A report is expected in March 2018. The NDIA plans to work with stakeholders to develop market information that is responsive and relevant to the needs of industry or the area of required growth.

A housing-specific Market Position Statement for each state and territory focusing on affordable housing and SDA would assist the housing sector in each jurisdiction to respond to market issues. The NDIA is well-placed to, as a matter of priority, share data about participants’ short and long-term housing needs and preferences[11].

Information about participants’ housing needs, including demand for SDA and participants’ long-term housing aspirations, receiving and/or eligible for SDA payments, and whether the market has responded to demand would also provide market intelligence to enable the market to respond to housing demand for people with disability further inform the market . To date it has not been possible for Queensland to obtain this type of information from the NDIA.

There is a risk of inadequate supply of suitable housing for participants, particularly in rural and remote areas, placing additional pressure on all forms of state housing assistance. Queensland is exploring strategic options to assist in facilitating the development of SDA in Queensland.

Recent research by the Australian Housing and Urban Research Institute (AHURI) reviewing the housing situation of Aboriginal people in three early NDIS sites (rural, remote and urban) evidences the depth of the challenge facing states and territories and the NDIA to deliver on the opportunity presented by the NDIS. The research found people with disability were more likely to have experienced homelessness compared with people who reported no disability. The research also found people with disability were living in housing that did not provide basic amenities, and the majority of housing included in the study did not meet minimum accessibility or visitability requirements.

[11] [citation omitted in source]

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h. The impact of the Quality and Safeguarding Framework on the development of the market

Queensland key message in relation to Term of Reference ‘h’

Queensland considers the NDIS Quality and Safeguarding Framework (the Framework) has not yet affected provider entry to the market.

A broad range of organisation types are submitting self-assessments prior to registering with the NDIA, seeking to deliver a wide range of support services. The range includes sole providers, small community organisations aiming to provide supports only in a specific geographic area, and large providers that have not previously delivered disability supports in Queensland. Nearly a third of registered providers are sole traders (32 per cent). Queensland has assisted approximately 80 per cent of the providers submitting self- assessments to understand the registration requirements. Sole traders (such as disability support workers) or small new businesses with limited business experience have required the greatest amount of assistance. Assistance has included:

understanding of the regulatory environment and safeguarding requirements for provision of disability services in Queensland
understanding of basic business requirements such as risk and financial management, business planning, recordkeeping, reporting requirements, basic policies and procedures
understanding the business requirements of the NDIS, for example e.g. many providers apply for professional registration groups without having the relevant qualifications, despite having signed the NDIS declaration of suitability committing to engage suitability qualified staff
understanding the relationship between state based quality and safeguarding requirements and NDIS registration approval
clarifying the market segment they wish to provide services in, e.g. to specific individuals known to them or to an identified gap or emerging market such as in a rural area.

Education materials for new entrants to the market to help build business capability and understanding of the regulatory environment, and provide information about demand for service types and locations of demand to inform provider decisions about the market segment they wish to target, would reduce the assistance Queensland is providing to new providers.

A total of 2,338 providers were registered with the NDIA in Queensland at 31 December 2017, but it remains to be seen whether all these providers will remain in the market once they are required to gain certification against the NDIS Practice Standards through an independent audit process. The audit process will continue to involve costs and further requirements for the provider to demonstrate how they meet the standards.

i. Provider of last resort arrangements, including for crisis accommodation

Queensland key message on Term of Reference ‘i’

Queensland considers the NDIA should resolve and communicate Provider of Last Resort / maintenance of critical supports arrangements as a matter of priority to give certainty to participants and providers.

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Queensland’s Operational Plan for transition to the NDIS specifies that the NDIA will lead on identifying and developing approaches to ensure that a provider of last resort is available, as well as support for participants in crisis. To implement this plan, Queensland and the NDIA have negotiated working arrangements for market readiness in case of last resort.

These processes respond where a provider withdraws from the market. Responses could include direct assistance (financial or non-financial) to the provider to delay their withdrawal, or sourcing an alternative service provider. During transition, the NDIA assumes full responsibility for maintaining supports to participants as the NDIS is fully rolled out in each geographic area. In areas where transition is not complete, Queensland could have a role in collaborating at a local level to assist in mitigating impacts on clients who have yet to become NDIS participants.

Once transition to full-scheme has been completed, the NDIA will be responsible where providers withdraw from the market to mitigate impact on participants. There must be capacity for the market to deliver short term, crisis responses. The NDIA has been working on this issue, which has not yet been finalised.

j. Any other matters – Nil

Conclusion

Thank you for the opportunity to provide a submission.

If you have any further questions in relation to the Queensland Government’s response, please contact:

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