February 2018
The Dietitians Association of Australia (DAA) is the national association of the dietetic profession with over 6000 members, and branches in each state and territory. DAA is a leader in nutrition and advocates for food and nutrition for healthier people and healthier nations. DAA appreciates the opportunity to provide feedback on Market Readiness by the Joint Standing Committee on the National Disability Insurance Scheme.
Contact Person: Annette Byron
Position: Senior Policy Officer
Organisation: Dietitians Association of Australia
Address: redacted
Telephone: redacted
Facsimile: redacted
Email: redacted
DAA interest in this consultation
The Dietitians Association of Australia (DAA) supports the rights1-3 of people with disability to access nutrition support products and Accredited Practising Dietitian (APD) services which meet their unique needs to promote physical, mental and social wellbeing.
NDIS participants experience physical, intellectual, sensory or psychiatric impairments that lead to unique and complex food and nutrition needs. These complex needs are related to function, and are in addition to those for growth and development, defence against infection, repair of injury, physical activity, maintenance, and mental health.5
The inclusion of the services of APDs and nutrition support products in NDIS participant plans is reasonable and necessary for participants to realise their goals and aspirations, and to increase their social and economic participation.
Responses to Terms of Reference
Our responses to the inquiry into market readiness for provision of services under the NDIS are provided below according to the Terms of Reference. The areas of greatest concern to us at present are the inconsistency of inclusion of APD services in NDIS Plans and the contested interface between the NDIA and health. This leaves NDIS Participants at risk of harm and APDs with doubts about the viability of being an NDIS Provider.
The transition to a market-based system for service providers
Latent unmet need exposed
The transition to a market-based system in disability is exposing areas of latent unmet need. One such area of need is equitable access to the services of APDs and nutrition support products. Prior to the NDIA, access to these items varied greatly across the country. This has reduced individual quality of life and shortened the lives of people with disability as they experience high rates of comorbidity which could be mitigated through diet.
Risk of harm with unresolved interface issues
Where services and products have been available through publicly funded means, there has been disruption to supply. Employees of health services consider the NDIA is now responsible for meeting the needs of people with disability, and the NDIA considers health has responsibility for supply. This is leaving people with disability at risk of harm from lack of timely access to nutrition support products and APD services.
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Market uncertainty
APD service providers are experiencing a high degree of uncertainty in the transition to a market-based system.
“What is the point in new providers entering the market when NDIS are phasing out dietitians? Experienced providers such as myself with 10+ years disability experience are seriously considering leaving the market.”
A contributing factor is the inconsistent decisions by NDIA Planners who do not understand the role of APDs in improving the health and wellbeing of participants to achieve greater social and economic participation. NDIS Participants who have been able to include APD services in their NDIS Plans have been able to build their skills and independence, and have increased their enjoyment of social and economic opportunities which may lead to reduced need for NDIS funding in the future.
It appears also that Planners are being directed by NDIA Managers that some dysfunction or impairments of people with disability are the responsibility of health services. This is of particular concern as there has been no approach by the NDIA to DAA as the peak body for the profession on the role of APDs in disability, nor has there been any credible evidence provided to support decisions denying some NDIS Participants nutrition support products or APD services in their Plans (despite NDIS Participants requesting APD supports in their Plan).
The uncertainty in the evolving NDIS environment is not helpful to the development of a market to meet the needs of people with disability. Evidence of thin markets in our profession are
- the small number of practitioners who nominate disability as an area of practice or claim that they are a NDIS Registered Provider on the ‘Find an APD’ service on the DAA website.
- The NDS State of the Disability Sector Report 20176 says 33% providers had moderate difficulty recruiting dietitians in last 12 months.
Skills needed at entry
New APD NDIS providers will require a mix of technical skills (food and nutrition related to function and impairments), communication skills (unique aspects of professional communication and building relationships with participant/family/care workers) and business skills (general and NDIS business rules) to meet the needs of NDIS participants and to achieve sustainable thriving business.
Entrants may enter with all or some of the requisite skills, and will require ongoing training and education from a range of sources i.e. the peak professional body with or without government grants, and other education/training organisations.
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Current and potential providers and education providers will only invest in education and training if there is a higher degree of certainty in the market.
Participant readiness to navigate new markets;
Some participants and their families will need time and support to build their capacity and confidence as consumers, partly because they have had poor access to products and services previously.
Unfortunately participant capacity for self-determination and feeling of self-esteem will be diminished by refusal of NDIA planners to include the services and products which NDIS participants wish to include in their NDIS Plans. This appears to be against the intent of the NDIS to empower people with disability, and can be considered a denial of human rights.
The development of the disability workforce to support the emerging market;
Many more APDs will be needed to meet the needs of NDIS Participants individually, and also to build the knowledge and skills of service provider managers, care workers and other health professionals.
Care workers
The Vocational Education Sector also has an important role in developing competencies in care workers supporting people with disability. There is a high prevalence of comorbid conditions amongst people with disability which has diet and physical activity as contributing factors. Training Certificate III and IV courses would be strengthened by the inclusion of food and nutrition content as core subjects. Workers require practical skills and knowledge to understand the role of APDs and the importance of food and nutrition across the spectrum of disability. Having the right skill set will enable care workers to support clients with a range of disabilities at a basic level and recognise when to refer clients for higher level assistance.
Risk of harm to NDIS participants
NDIS Participants may be exposed to disproportionate risk of harm if they are not supported by a skilled carer workforce guided by APDs and speech pathologists. Choking, aspiration pneumonia and death for people with intellectual disability in supported accommodation were identified as problems by the NSW Ombudsman7 when procedures are not in place to support mealtime management and dysphagia.
Education needs cross portfolios
Issues in the development of the disability workforce are shared in other sectors including aged care, mental health, health and workers may work in multipurpose
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facilities/organisations or move between sectors. Investment in building food and nutrition skills is needed across all of these sectors.
The impact of pricing on the development of the market
DAA was advocating for more equitable access for Australians to nutrition products and APD services in a national Home Enteral Nutrition program prior to the implementation of the NDIS. Access to products and services was highly variable across jurisdictions and even between jurisdictions. That variability aside, some people requiring home nutrition support were able to obtain products and services at no charge, or at state/territory contract prices.
The advent of the NDIS has disrupted well-functioning services, and now places some participants at risk of ham from lack of access to services and products.
Participants are likely not to be able to access state/territory contract prices as nutrition support product manufacturers and distributors calculate prices for individual clients which reflect deregulation and uncertainty in the market. Where this is the case, it is important that NDIS Plans are constructed on NDIS market prices otherwise participants will be unable to afford essential products.
Market intervention options to address thin markets, including in remote Indigenous communities
Allied health providers, including dietitians, have been identified as operating in thin markets. Every effort should be made to encourage providers to enter the market through the following basic measures
- Consistent decision making by NDIS planners
- Timely mechanisms between for resolving disagreement between NDIS and health services about who should fund services to participants
- Timely and transparent mechanisms for resolving NDIA appeals
- Options for covering travel for NDIS Providers or Planners
- Partnerships with metropolitan or regional service providers to meet the needs of NDIS participants living in remote areas
- Using telehealth and innovative communication strategies to connect NDIS Participants and NDIS Service Providers.
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
Reports published by the NSW Ombudsman7 recommend that people with disability living in supported accommodation have assistance as individuals and for workers to build their capacity with respect to food and nutrition skills. This is because of the high
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prevalence of co-morbidities in this group of people, co-morbidities which shorten lives but can be favourably influenced by access to professional services, healthy food choices and physical activity.
The impact of the Quality and Safeguarding Framework on the development of the market
The introduction of complicated and expensive registration processes which include third party auditing as part of the basis of Quality and Safeguarding Framework will deter providers from entering the NDIS market. The increase in red tape and greater burden of regulation for allied health professionals will not keep NDIS Participants safer because the risk to NDIS participants from this group of NDIS Providers is very low.
Third party registration costs have been estimated to be from some hundreds of dollars to thousands. This is not proportionate to risk for allied health providers who are already well regulated and have a record of safety and quality to the public, so much so that health ministers agreed not to regulate some professions under NRAS delivered by the Australian Health Practitioner Regulation Agency.
Decisions by NDIA Planners resulting in denial of APD services, insufficient APD hours in NDIS Participant plans or direction to inadequate health services are placing participants at risk of harm. Already there are accounts of participants presenting to emergency departments, being admitted to hospitals or experiencing frequent admissions because of lack of access to APDs in private practice.
Provider of last resort arrangements, including for crisis accommodation
The rights of people with disability to access services and products, and to self- determination should be upheld at all times. There should be a provider of last resort to ensure the rights of people with disability are met, but this should be a genuine last resort, not a default which is used because of inadequate training of NDIA Planners or cost containment by state/territory or Commonwealth government.
References
- Universal Declaration of Human Rights http://www.ohchr.org/EN/UDHR/Documents/UDHR_Translations/eng.pdf
- United Nations Convention on the Rights of Persons with Disabilities http://www.un.org/disabilities/documents/convention/convention_accessible_pdf.pdf
- Convention on the Rights of the Child https://www.humanrights.gov.au/convention-rights-child
- National Disability Insurance Scheme Act 2013 https://www.legislation.gov.au/Details/C2016C00934
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- Position of the Academy of Nutrition and Dietetics: Nutrition Services for Individuals with Intellectual and Developmental Disabilities and Special Health Care Needs. J Acad Nutr Diet 2015;115:593-608
- NDS State of the Disability Sector Report 2017 https://www.nds.org.au/news/state-of-the-disability-sector-report-2017-reflects-sector-under-pressure
- NSW Ombudsman. Report of Reviewable Deaths in 2012 and 2013. Volume 2: Deaths of people with disability in residential care June 2015. https://www.ombo.nsw.gov.au/news-and-publications/publications/annual-reports/reviewable-deaths-vol-1/report-of-reviewable-deaths-in-2012-and-2013-volume-2-deaths-of-people-with-disabilities-in-care
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