Australia buzza.com.au

SUBMISSION TO THE PARLIAMENTARY INQUIRY TO NDIS MARKET READINESS

Background

The author of this submission is Chantelle Robards. Chantelle has been supporting people with disabilities for 25 years. With a background in speech pathology she has worked across the non- government, government and private sectors and has been involved with the NDIS reform since the beginning of the trial in 2013. In 2015 Chantelle started a new business of which a significant component was Provider support. This business has since been sold.

More recently Chantelle has continued with Provider advocacy in a voluntary capacity much of which stems from issues raised by an online Provider Community (via a community of practice of which she is one of the administrators- set up via Facebook page Disability Community of Practice Australia as well as her own business pages) which altogether is approaching 2000 members. These are primarily small to medium business owners many of whom are sole traders.

We assert that the success of the small business segment of this marketplace is fundamental to achieving the philosophy of choice which is a key fundamental of the NDIS.

In late 2017 a survey was put to our Community requesting completion by small business owners to capture their NDIS experiences. Over 160 businesses from across Australia and across service delivery domains responded. Analysis revealed significant dissatisfaction and marked stress through working with the NDIS. The report is attached to this submission and will be referenced throughout.

Buzza is an Australian start-up which will also offer Provider support. Chantelle is one of the Directors of this business. This submission will be completed on behalf of this new business which will be launching in the coming month.

The aim of this submission is to express the issues of the small business segment of the NDIS marketplace. We have significant concerns about the future of small business and the NDIS.

The DCOP Community were asked whether they wanted to provide information for this submission and they did so in spades. These quotes will be included throughout the submission but have been de- identified. If the Inquiry should like to speak to

them directly please don’t hesitate to be in touch and we shall endeavor to connect you.

(a) The transition to a market based system for service providers

One would imagine that the for-profit sector would be in the best position to launch quickly and smoothly into the new disability marketplace. Many of these small businesses were already established and had been working within government funded schemes such as Medicare, Better Start, Veterans affairs and other funding schemes such as Health Funds, Insurance and Workers Compensation and so on. They were used to a business model which was based on a fee for service approach rather than block funding.

Unfortunately this has not been the case.

Moving a small business into a new market requires a careful analysis of risk vs reward. The initial transition to the market based system where Provider registration was straight -forward and fast, where plans were adequately funded and contact with the Agency was relatively easy which enabled efficient access to information and support. The reward well and truly outweighed the risk.

As time has gone on these key areas have not maintained previous performance and this has greatly impacted small business. The question of viability is being asked much more frequently in our observation.

Inequity of support

Our survey revealed that the private segment of the market overwhelmingly believes that the NGO segment has been far better supported with the transition to the NDIS. This includes larger organizations being invited to consult on changes, having greater capacity to attend forums and meetings which are rarely run via webinar and funding that was available to help NGO’s complete the expensive audit process.

As a result the small business community has rallied and formed it’s own informal alliances including within our online Community.

Difficulties obtaining accurate information

Our survey revealed that small business owners feel that they have had extremely negative experiences trying to obtain accurate information about the reform. This included a lack of responsiveness, receiving different information from different

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Agency staff and not knowing who to ask in the first place. Small business tend not to have huge capacity of off line talent to keep following up and depend on being able to enact changes in practice quickly to ensure that cash flow continues and that errors are not made that will require more red tape. There is also a significant amount of advocacy that seems to be happening when plans are returned with insufficient funding, plan gaps emerge or families just don’t understand what’s happening.

Note here that there is no ability to contact most NDIS staff directly.

‘Oh dear. Had a 1:1 consultation scheduled with NDIA staff today. After arming myself with my list of questions and firing them at the guy for 15 minutes, he informed me that I knew more about the ndis than he did. And he wasn’t being facetious…. oh and by the way- he did not answer one of my questions……I have to say- I did really feel for the guy who was helping me. He was lovely and really trying to do his job well. I think this is just so beyond anything he can do. Not at all his fault and such a difficult position to be in….’

There has been misinformation and incorrect information given by presenters at every NDIS forum I have attended. Information I have been given from the NDIS call centre, at forums and provider engagement teams has more often than not been incorrect. It is extremely challenging to attempt to adhere to the rules as a provider when I can not trust the information that is provided by representatives of the agency.

A very current example of this is the current roll out of workshops which involve the new registration process for the National Quality and Safeguarding. These are being provided by a third party and the Department of Social Services. These possibly contain some big changes for providers and there is a feeling of anxiety about the transition. We attended the first workshop yesterday and posted our interpretation of the information to the community. The information centred around standards that have not yet been released and we were given no documentation to take away.

There have been two more workshops in the past 24 hours and reports from other community members suggest the content has been different and answers provided are slightly different. There is nowhere for us to check anything as yet and perhaps not for another month when the Standards are uploaded to the website. Providers are comparing notes online and confusion is once again dominating. Many people did not receive an invitation to the event at all. It is likely that the messaging from the Q and S team will be to wait for the Standards and additional information in March. However small businesses need to plan ahead especially if the transition will involve an expensive audit. This all results in to a lack of confidence in the sector.

Unviable amounts of Admin time

Businesses report an unreasonable amount of unpaid administration time associated with working within the NDIS as a registered provider.

A Facebook poll was posted within our Community to which around 80 businesses responded. The question was: How much ADDITIONAL admin time is required for your NDIS caseload as opposed to clients who are referred through other funding schemes? The results are below.

Many providers believe that this alone makes being a registered provider unviable.

An exit Plan

Our survey revealed that the longer that businesses engage with the NDIS the more they are thinking about their exit plan. Working with the NDIS is exhausting and as a group providers often refer to ‘NDIS Fatigue’ as a phenomenon (often with accompanying meme).

‘I’m considering deregistering. And I have actively reduced my NDIS caseload to <50% and dropping every month. I no longer take on agency managed NDIS referrals as I’m in process of deciding what to do about my own registration. I have also started to heavily mainstream my practice in efforts to leave the sector.

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My disability caseload is >25%, from almost 100% at the start. Yep – NDIS totally sucks.’

‘We are about 90% on the way to deregistering. Honestly, the only reason we are staying in at the moment is for the benefit of two clients that I do not believe would have the capacity to move/change anything at this stage. I am also uncertain of the logistics admin wise and am aware the process could be taxing for my already overstretched admin team. I am meeting with the NDIS team for 20 minutes today and will be asking a few key questions. Their answers will be the make or break for us’

The devaluing of professionals

Many of the professionals in our community feel that their opinions and recommendations are often ignored or discounted by Planners / LACs. It seems to be rare for someone to be contacted with a request for clarification or collaboration.

‘Before we send a report or make a recommendation or send an email to NDIS, we always make sure that we have taken the time to listen to the participant and family and combine that knowledge with our professional experience and skills to make recommendations or seek answers that are in the best interest of the person and their family. It was what we do because of our professional ethics. When those recommendations are disregarded , ignored or altered without any opportunity for respectful collaborative discussion, I feel completely devalued and disrespected. This lack of trust and perceived assumptions about my personal interest in ‘getting the money’ has never ever happened to me in in over 40 years of working in allied health.’

‘Advice given to families by LACs is often incorrect or not suitable to the family. Many LACs do not appear to have an understanding of what speech pathology involves. This is especially the case for clients with complex communication needs. One LAC told a parent I should be working on getting the child to ‘talk’ (use speech) rather than his AAC. This child was showing great progress in using AAC, was 8yo, and had no functional speech.’

Sudden reinterpretation of principles, policy and guidelines

It would seem from a distance that the Principles to Determine the Responsibilities of the NDIS and Other Services are being re-interpreted and tightened. This results in supports that the Agency previously funded are pushed to other state based mainstream systems.

One recent example of this is the funding of Mealtime Management Plan creation which occurs when a person’s disability causes a swallowing problem. There are significant health risks for the person and as such NDIA are now directing this work to be completed by state based Health systems. This completely disregards the whole- of-life implications for the person which the NDIS is supposed to be about.

This highly specialized work has been completed by the disability sector for decades and NDIS have been funding it for the past almost 5 years.

This sudden shift has seen several small businesses lose their main income stream and with no notice of the changes there was no opportunity for them to transition away from that item and into other areas to protect themselves.

‘I was already frustrated with the other challenges that NDIS brings with it. Now I have gone from having a thriving business to having to let my admin support go and am hemorrhaging clients every week. I am applying for jobs now which are not in the NDIS world. I’ve had enough’.

Expensive registration requirements

All providers understand the importance of oversight and the safety of their clients is paramount. However the cost of registration for those wishing to provide support in ‘high risk’ areas is a huge barrier, starting at around $4 000 and increasing with the size of the business. This acts as a disincentive to enter the market and also as a disincentive to grow a business.

Aside from the added financial burden there is a significant administrative process to ready a business for a strict audit.

‘I am about to return to my business after maternity leave and was going to work on the frontline – I have other staff wanting to come back from maternity leave soon too. Now I will have to spend the next few months preparing for the audit.’

Businesses who have been through the process report that they do not see any benefit to their business (changes under the National Quality and Safeguards will make the audit mandatory for those who still wish to provide these high risk supports. Providers who provided the quotes posted here did so prior to the first Q and S workshop this week. Now they will have no choice but to do the audit).

‘We have seen little return on our ‘investment’ of TPV and at this stage, as a small business owner, I do not and have not seen any benefit to our business and worry that having to work to the NDIS funding model will negatively impact on the quality of care we offer. We have a waitlist well into 2018 (of self managed NDIS participants), and so do not see that NDIS registration has enhanced our viability as a business in any way’

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(b) Participant readiness to navigate new markets

Our impression is that not enough support was provided to Participants to manage the new world, Plans are confusing and it can be hard to know what they can purchase with their funding. There is little understanding of how much supports cost before the NDIS which makes everything look so much more expensive now.

There is also a lack of understanding that products that are being developed have been funded by individuals and so are being offered back to the sector with a fee attached rather than being available through open source.

(c) The Development of the disability workforce to support the emerging market

While we have no data to support our assertions we are confident in suggesting that anecdotally the specialist disability workforce in NSW seems to be already exhausted. There is some movement of talent from one organization to another and some are heading from organizational work to small business or operating as independent contractors however the actual growth of the workforce does not seem to be keeping up with demand.

Added to this an anecdotal and alarming situation whereby talent is actually exiting the sector altogether (also see above). This data is hard to capture quantitatively however is noticeable at a local level where networking is high and we are aware of the movement of our colleagues. Highly experienced and skilled people are choosing to exit the NDIS market and the challenges that it brings for adjacent sectors including Child Protection, Aged Care, Education and Health and most sadly – completely different sectors such as hospitality.

In my opinion, psychologists are leaving the sector because to stay in the disability is no longer rewarding or profitable due to the impasse of the NDIS interface. A psychologist in private practice being paid via Medicare is paid within hours of

seeing the client. Other organisations such as the veterans counselling service, pay at the end of every fortnight. Most insurance companies that I have done work for also pay within 5 days or I don’t deal with them. The extent of any additional work I might have to do post session is email an invoice. I am not required to prove my registration as that responsibility lies with AHPRA’s (and their requirements are extensive). I certainly don’t have to pay thousands of dollars and spend hours (more $) validating my credentials via a third party. There is no means to recover this additional cost and to be frank, I don’t need the NDIS to make a living. In fact, the reverse is true. The only thing that keeps me minimally involved is that I have 30 years experience in the field and feel a moral responsibility to pass some of my skills on and to help those who simply cannot find anyone else with my skill set. The big NGO’s appear to also be struggling and once they have lost all of their senior staff (and they are leaving too simply because the NDIS impost is so extensive, it flows through the NGO structure as well, robbing the clinician of face to face client time and replacing it with ever changing billing procedures), the sector will be populated with graduate clinicians with little hope to be supervised by experienced clinicians. At that point, service provision will plummet as the new clinicians are overwhelmed by the clinical complexity of the sectors presenting problems and also leave. NDIS clients will, I predict, increasingly find it difficult to spend their money due to their being less clinicians and less choice of who they can actually go to. Following this, the clients will have their packages cut because they will be seen as over estimating what their initial requirements were. I remain unconvinced at this stage of the NDIS experiment that it will even remotely succeed in achieving it original aspirations and indeed may yet do irreparable harm to this sectors clinical underpinnings and client service.’

This Provider specifically talks to the lack of supervision and mentoring that can be available for people who are new to the sector as well as student placements. This is partly due to the movement of experienced staff out of the sector and partly due to the added financial burden now that block funding has ceased. Small businesses have to build supervision and mentoring into their business plans and budget for this. In the past, government and non-government organisations offered the bulk of student placements under block funding situations. Now each and every provider would have to view this as a business decision and work out how they are going to bill for supports delivered by a student or new graduate.

(d) The impact of pricing on the development of the market

Our therapist members are frustrated that they are seen as rorting the system because their hourly rate is among the highest. However when this is broken down with the amount of unpaid admin time they are investing the hourly rate is far lower. Planners have openly told families that their therapists are ripping them off and that they should find a student to deliver their therapy at a lower rate.

Clients are often told to “find a cheaper therapist” or a uni student to implement therapy. I charge less than the NDIS rate. This message is more frequently given to long term clients (4+ years) with very complex issues. The suggestion that families

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should use uni students rather than qualified therapists to develop and implement programs is very concerning and is insulting, considering the ongoing professional development required to maintain skills and accreditation in the field.

(e) The role of the NDIA as a market steward

For many small business owners, the Agency do not give the appearance of a fundamental understanding how a small business works and the infrastructure that needs to be in place to best engage with them. Many small business owners also work on the frontline, administrative support tends to be kept minimal and there tends not to be much in the way of management hierarchy. This leaves little capacity for following up with NDIA, trying to establish correct information and stay on top of ever changing rules.

In the Agency’s defence they do seem to be aware, at least at a high level, of many of the operational issues which are presenting the most challenges for business. Unfortunately facilitating change is slow and clunky, often dribbling down to the front-line in patches which results in more disinformation and confusion. After all as we have demonstrated here, our Provider Community talks to one another.

This provider offers behavior support and as such underwent Third Party Verification which cost the business upwards of $10K. This Provider is committed to strong and careful recruitment, ongoing training for their staff, supervision and mentoring and outcomes based intervention. A short time ago one of the Directors happened to be looking at a page on the NDIS website which they noticed had been updated. It stated that there was a new requirement for particular team members since the provider registered. The provider was made to repay the Agency for funds claimed for the workers who had not provided the required information. When the Director raised that they had received no communication from the Agency about the change in criteria they were told that it was their responsibility to be continually checking the website for updates.

As soon as you are registered, you essentially give over your business model to the NDIS. Which would be fine if I felt that someone was steering the ship. But experience has taught me that decisions are being made rather arbitrarily and not as part of an overarching strategy supported by evidence and a vision of a thriving disability services sector. Who needs that? We certainly don’t.

There are also cases of government intervention – perhaps trying to fill gaps in the market that then break a small business.

I am very annoyed about the amount of money and time I have spent investing in my business. The government encouraged small providers to enter this market to provide choice and control. I do support connection, co-ordination and financial plan management of plans. The government has tendered out the Support Connection part to the new Local Area Co-ordinators – and support co-ordination is only available to participants in the first year of their plan and is being significantly reduced to only participant’s that have a major event happening in their life. I have stopped taking financially plan managed clients due to the angst with travel affecting plans, plans being ‘extended’ for 3 months etc. which throws everything in disarray. I am seeing that ‘government agencies’ are being provided with funding to do support co- ordination. They sit in their chair all day, attend meetings, travel etc etc whilst being paid and I attend meetings etc etc ‘volunteer’.

My background is business (have been a ‘local’ for 39 years); I love helping people and doing consulting and project management. I have worked out that I am probably not making more than $10 an hour with what I am doing, but this ‘job’ is working for the NDIA; not my own business and is not what I signed up for…. I cannot see myself working in this business for longer than this year….

(f) Market intervention options to address thin markets including in remote and indigenous communities

The only feedback we have here is that there are providers who are more than happy to travel to more rural areas however in many cases the funding for travel does not make this viable from a small business perspective. Some providers report grouping appointments in smaller towns and splitting the travel to make it work.

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

We have two small businesses who focus on housing in our Community. One of these businesses linked with another local business with an aim to provide affordable housing using an innovative design and product. Many of the personnel in this case came from outside of the sector so their understanding of the NDIS processes is not

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comprehensive – indicating this adds to the difficulty for outside business to engage with the reform.

We had really great intentions – we were excited to try and get this off the ground. But it seems that the process for a Participant to have their funding assessed and approved takes months – this leaves the organisations we are trying to lease to very nervous about committing and who could blame them? Ultimately the market is up and we decided we were better off going to the open market and not worry about the NDIS for now.

“There are significant issues in market capacity and therefore Market readiness is at an infancy stage. The inability to innovate is largely inhibited due to inefficiencies in the National Disability Insurance Agency (NDIA) to process plans, quotes and claims.

There is a gap between operational experience in complex care and 24/7 settings. These are difficult environments for service providers to manage. The gaps in knowledge surrounding disability types and syndromes and how these impact on functioning continues to floor me. I have resorted to providing additional information such as DSM-IV and fact sheets on certain conditions to try and educate NDIA staff.

The time taken to process SIL quotes continues to be inefficient and costly to service providers in our experience. We would welcome the opportunity to participate in the co-design of an efficient system designed by those that operate these services and those that use them.

Significant issues have been addressed and many of these will hopefully be addressed through Independent Pricing Review, NDIS National Practice Standards and the establishment of the Quality & Safeguards Commission.“

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

The requirements of the National Quality and Safeguarding Framework are still largely unknown. There is concern among the Allied Health small business community as to whether there will be a requirement to obtain Third Party Verification in order to retain their NDIS registration.

This audit is extremely expensive, starting at $4K and rising with the number of clients accessing services. This does not include the significant time it takes to prepare for the audit.

Our survey showed a trend for businesses to be accepting referrals only for people who are self managing. Business owners report barriers to payment when using some Plan Managers however this seems to be dependent on the agency providing the Plan Management service. As mentioned previously there are already a number of businesses considering de- registering from the NDIS so that they do not have to operate within the Agency rules and their clients will effectively enter the same pathway as a privately paying customer reducing the Agency administration burden.

(i) Provider of last resort arrangements, including for crisis accommodation

For the purposes of this submission we have no specifics to offer.

We are aware that there are significant challenges in this space including how providers are paid. For example if a person is hospitalized or remanded their NDIS funding ceases for that period which means that there are no funds to pay staff who have often received intensive training to manage the challenges that the Participant may present with. The staff are then redeployed or leave and so are not necessarily available when the person returns and the provider has to start recruitment again. This does not include keeping a bed open.

This is a very unattractive situation for any business.

(j) any other related matters

For tertiary businesses such as ours – it is almost impossible to know who to connect with at the Agency to assess the viability of a start up or to work with the Agency to offer a great product.

There is a constant risk that an innovative idea will become redundant overnight if the government have been working on something behind closed doors that undercuts your business.

I wanted to include the contributions below in full. The comments fit under a number of the categories above. They encapsulate the experiences of many. Over the past few years of supporting businesses this is a common story. For those of us providing this advocacy and support, it is taking its toll.

We are a small business offering mental health and behavior support services to children, teens and adults, with and without Autism. We are comprised of psychologists and behavior specialists. In addition to running the business, managing staff, supervising interns and participating in requirements to maintain my Psychologist licence with AHPRA, I am

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also seeing a full time caseload of clients. We commenced registration mid 2016 and finally succeeded end 2016. South East Sydney roll out wasn’t until Mid-2017. By early 2017, after having my time and headspace consumed by ensuring we were NDIS compliant, and after realising rules were being chopped and changed without much notice given to service providers, we decided that the cost and risk of being registered outweighed the benefits to the business and to the mental health of our staff. It was near impossible to be the clinician I wanted to be, for clients and staff, when my entire focus was on following NDIS trends and constantly monitoring changes and updates, in order to be considered kosher. Being a registered provider, especially for Behavior Supports and ECEI felt like engaging in a relationship with someone unpredictable, whose expectations change without much consultation, who will ambush and punish you for doing the “wrong” thing. It was walking on eggshells and feeling trapped by an abusive and manipulative partner who does not seem to care about you. You’re left not being able to make important choices for one’s well-being should you decide to remain in that relationship. It’s a toxic game. I didn’t need business related PTSD, in addition to the usual stress of running a small business and working as a clinician. We have not had to undergo TPV as we transitioned from HACWA straight into the NDIS ECEI.

The constant changes to provider eligibility requirements make it difficult, if not impossible, to keep up-to-date on whether relevant staff are qualified to provide services for a specific support under the NDIS. A staff member who was qualified before the changes may then not be qualified after they take effect. This causes a loss in income for the staff member in question, who can no longer provide services to clients under the NDIS, as well as the practice as a whole, as we will still be required to pay the staff member for any services they have performed after the changes, despite not being able to claim the cost of those services from the clients NDIS funding. It also necessitates having to recruit a new staff member, who is properly qualified under the new guidelines, to take over the client’s treatment, which also takes time and money. This causes a delay in the client’s treatment program, and any gains made by the client with the original provider may be lost while time is taken with the new provider to build sufficient rapport to continue the treatment. Changes to reporting requirements mean that we are constantly having to ensure that we are reporting the progress of the client’s treatment correctly, despite being unaware that changes may have taken effect. This requirement lessens the amount of time a provider is able to spend developing and implementing a treatment program for/with a client, as they will then be required to go back over any previous reporting done to ensure that it is correct under the new guidelines. Reporting requirements are also incredibly complex and easily misunderstood. The support provided to service providers by the NDIA is limited, with what should be simple questions unable to be answered quickly by support staff on the NDIA

Provider Support Line. We are constantly being advised that they are unable to answer a particular inquiry, or given contradictory information, and told to email through the inquiry. When this is done, an automated reply is generated indicating that it may be up to 2 weeks before a response to the inquiry is received. This is not feasible, as the majority of inquires we make are time sensitive. This may necessitate the suspension of a client’s treatment program until a response and clarification of the inquiry is received, once again disrupting treatment. The NDIS Provider Portal is constantly down or showing errors, making it impossible for us to lodge claims for services rendered. As the majority of clients being seen under the NDIS would be receiving multiple sessions with various service providers on a weekly basis, the fees associated with these add up very quickly. As we are a small practice, we need regular cash flow in order to remain operational and are not able to absorb large outstanding accounts for long periods of time. These delays cause a knock-on effect, disrupting the lives of our staff and suppliers, who are also not able to afford a delay in receiving funds due to them. The rates payable for certain supports under the NDIS fee schedule are incredibly low for the amount of reporting requirements for those supports, and is not sustainable for us, and can actually cost us money. The requirement for third party verification, when we are already registered with our industries accrediting body, is inconsequential and irrelevant, and the costs associated with it are exorbitant. Our research has indicated that it will cost $10,000.00 in order to become third party verified, which is an incredible amount of money for a small practice, and something that we are simply not able to afford.

Solutions

We are aware that the Agency are working through solutions to many of the operational issues. Overall we need as a Community better communication, better responsiveness, a reduction in administration requirements, acknowledgement of professional skills and experience and collaborative approaches when completing Plans. Stable policy and application of the Principles and warning and transition time when changes are going to be made. Clear rules that are accessible to everyone and that all Agency representatives are trained to understand.

Processes need to be sped up significantly and simplified so that new entrants to the market can adapt quickly.

We would like to see a willingness from the Agency to engage with the small business segment of the market as a specific audience with their own unique requirements.

We would like to be a part of that solution and have our Community, which we have built as a matter of necessity, acknowledged for the fabulous support

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network that it is and have it act as a conduit and connection between the Agency and Providers.

Please do not hesitate to contact me for further information

Chantelle Robards