JOINT STANDING COMMITTEE ON THE NATIONAL DISABILITY INSURANCE SCHEME
Submission from:
Scope (Aust) Ltd Level 2, 302 Burwood Rd Hawthorn, VIC, 3122
Contact:
- Dr Jennifer Fitzgerald
- Chief Executive Officer
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About Scope
Scope’s mission is to enable each person we support to live as an empowered and equal citizen.
We support people with physical, intellectual and multiple disabilities and developmental delays to achieve their goals.
Scope’s services – provided in metropolitan and regional Victoria – include therapy, supported living, short term accommodation and individual support. We also work with corporate and community organisations to improve inclusiveness for people with a disability.
Scope is a strong supporter of the National Disability Insurance Scheme (NDIS). We embrace the benefits the NDIS will bring to our customers and will actively contribute to its success.
We are one of the largest providers of services to people with a disability in Victoria, and one of the largest not-for-profit organisations in Australia. Our origins stretch back to 1948, when a group of parents who wanted better lives and options for their children with disabilities established the Spastic Children’s Society of Victoria.
In 2016-17, Scope provided services to more than 5,500 people with a disability from 108 locations with 1,643 employees: this included 1,167 customers in lifestyle options and individual support; supported living services to 290 residential customers; and 410 in short term accommodation.
We have a customer satisfaction rating of 92%.
Overview
Scope welcomes the opportunity to provide a submission to the Joint Standing Committee on the National Disability Insurance Scheme inquiry into market readiness. This submission provides a service provider perspective on the issues under discussion. We have, at times, drawn on de-identified case studies and feedback from our customers; and this content is acknowledged as appropriate.
Scope is cognisant of the fact that the NDIS market is still in the early stages of development: the rollout in Victoria is well progressed, but will not be completed for close to another 18 months; and the ongoing policy and practice changes initiated by the NDIA in response to feedback from a range of stakeholders will take time to influence the way the market operates. The issues being experienced at present, therefore, are very much issues related to transition rather than to a functioning marketplace.
The comments below focus on both the transitional state of the market, with consideration for some of the features that will be necessary in future and mature NDIS markets.
a. The transition to a market based system for service providers
For service providers as well as participants, the successful transition to a market based system is predicated on the individualisation of services that are underpinned by appropriate skills, knowledge, experience, infrastructure and technology.
There have been multiple transactional issues affecting Scope that impeded our ability to function as part of a market based system. The administrative issues with the NDIS portal and receiving service payments have been well documented. Ultimately, these matters should not have longer term impacts on the market.
Scope observes, however, that the Australian National Audit Office (ANAO) in their audit of the transition of the disability services market, noted advice from both the Department of Social Services and the NDIA about the potential timeline for progress toward market maturity:
“The department and the NDIS advised the ANAO that, due to the unprecedented scale and nature of reform, the maturing of a new disability services market under the NDIS is expected to take up to ten years, and perhaps longer in some market segments”.1
The expectations of how the market develops in the short to medium term should be tempered by this understanding. The forthcoming release in March 2018 of detailed information about Specialist Disability Accommodation (SDA), for example, will provide clearer signals to potential investors that inform longer term thinking for this market segment. Moreover, there are at present several pressing concerns that are affecting market development and need to be addressed in order to reduce uncertainty for service providers.
The interface with mainstream services has been extremely problematic for service providers attempting to work within NDIS market constraints, particularly the interfaces with health and education. This will require focused attention to resolve in the near future. Scope, for example, supports a significant cohort of people with physical and multiple disabilities, many of whom have complex health support needs that are continually changing. The extent to which these changes are attributable to a person’s disability, or to their medical needs is often unclear, and the specific responsibilities of disability service providers and health providers in these situations remains contentious.
The case study below illustrates some of the difficulties Scope has experienced:
Scope supports 42 year old RC in SDA with Supported Independent Living services. RC has, among other conditions: severe multifaceted neurodevelopmental disorder; mild intellectual disability; autism, epilepsy;
behaviours of concern; profound deficits in volitional motor activity that caused bilateral retinal detachment and total blindness; and unpredictable sleep patterns/circadian rhythms owing to blindness. RC’s parents are elderly and frail and RC has multiple specialists involved including a
Section Heading
psychiatrist, a gastroenterologist, a neurologist, a physiotherapist and an
occupational therapist.
Scope requires a person responsible for RC who understands the
intersections between each area and can facilitate significant administrative
coordination between the specialists. This involves time spent organising
appointments, tests and follow ups not funded by NDIA, as this is deemed
medical – and the medical system does not fund case coordination. Should
RC requires hospitalisation, the hospital would need Scope expertise to
ensure RC received optimal care, but there is no line item under which this
level of support would be available, as under NDIS rules this is considered to
be the responsibility of the hospital alone.
Similarly, the education sector in Victoria has delineated the responsibilities of schools vis-à-vis NDIS service providers in supporting students with disabilities in school settings. In Victoria, the Department of Education and Training funds therapy in schools to support students in the classroom for educational purposes. But the provision of other therapy services, including NDIS services, in school settings is subject to many policy and financial limitations that deter service providers from working alongside schools to achieve better outcomes for students. This is contrary to best practice, which for children is to deliver therapy services in natural environments, including schools.
While the arrangements outlined above are considered to be interim prior to the full implementation of the NDIS in Victoria, it is critical that the NDIA and the state and territory education systems work together to facilitate service coordination. If this does not occur, there is a very real possibility that therapeutic supports delivered by different providers, who adopt different treatment approaches, may result in reduced outcomes for the students receiving those supports.
The Information, Linkages and Capacity Building (ILC) grants are, to a large extent, targeted at ensuring mainstream services are able to support NDIS participants as they would any citizen. There has not, however, been sufficient progress in this regard. Scope would like to see the urgent allocation of ILC funding to improve interfaces with the health and education sectors in particular.
b. Participant readiness to navigate new markets
Scope provides the following comments on participant readiness from a provider perspective.
Scope supports a large number of people with complex communication needs, signifying that they use augmentative or alternative communication or, perhaps, have no formal communication system. There are also some of the same people who have limited or no family involvement and thus rely on advocates to represent their concerns. To ensure that people with complex communication needs are engaged and aware of the NDIS, considerable outreach and face-to-
Challenges Faced by Participants
Face-to-face communication is required. This type of support has not often been available to enable participants to navigate new markets.
These issues have been exacerbated during all phases of the planning process. As stated in the Productivity Commission Study Report into NDIS costs, “…many participants are ill-prepared for planning, and this is affecting the quality of plans”.
Scope has anecdotal evidence from many of our customers about the difficulties they experienced with the development and approval of their plans. The factors having the greatest impact on them include the following:
- Limited participation in planning meetings e.g. few reasonable
adjustments being made by planners in the conduct of planning
meetings involving people with complex communication needs
- Not being able to articulate the ways in which their needs translate into
reasonable and necessary supports
- Difficulty understanding the language used in their plans
- Inconsistent identification of participants who require support
coordination
- Families also report little time to visit and review possible service
providers
- Lack of information available for CALD families, particularly in North
East Metropolitan Area (NEMA)/Hume Moreland
The following comments paraphrase feedback from Scope customers about their experiences with the NDIS:
- “I didn’t get to participate in my planning meeting. I only had a phone
meeting with the nominated representative”.
- “It still takes a long time to contact a person in the agency and it’s
difficult”.
- “It takes too long waiting for a review”.
- “In some geographic regions there is no new market. Service providers
like council have already ceased service provision, but there is no
alternative. We are left with no service and no choice and control”.
- “Inconsistent funding made available for same needs. I can see other
participants who have similar needs to me but they get different funding
to me”.
- “I don’t know when my plan has ended. It’s not until I get a call from my
provider that I find out I can’t access services any more”.
- “My plan has been rolled over and extended but I haven’t been notified
by the agency and I haven’t had input”.
- “Things aren’t flexible enough. I would like to be able to use my core
funding to access community. The funding needs to be more flexible. I
The consequences of poor engagement for some participants is that they have a restricted view of what might be possible in enacting their plans. The ANAO referred in their audit report of the transition to “emerging evidence” of “higher than expected numbers of ‘no claim plans’”, reflecting a lack of capacity “to fully engage with the Scheme”.
Scope would like to see greater effort made to ensure that participants are meaningfully involved in planning and review processes, and particularly to engage with people with complex communication needs. This will entail significant resources as the time needed to engage with people who have complex communication is considerable. This would be in line with the overarching principles of participants exercising choice and control rather than these responsibilities being routinely passed onto substitute decision makers.
c. The development of the disability workforce to support the emerging market
The principles of choice and control guiding the NDIS have, for many service providers, created difficulties in anticipating demand from participants and developing rosters as required. Previously, service providers have been able to predict and plan according to known and sustainable patterns of work, in particular for those service lines that have set days and hours. The move toward casualization as a strategy to manage costs is usually successful, but also has the unintended side effect of turning a lot of people looking for job security away from the sector – and this is at a time when there is a need for rapid growth in the disability workforce.
For service providers, the relationship with a casual workforce has a different tenor to the relationship with permanent staff. There is less opportunity to influence beyond ensuring that workers are screened and have the skills and qualifications needed to perform their role. The reliability and availability of casual workers can also be problematic, both for disability workers (who may experience under employment) and service providers (who are unable to roster workers in response to customer demand or choice).
Adopting a narrower view, over the past decade Scope has received decisive feedback from our supported independent living customers in our satisfaction surveys that they want to choose the people who support them with their personal care; and their clear preference is to be supported by people who know them – not by casual staff.
Casualization is, of course, only one element of the workforce policy needed to meet NDIS participants’ expectations. There will have to be varied approaches to
workforce policy to ensure that participants’ plans are delivered in keeping with their wishes. The Productivity Commission, however, drew attention to the risk “that a fragmented workforce policy may lead to inaction, or result in duplication or unnecessary programs at a time when the scheme can least afford it”.6 Scope is likewise concerned that workforce issues may undermine overarching NDIS objectives. The Productivity Commission further noted that:
"In making the transition to a market-based system for disability supports,
providers are facing the prospect of workforce shortages and coming to
grips with operating in a market that will, for some time, be characterised by price caps“.7
Scope has identified several issues around workforce, both in this time of transition and in the future market:
- Mandatory workforce compliance requirements, together with the
increased numbers of staff working across different providers, have
created inequities in training and compliance checking costs. These
costs appear to be borne disproportionately by some service providers.
- There is no standardisation of baseline skills e.g. manual handling. This
creates obstacles around introducing more innovative programs such as
student placement. The registration of disability workers may ameliorate
this issue in future.
- The direct hire market does not have the same compliance burden as
other service providers.
- The possibility that service providers will be required to employ
accredited disability workers (as opposed to health and allied health
professionals) raises concerns around customer choice and control.
- The accreditation of disability workers may oblige service providers to
employ a more expensive workforce, and this may not be viable under
the efficient price.
- Service Providers are still uncertain about how to meet the cost of
professional and on the job training for their employees in a price
controlled market where productivity benchmarks are onerous.
- The pricing model has exposed a shortfall in delivering services under
existing enterprise bargaining and award arrangements and the revenue
price (between 6-30 and 8pm).
d. The impact of pricing on the development of the market
Scope again notes the Productivity Commission report and the comment that “…there is a risk that demand for disability supports will exceed supply, creating inflationary and quality pressures in the market”.8 While prices remain controlled by the NDIA market forces similarly continue to be constrained.
6 Productivity Commission, op cit, p. 38. 7 ibid, p. 32. 8 ibid, p. 12.
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Scope concurs with the observation from the ANAO that “…the NDIA’s dual roles
in the market as both a funder or ‘purchaser’ on behalf of governments, and as a price ‘regulator’ presents a conflict of interest which needs to be transparently managed”.9
e. The role of the NDIA as a market steward
Scope considers that the NDIA has a valuable, yet still evolving, role to play around market stewardship. In the current environment, the availability of information about the emerging market, and various market segments, is vital.
Among the most useful information for service providers during the transition period have been the suite of market analytics, including the quarterly data and dashboards. There has, however, been (understandably) slow progress with the release of market insights. Following the publication of the market position statements in early 2016, the first of the market insights (Assistive Technology), was not published until more than 12 months later. More frequent distribution and updating of this type of information would be appreciated by service providers.
The greatest benefit to service providers is likely to come with implementation of the eMarketplace. Scope believes that working to ensure the eMarketplace is fit for purpose is more important than timely delivery of the final product.
See also comments in respect of provider of last resort arrangements (refer (i) below).
f. Market intervention options to address thin markets, including in remote indigenous communities
Scope suggests that the use of provider panels may begin to obviate some of the concerns being expressed about thin markets, including in remote indigenous communities. There may be a need to incentivise the members of these panels, at least in the short to medium term.
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
The supply of SDA does not meet current demand owing to the shortage of suitable housing stock. For this to be done at scale, and with the appropriate separation of SIL and SDA, there need to be sufficient incentives provided by government to attract institutional investment. While SDA payments under the Scheme are generally adequate, these payments need to be made at a guaranteed rate for twenty years, rather than five as is the current arrangement.
h. The impact of the Quality and Safeguarding Framework on the development of the market
The impending launch of the Quality and Safeguards Commission in July 2018, and in particular the Commission’s role around market oversight, will begin to address concerns about the NDIA’s dual function as purchaser and price regulator. Scope supports the recommendation from the Productivity Commission in their study report on NDIS costs to transfer the NDIA’s power to set price caps to the Quality and Safeguards Commission by no later than 1 July 2020.
i. Provider of last resort arrangements, including for crisis accommodation
The lack of progress with formalising future provider of last resort arrangements is concerning. Under the NDIS, the mechanisms that were in place under state government funding will cease to operate – and with the rapid approach of full Scheme implementation in New South Wales and South Australia, Scope highlights the need for a provider of last resort policy to be developed as a matter of urgency.
The policy may in the short term involve the continuation ‘in-kind’ services or the variation of existing arrangements e.g. block funding or subsidisation by government of funded providers to fulfil the role of provider of last resort. The Productivity Commission recommends that the “widest range of approaches” be considered.* * *. The selection of providers to carry out this function would most likely be through a targeted tendering process in each state or territory affected.
The policy would be temporary until the NDIA implemented longer term provider of last resort arrangements.
Furthermore, it is clear that providers of last resort will continue to be needed into the future. The scenario where families relinquish the care of adults with disability, perhaps following a period in short term accommodation, is likely to persist for some years regardless of any innovations under the NDIS.
* Productivity Commission, op cit, p. 36.