Feedback to the inquiry into market readiness

for provision of services under the NDIS

Date: 22nd February 2018

Home Parliamentary Business Committees

Joint Standing Committee on the National Disability Insurance Scheme

Merri Health welcomes the opportunity to provide feedback to the Joint Standing Committee into the inquiry into the implementation, performance and governance of the National Disability Insurance Scheme (NDIS) with regard to the market readiness for the provision of services.

Merri Health creates healthy, connected communities through local health services for people at every age and stage of life and we are among the largest community health providers in Victoria. Our approach is holistic, addressing the medical, social, environmental and economic aspects that affect health, with services spanning across children and young people, carer support, chronic disease management, mental health, disability support, dental services, population health and aged care. We’ve been the trusted health service of local communities for over 40 years and given the often privileged relationships we have with many of our clients we have unique knowledge and understanding of the struggle some people experience due to their inability to access and/or navigate health and disability services.

A detailed description of Merri Health can be found at https://www.merrihealth.org.au

General comments on market readiness in the transition for provision of services under the NDIS:

Merri Health (Merri) acknowledges the enormity of the significant change the introduction of the NDIS brings across the sector and also is acutely aware that this period of transition will cause some disruption across all stakeholders – consumers, providers, the NDIA and all other interested parties – as this new model of service provision for disability services is developed and implemented across Australia.

Merri has a dual role with the NDIS – a state-wide provider of supports in Victoria and a Partner in the Community in Early Childhood Early Intervention in the Ovens Murray region of Victoria. This places us in a unique position with regard to insight from differing perspectives in terms of market readiness. Merri commenced preparation for the transition to NDIS in late 2015 and in late 2016 commenced providing ECEI support services in the North East Melbourne Area. In March 2018 the

Transition to NDIS

transition to NDIS commences in the Hume-Moreland region where the majority of our consumers and our services are located and the preparation for this has been an organisational priority for some time.

Our experience on the ground leads us to the following observations:

The majority of service provider organisations have not realised the full impact of this transition and the need for different models of service delivery from our traditional block funded programs.
Vast changes to organisational infrastructure needs and operational methodologies have resulted in service gaps, financial instability and the long term sustainability of organisations.
System implementation across the sector has been hasty given the magnitude of the change, and the NDIA, being a fairly new body in itself, has struggled to offer concrete direction and guidance to service providers ranging from the implementation of the NDIA ‘rules’ to utilisation of the NDIA systems and IT platforms.
Increased market competition amongst service providers has led to and will continue to lead to more fragmentation across the sector and this will transpire into fewer opportunities and less positive outcomes for consumers.
Consumers are confused and those more complex and marginalised individuals/families, who do not have the capacity to advocate will effectively receive less supports and/or completely fall through the system.
Key stakeholders such as General Practice are not well engaged and the resource and financial impact on other areas of health and community services has not been fully assessed and addressed.

Of particular concern to Merri is:

Mental health clients are falling through the gaps, there needs to be a greater understanding of psycho-social supports and better pathways for these consumers to access the NDIS.
In the mental health arena, one of the key gaps in the market is the provision of individual support to access the community. Whilst there are a number of general disability services who are providing this service, there is a lack of mental health specific agencies offering this work. As a result, the mental health agencies that do provide this work are under significant pressure with demand exceeding available resources. This poses a significant risk to mental health consumers who may end up either waiting for extensive periods of time for service, or receiving a service from providers who aren’t skilled or experienced in supporting people with Mental Health issues.

The underlying issue in this gap is the costing associated with the individual support line items. The costing for this work is considerably less than what the current workforce is paid, d therefore making it non-financially viable for agencies to continue to provide this support.

NDIS currently does not adequately fund volunteer supports for clients either in participant plans or through ILC funding. Volunteers are currently funded at a unit cost of $57.61 which is vastly below the unit cost of supervising paid staff ($94.06 per hour). Quality, safety and c临ical requirements across paid and unpaid staff remain the same and as such should be funded equally.
The rules around costing staff travel remain unclear.

Merri Health provides the following feedback with regard to the specified elements of the inquiry:

a. the transition to a market based system for services providers

The transition to a market-based system brings with it a range of challenges and opportunities for service provision. Some of the key challenges are:

Establishing the financial viability of existing services, then adjusting service offerings to remain viable in a marketplace;
Prices in a number of categories from a providers perspective are not profitable or breakeven, this feedback has been given to the Independent Pricing Review;
Maintaining quality services, particularly in the face of a changing, less qualified/skilled workforce;
Ensuring the safety of staff and participants in a service context where financial viability needs to be considered. For example, not having the available funding to send out multiple workers to a complex client or the deployment of staff who may be less qualified/skilled;
Workforce. Significant risk of losing experienced staff who believe in and adhere to best practice principles, burn out and workplace frustration re: administrative burden and accountable time requirements;
Poor understanding by the community and misinformation presented by NDIA planners in regards to a number of areas including expectation of funding supports and packages;
Inadequate and/or insufficient information flow from the NDIA. For example, in mental health, the information that we receive from the NDIA about the consumer does not include diagnosis or any relevant safety and risk concerns. This makes it very difficult to allocate a suitable worker to undertake the intake and assessment meeting and does not protect the safety of our staff;
Unique innovative services (Merri’s Relate service, Flying Fox and Homeshare Australia) do not fit into the price guide and we have not been able to elicit advice from the NDIA with regard to trouble shooting such issues;
Unfunded time. An unreasonable amount of time is being spent by middle management problem solving, troubleshooting, and seeking clarification on NDIS changes, this poses a significant financial burden;
Service gaps. Services being funded in plans and services available in communities, ie. some people are receiving funding for services that don’t exist in their geographic region which may result in participants missing out on support required.

Key opportunities that we have identified include:

Flexibility to provide services that may have been limited under block funding;
The ability to think creatively about the best way to meet the needs of participants;
Opportunity to make system more streamlined and efficient over time with greater staff flexibility in working hours and conditions;
Opportunity to co-design the NDIS with service providers and consumers and undertake periodic reviews to ensure best practise, and consumer, service provider and NDIA goals are achieved.

b. participant readiness to navigate new markets

Our observations to date are that some participants seem to be able to effectively navigate the new market whilst for other participants this is proving problematic. Our observations to date include:

At a superficial glance those whom have accessed services previously appear prepared and ‘savvy’. However for many individuals and families have had limited experience with choice, i.e. they took what was available previously, it appears that the majority do not fully understand the new marketplace. With competitive market forces organisations are marketing, promoting, and upselling their services, and whilst this is common in other open market sectors it is relatively unknown in the disability space.
Vulnerable groups. Well educated and ‘savvy’ participants (generally self-managed consumers) seems to navigate the NDIS well, however the majority of our clients come from low socio economic backgrounds with many complex social issues including being culturally and linguistically diverse and/or newly arrived and as such have limited or no understanding of the system and how to navigate it.
Whilst information sessions from LACs and the NDIA are a great initiative and have the best intentions of engaging with and educating the community, they often have the impact of leaving consumers with many unanswered questions and this can be quite unsettling and create distress, confusion and fear.
Understanding of services. Participants and their families may feel they know what supports they need to reach their goals, however, to date there has been limited focus on educating participants with regard to the specifics of supports and associated outcomes. For example in ECEI, families will not always understand that an upskilling technique is not necessarily a ‘therapeutic recommendation’. Such information may impact long term outcome goals.
Pre-planning funding.Whilst most service provider are working with current clients to help them prepare to navigate the new market, some clients need more intensive support that may not be available and new potential clients are often missing out. whilst funding by the ndia for pre-planning to organisations like valid has proven vital and critical to supporting consumers, additional funding is needed to further target vulnerable groups.
Service offerings. Participants may have the capacity to select the best service and value for money for them on face value however the question we now pose is that, do they understand the disability sector is now a marketplace similar to health insurance and electricity? Whilst the price guide regulates what can be charged for specific services, there are many other factors that registered provider of supports can manipulate such as travel hours, quantity of direct service delivery hours, what services they provide and in which combination that can significantly impact both the quality and the quantity of required supports.
The transition to a marketplace has been challenging for mental health consumers as it has been difficult for them to understand how the scheme works and their ability to choose from a broader range of services. Access to ongoing Support Coordination is key to continuing to support mental health consumers through this service system change.
Another key issue we have identified and previously mentioned in this submission is that many General Practitioners have limited knowledge of the NDIS and how to support consumers to access the scheme. This has the potential to lead to consumers receiving less than desirable funded packages and as such compromise both their immediate goals and long term outcomes.

c. The Development Of The Disability Workforce To Support The Merging Market

Emerging evidence suggests that we will be faced with a significant disability sector workforce shortage resulting from both experienced staff exiting the system but also due to a lack of appropriate training opportunities and workforce planning.

The current workforce has and is struggling with the required changes due to changing funding models, work flow practices and the strong cultural change sweeping the sector. Organisations need to be more supportive with change but also very firm with employees, providing clear guidelines around expectations of workload and billing, which has not been the main focus of not-for-profit organisations. This is proving difficult for organisation to enact given guidelines around billing still remain unclear leaving workers frustrated and demoralised, concerned about long term viability of their positions and their services.

Previously, the workforce was able to provide very generous time allocations for clients with little accountability required on the part of the workers. Likewise, providers are now often caught not being able to provide workforce flexibility as much as needed for participants due to industrial obligations, leaving all parties frustrated and questioning sustainability of services. It would be remiss of the NDIA to not consider this broad industrial issue.

In particular, there are some significant concerns and issues about the changing Mental Health workforce under the NDIS. Given the quite significant changes that need to occur in the Mental Health space (ie. development of a less qualified workforce- Certicate III/IV) it is unlikely that it will be able to respond to the emerging market in the short term.

Ideally, an increase in the costing of the individual support line items would be the best way to address this issue as it would allow for the existing workforce to continue providing specialised support. Alternatively, the provision of mental health specific training to general disability support workers would help to address some of the skill/knowledge gaps.

Whilst there seems to have been quite a focus on workforce development and expansion in the low skilled areas such as direct support workers, home help services (domestic, gardening etc) and to a degree NDIA planners, there seems to have been a lesser focus on ensuring the workforce capacity of skilled / therapeutic / professional services. The reality is that allied health professionals from medical models/sectors are moving into the disability sphere without adequate experience or training. They are entering with a medical mindset of ‘treat condition’ and ‘maintain health’ rather than the core understanding underpinning the NDIS – that of ‘capacity building’.

The NDIA should consider systemic change at undergraduate training level and professional peak body engagement in developing entire new professional sectors in response to the development of this new sector.

d. The Impact Of Pricing On The Development Of The New Market

Our assessment of NDIS pricing is that many of the support offerings are financially unviable and this will severely impact the development of the new market. Financial viability is a key consideration for many not-for-profit providers who have traditionally provided services in disability and early evidence suggests that many of these providers will exit or consider exiting this market so as to compromise the sustainability of their agencies.

There are a number of pricing issues that need to be considered by the NDIA to ensure market development and sustainability. A key issue is the limitation of pricing that does include/consider broader staffing obligations such as student supervision, compulsory professional development, staff meetings, organisational working groups, management oversight, etc.

running an organisation and providing the appropriate quality and safety guards, which are not

always features in private practice models, have proven evidence of being best practice, eliciting better participant outcomes and support the stability of an engaged and highly skilled workforce, all vital elements of an effective market.

In addition, the NDIA should consider a review of actuary assumptions when setting NDIS unit cost pricing and consider specialised needs/aspects of particular consumer cohorts, i.e. mental health support and the provision of Support Coordination in plans longer term.

e. the role of the NDIA as a market steward

Whilst the role out of a scheme of this size brings with it a multitude of challenges, the NDIA could better support the emerging market by attempting to address some of the key market issues. In addition, the current reform environment across a number of health and community sectors does not assist with a smooth planning transition process. We have to date witnessed inadequate plan approvals across a number of support provisions and inconsistent planning processes and experiences for consumers. Whilst unintentional, NDIA have set up a system which rewards people being ‘maximum’ disabled rather than encouraging ability and rewarding that, this in particular plays out in mental health, where participants need to be diagnosed with permanency to their condition.

Key issues that need consideration are:

Community capacity building

- The provider engagement teams have focussed on engaging 'willing' service providers who
    voluntarily attend engagement sessions, providing them with a range of information
   regarding the scheme, ranging from the pricing schedule to some systems information such
   as using the portal, developing service agreements etc. These sessions are generally 'catch
       all' sessions that try and provide generic information to different service providers all at
   once, for example within one session there may be residential service providers, therapists,
   support coordinators, contract cleaners, and respite providers. Therefore such sessions are
   very much generic and do not provide targeted information needs tailored to specific
   stakeholders and as such do not achieve the desired capacity building;
-Whilst it is the role of individual partners in regions includes the engagement with community

in a capacity building context, this is not possible at the broader workforce capacity level as this requires a much more coordinated approach that works across borders and jurisdictions.

Planners’

Inconsistency in ‘planners’ across region do not support a consistent and equitable service model and does not instil confidence in the scheme. Better planning, clearer guidelines and consistent training by the NDIA would result in better community understanding of the scheme, better engagement with participants and better health and social outcomes for consumers.

Service provision

Ongoing and continual changes to NDIA rules and guidelines around provision of services or lack of, which are not always clearly supported by evidence, i.e. funding of Music Therapy which is supported by research and clear evidence in ECEI practice is not an approved service offering. Implementation of the learnings from the trial sites need to be better incorporated across the sector with clear directions and frameworks applied rather than pursuing with a roll-out schedule that might achieve less than desirable long term outcomes.

Opportunities That The Ndian Need To Consider In Improving Its Stewardship Role

Opportunities that the NDIA need to consider in improving its stewardship role Include: - Adjusting roll out schedules to allow for the market to ‘catch up’ to demand; - Accessibility and health literacy for new and existing disability consumers need to be a key consideration, and in order to ensure that the most vulnerable and in need of NDIS support are accessing the service, it is important that a variety of means are used to support access; - Consistent and clear communication would be beneficial in supporting the market; - Targeted information to key stakeholders and cohorts is necessary to further build the capacity of the sector and the broader community; - NDIA consider the production of updated and new market position statements for all regions to support the market and that providers can better prepare. - Development of a COAG agreement on the interface between NDIS other sectors and also how existing professional peak bodies will be supported to ensure their members are equipped to working within the NDIS sphere.

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

Key issues that we have observed that severely impact quality and safeguards and need remedial strategies to be implemented by the NDIA include: - Client packages need to have greater flexibility to allow for consumer ‘crises’ and appropriate responses. The NDIA does not appear to be set up to deal with crises. We have encountered situations where services are provided to the client as per the plan and on completion recommendations are sent back to NDIA, and these are not acted upon, thus at times leaving the client at risk and/or in crisis. - Unscheduled reviews are currently taking approximately 3 months to complete, this poses some consumers at high risk, reviews need to be conducted more timely. - We have experienced NDIS clients who do not have a plan nominee, are vulnerable or are not in a position to make informed choices and require a plan nominee to be appointed by NDIA, the NDIA needs to be more pro-active in this area.

Summary

Merri Health appreciates the opportunity to comment on the market readiness for the provision of services under the NDIS and is committed to improving outcomes for consumers in our community. Merri Health would welcome the opportunity to further share our thoughts and experience on the challenges and opportunities that present with the introduction of NDIS.

This feedback is provided on behalf of Merri Health by:

Tassia Michaleas General Manager, Family & Community Merri Health

7/7