NDIA Accountability Project

National Disability Insurance Scheme Amendment: Aboriginal Community Controlled Health Organisation perspective

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National Disability

Insurance Scheme Amendment (Getting the NDIS Back on Track No. 1) Bill 2024

Submission to the Senate

Standing Committees on Community Affairs

May 2024

ABOUT NACCHO

NACCHO is the national peak body representing 145 Aboriginal Community Controlled Health Organisations (ACCHOs). We also assist a number of other community-controlled organisations. The first Aboriginal medical service was established at Redfern in 1971 as a response to the urgent need to provide decent, accessible health services for the largely medically uninsured Aboriginal population of Redfern. The mainstream was not working. So it was, that over fifty years ago, Aboriginal people took control and designed and delivered their own model of health care. Similar Aboriginal medical services quickly sprung up around the country. In 1974, a national representative body was formed to represent these Aboriginal medical services at the national level. This has grown into what NACCHO is today. All this predated Medibank in 1975.

NACCHO liaises with its membership, and the eight state/territory affiliates, governments, and other organisations on Aboriginal and Torres Strait Islander health and wellbeing policy and planning issues and advocacy relating to health service delivery, health information, research, public health, health financing and health programs.

ACCHOs range from large multi-functional services employing several medical practitioners and providing a wide range of services, to small services which rely on Aboriginal health practitioners and/or nurses to provide the bulk of primary health care services. Our 145 members provide services from about 550 clinics. Our sector provides over 3.1 million episodes of care per year for over 410,000 people across Australia, which includes about one million episodes of care in very remote regions.

ACCHOs contribute to improving Aboriginal and Torres Strait Islander health and wellbeing through the provision of comprehensive primary health care, and by integrating and coordinating care and services. Many provide home and site visits; medical, public health and health promotion services; allied health; nursing services; assistance with making appointments and transport; help accessing childcare or dealing with the justice system; drug and alcohol services; and help with income support. Our services build ongoing relationships to give continuity of care so that chronic conditions are managed, and preventative health care is targeted. Through local engagement and a proven service delivery model, our clients ‘stick’. Clearly, the cultural safety in which we provide our services is a key factor of our success.

ACCHOs are also closing the employment gap. Collectively, we employ about 7,000 staff – 54 per cent of whom are Aboriginal or Torres Strait Islanders – which makes us the third largest employer of Aboriginal or Torres Strait people in the country. Enquiries about this submission should be directed to:

NACCHO Level 5, 2 Constitution Avenue Canberra City ACT 2601 Telephone: Email: Website: naccho.org.au

Acknowledgements

NACCHO welcomes the opportunity to provide a submission to the National Disability Insurance Scheme Amendment (Getting the NDIS Back on Track No. 1) Bill 2024 and supports the submissions to this consultation made by NACCHO Members and Affiliates.

National Agreement on Closing the Gap

At the meeting of National Cabinet in early February 2023, First Ministers agreed to renew their commitment to Closing the Gap by re-signing the National Agreement, first signed in July 2020. The reforms and targets outlined in the National Agreement seek to overcome the inequality experienced by Aboriginal and Torres Strait Islander people, and achieve life outcomes equal to all Australians. This Government’s first Closing the Gap Implementation Plan commits to achieving Closing the Gap targets through implementation of the Priority Reforms. This represents a shift away from focussing on the Targets, towards the structural changes that the Priority Reforms require, and which are more likely to achieve meaningful outcomes for our people in the long term:

  • Priority Reform Area 1 – Formal partnerships and shared decision-making This Priority Reform commits to building and strengthening structures that empower Aboriginal and Torres Strait Islander people to share decision-making authority with governments to accelerate policy and place-based progress against Closing the Gap.

  • Priority Reform Area 2 – Building the community-controlled sector This Priority Reform commits to building Aboriginal and Torres Strait Islander community-controlled sectors to deliver services to support Closing the Gap. In recognition that Aboriginal and Torres Strait Islander community-controlled services are better for Aboriginal and Torres Strait Islander people, achieve better results, employ more Aboriginal and Torres Strait Islander people and are often preferred over mainstream services.

  • Priority Reform Area 3 – Transformation of mainstream institutions This Priority Reform commits to systemic and structural transformation of mainstream government organisations to improve to identify and eliminate racism, embed and practice cultural safety, deliver services in partnership with Aboriginal and Torres Strait Islander people, support truth telling about agencies’ history with Aboriginal and Torres Strait Islander people, and engage fully and transparently with Aboriginal and Torres Strait Islander people when programs are being changed.

  • Priority Reform 4 – Sharing data and information to support decision making This Priority Reform commits to shared access to location-specific data and information (data sovereignty) to inform local-decision making and support Aboriginal and Torres Strait Islander communities and organisations to support the achievement of the first three Priority Reforms.

Review of Closing the Gap

In its first review of the National Agreement on Closing the Gap, the Productivity Commission found that governments are not adequately delivering on their commitments. Despite support for the Priority Reforms and some good practice, progress has been slow, uncoordinated, and piecemeal. The Commission noted that to enable better outcomes, the Australian government needs to relinquish some control and acknowledge that Aboriginal and Torres Strait Islander people know what is best for their communities. It needs to share decision making with Aboriginal Community

Controlled Organisations (ACCOs)

Recognise them as critical partners rather than passive funding recipients, and then trust them to design, deliver and measure government services in ways that are culturally safe and meaningful for their communities.

‘Without external perspectives, government organisations will not be able to overcome any blind spots relating to institutional racism, cultural safety and unconscious bias.’1 NACCHO recommends any NDIS Legislation, Rules and Operational Guidelines align with the National Agreement and its four Priority Reform Areas.

Alignment with Royal Commission policy intent and vision

NACCHO reiterates its support for full implementation of the 13 recommendations in Volume 9: First Nations people with disability of the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability.

We welcome the appointment of a First Nations Deputy CEO in the NDIA, to foster, promote and develop culturally safe and tailored, flexible disability services for Aboriginal and Torres Strait Islander people.

Introduction

NACCHO welcomes and broadly supports the findings of the Independent Review into the NDIS and eagerly awaits the formal response from Government regarding the recommendations of the Review. NACCHO also recognises that NDIS Act amendments need to occur in order to provide a framework for improving the scheme for NDIS participants, particularly a need to provide more clarity on the basis on which people enter the Scheme, and definitions of NDIS supports. NACCHO welcomes greater flexibility of funding and the setting of whole-of-person level funding. We acknowledge that changes to the bill, around specifying funding, is required to support the introduction of alternative commissioning models for Aboriginal and Torres Strait Islander and remote communities, which NACCHO strongly supports. NACHO further welcomes the introduction of multi-year plans where appropriate, and supports the rolling over of unused funds within plan periods, allowing for flexibility of plan utilisation, reducing the burden of re-assessment and minimising administrative burden on participants.

Needs assessment & participant funding

Needs assessments have the ability to ensure transparency and equity in the NDIS process and to better capture a person’s functional capacity and unique circumstances. NACCHO supports a need for greater funding equity, as we know that Aboriginal and Torres Strait Islander people do not access the NDIS at a rate commensurate with or appropriate to their level of need. Ensuring that participant funding accurately reflects their true service needs over time is an essential change required of the Scheme. As needs assessments will inform calculation of participant funding, it is critical to ensure the assessment tool and processes are appropriate for Aboriginal and Torres Strait Islander clients. Recognising that implementation of a needs assessment framework will be governed by NDIS Rules and Operational Guidelines, NACCHO makes the following comments:

Appropriately designed assessments should support further inclusion of Aboriginal and Torres Strait

Islander communities in the NDIS by ensuring that cultural safety is paramount to the assessment process. Standardised assessments have significant limitations for Aboriginal and Torres Strait Islander people, and considerable caution needs to be taken when applying mainstream assessment tools to Aboriginal and Torres Strait Islander populations. Tools that benchmark norms against mainstream populations are culturally biased and do not take into consideration the needs of Aboriginal and Torres Strait Islander people. Using tools of this nature creates bias when assessing Aboriginal and Torres Strait Islander participants. NACCHO advocates that the development of any tool must be undertaken in partnership with the sector in line with Priority Reform 1. Aboriginal and Torres Strait Islander clients have a range of complex needs, including experiences of intergenerational trauma which must be taken into account from the start in the development of any assessment tool. Design and development of a tool in partnership is therefore essential to ensure the cultural competence of staff and/or health professionals to undertake the assessments.

Social model of disability The World Health Organisation (WHO) International Classification of Functioning, Disability and Health2 recognises the need to consider other parts of an individual in context of their disability. It provides a framework to consider the dynamic between body, health, environment and personal factors, including culture3. The social model of disability distinguishes between impairment and disability and notes that it is not the impairment or diagnosis that disadvantages a person, it is society4. This approach reflects the Aboriginal and Torres Strait Islander view of health as holistic encompassing physical, cultural, and spiritual components of health and wellbeing and should be a key element in any assessment model.

Aged Care Single Assessment Tool There are important lessons to be learned from attempts in recent years to introduce a single assessment tool in the aged care space, the design and development of which did not consider Aboriginal and Torres Strait Islander people or their cultural safety. The tool was developed in isolation of Aboriginal and Torres Strait Islander stakeholders, which meant that considerable work needed to be done to ensure implementation of a culturally inappropriate tool could be done in culturally safe ways. Feedback from the Indigenous Assessment Advisory Committee was such that the decision has since been taken to develop a separate tool for Aboriginal and Torres Strait Islander clients, no doubt at considerable additional cost. In the meantime, Aboriginal and Torres Strait Islander clients continue to be assessed using a tool and methods that are not culturally safe.

2 WHO. (2001). International Classification of Functioning, Disability and Health. 3 WHO. (2001). Ibid. 4 Goering, S. (2015). Rethinking disability: the social model of disability and chronic disease. Current Musculoskeletal Medicine. 8(2).

Implementation of a needs assessment tool

NACCHO advocates that Aboriginal Health Practitioners and ACCHOs should lead in the development and delivery of needs assessments to ensure cultural safety is upheld and cultural bias in the assessment process, and consequently in the planning and budget setting, is reduced. ACCHOS are best placed to support Aboriginal and Torres Strait Islander participants in accessing and utilising NDIS supports and should be included in every stage of the assessment pathway for all urban, regional and remote Aboriginal and Torres Strait Islander participants.

There remain concerns regarding already existing workforce shortages of culturally safe and appropriately skilled workers, and the possibility that needs assessments could further contribute to staff shortages. This will be particularly pertinent when trying to source assessors in regional and remote areas. With the current gap in NDIS service provision, and allied health professionals already highly sought after in all areas of the care sector, needs assessment will add greater pressures, especially in areas of culturally thin-markets and in Aboriginal and Torres Strait Islander communities.

While frameworks and processes are planned to be developed in consultation with people with disability, and other stakeholders, design in partnership with Aboriginal and Torres Strait Islander people, community-controlled organisations, and peak bodies is key.

Noting the findings of the recent Productivity Commission review of implementation of Closing the Gap5, Aboriginal and Torres Strait Islander stakeholders must be critical partners in the development of both the tool and its implementation.