National Disability Insurance Scheme

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

Submission to Senate Community Affairs Legislation Committee

By

Ricki Smith CEO

11 July 2024

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

Access Care Network Australia

Introduction

1.1 Access Care Network Australia

Access Care Network Australia (ACNA) is the largest not for profit supplier of assessment, coordination, and case management services for aged care in Australia, delivering high-quality services on behalf of federal and state governments. Our model of functional capacity assessment was the foundation for the establishment of the My Aged Care Regional Assessment Service, which has proven to be a highly effective model used at scale. Our workforce of more than 330 dedicated professionals deliver services across multiple national programs, including the My Aged Care Regional Assessment Service (RAS), Aged Care Assessment Services (ACAT) Australian National Aged Care Classification (AN-ACC), Residential Experience Survey interviews, (as part of the Star Ratings for residential aged care) Continuity of Support (WA), Out of Hospital Care (NSW) and until we recently withdrew, the National Panel of Assessors (Disability Employment Service). ACNA recognises the wider care sector is a historically tight labour market, particularly across the disability and aged care sectors where the skill mixes are the same or complementary. We have invested heavily in analysis (and initiatives) to identify untapped labour markets so as not to exacerbate existing workforce shortages. Our efforts are delivering results; we continue to attract a diverse workforce of mature age (55+) workers, 33% of whom are new to the care and support sector. Currently, 6.7% of our employee’s report living with a disability and a further 11% report caring for someone with a disability. We are active supporters of government’s reform agendas in aged care and disability, with assessors supporting trials of the Integrated Assessment Tool (IAT) in aged care, the CEO a member of the Department of Health and Aged Care’s Support At Home Implementation Working Group (which designed the IAT), and a champion of a reablement approach to social services. When the then government tendered for providers to undertake independent assessments for the NDIS, ACNA was the only successful not for profit organisation in the tender process. However, independent assessments for the NDIS were later abandoned. ACNA is well regarded for its quality services. An audit by EY Australia of aged care assessment organisations for the Commonwealth and ACNA was within 5% of expected outcomes compared to others of 50% or more. The current aged care assessment quality measures were heavily influenced by ACNA’s own measures at the time.

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ensure fairness and equity across Australia for people with significant and permanent disability. The NDIS has been operational for 10 years, commencing in 2013. The NDIS has been lifechanging for many people with a disability and their families and carers where their supports have improved vastly, they are able to participate in everyday life more easily, many participants are now in paid work, and many families have been able to return to work. Participants have more independence, dignity, and choice and control in their everyday life. However, the NDIS has not been a universally positive experience for everyone. Some participants of the NDIS have found it to be complex, inefficient, and sometimes adversarial in nature, and have experienced poor outcomes. The original concept was a cohesive national system characterised by clear processes to gain access to the scheme if eligibility requirements were met, fair and consistent planning and funding packages that met the individual needs of participants, which recognised their individual and unique needs and gave them the flexibility to choose how they spent their funds to best meet their support needs. However, a decade later, and after a Royal Commission and series of independent reviews, there are concerns amongst stakeholders including state and territory governments and the Commonwealth, about the escalating cost of the NDIS with the estimated expenditure being $41.9 billion in 2023-34. Related to this is the issue of fraud with reports of NDIS funds being misused and fraudulent providers who overcharge NDIS participants. Other criticisms include the eligibility criteria, and the burdensome access process. The NDIS Act provides insufficient guidance for planners to determine reasonable and necessary supports, and the item-by-item planning and funding allocation in the plan leads to inflexibility for the participant. A further concern is the large numbers of children in the Scheme.

Actions taken to address these issues

To contain the escalating costs, the government committed to an 8% growth target which is to be in place by July 2026. The government also set up the Fraud Fusion Taskforce, a coordinated approach across sixteen government agencies to detect, resolve and prevent NDIS fraud. Additional funding was provided by the Commonwealth government to the National Disability Insurance Agency (NDIA) to build its capability to address the above and other issues. The more significant intervention will come from the passage of the National Disability Insurance Scheme Amendment (Getting the NDIS Back on Track) No.1 Bill 2024. The amendments in this Bill will aim to tighten up regulatory oversight of providers, improve scheme entry through an improved needs assessment process and determine whether entry is via the early intervention pathway or disability pathway (or both), provide new definitions of reasonable and necessary supports with a focus on valid supports, provide more plan flexibility for the participant, and sets out plan transition arrangements. It is the first in a series of Bills to amend the National Disability Insurance Scheme Act 2013 in response to the findings and recommendations of the recent Independent Review into the National Disability Insurance Scheme.

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2 National Disability Insurance Scheme Amendments (Getting the NDIS back on track) No. 1 Bill 2024

2.1 General Comments

ACNA applauds the government’s efforts to streamline and improve the experience for NDIS participants and prospective participants and their families and carers. Similarly, there is an imperative to contain escalating costs to ensure future sustainability and longevity of the NDIS. Further, there is resounding support for efforts to identify and excise fraudulent providers from the system. It is in the interests of all stakeholders to get the NDIS working better. It is critical for people who need the support of the NDIS, and critical to the states and territories and the commonwealth who bear the risks of cost escalations. The original scheme architects and the early Productivity Commission work envisaged a system that was participant centred and that maximised choice and control and opportunities for participants to participate in everyday life. The modelling predicted the NDIS would also lead to an improved GDP, through greater independence, less reliance on welfare funded supports, higher employment, and the like. The scheme actuary reports illustrate that there have been many gains in these areas over the last decade, with the opportunities for further gains. While ACNA is supportive of the broader reform envisaged by the Bill, the remainder of this submission will focus on the needs assessment process, because assessment is one of ACNA’s strengths and core business. We offer these insights in the hope that sharing our experience may inform the next steps in relation to needs assessment.

3 Needs Assessment Process

3.1 Proposed Needs Assessment

In reading the proposed Bill it proposes to use the needs assessment in several ways, including (but not limited to):

• to assist in determining eligibility and access to the NDIS. The needs assessment will focus on functional capacity rather than diagnosis (although in some cases, diagnosis will not be entirely irrelevant, for example, high level spinal injury leading to quadriplegia)
• once accepted into the NDIS, the needs assessment will help to determine the support needs of a new participant and inform the plan supports and level of funding

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• when circumstances change for existing participants and a new assessment is required to inform a different level of support
• as existing participants are being transitioned from the old framework plans to new framework plans
• if the CEO or delegate is considering revoking access for an existing participant, they may request a needs assessment to be undertaken
• potentially be used in internal or external review circumstances.

Importantly, the needs assessment will be made available to the participant. The Bill proposes to anchor the detail of the needs assessment in the Regulations rather than the legislation which is practical, considering national and international assessment tools will continue to develop and improve. The Minister has committed to genuine consultation and codesign with the sector and other stakeholders in the development of the needs assessment. This is essential because there is a level of anxiety and distrust in the disability community about assessment processes.

3.2 Suggestions to guide the needs assessment process

3.2.1 Entry to Scheme

Access to a needs assessment should be made easy, for example, in aged care, individuals can self-refer. ACNA is not necessarily advocating self-referral in the NDIS system; however, ease of referral is important because the current process requiring the individual seeking access to the NDIS having to gather information, obtain letters of support from GPs and specialists and the like is daunting and expensive for many individuals. There is a perception from the outset it will be difficult and adversarial. Ensuring that individuals can more easily access a needs assessment takes the ‘fight out’ of the process. If access to assessment were made easy, care would need to be taken in designing the approach to ensure the assessment process is not used indiscriminately resulting in long queues and escalating assessment costs.

3.2.2 Where should the needs assessment be undertaken?

The participant should have choice in where the needs assessment is undertaken. However, ACNA would strongly recommend it be undertaken in their home so the assessor can observe the environment, the family dynamic, see firsthand how the person navigates their home. The assessment should:

• Learn about the person’s goals and aspirations

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• Obstacles to achieving those goals
• Current strategies in place to maintain their current level of independence
• Where possible (and safe of course) enable the person to demonstrate how they perform tasks
• Ask them what is stopping them from achieving their goals (most people have a good idea – and usually it is less expensive than you think)
• Take into consideration current informal supports – and the longevity of those supports/contingency plans if the support is unavailable for a short period
• Most specific assessment tools can be undertaken in an individual’s home, and these can supplement the base needs assessment
• Discuss the supports that may benefit the individual (and that can inform the content of a draft plan if the participant gains access to the scheme).
• This allows the person to have some awareness of what is going to be suggested and the assessor to see if it is likely to be helpful. NB In the aged care assessment process, the draft plan is developed by the assessor with the participant in their home. There are set parameters to inform the budget and the higher budgets require approval from a delegate. However, it is noted that the NDIS pathway requires an access decision prior to moving to the next stage of developing a plan with funded supports, which requires a separate decision again.
• Consideration should also be given to whether the participant or Agency can seek a second independent assessment if they believe the initial assessment is inaccurate.

Assessment Tools

ACNA has considerable experience with needs assessments and acknowledges there are many different and specific tools for different cohorts. For example, children require different tools in consideration of their age and stages of growth. For adults, some of the generic tools apply to all individuals supplemented where necessary with more specific assessment tools in certain cases, such as for mental health participants. Tools which assess activities of daily living can be similar across sectors for example aged care and disability. Each year ACNA conducts 193,208 assessment, case management and consumer experience surveys. Assessments are not just about the tools, but the art of conversation. The ability to listen and not make assumptions about a person’s need based on disability or diagnosis but rather the impact of the disability or diagnosis on a person’s life. This means considering the environment, the person’s support networks, their goals and aspirations and their current strategies to achieve their goals are critical to understanding their daily life. ACNA believes that assessment that is reliably applied nationally using evidence-based assessment tools used in close consultation with the participant and their family will not only result in a higher

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level of consistency and fairness, but the outcomes of the assessment are far more likely to be accepted by the participant because they understand and have been part of the process.

A further consideration is the assessor workforce. Clinical qualifications and/or disability experience are highly valued and important; however, the attitude and empathy of the assessor is equally or even more important. The person with disability is the only person who really understands the impact of their disability on their lives and the ability to live a good one. In ACNA’s experience some clinicians make assumptions about the impact and run the risk of using their own judgement over the opinions of the person seeking support. The ability to ‘read the room,’ to read the body language of family members when listening to the responses of the person and carers are equally important. This is not to say that professional people do not have both, and in fact, most usually do have both, but the importance of attitude cannot be overstated. A substantial risk to the sustainability of the NDIS is mandating the qualifications and experience of assessors too tightly which appears to have been the experience during the abandoned Independent Assessment process. The demand for skilled, trained and importantly experienced clinicians is extremely high. Consideration will need to be given to the mix of labour force to achieve the best outcome. While ACNA has considerable experience and insights to offer on the range of assessment tools available for use, it does not serve any purpose detailing them in this submission. The purpose of the envisaged consultation and codesign committed to by the Minister is to work with participants and other stakeholders to identify the most appropriate assessment tools for use in the NDIS. In our experience, there is so much that can be learnt from those people with a disability who have experienced the assessment process, as well as from the range of professionals and academics who will bring a distinct perspective.

3.2.4 Next steps and Consultation

ACNA would strongly advise those who are charged with leading the consultation and co-design process to go to the coalface and watch how assessment processes are undertaken in a range of settings and locations. ACNA also believes it is important to pilot tools prior to their implementation. This enables the tools to be tested in a managed way, which then can lead to refinements/adaptations where necessary. This is important before tools are implemented at scale. Similarly, it is important to pilot assessment tools with First Nations participants and diverse cultural groups. Consideration should also be given to location and availability of experienced assessors such as in remote Indigenous communities. While there are many differences between the community and aged care system and the NDIS, ACNA has observed that there are also similarities. Both sectors share a similar workforce profile and use many of the same professional groups and practices. Knowledge and professional practice should be shared between both to avoid duplication and to avoid unnecessary pitfalls in implementation of assessments that may have already been experienced by either sector.

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Summary

A robust needs assessment process presents a significant opportunity to ease the burden for people with a disability to access the NDIS, and to receive individual plans that reflect their unique needs. At the same time. If implemented well, it should provide assurance that the approach to assessment is more consistent nationwide, and the resulting supports are similar for similar groups of people (adjusted as necessary for the individual). It will be important when consulting and codesigning the assessment tools to go to the coalface to see them in action. ACNA would welcome people to come and observe needs assessments being undertaken, subject to the gaining the consent of relevant individuals. It will also be important to pilot ideas, models, and tools to ensure that proven tools only are implemented at scale, otherwise, there could be unintended impacts on participant outcomes as well as their level of trust of the process. ACNA has experience in undertaking pilots and would be interested and willing to run one of the pilots if there was an opportunity. Finally, thank you for the opportunity to provide ACNA’s thoughts to the Committee. ACNA would be available to provide further detail if requested and we would also be pleased to present to the Committee if this assisted in the Committee’s deliberations.