Submission to the Senate Community Affairs Legislation Committee

Inquiry into the National Disability Insurance Scheme Amendment (Securing the NDIS for Future Generations) Bill 2026

Submitted by: Nicole Green Founder and Director, Health Works NSW Occupational Therapist

Date: 27 May 2026

Publication Consent: I consent to this submission being published with my name and company name.

About the Author

My name is Nicole Green. I am the founder and director of Health Works NSW, a small regional allied health practice predominantly servicing rural and regional communities across New South Wales. I am also an Occupational Therapist with more than 20 years of clinical experience.

Over the course of my career, I have worked across multiple disability, health, aged care and compensation schemes both prior to and alongside the National Disability Insurance Scheme (NDIS). I have worked directly with people living with significant physical disability, psychosocial disability, autism, intellectual disability, progressive neurological conditions, acquired brain injury, degenerative disease, complex trauma, behavioural presentations and significant functional impairment.

I am writing this submission not only as a clinician and business owner, but also as:

• a regional employer of allied health clinicians, predominantly Occupational Therapists;
• a parent of a child with disability who does not access the NDIS;
• the sister of a proudly disabled brother who has since passed away;
• a long-standing informal disability advocate within my local community;
• and a person who has recently experienced significant personal loss following the death of my husband while continuing to raise three very young children and maintain a regional allied health service and a farm.

This is the first formal Senate submission I have ever written.

I acknowledge openly that I am not a large organisation with policy teams, legal departments or dedicated submission writers. I am writing this submission late at night after work, after putting

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my children to bed, because I genuinely believe these proposed reforms will have profound impacts on the people, families, clinicians and regional communities I work alongside every day.

I would like to disclose that I have used some AI assistance for grammar, structure and consistency due to time constraints and personal circumstances. However, the views, concerns and experiences expressed throughout this submission are entirely my own and reflect my direct clinical, professional and lived experience.

Over the last week I have reviewed and discussed with my team the following:

• the National Disability Insurance Scheme Amendment (Securing the NDIS for Future Generations) Bill 2026;
• the Explanatory Memorandum;
• the Integrity and Safeguarding legislation;
• published commentary and analyses;
• and a number of publicly available submissions and discussion papers.

In particular, I acknowledge the work and publicly available material prepared by:

• The Growing Space and Ms Sam Paior;
• OTSi (Occupational Therapy Society for Hidden and Invisible Disability);
• Verve OT Learning and the “NDIS Reform & Reset” webinar I attended on 27 May 2025 with my Team and Verve /discussion materials;
• the Justice and Equity Centre;
• Villamanta Disability Rights Legal Service;
• Intrepidus Law;
• and other disability advocates and clinicians who have attempted to unpack this extremely complex legislation in a very short timeframe.
• various social media sites that have open forums and discussions relating to community and user group concerns

I support the long-term sustainability of the NDIS.

I do not support this Bill in its current form.

Executive Summary

The National Disability Insurance Scheme has transformed the lives of many Australians, particularly people living in rural and regional communities where disability services were previously limited, fragmented or unavailable.

I have been proud to work as an Occupational Therapist throughout the development and implementation of the NDIS since its early years. I have seen first-hand the difference the Scheme can make when it works well. However, over the past 12 months, this work has become increasingly difficult due to ongoing uncertainty, repeated policy and process changes, inconsistent communication and poor rollout of information to participants, families, providers and clinicians.

I am deeply concerned that the National Disability Insurance Scheme Amendment (Securing the

NDIS for Future Generations) Bill 2026 represents one of the most significant restructures of the Scheme since its inception, yet it is being progressed within an extraordinarily compressed consultation timeframe.

My concerns do not arise because I oppose reform. I support the long-term sustainability of the NDIS. My concerns arise because the cumulative effect of the proposed reforms appears to risk narrowing access, reducing flexibility, weakening safeguards, increasing Ministerial discretion, destabilising regional providers and moving the Scheme away from individualised, contextualised and person-centred support.

As an Occupational Therapist, I am particularly concerned that the proposed reforms risk reducing disability support to narrow functional measurement frameworks that fail to properly consider context, environmental barriers, fluctuating presentation, fatigue, sensory regulation, psychosocial complexity, behavioural risk, trauma, executive functioning, informal care sustainability and the interaction between disability and rural disadvantage.

I am also deeply concerned about the likely impacts on participant safety, family sustainability, workforce retention, provider viability, small rural businesses, clinician burnout and continuity of care.

The NDIS absolutely requires sustainability. However, sustainability cannot be achieved through measures that reduce flexibility, narrow access, destabilise providers, increase administrative burden, create fear and uncertainty, or shift disability-related costs onto families, unpaid carers, hhealth systems and already under-resourced regional services.

I urge the Committee to consider the cumulative impact of these reforms, rather than assessing each amendment in isolation.

• Behavioural and sensory regulation support;
• Environmental assessment and risk mitigation;
• Assistive technology review and ongoing clinical oversight;

A significant proportion of our work involves highly complex participants with intersecting physical, neurological, psychosocial, behavioural and environmental support needs.

We regularly travel significant distances to reach participants and families in rural and remote NSW areas.

Many of the communities we service experience:

• workforce shortages;
• limited specialist access;
• housing shortages;
• reduced transport access;
• clinician recruitment challenges;
• increased socioeconomic disadvantage;
• limited disability-specific infrastructure;
• and high levels of informal caring burden.

In many regional areas, if a single Occupational Therapist leaves, there may be no replacement for months.

Participants may already wait:

• months for therapy;
• months to even years for complex AT equipment;
• months to years for complex home modifications;
• and significant periods for complex assessments.

Many families already operate in crisis-management mode.

The reforms proposed within this Bill risk compounding existing instability within regional disability systems.

General Concerns Regarding the Bill

A recurring concern throughout the disability sector is that many of the proposed changes appear individually administrative, technical or procedural, but cumulatively represent a major philosophical and operational shift in the Scheme.

The legislation appears to move away from:

• individualisation;
• participant choice and control;
• contextual assessment;
• flexibility;

• therapeutic reasoning;
• and collaborative planning.

Instead, there appears to be increasing movement toward:

• standardisation;
• centralised control;
• actuarial management;
• functional categorisation;
• reduced flexibility;
• and fiscal containment.

Many frontline clinicians, participants and families feel overwhelmed by the scale and complexity of the reforms.

There is widespread concern that:

• people do not fully understand what is changing;
• the practical implications are unclear;
• safeguards are insufficiently defined;
• implementation systems are not ready;
• and many changes are being introduced through Rules and subordinate legislation rather than primary legislation.

I am particularly concerned that people living with disability are increasingly being spoken about in economic and budgetary terms rather than as citizens entitled to dignity, participation and meaningful support.

Rural and Regional Impact

One of my strongest concerns is that the practical impacts of these reforms on rural and regional communities appear significantly underestimated.

Regional disability systems are already fragile.

Unlike metropolitan areas, rural communities often do not have:

• multiple provider options;
• specialist services nearby;
• replacement clinicians;
• accessible public transport;
• large workforce pools;
• or service redundancy.

Travel within regional NSW can already be extreme.

For example, Health Works NSW may travel from Mudgee NSW to communities such as Quambone, Coonamble, Carinda and Walgett to provide Occupational Therapy services. Travel

Quambone alone can exceed 3 hours and 40 minutes one way, approximately 290 kilometres each direction.

Despite these distances, I am still one of the closest Occupational Therapists for some of these communities with experience in:

• complex spinal injury;
• neurological disability;
• complex assistive technology;
• vehicle modifications;
• environmental modifications;
• and occupational therapy driving assessment.

Many participants in these areas require highly specialised assessment and intervention.

For participants with spinal injuries, acquired neurological conditions or progressive disability, support often involves:

• highly complex seating and mobility prescription;
• environmental control systems;
• home modifications;
• pressure care;
• vehicle modifications;
• wheelchair accessible transport solutions;
• and complex community access planning.

However, in many cases there is currently insufficient or no funding available to adequately cover travel to these remote locations.

Many OT providers and ultimately the business owners, continue attending these communities,often absorbing significant unreimbursed travel and operational costs,because regional participants deserve access to safe, skilled and dignified disability services regardless of postcode. However,there is a limit to what small regional providers can continue to absorb financially.

I am not in business to make excessive profit.However,I am also not in business to go broke while attempting to provide services to communities that already experience substantial disadvantage.

When regional providers become financially unstable or unable to recruit and retain staff,participants are not simply able to choose another provider.

Often there is no alternative provider.

The cumulative effect of:

• pricing pressure;
• increased registration burden;
• administrative complexity;
• payment delays;

• tighter funding;
• uncertainty around therapy supports;
• and reduced flexibility I feel not may but will result in further withdrawal of skilled providers from regional communities first and then the same in larger cities/areas will follow.

The impact of this will not be theoretical.

It will result in:

• delayed therapy;
• increased hospital admissions;
• carer burnout;
• participant deterioration;
• increased safeguarding risk;
• crisis presentations;
• and greater pressure on state health systems.

Many participants in regional communities already rely heavily on a small number of trusted clinicians who understand:

• local systems;
• family dynamics;
• environmental barriers;
• farming contexts;
• transport limitations;
• housing shortages;
• and community realities.

Highly standardised or centralised planning approaches risk losing this contextual understanding entirely.

One of my strongest concerns is that the practical impacts of these reforms on rural and regional communities appear significantly underestimated.

Regional disability systems are already fragile.

Unlike metropolitan areas, rural communities often do not have:

• multiple provider options;
• specialist services nearby;
• replacement clinicians;
• accessible public transport;
• large workforce pools;
• or service redundancy.

When regional providers become financially unstable or unable to recruit and retain staff, participants are not simply able to choose another provider.

• Often there is no alternative provider.

The cumulative effect of:

• pricing pressure;
• increased registration burden;
• administrative complexity;
• payment delays;
• tighter funding;
• uncertainty around therapy supports;
• and reduced flexibility

may result in further withdrawal of providers from regional communities.

The impact of this will not be theoretical.

It will result in:

• delayed therapy;
• increased hospital admissions;
• carer burnout;
• participant deterioration;
• increased safeguarding risk;
• crisis presentations;
• and greater pressure on state health systems.

Many participants in regional communities already rely heavily on a small number of trusted clinicians who understand:

• local systems;
• family dynamics;
• environmental barriers;
• farming contexts;
• transport limitations;
• housing shortages;
• and community realities.

Highly standardised or centralised planning approaches risk losing this contextual understanding entirely.

Area of Concern 1 – Functional Capacity and Changes to Eligibility

As an Occupational Therapist, I have significant concerns regarding proposed changes relating to functional capacity assessment and eligibility.

Occupational Therapy assessment is not simply the measurement of tasks.

Functional Capacity Exists Within Context

A person’s functioning can vary significantly depending on:

• environment;
• fatigue;
• sensory load;
• trauma history;
• mental health;
• informal support availability;
• communication supports;
• executive functioning demands;
• transportation;
• and socioeconomic factors.

I am deeply concerned that the proposed reforms may move toward increasingly reductionist and standardised approaches to disability assessment.

There is substantial risk that people with:

• psychosocial disability;
• autism;
• fluctuating conditions;
• hidden disabilities;
• executive functioning impairment;
• sensory processing disorders;
• chronic fatigue;
• acquired neurological conditions;
• and complex behavioural support needs

will be disadvantaged by systems that rely heavily on narrow functional categorisation.

Many participants function differently across environments.

For example, a participant may appear “functional” during a brief structured assessment while being entirely unable to sustain:

• employment; safe community access; emotional regulation; independent living; medication management; or social participation.

Occupational Therapists understand that disability cannot be accurately understood in isolation from context.

As an experienced Occupational Therapist, I actually value the NDIS using function as a benchmark. Functional capacity and occupational performance have always sat at the centre of Occupational Therapy practice, long before the NDIS existed. Assessing how people function safely and meaningfully within their actual environments is what Occupational Therapists are specifically trained to do.

• However, my concern is that the proposed reforms risk reducing function to narrow measurement rather than understanding the broader occupational realities of a person’s life.

• At Health Works NSW, our clinicians regularly see participants whose true functional challenges would not be accurately captured within brief, isolated or overly standardised assessment processes.

Examples include:

-   **A participant with autism** who may present as highly articulate, calm and capable within a quiet clinic setting, yet becomes completely overwhelmed, behaviourally dysregulated and unable to safely function within real-world community environments due to sensory overload, executive dysfunction and environmental demands.

-   **A participant with spinal injury living rurally** who may technically transfer independently indoors during brief observation, but cannot safely:
    

• access uneven outdoor terrain;

• move through cattle yards;

• get on and off a tractor;

• access the family vehicle;

• transport children;

• get safely to the school bus stop;

• navigate essential farming and community environments without highly specialised equipment, environmental modification and ongoing support.

  • A participant with psychosocial disability who may present as well-groomed, articulate and outwardly coping during appointments, yet lives within significant domestic disorder, clinical hoarding, squalor, self-neglect, food insecurity or unsafe living conditions that are not apparent through phone calls or short office-based interactions. These realities are often only identified through in-home Occupational Therapy assessment and direct environmental observation.

  • A participant experiencing domestic and family violence who may minimise risk or present as coping during formal discussion, yet demonstrates significant trauma responses, hypervigilance, environmental instability, parenting strain and functional decline once assessed within their actual living environment.

  • A participant with progressive neurological disease whose fatigue, pain and functional decline fluctuate significantly throughout the day and who may appear considerably more functional during short observations than they are able to sustain safely over extended periods.

  • A participant with complex pressure care needs whose wounds, skin breakdown risk, seating tolerance, transfer safety and equipment concerns cannot be adequately assessed over the phone and instead require physical assessment, pressure mapping, environmental review and direct clinical observation to prevent deterioration and hospitalisation.

My Recommendations

I respectfully recommend that the legislation and associated Rules:

• Ensure functional capacity assessments consider: - environmental context; - assistive technology; - informal supports; - behavioural regulation; - fatigue; - sensory demands; - and sustainability of function over time.

• Ensure assessments are conducted by appropriately qualified allied health professionals with substantial clinical expertise in functional assessment, particularly Occupational Therapists with more than five years’ experience in complex disability assessment.

• Explicitly recognise fluctuating conditions, invisible disability and masking presentations within assessment frameworks.

• Ensure assessments consider: - safety; - sustainability; - participation; - cumulative fatigue;

• behavioural impact;
• and real-world functioning, rather than isolated observed performance. Preserve the role of Occupational Therapists in functional assessment processes given the profession’s long-standing expertise in occupational performance, environmental fit and functional participation.

Area of Concern 2 – Permanence and Appropriate Treatment

The proposed changes relating to “permanence” and “appropriate treatment” are particularly concerning.

Many disabilities are lifelong, even where function may fluctuate.

The legislation appears to indicate that “appropriate treatment” should be:

• evidence-based;
• reasonably expected to materially improve or reduce impacts;
• and regularly undertaken in Australia.

However, the Bill itself does not clearly define:

• who determines what constitutes “treatment”;
• where the boundaries sit between medical treatment, rehabilitation, therapy and behavioural intervention;
• what happens when services are unavailable regionally;
• what occurs where treatment is clinically inappropriate or poorly tolerated;
• or how participant choice and autonomy are protected.

There is substantial risk that people may be denied access to support because:

• they have not trialled every conceivable treatment;
• treatment availability is limited in rural areas;
• waitlists are excessive;
• interventions are financially inaccessible outside the NDIS;
• they cannot physically access specialist systems;
• or because improvement has been interpreted as absence of disability.

As a regional clinician, I regularly work with participants who:

• cannot access specialists locally;
• wait months or years for appointments;
• travel significant distances for treatment;
• or are unable to tolerate repeated interventions due to trauma, fatigue, behavioural distress or sensory overload.

The expectation that participants continually pursue “appropriate treatment” risks becoming:

• unrealistic;

• coercive;
• inequitable;
• and disconnected from real-world service access.

I am particularly concerned that the reforms may unintentionally create systems where participants are required to continually prove disability permanence despite clear lifelong impairment.

This creates emotional distress, administrative burden and repeated retraumatisation for families.

I also note concern from the disability sector that many disabilities do not respond neatly to linear treatment frameworks.

For many participants, Occupational Therapy is not about “curing” disability. It is about:

• looking at the entire person and maximizing functional independence within their own environment
• supporting participation and facilitating and/or maintaining functional gains in activities of daily living

These outcomes may not always fit narrow medical treatment models.

At Health Works NSW, we regularly support participants who continue engaging in therapy, rehabilitation or medical intervention despite clearly living with permanent and lifelong disability.

Examples include:

• participants with acquired brain injury requiring ongoing Occupational Therapy intervention to support executive functioning, routine development, community safety and independent living skills;

• participants with spinal cord injury requiring regular seating reviews, pressure mapping, transfer assessment and wheelchair adjustments to prevent pressure injuries, maintain posture and preserve long-term function;

• participants with progressive neurological conditions requiring ongoing therapy and environmental review to maintain mobility, reduce falls risk and support safe access within the home and community;

• children with autism requiring sensory regulation strategies, emotional regulation support, environmental modification and functional intervention to sustain school participation and reduce behavioural escalation;

• participants with psychosocial disability requiring ongoing support with daily routines, organisation, meal preparation, medication management and community participation to maintain stability and prevent deterioration;

• participants living rurally requiring ongoing vehicle modification review, driving assessment and assistive technology adaptation to safely access farming environments, employment, medical appointments and community participation;

• participants with significant physical disability requiring ongoing home modification review and assistive technology adjustments as their functional needs, carers or environments change over time;

• and participants with complex pressure care needs requiring ongoing Occupational Therapy review of bedding, seating, transfers, positioning and equipment to prevent skin breakdown, hospitalisation and prolonged bed rest.

These participants are not “curing” their disability.

They are attempting to maintain function, preserve dignity and reduce secondary complications.

I am concerned about any interpretation of permanence that suggests participants must exhaust all possible intervention before disability is recognised as permanent.

I am also deeply concerned that participants experiencing financial disadvantage, regional disadvantage or specialist access barriers may be disproportionately impacted.

Many regional participants simply cannot access the level of specialist intervention that metropolitan assumptions appear to rely upon.

Area of Concern 3 – Tightening Reasonable and Necessary

The proposed narrowing and restructuring of “reasonable and necessary” supports is one of the most concerning aspects of the Bill.

The current legislation already contains mechanisms to assess value, necessity and appropriateness.

However, the proposed reforms appear to significantly narrow interpretation while simultaneously increasing uncertainty.

I am concerned that the reforms risk:

• reducing flexibility;
• reducing participant choice and control;
• increasing rigidity;
• narrowing preventative supports;
• and shifting toward highly standardised support allocation.

One particularly concerning proposed amendment relates to “value for money”.

The Bill appears to remove the long-standing concept that a lower-cost alternative should achieve the same or substantially similar outcome.

Instead, the legislation appears to focus on whether:

• a lower cost “comparable support” exists; and
• whether that support represents “better value for money”.

This is a major philosophical shift.

The legislation no longer explicitly states that lower-cost alternatives should provide:

• equivalent outcomes;
• substantially similar outcomes;
• equivalent functional benefit;
• equivalent safety; or equivalent independence.

This creates substantial concern that:

• cost weighting may become disproportionately dominant;
• acceptable participant outcomes may lower over time;
• participants may increasingly be expected to accept “good enough” rather than clinically appropriate supports;
• and clinical nuance may be lost.

As an Occupational Therapist, I regularly prescribe highly individualised supports because disability is highly individualised.

For example:

• a participant living on a rural property may require equipment capable of safely traversing uneven terrain, paddocks, cattle yards or long outdoor distances;
• a participant with severe behavioural dysregulation may require 2:1 community support despite limited published research literature;
• a participant with complex spinal injury may require highly customised seating for specific indoor use (eg a customised self-propelled wheelchair) and specific alternate chair for outdoor environment (eg Customised power chair), a lift in the home, systems or vehicle modifications to the primary car as well as the primary transport mode on the farm such as a side by side or a Tractor;
• and a participant in a remote area may require supports that appear more expensive initially but are significantly safer and more sustainable long term.

These situations do not always fit neatly into standardised evidence hierarchies.

I am also deeply concerned regarding the proposed amendments relating to “effective and beneficial” supports.

The legislation appears to prioritise:

• 1. published, peer-reviewed and generalisable research evidence;
• 2. participant-specific evidence;
• 3. prior participant outcomes;
• 4. and other matters.

While evidence-based practice is important, there are major practical concerns with this hierarchy.

There are many disability supports, assistive technologies, environmental modifications and behavioural interventions where:

• high-level published research does not yet exist;
• evidence is difficult to generalise;
• participant cohorts are too small;
• innovation occurs faster than research publication;
• or participant needs are too individualised.

Regional and complex disability practice often relies heavily on:

• clinical reasoning;
• participant-specific assessment;
• lived experience;
• environmental analysis;
• risk assessment;
• and multidisciplinary expertise.

There is significant concern that the proposed weighting system does not place the participant sufficiently at the centre of decision-making.

For example, there may be limited peer-reviewed literature regarding:

• highly specialised farm-access wheelchairs;
• customised regional environmental modifications;
• specific behavioural support staffing configurations;
• or innovative assistive technology combinations.

However, these supports may still be clinically necessary, effective and life-changing for the participant.

I am deeply concerned by the provision allowing the CEO to reject supports where there is limited published research evidence even where:

• participant-specific evidence exists;
• previous participant outcomes demonstrate benefit;
• or extensive clinician reasoning supports the intervention.

This risks creating systems where:

• standardisation overrides lived experience;

• innovation is discouraged;
• complex participants are disadvantaged;
• and regional participants experience even greater inequity.

Occupational Therapy intervention often works preventatively.

Supports that may initially appear “non-essential” can prevent:

• hospitalisation;
• carer collapse;
• pressure injuries;
• falls;
• behavioural escalation;
• mental health deterioration;
• social isolation;
• and premature residential care placement.

In rural areas, prevention is critical.

When systems fail regionally, there are often fewer fallback supports available.

I am deeply concerned that increasingly narrow interpretations of “reasonable and necessary” may result in delayed intervention until people reach crisis point.

This is neither humane nor economically sustainable.

Another major concern relates to the proposed requirement that supports arise “directly” from impairment.

The explanatory material appears to define this as the “direct and immediate” source or cause of the support need.

This creates significant concern because disability support needs rarely arise from impairment alone.

As an experienced Occupational Therapist, I know that support needs often arise through the interaction between:

• impairment;
• environment;
• fatigue;
• housing;
• transport barriers;
• behavioural regulation;
• sensory demands;
• executive functioning;
• social participation expectations;
• and support availability.

Many participants currently function safely only because environmental risks have already been

reduced through:

• assistive technology;
• home modifications;
• specialised housing;
• transport supports;
• behavioural support frameworks;
• or support worker assistance.

If supports are required to arise only from the “direct and immediate” impact of impairment, there is substantial risk that the broader realities of disability participation may increasingly be excluded.

Occupational Therapists assess:

• function in context;
• participation barriers;
• environmental fit;
• safety;
• sensory regulation;
• behavioural risk;
• and occupational performance.

For example:

• a participant may require transport because public environments are inaccessible;
• a participant may require Specialist Disability Accommodation because current housing is unsafe;
• a participant may require support workers because behavioural dysregulation escalates within community settings;
• a participant may require meal preparation support due to executive dysfunction and safety risk;
• and a participant may require environmental modification because their rural home terrain creates significant falls risk.

These supports remain fundamentally linked to disability even where environmental and social factors contribute.

I am concerned the proposed wording risks oversimplifying disability by attempting to separate impairment from the real-world environments in which people actually live.

• Ensure supports are not excluded simply because environmental, behavioural or social factors contribute to functional impact.

• Preserve contextualised Occupational Therapy assessment regarding:

  • environmental safety;
  • participation barriers;
  • executive functioning;
  • behavioural regulation;
  • sensory processing;
  • and community access.

• Ensure assessment processes acknowledge that many participants remain safe only since existing supports, housing modifications or assistive technology are already in place.

• Avoid overly narrow interpretation of the phrase “directly from impairment” that may unintentionally exclude legitimate disability-related supports.

The proposed narrowing and restructuring of “reasonable and necessary” supports is one of the most concerning aspects of the Bill.

The current legislation already contains mechanisms to assess value, necessity and appropriateness.

However, the proposed reforms appear to significantly narrow interpretation while simultaneously increasing uncertainty.

I am concerned that the reforms risk:

• reducing flexibility;
• reducing participant choice and control;
• increasing rigidity;
• narrowing preventative supports;
• and shifting toward highly standardised support allocation.

Occupational Therapy intervention often works preventatively.

Supports that may initially appear “non-essential” can prevent:

• hospitalisation;
• carer collapse;
• pressure injuries;
• falls;
• behavioural escalation;
• mental health deterioration;
• social isolation;
• and premature residential care placement.

In rural areas, prevention is critical.

When systems fail regionally, there are often fewer fallback supports available.

I am deeply concerned that increasingly narrow interpretations of “reasonable and necessary” may result in delayed intervention until people reach crisis point.

This is neither humane nor economically sustainable.

Area of Concern 4 – Value for Money, Funding Pressures and Ministerial Powers

Another significant concern relates to the strengthening of “value for money” provisions and the increased emphasis on lower cost “comparable supports”.

Throughout the disability sector there is growing concern that lower cost may increasingly become the dominant consideration even where:

• outcomes are poorer;
• independence is reduced;
• safety is compromised;
• supports fail prematurely;
• or long-term costs ultimately increase.

A major concern is that “comparable” does not necessarily mean:

• equally safe;
• equally effective;
• equally sustainable;
• equally durable;
• equally appropriate;
• or equally functional.

Occupational Therapy recommendations are rarely based solely on upfront cost.

They are based on:

• safety;
• participation;
• sustainability;
• prevention;
• independence;
• pressure care;
• behavioural regulation;
• long-term functional outcomes;
• and reduction of future system burden.

At Health Works NSW, we regularly see the consequences of failed or inappropriate supports.

                                                         Health Works NSW Formal Submission. pg. 21

Examples

Examples include:

• complex wheelchairs replaced with lower-cost alternatives that fail within rural terrain;
• reduced staffing ratios leading to behavioural escalation and safeguarding risk;
• partial home modifications that do not adequately address falls or transfer safety;
• delayed assistive technology resulting in hospitalisation or pressure injury;
• reduced therapy intensity contributing to carer burnout and functional decline;
• and participants withdrawing from community participation because supports are technically “available” but not practically usable.

I am deeply concerned that participants may increasingly be expected to accept “good enough” supports rather than supports that genuinely maximise safety, participation and long-term sustainability.

Poorly supported disability does not disappear.

Instead, it may re-emerge through:

• hospital admissions;
• family breakdown;
• homelessness;
• safeguarding concerns;
• mental health deterioration;
• school disengagement;
• carer burnout;
• crisis-driven intervention;
• and increased long-term system costs. Recommendations

I respectfully recommend that the legislation and associated Rules:

• Require “comparable supports” to provide:
  • equivalent safety;
  • equivalent functional benefit;
  • equivalent sustainability;
  • and equivalent participation outcomes.
• Require consideration of:
  • long-term costs;
  • prevention;
  • safeguarding risk;
  • carer sustainability;
  • participant dignity;
  • and future system burden, not solely upfront expenditure.
• Ensure participants are not forced to accept supports that are:
  • unsafe;

• Ensure supports are not funded if they:

    o clinically inappropriate;
    o ineffective;
    o poorly fitted;
    o or unsustainable long term.
  

• Ensure value for money considerations include:

    o quality of life;
    o independence;
    o dignity;
    o community participation;
    o and long-term outcomes.
  

• Preserve clinician capacity to recommend highly individualised supports where required for participant safety and function.

• payment systems are unstable;
• and service viability becomes difficult to predict.

Area of Concern 5 – Whole of Person Assessment

The proposed Whole of Person Assessment framework raises substantial concern.

Occupational Therapy recognises that people are complex, contextual and dynamic.

While standardised tools can support assessment processes, they should never replace:

• clinical judgement;
• contextual understanding;
• participant voice;
• longitudinal observation;
• and multidisciplinary reasoning.

There is considerable fear within the sector that Whole of Person Assessment processes may:

• oversimplify disability;
• reduce people to impairment categories;
• fail to account for fluctuation;
• ignore environmental context;
• disadvantage hidden disability;
• and create inequitable outcomes.

I am particularly concerned about the impacts on:

• autism;
• psychosocial disability;
• sensory processing impairment;
• intellectual disability;
• and complex trauma presentations.

Participants are not data sets.

People cannot be accurately understood solely through functional scoring frameworks.

Area of Concern 7 - Quality and Pricing of Providers

I understand and support the intent behind improving provider quality and safeguarding within the disability sector.

However, I am deeply concerned that increasing pricing pressure and administrative expectations may disproportionately disadvantage small regional providers and unintentionally favour larger metropolitan organisations.

Large metropolitan providers often benefit from:

• economies of scale;
• larger workforce pools;
• the ability to geographically cluster participants;
• centralised clinics and equipment showrooms;
• and reduced travel burden between appointments.

Regional service delivery is fundamentally different.

Rural and Remote Service Delivery Challenges

In rural and remote areas, participants are often located hundreds of kilometres apart in entirely different directions. No matter how strong administration and scheduling systems are, geography itself creates unavoidable inefficiency.

Unlike metropolitan providers, regional clinicians frequently cannot expect participants to attend clinics or equipment trial sites. We must physically travel to participants within their homes, farms, communities and environments in order to complete meaningful assessment and intervention.

This includes:

• wheelchair and seating trials;
• pressure care review;
• home modification assessment;
• transfer assessment;
• environmental risk assessment;
• vehicle modification assessment;
• and real-world functional observation.

Providers continue attending these communities, often at significant unreimbursed cost, because regional participants deserve access to safe, skilled and dignified services regardless of postcode.

Many rural businesses are already struggling to recruit and retain clinicians.

Occupational Therapists are increasingly leaving disability work due to:

• burnout;
• emotional fatigue;
• workforce instability;
• increasing administrative pressure;
• and uncertainty regarding the future direction of the Scheme.

If small regional providers collapse or withdraw from the NDIS, many rural participants may lose access to services entirely.

There is substantial risk that the reforms may unintentionally consolidate the sector toward larger metropolitan providers while reducing localised, relationship-based and community-connected care.

This would be devastating for many regional communities.

• recognise the unique operational realities of rural and remote service delivery;

• ensure pricing structures adequately account for:

  • rural travel;

  • outreach service delivery;

  • equipment trials;

  • environmental assessment;

  • and complex multidisciplinary assessment;

• ensure regional participants are not disadvantaged by pricing structures designed primarily around metropolitan service models;

• support retention of experienced clinicians within rural disability practice;

• and recognise that regional providers often deliver highly specialised services across enormous geographical areas with substantially higher operational burden than metropolitan services.

Area of Concern 8 – Expanding Mandatory Provider Registration I support mandatory registration requirements for higher-risk sectors of the disability industry, particularly:

• Support Coordination providers;

• Behaviour Support providers;

• Supported Independent Living (SIL) providers;

• and Specialist Disability Accommodation (SDA) providers.

These sectors involve significant safeguarding responsibility and historically have not had the same professional governance, registration or accountability structures that already exist within allied health professions.

However, allied health clinicians already operate within substantial regulatory frameworks through:

• AHPRA registration;

• Peak Bodies and Registered associations such as Occupational Therapy Australia

• adhering to professional development requirements and professional standards;

• ethical obligations;

• and disciplinary oversight.

Area of Concern 9 - Foundational Supports Outside the NDIS

The concept of foundational supports has potential.

However, there is widespread concern across the sector that foundational supports are being referenced before:

• systems exist;
• funding is secured;
• eligibility is clear;
• workforce capacity is established;
• and implementation pathways are defined.

Health Works NSW Formal Submission. pg. 28

Area of Concern 10 - Overhauling Payments and Claims

The proposed payment and claiming reforms create substantial anxiety within the provider sector.

Small businesses require predictable and timely payment systems to survive.

Many allied health providers are already carrying:

• delayed payments;
• increased administrative burden;
• high cancellation rates;
• travel costs;
• and workforce pressures.

In regional areas, service delivery often involves:

• long travel distances;
• outreach costs;
• reduced economies of scale;
• and extensive coordination.

Any payment system instability may significantly impact service viability.

One of the strengths of the NDIS has been flexibility.

Many families have developed highly individualised systems that work for them.

I am also concerned about any future movement toward pooled or combined allied health funding categories that fail to recognise the distinct clinical role of different disciplines.

Workforce Sustainability

I do not believe the workforce implications of these reforms have been adequately considered.

The disability workforce is already exhausted.

Many clinicians are:

• emotionally fatigued;
• carrying excessive administrative burden;
• working in workforce shortage environments;
• managing complex safeguarding issues;
• and attempting to navigate constant reform.

There is increasing fear, confusion and instability across the sector.

Health Works NSW Formal Submission. pg. 30

Many allied health clinicians entered disability work because they believed deeply in:

• participant-centred practice;
• social inclusion;
• meaningful therapy;
• advocacy;
• and improving quality of life.

There is growing concern that the Scheme is shifting away from these principles.

If clinicians continue leaving the sector, participants will ultimately suffer.

The Human Impact

Throughout the discussion surrounding these reforms, I believe it is critical not to lose sight of the fact that disability policy affects real people.

The people impacted by these reforms are:

• children;
• ageing carers;
• exhausted parents;
• people with progressive disease;
• people with communication impairment;
• people with trauma histories;
• isolated rural families;
• and people attempting every day to maintain dignity, participation and safety.

Many families are already overwhelmed.

Many participants are frightened.

Many clinicians, including myself are frightened.

I am deeply concerned that cumulative fear and uncertainty are becoming defining features of the current reform environment.

Recommendations

I respectfully recommend that the Committee:

1. Do not pass the Bill in its current form.
2. Extend consultation and engagement timeframes to allow genuine disability community and participation.
3. Undertake detailed rural and regional impact assessment prior to implementation.
4. Ensure any reforms preserve participant choice and control.

• 5. Ensure clinical reasoning and contextual assessment remain central to disability assessment processes.
• 6. Avoid overly reductionist or excessively standardised assessment frameworks that prioritise isolated scoring systems over understanding how a person actually functions safely, sustainably and meaningfully within their real-world environment
• 7. Avoid the use of the term “functional assessment” within NDIS processes unless the assessment has been completed or overseen by a suitably qualified Occupational Therapist with recognised experience in functional capacity evaluation and real-world occupational performance assessment.
• 8. Protect flexibility within participant plans and ensure funding for allied health disciplines is not grouped or pooled together in ways that disadvantage participants or create competition between essential supports
• 9. Provide significantly greater transparency regarding Rules, subordinate legislation and implementation pathways.
• 10. Ensure foundational supports are fully established, funded and operational before any reduction in participant access occurs.
• 11. Implement safeguards preventing participants from being disadvantaged due to geographic location.
• 12. Protect flexibility within plans
• 13. Ensure provider registration requirements are proportionate and achievable for small regional allied health providers.
• 14. Undertake workforce modelling regarding likely impacts on allied health retention and regional service viability.
• 15. Ensure reforms do not increase reliance on unpaid carers without appropriate recognition and support.
• 16. Preserve preventative and early intervention supports that reduce long-term costs and improve participant outcomes.
• 17. Ensure any Whole of Person Assessment framework includes strong clinical oversight, appeal pathways and contextual consideration.
• 18. Ensure automation and standardisation do not replace meaningful human decision- making.
• 19. Release further modelling and evidence demonstrating how the proposed reforms will improve participant outcomes rather than solely reduce expenditure.

Closing Statement

I remain supportive of the National Disability Insurance Scheme and its long-term sustainability.

The NDS has transformed many lives, particularly in regional and rural Australia where disability supports previously did not exist in meaningful ways.

I have seen first hand:

• people remain living safely within their homes and communities rather than entering premature residential aged care or repeated hospital admission;

• participants engage in activities, routines and community life that are genuinely meaningful to them;

• participants develop daily living, social, emotional regulation and vocational skills leading to greater independence and, at times, paid employment;

• rural participants continue farming, parenting and community roles through appropriate assistive technology, vehicle modifications and environmental supports;

• participants gain the ability to drive safely for the first time through Occupational Therapy driving assessment, training and vehicle modification;

• and participants access equipment, seating, pressure care and home modifications that significantly improve dignity, safety, comfort and independence.I was proud to be part of the Scheme in its earlier years.

However, I do not believe this Bill in its current form adequately protects: Participants; families; regional communities; workforce sustainability; or the foundational principles upon which the NDIS was established.

I believe many of the proposed reforms carry significant risk of unintended harm.

I am particularly concerned and disappointed that rural and regional Australians may bear a disproportionate burden of these impacts.

I respectfully ask the Committee to carefully consider not only the fiscal objectives of reform, but also the human, clinical, practical and community consequences.

This submission has been written honestly and to the best of my ability as a tired mother, regional business owner and Occupational Therapist attempting to advocate for the people, families and communities I work alongside every day.

I acknowledge there may be errors or omissions given the scale and complexity of the legislation and the limited timeframe available for consultation.

Health Works NSW Formal Submission. pg. 33

Nonetheless, I felt strongly compelled to contribute because these reforms will directly affect:

• the people I work with;
• the staff I employ;
• the communities I serve;
• and the future sustainability of disability services in regional Australia.

Thank you for the opportunity to provide this submission.

Nicole Green Founder and Director Health Works NSW Occupational Therapist

e:

a: Suite 3, 24 Sale Street, Orange NSW 2800 .

Other offices: Mudgee, Coffs Harbour, Dubbo and Bathurst

w: www.healthworksnsw.com

                                                       Health Works NSW Formal Submission. pg. 34