NDIA Accountability Project

NDIS supports in rural, regional, and remote Australia

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@APS sa

Society

23 February 2024 Level 11, 257 Collins Street

Melbourne VIC 3000

PO Box 38

Flinders Lane VIC 8009

Joint Standing Committee on the NDIS T: (03) 8662 3300

PO Box 6100

Parliament House

Canberra ACT 2600

Submitted online at: https://www.aph.gov.au/Parliamentary_Business/Committees/OnlineSubmission

Dear Committee Members,

The Australian Psychological Society (APS) is the peak professional body for psychologists in Australia. We advocate on behalf of our members and the community for the implementation of evidence-informed prevention, intervention and systemic reform approaches that deliver health and wellbeing for all Australians. Our work is informed by the United Nations international human rights conventions’ and the Sustainable Development Goals? which champion health and wellbeing as a human right for all.

We commend the Joint Standing Committee for its inquiry into NDIS participant experience in rural, regional and remote Australia. It is imperative that participants in these locations experience equitable access to NDIS services. We welcome the opportunity to provide input regarding the role of psychologists in the NDIS and factors that impact participant experience in rural, regional and remote areas.

Psychologists have witnessed the potential for the NDIS to work well for people with disability and their families across Australia when funding is sufficient and when there is access to effective support. The Scheme provides much-needed services to participants who previously could not afford them, and the ability to exercise greater control and flexibility in choosing the services to best meet their needs.

Notwithstanding the positive contributions of the NDIS, in our response we have identified a number of challenges that impact the role psychologists have in providing NDIS services in rural, regional, and remote locations and the effect this has on participants.

The contribution of psychologists to the NDIS:

Psychologists have been working flexibly in order to help NDIS participants in all parts of Australia (including rural, regional and remote areas) to achieve their goals through the provision of meaningful, consistent support. Psychologists provide a wide-ranging, responsive and participant-led contribution to the NDIS which is adapted to the participant’s location and local context as much as possible. Some of the most common NDIS-related services provided by psychologists include:

psychology.org.au The Australian Psychological Limited

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 Individual therapeutic supports to promote functional capacity and independence;  Assessments (including cognitive, neurodevelopmental and psychosocial) and providing reports to planners, the NDIA and other health and disability practitioners;  Specialist Behavioural Intervention Support;  Early Childhood Interventions, and parent support/training and family systems supports, for parents and families of a child with disability;  Multidisciplinary/team care arrangements for NDIS participants, including coordinating and facilitating supports with other local professionals or agencies, planners, support coordinators, local area coordinators or the NDIA.

Psychologists provide NDIS-related services from a variety of settings, ranging from solo or small practices to leading large multidisciplinary NDIS-focused practices, and working within public and community health organisations. Although it is not a replacement for in-person consultations, psychologists in larger geographical centres will also provide telehealth assessments and other supports for NDIS participants in rural, regional, and remote locations when there is no viable in-person alternative, or where telehealth services are more appropriate for the participant.

Psychologists in rural, regional, and remote areas

Effective policy, pricing and workforce development requires accurate data in relation to the provision of NDIS services in rural, regional and remote communities. This includes having a clear view of the number of psychologists providing services to participants in these parts of Australia. Unfortunately, the NDIA does not provide item utilisation data at this level of geographical granularity.

The APS therefore conducted a survey in 2023 of members providing NDIS services. The results suggest that while slightly overrepresented in metropolitan areas (MM1) and underrepresented in small rural towns (MM5), the distribution of psychologists in increasingly remote areas is generally proportional to the distribution of the Australian population (see Table 1). We know that the practical reality, however, is that the number of psychologists available to NDIS participants in rural and remote areas is limited. Beyond purely an analysis of provider headcount, the shortage of psychologists has other implications which are often overlooked:

 Although trained to have a broad set of skills and competencies, psychologists will choose to pursue advanced areas of practice including through an Area of Practice Endorsement (AoPE) or other training and supervised practice to define their own scope of practice. Not every psychologist, for example, provides early childhood supports or behavioural support, but will have strengths and competencies in other areas. We therefore need to maintain and further develop the full breadth of skills and practice areas in order for psychologists to work most effectively and efficiently with the NDIS across Australia. Unfortunately, current government policy settings continue to reduce diversity in psychological practice and maintain the geographical concentration of psychologists in metropolitan areas.

 A good therapeutic relationship or ‘fit’ between a participant and psychologist is essential for supports to be effective. This ‘fit’ cannot be forced, and the participant’s subjective experience must always be respected. As part of upholding the principle of choice and control, it is essential that participants in rural, regional and remote Australia have access to a range of different psychologists so that they can choose someone who they feel can support them most effectively.

These problems require structural reform and incentives to enable the psychology profession to bring about change to ensure equity of access, and improved supports, for regional, rural and remote participants.

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Table 1. APS members providing NDIS services by Modified Monash Model (MMM) location

Modified Monash Model (MMM) % of APS % of Australian Category psychologists population® surveyed MM1: Metropolitan areas 78 71 MM2: Regional Centres 10 9 MMs: Large rural towns 6 7 MM4: Medium rural towns 5 4 MMS: Small rural towns 1 7 MM6: Remote communities <1 1 MM7: Very remote communities <1 <1

Funding for travel as an essential aspect of support in rural, regional and remote communities

It is essential that NDIS participants’ plans recognise and account for the significance of travel as an aspect of support through the provision of adequate funding. In many instances, especially with children, travel is important to enable the provision of NDIS supports in a more appropriate or naturalistic setting, such as the participant’s home or school environment. Providers, including psychologists, need to be adequately remunerated for travel associated with delivering NDIS services for which there is a clear rationale for how this improves the provision of support and the attainment of participant outcomes.

The rules pertaining to travel may also restrict choice and control for participants, especially if they are not able to select a provider that specialises in services specific to their needs. This raises issues around equity and access and may contribute to already thin markets. Current arrangements fail to incentivise the provision of services beyond a limited geographical area, even within major centres, due to capped time limits that do not reflect the realities associated with travelling in these locations. In remote and very remote areas, the time cap on provider travel does not account for the difficulties that can be experienced in reaching participants.

APS recommendations:

The APS believes that significant improvements can be achieved to participant experience by adopting more inclusive approaches that encourage the involvement of participants in decisions about their care and mobilising professional groups via incentives in rural, regional and remote locations. We commend the current JSC Inquiry for the focus on participants and the intention to identify and better understand their experience of NDIS service provision in rural, regional and remote locations. Our recommendations are as follows:

  1. Adequately remunerate travel costs to improve accessibility for participants To overcome barriers associated with travel, it is essential for the NDIS Price Arrangements and Price Limits to recognise and appropriately remunerate providers for both travel costs and their time to ensure that they can provide the right support at the right location to meet the needs of participants.

Families will often need a strong outreach approach that allows for providers to actively engage with them through relationship building within their local community setting. This aspect of NDIS service provision needs much greater focus, especially in rural, regional and remote areas where time spent with families can be restricted due to funding arrangements and the costs associated with travel.

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  1. Undertake benchmarking and data collection to better understand and meet participants’ needs across jurisdictions

The APS notes that the NDIS Pricing Arrangements and Price Limits, which partially applies the MMM in setting price limits, recognise the higher costs associated with delivering NDIS supports in rural, regional and remote locations. Benchmarking data is required with respect to understanding the impact of different economic conditions and trends in these areas to ensure that NDIS pricing categories are sufficiently nuanced to appropriately enable the breadth and depth of support required by participants who live in these communities.

We recommend that the NDIA work with peak bodies, including the APS, to develop an open, accurate and up-to-date dataset which establishes: (1) the current geographical distribution of providers, and (2) the additional costs associated with operating a practice in rural, regional, and remote locations. In addition, data about current NDIS support requirements in rural, regional and remote locations needs to be considered. Only then can NDIS policy and practice reform accurately plan for, and meet, the required level of services for participants in these areas.

By mapping participant need and the geographical distribution of providers (i.e., identifying gaps in service), and understanding cost-drivers, we will be in a position as a peak body to advocate for funding for programs that support the NDIS. Working with the NDIA, we can then optimise resource allocation and use of funding to enhance participant access and experience.

  1. Appropriately utilise technology to enhance participant experience and to support providers

Although we acknowledge that technology cannot completely replace in-person support, it can provide new ways of accessing support for NDIS participants in rural, regional and remote locations. This may include different treatment modalities, e.g., one-on-one telehealth consultation or online peer and support groups.

Investment in technological infrastructure would also reduce the geographical barriers for providers in accessing needed support and development to do their best work in the NDIS. Well-developed technological solutions could, for example, facilitate professional supervision for less experienced psychologists, encourage peer supervision across regions and accelerate the development of communities of practice. This is particularly important for psychologists who may be sole providers of NDIS services and may not have relevant professional support in their geographic area. The opportunity for providers to develop and share their knowledge about the local communities in which they work is critical to optimising participant experience in rural, regional and remote communities.

Once again, the profession cannot meet these challenges by itself without investment in the workforce to enable psychologists to work in a sustainable, connected, and generative way for their communities. However, the capabilities of technology augmenting in-person support cannot be realised if basic infrastructure (e.g. affordable and stable internet connectivity) and participant (or family) digital literacy are insufficient. We advocate for ongoing sustainable funding to ensure every Australian is able to access online support irrespective of where they live. This is critical to NDIS participants who may experience other barriers to accessing much needed supports, including challenges associated with travel and communication.

  1. Acknowledge and account for intersectional disadvantage of vulnerable groups to ensure equity for participants

While equity and access goals are very important, systematic barriers need to be addressed in order to achieve them for NDIS supports. Different approaches are needed for different groups. For example, separate and distinctly targeted approaches are needed to appropriately support Aboriginal and Torres Strait Islander communities (especially those in more remote parts of Australia).

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This also includes participants in rural, regional and remote areas who experience socio economic disadvantage, or who have multi-cultural/linguistic diversity, come from a LBGTQIA+ community, and participants from other diverse and/or vulnerable groups.

The impacts of intersectional disadvantage need to be acknowledged and accounted for in every action and initiative in order to address potential inequalities for vulnerable families, and particularly those living in rural, regional and remote locations.

  1. Address the cost of providing services in rural, regional and remote locations to increase availability, responsiveness, consistency and effectiveness of supports for participants

In addition to our recommendations regarding travel allowances (as outlined above), the APS understands that the costs associated with delivering supports in rural, regional, and remote Australia have the potential to outstrip those in metropolitan areas. The APS, however, contends that NDIS price limits themselves are only one aspect of addressing the complexities of factors that may be influencing the provision of appropriate supports in these locations. Other considerations include:

 Policies aimed at improving provider availability,  Addressing support costs, and  Utilising the broader disability, health, and mental health ecosystem in rural, regional and remote areas.

Overheads and expenses involved with running a practice in rural, regional and remote areas are increased through additional administrative burdens associated with the NDIS, such as registration and compliance costs. One member highlighted this issue in our 2023 survey:

“I am a sole practitioner in a regional area [Modified Monash category 7]. I previously worked with an NDIS registered and nonregistered service… It is not worth the hassle and cost to register with the NDIS”.

Given this, we recommend that the current administrative costs and obligations (e.g., associated with registration) should also be addressed. We acknowledge that the Registration Taskforce will be looking into this issue as part of the 2023 NDIS Review reform agenda. This reform must consider the associated costs for providers, particularly in rural, regional, and remote locations where overheads are already higher than in larger town centres and metropolitan areas, as they impact the availability and provision of supports for NDIS participants.

Ultimately, high overheads and other costs associated with providing NDIS supports may contribute to blow-out in participants’ plans. This must be avoided. The systemic nature of the different aspects of the NDIS within each context in which it operates (e.g., rural, regional, and remote areas), need to be kept in mind as part of any reform measures aimed at improving participant experience. For example, one solution might be to create a scale of registration fees based on the geographical location of the provider, where they are lower in more rural and remote areas.

  1. Incentivise psychologists to be based in regional, rural, and remote locations to optimise participant choice and control

While noting that thin markets are driven by broader workforce issues, we recognise that the NDIS ecosystem can contribute to reform in a synergistic way alongside other health and disability systems. It would be unreasonable to expect that there are sufficient NDIS providers without there being policy settings, incentives or NDIA-led initiatives that help attract and develop the NDIS workforce, especially in rural, regional and remote locations. Relevant professions, including psychology, would benefit from support from the government and NDIS ecosystem to address structural workforce challenges in these locations, including through the

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funding of training, placements, and practice opportunities. The shortage of providers in regional, rural and remote locations is, in part, a direct result of long-standing government funding levers and must be addressed through a recalibration, or reinvention, of these levers.

Other incentives could also be considered to motivate providers (and psychologists in particular) to reside and/or provide services in rural, regional, and remote areas, including through: (1) Zone allowances, (2) Supervision allowances, and (3) Continuing professional development support. Improving the experience of NDIS participants in rural, regional, and remote areas relies on the provision of support services by the appropriate provider and the capacity to exercise their basic rights of choice and control.

Thank you for the opportunity to provide input into this Inquiry. If any further information is required from the APS, I would be happy to be contacted through the national office on (03) 8662 3300 or by email at z.burgess@psychology.org.au

Yours sincerely

Dr Zena Burgess, FAPS FAICD

Chief Executive Officer

References

  1. United Nations Office of the High Commissioner. (2023). The core international human rights instruments and their monitoring bodies. https://www.ohchr.org/en/core-international human-rights-instruments-and-their-monitoring-bodies

  2. United Nations, Department of Economic and Social Affairs. (2023). Sustainable development goals. https://sdgs.un.org/goals

  3. Versace, V. L., Skinner, T. C., Bourke, L., Harvey, P., & Barnett, T. (2021). National analysis of the Modified Monash Model, population distribution and a socio-economic index to inform rural health workforce planning. Australian Journal of Rural Health, 29(5), 801–

  4. https://doi.org/10.1111/ajr.12805 Page 6 of 6