Submission 57
CHALLENGE
@ PO Box 487, Tamworth NSW 2340 e 2/ 383 Goonoo Goonoo Rd, TamworthABN: 17 059NSW2092340675
Response to the Inquiry into the NDIS participant experience in rural, regional and remote Australia
Challenge Community Services (Challenge) is a not-for-profit disability services organisation based in New South Wales. We began in 1958 as a small group of concerned parents who formed the Tamworth and District Handicapped Children’s Association and School. We have provided innovative and people-focused disability services to rural, regional and remote communities for over 65 years. We are now one of the largest community support services supporting over a thousand NDIS participants in over 100 communities in NSW as well as South East Queensland.
Challenge is well placed to comment on the disparities between NDIS participants living in metropolitan and rural areas because we operate in both areas. Our regional and rural employees and Board members are community members and experience the daily joys and challenges of living in the bush. We have formal client engagement processes to identify and address system-issues that affect our clients’ experience with us. These are predominantly NDIS-related because it is the framework that underpins our operations.
Our rural, regional and remote NDIS footprint
While we have grown to include parts of Sydney and Brisbane, the vast proportion of our NDIS services are in rural, regional, and remote areas. We operate in Western and Central NSW including
Trangie, Dubbo, Mudgee, Orange, and Bathurst; the New England region including Tamworth,
Narrabri, Gunnedah, Barraba, Armidale, and Quirindi; and the Hunter Region including Singleton,
Muswellbrook and Cessnock. We employ over 650 disability staff in both regional and metropolitan areas. Our workforce data is not disaggregated to regional and metropolitan areas, however regional and rural represent the greater portion of our support services.
Our Disability Support Services include: Supported Independent Living (44 homes in rural and regional areas); Group Supports in the community and in a Centre (23 in rural and regional areas); Assistance with Daily Life; and Community Supports.
We also provide employment opportunities for 70 supported employees across six sites in rural NSW as well as allied health therapeutic services to NDIS participants. This includes psychology, social work, and behavioural support. Our allied health team services Tamworth, Armidale, Maitland, Gunnedah, Taree, the Central Coast and Narrabri, as well as Sydney and Brisbane.
Overarching comments
Not-For-Profit (NFP) providers need an effective governance framework across governments and agencies that incentivises and builds the capacity of organisations to deliver high-quality supports to NDIS participants. We need a framework that supports investment in rural areas within a healthy competitive environment, to allow rural participants greater choice and control over their supports.
Disability Services Foster Care Allied Health
1800 679 129 1800 084 954 1800 795 441
To build business confidence there needs to be certainty in conditions without the frequent changes we have experienced since the rollout of the NDIS. Much of this submission therefore echoes the recent NDIS Review findings and recommendations, noting that the impact of issues highlighted in the Review, such as workforce, service delivery and transport, transparency and safety, are felt far more in regional, rural and remote areas in comparison to metropolitan areas.
a. the experience of applicants and participants at all stages of the NDIS, including application, plan design and implementation, and plan reviews;
Disproportionately higher numbers of unregistered providers and plan managers in rural areas
The 2023 NDIS Review raised the issue of the large number of unregistered providers within the Scheme. In our experience, there is a greater proportion of unregistered NDIS providers in rural and regional areas than in metropolitan areas. The greater number of unregistered providers has driven demand for plan-management (NDIS Review p. 207). The implications of unregistered providers include a lack of oversight for high-risk supports, as well as delayed payments for services to providers by plan managers. This risks quality and safety, particularly in areas where there is already a lack of visibility and transparency, and distorts competitive markets.
Restrictive practices and unregistered providers in regional, rural, and remote areas
Restrictive Practices are a grey area in regional, rural, and remote areas as there are fewer specialists and a higher rate of providers who are not registered. Unregistered providers must work with the NDIS to implement Restrictive Practices, however, there is no transparency on how the practice takes place and is monitored. For example, when our allied health practitioners recommend a Restrictive Practice for a participant who is with an unregistered provider, there are no feedback systems in place to notify of the outcome and ongoing needs of the participant.
Higher costs for registered providers and delayed payments
In our experience, the high rate of unregistered providers and corresponding use of intermediaries has distorted the market including creating unfair costs to registered providers. Challenge experiences longer delays in payments through plan managers for services we have already provided. We are currently owed $1.2 million through plan panagers in rural areas. Carrying the cost of these delayed payments risks the viability of long-term providers in rural markets, as well as our capacity to reinvest in our rural and regional disability services.
Systems to support market development and investment decisions in rural and regional services
Challenge agrees with the NDIS Review’s vision of markets and support systems that empower people with disability, including the recommendation to ‘invest in digital infrastructure for the NDIS to enable accessible, timely and reliable information and streamlined processes that strengthen NDIS market functioning and scheme integrity’.
Facilitating real-time claims for services as proposed by the NDIS Review would make it easier for participants to pay for services and monitor budgets, ensuring the viability of existing providers in rural areas and the potential for reinvestment. Additionally, as noted in the Review, providers would have more timely market signals, to be able to respond better to need, including investment and innovation.
Data, monitoring and improving quality within regional, rural and remote areas
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In our experience, as a larger hub and spoke provider, monitoring the quality of supports and consistency in practise in our smaller communities can be challenging due to the physical distance.
The capacity of not-for-profit organisations to monitor the quality and effectiveness of service delivery across numerous sites differs from larger public and community providers. Health facilities, for example, have well established and automated quality monitoring systems supported by greater funding capacity. This means people living in regional, rural, and remote areas can expect a consistent standard of service, connected to larger centres.
Disability NFP providers are not funded for quantifying and measuring services, such as outcomes and quality. For NDIS participants, consistency in quality will be variable even within the same organisation due to the investment, capability and capacity required in establishing automated quality systems, which is beyond many NFPs. This also has implications for the numerous unregistered providers who have even less capacity to monitor and report on quality.
Challenge supports the NDIS Review’s recommendations on quality and evidence-based service delivery
Challenge agrees with the NDIS Review’s vision to raise the standard of service delivery through continuous improvement enabled by better data and market monitoring (p 46). Deidentified data sharing between providers, the NDIA, the Commission, and research facilities could also be used to measure and improve outcomes for participants and develop evidenced-informed responses to the needs of people with disability at a population level, as well as support value for money investments (p49-51). This would enable greater visibility and improvement of services to participants in rural areas, as well as identify areas for investment.
From our point of view, this would require providers to have effective and automated systems for data collection. We agree with the Review’s observation that providers have limited capacity and incentive to develop the systems required for quality improvement (p 176). We also agree with the need for leadership,guidance and capacity-building for providers to develop quality systems.
b. the availability, responsiveness, consistency, and effectiveness of the National Disability Insurance Agency in serving rural, regional and remote participants;
The NDIA’s availability, responsiveness, consistency, and effectiveness has a greater impact in regional, rural and remote areas
Our experience with the NDIA reflects the general issues government agencies have in administering services to regional, rural, and remote communities, including workforce, upskilling and training, and capacity challenges. The impact of delays in administrating the Scheme, for example, accessing a participant’s budget and plan, delays in administering plan changes, or gaining information from Support Coordinators often have a bigger impact in rural areas as administrative delays are compounded by existing service delays.Ddelays in plan reviews can lead to lengthier delays in service provision.
Attitudes about rural; poorer responsiveness
Anecdotally we as providers and our participants’ representatives have experienced attitudes that are not helpful in rural communities for example: rural living is a person’s choice and therefore their problem; responsiveness including email and phone contact only being through larger call centres for every communication requiring the person to repeat their story each time and, again, lengthy
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delays in response times. Challenge and our participant representatives have had mixed face-to-face experiences in working with the NDIA in regional centres, ranging from helpful to rushed, understaffed and impersonal. We note that if this is our experience as providers and intermediaries, then it is likely to be confronting and difficult for people with a disability, Aboriginal and Torres Strait Islander participants, participants from culturally and linguistically diverse backgrounds, and participants from low socio-economic backgrounds.
Confusion around roles; and common-sense measures to support participants
There is also a lot of confusion for participant representatives around who is responsible for what between local area coordinators and the NDIA, and who to approach for specific answers. This issue was also raised in the NDIS Review. This leads to delays and related costs to participants. For NDIA workers within metropolitan or regional centres, practical measures can improve administrative processes for participants, such as plan reviews, for example, by doing a simple online search to find out about the services and about the location of the participant.
Advocacy services for small and remote communities
Moreover, increasing availability and access to advocacy services for people in smaller and remote communities would also improve engagement. We’ve found that unless participants have representatives who can advocate for them, there are limited resources for many vulnerable participants the further remote they live.
c. participants’ choice and control over NDIS services and supports including the availability, accessibility, cost and durability of those services;
Availability of services; investing in service development
Access to disability providers is disproportionately poorer in regional and rural areas than in metropolitan areas. This is a well-known issue that is common across health, social and community services. If participants are unable to use all of their budget due to a lack of availability of services, they can lose their funding. We have heard of participants being denied supports in smaller towns i.e. where there are fewer providers, if they have a record of being incarcerated and/or have a violent history. This is particularly devastating for vulnerable participants who need psychosocial supports to remain out of gaol.
As a NFP provider in a commercial environment, developing new service offerings in rural areas requires an initial investment that is not covered by the NDIS. As noted above, investment decisions rely on reliable data alongside a governing framework that provides a degree of certainty for providers.
Building modifications and fully accessible bathrooms
The current availability of tradespeople and materials means creating and modifying buildings so that they are accessible and functional is costly and has long time frames with delays. Modifications are often not up to the standard that the NDIS will pay for.
Additionally, in our customer’s experience, there are rarely fully accessible bathrooms in rural and regional communities. While the NDIS may pay for accessible bathrooms at home for participants with severe disability (i.e. requiring a ceiling hoist, over-the-toilet commode and adjustable change table), there is a lack of community bathrooms in rural areas. This means that participants need to return home to use a bathroom, restricting outings, going to work and travel plans. People with a
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severe disability should be able to live and work in their hometowns, go to activities and events outside the home, and be able to safely and with dignity use a bathroom. While this may be more of an issue for local governments than the NDIS, it illustrates the disconnection of services and funding responsibilities highlighted in the NDIS Review, and has a huge impact for people with a severe disability living in rural areas.
Workforce
The lack of a sustainable workforce is a major risk for providers in entering rural and regional markets. Nationally, the disability support workforce is critically low, worse in rural areas, and cannot match current demand. It is expected to decline further with people leaving the workforce while demand for supports increases. This is well documented in the NDIS Review.
Our experience reflects these issues including recruitment and retention, and training and supervision across long distances. Face-to-face training is difficult, particularly when support workers require time outside of NDIS-billable hours and not all training can be done online. Training for High Intensity Supports requires face-to-face training which includes travel to hubs as well as accommodation. For example, travel and training to a regional area (exclusive of the cost of training) for specialised manual handling has recently cost $1700. These additional costs do not encourage the level of training needed in rural areas to meet demand.
A lack of consistency in disability support workers and team leaders is an issue that has been raised by our clients. Additionally, there is a lack of specialist/high-needs trained workers and support coordinators. In rural and remote areas, the few support workers available may work several jobs because they are in high demand and consequently work an unsafe number of hours.
As a NFP provider, we have little organisational capacity to incentivise a rural workforce. While the NDIS has adapted the Modified Monash Model to determine prices in regional, rural, and remote areas, it is complex to use and does not apply to most of our service areas unless they are remote, even though we service several rural areas. It is our observation that other providers are not using this effectively due to its complexity.
Where markets fail, stable conditions for a regional, rural and remote workforce should be the responsibility of governments in collaboration with providers and local communities. These strategies should include incentives; support for training; face-to-face; recruitment schemes; support for housing and training; as well as flexibility in roles that are recognised by NDIS i.e. skill based and not limited to specific NDIS-funded roles. Health services have strategies and schemes to increase the numbers and quality of the workforce in rural areas. The broader disability governance ‘ecosystem’ should do the same.
Meeting participant needs vs plans; visibility of participants’ plans to provide more effective solutions
We have also found that participants’ needs can be greater than what their funding plans account for, or there might be a higher cost of services than anticipated. This situation could imply that participants are not receiving sufficient funding to fully meet their needs for living independently and safely. The limitations of providers in being able to see a participant’s plan make conversations on the reality of service provision within their NDIS budget very difficult. Limited visibility over a plan (which is often determined by the responsiveness of individual Support Coordinators or Plan Managers) means that providers are unable to coordinate and work with the client’s other providers to ensure they are getting a thorough and effective range of supports. Lack of coordination between
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multiple providers, again, dependent on the effectiveness of Support Coordinators which is highly variable, can lead to major service gaps. For example, a client in a Group Community Support program run by Provider X may be waiting on a new wheelchair through Provider Y, yet neither provider is aware that the client is receiving their services to be able to work together to coordinate an effective solution. Practical problem-solving across providers is essential and otherwise commonplace in rural and resource-poor areas.
Access to mental health treatments
Additionally, the NDIS does not fund mental health treatments as it only funds skill-building. Treatments are provided through the MBS Mental Health Care Plan which does not cover the full cost, leaving clients out of pocket, or in many cases unable to afford the care.
Transport
Through our formal and informal client engagement processes, we regularly hear how NDIS-funded transport disadvantages clients. It is not uncommon for an hour of a participant’s plan to be taken up by transport costs, and providers will often bear the costs to provide a reasonable service. Public transport is rarely an option, and there are disparities which become obvious for clients sharing accommodation. The complexities related to charging for transport means providers often bear the costs of allied health practitioners driving to see clients. Telehealth options for allied health are not always a viable or effective option.
There is also no provision or solution to scaling resources in small communities e.g. how to share a modified vehicle across participants and providers to achieve economies of scale. Matching tools to pool supports has also been recommended in the NDIS Review. This would benefit rural communities. We also agree with the NDIS Review that the Productivity Commission should develop an NDIS transport policy that better meets the needs of participants (recommendation 2.9).
d. the particular experience of Aboriginal and Torres Strait Islander participants, participants from culturally and linguistically diverse backgrounds, and participants from low socio-economic backgrounds, with the NDIS; and
There is great potential to use the NDIS to connect Aboriginal and Torres Strait Islander clients to culture as part of their NDIS plans, or even cultural support plans that link to NDIS funding in delivering and being accountable for this. While some of our clients have been able to access supports for cultural connection, for example, art, we understand that this is often not prioritised over other supports. However, the positive impact it has on social, emotional, physical, and spiritual wellbeing is key to ensuring ongoing holistic support for people with disability. This was also picked up by the NDIS Review. Disability in First Nations communities is twice as prevalent so there is a clear indication that NDIS supports need to be culturally safe and appropriate.
Additionally, information and resources in related and culturally secure languages should be provided to all First Nations participants. Education and information from First Nations people with lived experience as an NDIS participant can demonstrate the benefits of the NDIS to other First Nations people.
Access to interpreters in regional, rural, and remote communities is also essential from a therapeutic perspective, particularly for people with a complex diagnosis and those who may have experienced trauma. This is critical for treatments to be effective.
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