Submission 88 — Western Australian Government — NDIS participant experience in rural, regional and remote Australia | External submission

GOVERNMENT OF

WESTERN AUSTRALIA

Western Australian

Government

Submission to the

Joint Standing Committee on the National

Disability Insurance Scheme:

NDIS participant experience in rural, regional and remote

Australia

………………………………………………………………………………………………………………….. 1

Introduction ……………………………………………………………………………………………. 3
The NDIS in WA …………………………………………………………………………………….. 4 2.1 Population and Geography ………………………………………………………………… 4 2.2 Participation and Utilisation ………………………………………………………………… 4
Systemic Issues Affecting the NDIS in Regional and Remote WA …………………. 5 3.1 Thin markets and market failure ………………………………………………………….. 5 3.2 Pricing framework …………………………………………………………………………….. 6 3.3 Workforce ………………………………………………………………………………………… 7 3.4 System navigation and plan implementation …………………………………………. 7
Priority Cohorts ………………………………………………………………………………………. 8 4.1 Aboriginal people with disability ………………………………………………………….. 8 4.2 Participants with complex needs …………………………………………………………. 9
Priorities for Scheme Improvements ………………………………………………………….. 9 5.1 NDIS system design ………………………………………………………………………….. 9 5.2 Market development ………………………………………………………………………… 10 5.3 NDIS pricing …………………………………………………………………………………… 10 5.4 Embedding flexible and place-based commissioning ……………………………. 10 5.5 Foundational Supports Strategy ………………………………………………………… 11 5.6 Workforce ………………………………………………………………………………………. 12 5.7 Advocacy ………………………………………………………………………………………. 12
Conclusion …………………………………………………………………………………………… 12 2

Introduction The Western Australian (WA) Government is committed to a NDIS which delivers outcomes for all participants, and more broadly to meeting our obligations under the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) through the State Disability Strategy, Australia’s Disability Strategy, and the 2020 National Agreement on Closing the Gap. In addition to significant investment in the NDIS, the WA Government provides a range of services to support the inclusion of people with disability. The WA Government’s ‘A Western Australia for Everyone – State Disability Strategy 2020-2030’ drives the commitment to further the inclusion, social and economic participation of people with disability in this State. The NDIS represents a fundamental shift in how disability supports are funded and delivered. Moving away from a traditional welfare model, the NDIS sought to address the ration based and fragmented service systems through the provision of individualised funding for specialist disability services. WA joined the Scheme in December 2017, signing a Heads of Agreement and a Bilateral Agreement – ‘Transition to the National Disability Insurance Scheme in Western Australia’ with the Commonwealth Government. In doing so, WA committed to a NDIS that was designed to provide individualised packages to eligible people with disability based on supports deemed ‘reasonable and necessary’ to meet disability support needs, as well as to support all people with disability to have increased linkages to community supports and foster social change. WA’s commitment was predicated on the NDIS being fairly, sustainably and equitably accessible across the State, delivering positive outcomes for individuals, their families, and carers. However, the Scheme has not been delivered as intended and implementation issues are impacting its performance in WA. There are persistent issues with key enabling elements of the NDIS, which include the operation of the National Disability Insurance Agency, the NDIS provider market, the disability workforce and the failure to establish and administer Tier 2 disability services as intended to support people outside of individualised budgets. These have resulted in thin markets remaining prevalent across regional and remote areas of Western Australia, with people with disability facing ongoing difficulty accessing support from the NDIS. As well as impacting participant outcomes, this has implications for the WA Government, including increasing pressure on State services and the State having to intervene with stop-gap measures in some instances. The final reports of the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability (October 2023) and NDIS Review (December

highlighted the lack of appropriate NDIS supports in regional and remote areas, recommending significant reforms to the NDIS as well as the wider disability support ecosystem the NDIS is a critical part of. Addressing these recommendations needs to explicitly consider how to improve outcomes for NDIS participants in rural, regional and remote Australia.

The NDIS in WA 2.1 Population and Geography There are challenges in operating the standard NDIS market model in WA due to its size, climatic/geographic variation and sparse population. For example, WA has:

A comparatively small population, approximately 2.9 million people;
a dispersed population, at 1.1 people per square meter compared to 10.2 in New South Wales and around 29.4 in Victoria;
12,000 people live in more than 200 remote Aboriginal communities throughout Western Australia, and 3,000 Aboriginal people live in 37 town based communities;
isolation from the rest of Australia. The nearest city to Perth with a population of more than 100,000 is Adelaide, South Australia, over 2,100 km away;
commodity-driven economic cycles; and
limited supply of housing and higher overall cost of living in regional, remote and very remote areas.

Effective service delivery to regional and remote areas of the State, particularly for Aboriginal communities, need to prioritise a place-based approach focused on shared-decision making and partnerships, and the notion that no one size fits all to help establish cultural safety and ensure Aboriginal expertise is incorporated. There should be a priority on service delivery through Aboriginal Community Controlled Organisations (ACCOs). However, to date, the NDIS has struggled to meet the needs of Aboriginal peoples, or to build the ACCO sector effectively. i As a result of the NDIS model not being well adapted to WA’s population and geography, people with disability in regional areas experience numerous barriers to accessing culturally appropriate specialist disability support. This negatively impacts outcomes, and compounds the disadvantage faced by people living in regional and remote areas, who experience poorer general health than those in metropolitan areas. Further, the State Government acknowledges that Aboriginal people experience ongoing and complex disadvantage because of the ongoing impacts of colonisation. The NDIS has a role to play in partnering with Aboriginal communities and peak organisations to address this disparity.

2.2 Participation and Utilisation

WA experiences significantly lower Scheme participation rates than the national average, and low utilisation of participants’ plans. This issue disproportionately impacts vulnerable cohorts, including:

participants in regional or remote areas of WA;
Aboriginal participants;
participants with complex needs;
participants with psychosocial disability; and
culturally and linguistically diverse (CaLD) participants. 4

Overall in WA:

participation rates (e.g. participants as a proportion of the relevant population) are around 15 per cent below the national average (after accounting for WA’s lower disability prevalence rate);
utilisation rates (e.g. actual spend against approved plans) are around 5.1 percentage points below the national average.

Scheme performance in WA’s regional and remote areas lags the national average in comparable areas, with lower participation, utilisation and levels of committed supportsii.

Utilisation rates for priority cohorts remain low across WA, with rates for Aboriginal participants at 69 per cent (3.7 percentage points below the national average for Aboriginal participants), and rates for participants with psychosocial disability at 66 per cent (6 percentage points below the national average for participants with psychosocial disability).

Utilisation of supports in specific regions and sub-regions are very low, and some cohorts are disproportionately impacted, as highlighted belowiii:

Table 1 –Utilisation rates for specific regions/sub regions and specific cohorts in WA

Average utilisation rates iv   Derby - West Kimberley  Wheatbelt  WA

Overall                47%                60%       73%

First Nations People        47%                55%       69%

participants

Participants with          17%                49%       69%

psychosocial disability

CaLD participants         24%                80%       76%

Low plan utilisation rates indicate that participants are unable to access the services they are funded to receive. This may be due to lack of provider availability in the local area, either for one type of service or no services available at all, lack of navigation or coordination support to assist implementing plans, and/or lack of culturally appropriate service options. These factors are discussed in detail below.

Systemic Issues Affecting the NDIS in Regional and

Remote WA

3.1 Thin markets and market failure Across WA there are multiple thin or non-existent markets which result in people with disability either failing to receive supports or having to leave their local community to access services. Thin markets impact the delivery of personal care, health, psychology, and allied health services such as occupational therapy and speech

therapy. This is particularly pronounced for participants with complex behaviour and those from very small remote communities. In Scheme implementation, a predominantly one-size-fits-all approach has been taken to market development, which does not take into consideration the need for bespoke solutions across priority cohorts, as well as service delivery challenges in remote areas. The result is a limited supply of services in regional, remote, and very remote areas in WA. This impacts negatively on participant outcomes due to the lack of, or insufficient services and safeguarding. In some cases of market failure, a more costly crisis response and the State intervening with stop-gap measures may also be required. An area of specific concern is the ongoing gap in suitable accommodation for NDIS participants including supported independent living (SIL) and specialised disability accommodation. This is particularly evident outside of metropolitan WA, with multiple examples of participants across the State moving to Perth to access appropriate home and living supports. Relocation in these circumstances is particularly detrimental for Aboriginal people for whom connection to Country, community and culture is essential to their wellbeing. Lack of access to appropriate SIL supports and crisis response services, and delays in the NDIA’s response to changes in participant circumstances result in preventable Emergency Department (ED) presentations and hospital admissions, and reliance on hospitals for broader supports such as replacement aids and equipment. Unnecessary hospital admission due to failure of support services impacts participant outcomes and results in significant preventable cost to the State. The State has taken steps to address this issue on top of its contribution to the NDIS. For example, in response to market failures in regional WA, the WA Department of Health commenced its first regional From Hospital to Home (FH2H) pilot in the Southwest region in November 2023. FH2H supports eligible adults for up to 18 weeks while NDIS, housing, and other long-term community supports are secured. The Southwest FH2H pilot has supported the discharge of patients who no longer need hospital care to more appropriate community living, increased the availability of hospital beds in the region and enabled funding to be redirected to patients requiring hospital care. In addition, the WA Country Health Service (WACHS) has increased allied health services for clients in areas with no or limited access to NDIS supports. This action has been taken to ensure service continuity to local communities. However, given that these services are within the scope of the NDIS, it is not the intended long-term role of WACHS.

3.2 Pricing framework The NDIA pricing framework does not support the development of sustainable markets in regional areas. The individual funding model makes it difficult for providers to identify cohorts of target participants, and for potential services to be deemed cost effective and viable. While visiting services are improving access in some areas, the high cost of these significantly reduces the quantum of services a participant can purchase with their plan funding. In addition, lack of local service availability results in travel costs to the participant or significantly increased service costs. As funding for travel costs are 6

only available to providers, not participants, this can also impact the proportion of plan funding utilised for service provision. The Remote and Very Remote Allowance applicable to some areas has supported the growth of local, drive-in-drive-out and fly-in-fly-out providers. However, many areas of regional WA do not have access to this allowance and continue to experience market development and service provider attraction issues. In addition, the allowance is applied to the location of the provider and does not consider the further remoteness or isolation of the participants it may service.

3.3 Workforce

Workforce shortages are a key contributing factor to thin markets. Developing, attracting and retaining an enduring workforce to deliver services and supports is a challenge across the State. It is exacerbated in regional and remote areas, including by limited housing options and the high cost of living. This is in a context where the demand for services in the social assistance and allied health sectors is escalating, with the demand for workers predicted to rise across all sectors, led by the disability and aged care sectors. Concurrent reforms across disability, aged care, health and mental health will continue to create competition for the allied health and social care workforce. Without appropriate attraction and retention incentive structures, regional and remote WA cannot attract the workforce required to meet current or future need.

The largest occupational group in these sectors, support workers, has been identified as needing to double over the course of 2019-2024v. Other support types experiencing significant market issues are:

Positive Behaviour Practitioners, resulting in lengthy waits in Behaviour Support Plans being developed and delays to authorisation processes.
Supports for participants with psychosocial disability such as Recovery Coaches, Support Coordination, and core support providers in remote WA. The limited psychosocial disability skilled workforce contributes to poor outcomes and increases the pressure on primary and community mental health services.
Specialist support workers (such as for participants with complex needs). The planned introduction of state- and territory-funded foundational supports services (outside of the NDIS) will increase the pressure on the WA government to attract and retain disability services workforce in regional and remote areas.

3.4 System navigation and plan implementation The limited NDIA footprint in regional areas, including the lack of Partners in the Community, impacts plan implementation. Many potential participants struggle to navigate the NDIS access process and burden falls on existing mainstream services. This difficulty will be further exacerbated with the introduction of a foundational supports system that is separate to the NDIS. These reforms will require a coordinated approach to ensure that people can access the right services and navigate between the systems.

Public schools in rural and remote areas play a key role in increasing NDIS access for students to ensure they receive the required services. Remote schools often serve as hubs for coordinating support services, which involves collaborating with parents, NDIS planners and coordinators, healthcare providers, and allied health care professionals. Remote schools often provide extensive support to local families to navigate the NDIS application process and provide infrastructure for service providers visiting the community. Taking on this role represents a significant input of time and school-based resources, however without this input and co-ordination fewer students would be able to access the supports necessary for their physical, social and emotional development. Health services often play a similar role, although this is further impacted by General Practitioner capacity, long wait times for assessments and high costs. For individuals who are not engaged with health professionals, or who lack phone or internet access, the NDIS access process is even more challenging. The State Government would welcome a permanent extension of Partners in the Community to all regional areas of WA to support people at the interface. Support Coordinators, and in line with the NDIS Review, potentially navigators, that are not based in regional communities often have a limited understanding of the context and local service availability, resulting in poor plan implementation support, especially for vulnerable populations. It is understood the NDIA has recently reinvigorated the role of internal Local Area Coordinators, who support plan implementation and utilisation of supports. The State Government is supportive of this and looks forward to understanding more about how the program is being developed. The State also acknowledges the funding provided by the NDIA to Aboriginal Community Controlled Health Organisations to undertake a Community Connector role in some remote communities.

Priority Cohorts 4.1 Aboriginal people with disability Aboriginal people are disproportionately impacted by disability and under represented in the uptake of disability services. Aboriginal NDIS participants in regional WA face many challenges accessing and using their supports, including:

Lack of cultural and place-based consideration in plan development that can result in inappropriate, impractical and underfunded plans;
limited service choice and availability, impacted by thin markets/market failure;
limited or no availability of Aboriginal community controlled health organisations;
the need for extensive travel and transportation;
lack of suitable accommodation options;
lack of culturally appropriate service options;
lack of specialist disability expertise, noting the challenges to recruiting, training and retaining professionals in these areas; and
issues with service quality including cultural appropriateness and safety. 8

In some cases, these factors have contributed to Aboriginal people under age 50 accessing Residential Aged Care in order to remain close to family, community and Country. A ‘one size fits all’ implementation of the NDIS often does not work for Aboriginal participants, and what might work for one Aboriginal community may not work for another. Significant improvements to the NDIS are required to ensure equity of access and culturally appropriate services. The NDIA could seek to implement the National Agreement on Closing the Gap and the associated Disability Sector Strengthening Plan to strengthen the NDIS and build culturally secure care for Aboriginal Western Australians.

4.2 Participants with complex needs

Participants with complex needs face additional barriers in accessing NDIS supports due to thin markets and workforce shortages. The funding and regulatory environment of the NDIS, in combination with difficulty recruiting skilled support workers, may render providers unable to take on participants who have complex needs and/or present with behaviours of concern. This can result in vulnerable individuals experiencing crises due to lack of critical supports. It can be challenging to establish sustainable living arrangements in the metropolitan area, and it is even more challenging in regional and remote areas due to the higher costs for providers, lower workforce capacity, and reduced access to allied health services for capacity building. The State is aware of a number of individuals who have been unable to live in their community or on Country due to a lack of local providers capable of supporting complex needs, and this in turn results in poorer outcomes for individuals.

Priorities for Scheme Improvements 5.1 NDIS system design The State Government looks to the Commonwealth to implement the NDIS Review in a way that fulfils its promise to restore trust and put people with disability at the centre of the NDIS. To ensure regional and remote communities benefit from the NDIS Review, implementation should focus on:

Reducing complexity at planning and review stages;
more supports for priority cohorts to enter and navigate the Scheme, including through relevant ACCOs;
more timely responses to changed circumstances, and a focus on participant outcomes;
alignment with the National Agreement on Closing the Gap;
provision of Local Area Coordination (LAC) or navigation would also be valuable to support people with disability, their families and carers to navigate access, eligibility and engagement with services in regional areas. This is another area the ACCO sector is positioned well to deliver.

5.2 Market development

The Mid Term Review of the National Health Reform Agreement (NHRA) recognises

that thin NDIS markets add to hospital bed block pressures. It also recognises that the NHRA falls short in defining the Commonwealth’s market development role to ensure disability (and aged and primary care) services in rural and remote areas are accessible and sustainable. An effective and sustainable Provider of Last Resort mechanism would support service delivery where markets fail. In line with recommendation 35 of the Mid Term Review of the National Health Reform Agreement, WA recently sought the Commonwealth’s commitment to embedding stronger accountability arrangements to support WA’s role as Provider of Last Resort in disability, aged and primary care. This would include clear escalation pathways, flexibility to develop service responses, and equitable funding models.

5.3 NDIS pricing The NDIS must implement flexible price settings that are responsive to local market conditions. The State Government supports the position of the Aboriginal Health Council of Western Australia (AHCWA) which, in its NDIS Review submission, stated that NDIS pricing should be revised to accommodate the higher cost of delivering services in regional and remote areas, in recognition of the clear disparity in the availability of services.vi Geographic pricing differentiation should not only account for direct operational costs such as travel, but also consider the cost of staff attraction and retention (including housing) and service capacity building in regional and remote areas.

5.4 Embedding flexible and place-based commissioning Place-based and collaborative approaches have been shown to achieve better outcomes, especially for Aboriginal people, whose cultural needs can vary significantly between communities. This includes the continued use of coordinated funding proposals and alternative commissioning models. The State Government believes these approaches are the best option to ensure equitable and culturally safe access to services in regional and remote areas. In addition, block funding could be utilised to address shortfalls in specific professions such as allied health by incentivising outreach or fly-in supports models of service. The State acknowledges the NDIA’s commitment to working with communities in remote areas to address market gaps, with activities such as the Integrated Care and Commissioning trials and Alternative Commissioning pilots. For example, the NDIA recently partnered with the Kimberley Aboriginal Medical Service aiming to co design a model to assist Aboriginal people to test their eligibility for the NDIS, link people with disability to the NDIA through trusted community members using

Community Connectors, and deliver the Early Childhood Intervention Services. This

is an example of a successful partnership that is making a difference in remote WA by addressing barriers to access and supports.

Using trusted providers with existing infrastructure and relationships builds on the strengths of ACCOs in their delivery of holistic, culturally safe services, aligned to the Disability Sector Strengthening Plan and supporting the development and delivery of

Priority Reform Two of the National Agreement on Closing the Gap. Embedding this approach through new partnerships with local communities will be key moving forward.

To make progress however, Aboriginal Community Controlled Organisations (ACCOs) need to be supported to enter the disability services market and resourced to build on their existing infrastructure. AHCWA provided sound advice on this in its NDIS Review submission. AHCWA noted:vii

Coordinated Funding Proposals must be a sustainable line of business for the ACCOs that play the coordinating role.
Many ACCOs will not reach sustainability in the NDIS space unless the Commonwealth reduces the administrative burden for providers. The implementation of the NDIS Review should address these issues. The Commonwealth should also undertake further market development work with regional providers to deliver broader social care services, including disability and aged care, to improve their viability and address the administrative burden of operating under multiple service systems with varied regulatory frameworks. The State Government also looks to the Commonwealth to consider the recommendations of the 2023 Deloitte research report on ‘Options to improve service availability and accessibility for First Nations people with disability’. This report, commissioned by the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability, makes numerous recommendations to improve cultural safety and address thin markets in regional and remote areas.

5.5 Foundational Supports Strategy

National Cabinet commissioned the design of a Foundational Supports Strategy, to guide the implementation of a foundational supports system for disability services delivered outside the NDIS. The Strategy provides an opportunity to carefully consider the challenges faced by regional and remote NDIS participants, and to make appropriate changes to see improvements under the foundational supports system. In particular, the State Government would like to improve accessibility of supports, service navigation and to better connect regional people with disability to appropriate services. While the strategy must be nationally consistent, each government will have nuanced, place-based approaches to its local implementation. This will be particularly important for jurisdictions like WA with complex geographical challenges that report significant NDIS underperformance in regional, remote and very remote communities. However, existing service gaps need to be addressed to ensure that the simultaneous reforms to the NDIS and implementation of the Foundational Supports Strategy do not increase complexity for people in WA with disability to access the appropriate supports. Further, foundational supports in regional and remote areas must not be expected to fill market gaps due to challenges with implementation and performance of the NDIS. In particular, the Commonwealth, states and territories will need to carefully consider the scope, eligibility criteria and commissioning approach for targeted foundational

supports. These important supports must be adequately funded and delivered across regional and remote areas, or risk exacerbating the existing disparity in service availability from the NDIS.

5.6 Workforce Consideration should be given to co-designing regional disability workforce development strategies that address workforce requirements. These should include measures targeted at the professional development needs of regional workforces, to build the skills, knowledge and expertise in priority areas. Building workforces within Aboriginal communities to deliver services through Aboriginal organisations should be an area of focus. ACCOs are placed-based and provide culturally safe service delivery, and can therefore:

Be a conduit between NDIS and Aboriginal people with disability, their families and community by providing cultural and local considerations in plan development;
safely recruit, train and retain staff from the community. Community working with community is a proven way of providing an accessible and inclusive environment for everyone.

5.7 Advocacy Advocacy is a key element to building choice and control for people with disability, especially for the priority cohorts of Aboriginal people and those with complex needs, who face intersecting forms of discrimination and disadvantage. The State and Commonwealth governments are working together to improve access to disability advocacy under Australia’s Disability Strategy - Disability Advocacy Work Plan 2023 2025.

Conclusion While the NDIS has positively impacted many participants, families and carers, the State Government is concerned that many people with disability in regional and remote WA are not benefitting to the same extent as other NDIS participants. The NDIS Review promises fundamental reforms to the scheme that will improve participant outcomes, but risks seeing further one-size-fits all solutions implemented. The Commonwealth must instead partner with states and territories, local communities, the disability services sector and the Aboriginal community controlled sector to address the disparity in access and outcomes across the State. The State Government appreciates the opportunity to submit to this Inquiry and remains committed to ensuring all people with disability can access the services they need and participate fully in the community regardless of where they live.

i NACCHO (2019) More support to the Aboriginal Community Controlled Health Sector is needed to increase Aboriginal and Torres Strait Islander peoples access to the National Disability Insurance Scheme (NDIS) https://www.naccho.org.au/more support-to-the-aboriginal-community-controlled-health-sector-is-needed-to-increase-aboriginal-and-torres-strait-islander peoples-access-to-the-national-disability-insurance-scheme-ndis/ ii NDIS data, Q1 FY23/24 2023

iii Explore data | NDIS

iv NDIS (2023) Explore data | NDIS - https://data.ndis.gov.au/explore-data. Accessed February 2024

v State Training Board (2018) Social Assistance and Allied Health Workforce Strategy. State Training Board, Government of Western Australia https://www.stb.wa.gov.au/sites/default/files/SAAHWorkforceStrategy_Final.pdf

vi AHCWA (2023) Submission to Professor Bruce Bonyhady AM and Ms. Lisa Paul AO PSM: Independent Review

into the National Disability Insurance Scheme (NDIS) https://www.ahcwa.org.au/wp-content/uploads/2023/11/AHCWAs-Submission-to-the-Independent-Review-into-the-National-Disability-Insurance-Scheme-NDIS.pdf pp. 12, 15, 19.

Submission 88 — Western Australian Government — NDIS participant experience in rural, regional and remote Australia