NDIA Accountability Project

NDIS Planning for Aboriginal Community Controlled Health Organisations

‹ PrevPage 1 of 9 · Source p. 1Next ›

NDIS

Planning

Submission to Joint Standing

Committee on the National

Disability Insurance Scheme

October 2019

About NACCHO

NACCHO is the national leadership body representing 144 Aboriginal Community Controlled Health Organisations (ACCHOs) across the country on Aboriginal and Torres Strait Islander health and wellbeing issues. ACCHOs range from large multi-functional services employing several medical practitioners and providing a wide range of services, to small services which rely on Aboriginal Health Workers and/or nurses to provide the bulk of primary care services, often with a preventive, health education focus. The services form a network, but each is autonomous and independent both of one another and of government.

In 1997, the Federal Government funded NACCHO to establish a Secretariat in Canberra, greatly increasing the capacity of Aboriginal peoples involved in ACCHOs to participate in national health policy development.

Our members provide about three million episodes of care per year for about 350,000 people across Australia, which includes about one million episodes of care in very remote regions.

ACCHOs specialise in providing comprehensive primary care consistent with clients’ needs. This includes home and site visits; provision of medical, public health and health promotion services; allied health; nursing services; assistance with making appointments and transport; help accessing childcare or dealing with the justice system; drug and alcohol services; and providing help with income support.

Collectively, we employ about 6,000 staff, 56 per cent whom are Indigenous, which makes us the single largest employer of Indigenous people in the country.

Any enquiries about this submission should be directed to:

NACCHO

Level 5, 2 Constitution Avenue

Canberra City ACT 2601

Telephone: 02 6246 9300

Website: naccho.org.au

Introduction

This submission will look at four specific areas outlined in the Joint Standing Committee’s Terms of Reference:

a. The ability of planners to understand and address complex needs b. The ongoing training and professional development of planners c. Participant involvement in planning processes and the efficacy of introducing draft plans d. The adequacy of the planning process for rural and regional participants

Background

Aboriginal and Torres Strait Islander peoples are twice as likely to experience a disability than other Australians (9% with a severe condition compared to 4% for non - Indigenous)1. Currently 5.7% of NDIS participants are Aboriginal and Torres Strait Islander peoples (16,417 active participants as at 30 June 20192) which is considerably less than the percentage thought to have a significant disability. The percentage of NDIS participants who are Aboriginal and Torres Strait Islander is indicative of the numbers of Aboriginal and Torres Strait Islander peoples with plans. It is not, however, necessarily representative of the extent to which Aboriginal and Torres Strait Islander peoples are receiving assistance under those plans as a result of services (or appropriate services) not being available.

The challenges of delivering the NDIS to Aboriginal and Torres Strait Islander peoples are complex, multi-faceted and have been well documented. Most significantly this has been recognised in the Transitional Arrangements for the NDIS Report, provided to the Joint Standing Committee on the NDIS, in 20183. There are a number of barriers at each access or referral point for Aboriginal and Torres Strait Islander peoples including:

  • Aboriginal and Torres Strait Islander peoples understanding of disability, the NDIS and their entitlement to access.

  • The withdrawal of historical disability supports creating gaps in services leading to barriers to access.

  • The availability of culturally appropriate services for Aboriginal and Torres Strait Islander people.

  • A true understanding of the disability needs in ACCHO service areas to plan, prepare and service the Aboriginal and Torres Strait Islander participants.

  • The availability of a suitable qualified workforce.

  • Higher needs for support coordination with approximately 75% of Aboriginal and Torres Strait Islander participants requiring this support compared with 25% for other Australians. NACCHO would argue that support coordination should be for 100% of Aboriginal and Torres Strait Islander participants.

  • Complex needs and causes, specific to transgenerational trauma resulting from the effects of colonisation.

1 Aboriginal and Torres Strait Islander Health Performance Framework 2017 report, section 1.14 Disability 2 National Disability Insurance Scheme (2019) COAG Disability Reform Council Quarterly Report, 30 June 2019 pp 16 3 Joint Standing Committee on the National Disability Insurance Scheme 2018, Transitional Arrangements for the NDIS, Commonwealth of Australia February 2018

Overarching findings The fundamental structure of the NDIA fails to put in place the necessary checks and balances to ensure that decisions and policies are not institutionally racist. The impact of this on individual members of the population can be hugely detrimental and our members, the ACCHOs, have found they need to provide additional support to community members to plug the gap.

A failure to consider Aboriginal and Torres Strait Islander people’s advice in the development of the NDIS has resulted in ACCHOs, and other Indigenous organisations, having to adapt a fundamentally flawed system to the needs of the community. This requires much energy, resources and workforce. It is delaying access for Aboriginal and Torres Strait Islander peoples with a disability to the NDIS and restricts the availability of culturally appropriate support services for those who are eligible to access services. A more constructive approach is to work with community to develop a model which is appropriate to their needs.

NACCHO recommends:

  1. The NDIA, through co-design with community, redesigns the NDIS model to make it appropriate and accessible for Aboriginal and Torres Strait Islander peoples.

  2. Support coordination be included in all Aboriginal and Torres Strait Islander peoples NDIS plans.

a. The ability of planners to understand and address complex needs Aboriginal and Torres Strait Islander peoples often require more support than other Australians to gain access to, and participate in, the NDIS. This support must be specialised. Therefore in ‘healthy’ markets there will also be sub-sets of thin market cohorts where operational costs are prohibitive to suppliers. The ACCHO Model of Care4 recognises cultural needs (for example, the concept of taking the appropriate time to establish a trusting and respectful relationship with the whole family unit and their cultural values) and the additional needs of a population with high co-morbidities who often have poor housing, are financially poor and have limited access to transport. This Model of Care has proven to be successful, however, there are additional costs involved with providing culturally appropriate care which further complicate this environment. Disability support responsibilities have gradually transitioned from States and Territories to the NDIS. This transition has not been smooth and in many instances, ACCHOs have found they need to provide additional support to community members to plug the gap. The transition’s flaw is due, in part, to the challenges around uptake for Aboriginal and Torres Strait Islander peoples with the NDIS as participants and service providers. It is also due to the lack of culturally competent planners and Local Area Coordinators (LACs). For many ACCHOs, disability support work actually commences at the stage of making an application (e.g. pre-planning). This activity is extremely labour and resource intensive, and further exacerbated by the unique needs of Aboriginal and Torres Strait Islander peoples with a disability. However, ACCHOs are picking up this activity pro bono to ensure their community members are able to access the services they require and to which they are entitled.

4 Panaretto et al., 2014. Aboriginal community controlled health services: leading the way in primary care. The Medical Journal of Australia, 200 (11)

Shifting NDIS access, planning and LAC services to culturally competent and easily accessible providers can be achieved in two ways: (i) embedding these services in the Aboriginal Community Controlled Organisation (ACCO) sector and (ii) ensuring the cultural competence of mainstream providers.

NACCHO recommends:

  1. A stream of funding be provided to ACCHOs for pre-access work undertaken.
  2. NDIA establish, in collaboration with NACCHO and the affiliates ‘Indigenous cultural safety accreditation standards’ for mainstream providers to meet and gain certification.

b. The ongoing training and professional development of planners Despite being preferable, it will not always be feasible to embed the provision of NDIS information, planning and LAC within an ACCO. Accordingly, these services need to be provided by culturally competent people and organisations. The vision statement in the NDIA Reconciliation Action Plan (RAP) is:

‘to work alongside Aboriginal and Torres Strait Islander peoples and communities, to build and manage a world leading NDIS that provides Aboriginal and Torres Strait Islander communities with culturally - responsible and equitable access to both the Scheme and employment opportunities and provisions within the Agency’5.

Specifically, action five of the NDIA RAP states the need for all employees to engage in ‘continuous cultural learning’. To ensure the cultural safety of all Aboriginal and Torres Strait Islander NDIS participants, all NDIA staff, contractors and NDIS planners should be required to have completed a minimum level of cultural awareness training. In addition, the NDIA should develop a strategy, in partnership with community, for building a workforce of Aboriginal and Torres Strait Islander planners that would culminate in a culturally appropriate workforce for Aboriginal and Torres Strait Islander peoples and communities in all regions of Australia. Similarly, the NDIA should establish a requirement that all LAC staff have undertaken as a minimum, cultural awareness training. The NDIA in collaboration with NACCHO and First Peoples Disability Network (FPDN) could establish ‘Indigenous cultural safety accreditation standards’ for LACs to meet and gain certification. Again, the NDIA should encourage (perhaps incentivise) support and facilitate the building of an Aboriginal and Torres Strait Islander LAC workforce. Affiliates and/or ACCHOs should be commissioned to undertake the training for staff where possible as many of them are Registered Training Organisations (RTOs).

5 National Disability Insurance Agency Innovate Reconciliation Action Plan 2019 – 21, pp10.

Case study: In Western Australia (WA), as part of the new Remote Community Connectors (RCC) program, ACCHOs are delivering cultural awareness training to local and national NDIA Planning staff. This is done in combination with the NDIA training for the Remote Community Connectors, in a two-way training situation. ACCHO staff provide cultural safety training for teams for the first part of the day and then NDIA staff deliver training on what the NDIS is and the Remote Community Connectors Program. This program has been found to be very useful as those planners who are involved in the planning meetings and planning process with Aboriginal and Torres Strait Islander participants are gaining cultural awareness training locally. Planners are using this local knowledge, and a greater understanding of Aboriginal and Torre Strait Islander culture more generally, to start thinking about more culturally appropriate plans for participants.

NACCHO recommends:

  1. All NDIS planners and NDIA staff should be required to have completed a minimum level of cultural awareness training, with an accredited certificate being the preferred option.

  2. The NDIA develop a strategy, in partnership with community, for building a workforce of Aboriginal and Torres Strait Islander planners.

  3. The NDIA explore the potential for Indigenous specific LACs (or RCCs) to be established in each jurisdiction.

  4. The NDIA encourage (perhaps incentivise) support and facilitate the building of an Indigenous LAC workforce.

c. Participant involvement in planning processes and the efficacy of introducing draft plans Aboriginal and Torres Strait Islander peoples with a disability who are eligible for a plan under the NDIS should be (and often are) involved in the planning meeting. In many instances the participant attends with a representative who is able to support them in communicating their needs. This may be a representative from a support organisation, a family member or friend. ACCHOs frequently support their clients through this process in the background, receive ‘draft plans’ and provide support coordination to the client once plans are finalised. Despite ‘draft plans’ existing, the NDIA does not tend to enter into any discussion about the supports included in the plan and the ‘draft plans’ are most often finalised with no opportunity for adjustments. This can lead to inadequate plans for the participant with limited options to adjust the plans.

Case study: One Queensland ACCHO who provide NDIS services find that roughly 20% to 30% of their clients receive plans that do not include support coordination when support coordination is required by the applicant. Rather than being able to address this at a ‘draft plan’ stage, ACCHOs often find they need to submit a ‘change of circumstances’ form or a ‘request for review document’ to secure support coordination funding for their clients, or they support the client for the first year at the ACCHOs cost, and promote the need for support coordination to be included at the 12-month review stage. The ‘draft’ process has not yet provided sufficient opportunity to negate the need for later adjustments.

Case Study: A participant living in remote SA attended a pre-planning meeting. It was noted that the participant had no idea about the NDIS, so the Planner introduced themselves as ‘disability’. The participant is considered a ‘defined client’ and therefore, the local health service was not required, or asked, to submit any supporting medical information, or any information about their social needs throughout the process. This has meant that the plan has now been developed on the basis of the ‘defined client’ process, which in this instance only considered some of the participant’s medical history. Therefore, the participant received a plan based on their requirements as an amputee, however, the participant also suffers with mental health which is unaccounted for or addressed in the plan. Although the participant was fortunate enough to have a representative from their local health service with them in this meeting, due to the participant being a ‘defined client’ there is no avenue available for the health service to provide additional information that would provide a holistic view of this client (i.e. functional capacity, housing, environmental, social emotional wellbeing) At the end of the planning meeting the participant was asked to choose a Coordinator of Support (C.O.S). This was done by showing the participant a poster with the names and associated logos of all the available C.O.S’ and they were asked to choose. There was no explanation what a C.O.S is, what a C.O.S might offer, or the difference between the COS’ available. It was at this point that the representative from the local health service pointed out that a certain organisation did not service that particular community, and questioned participants’ ability to make informed decisions with a lack of information or incorrect information.

d. The adequacy of the planning process for rural and regional participants Even if Aboriginal and Torres Strait Islander peoples are successful in applying for, and meeting the eligibility criteria for the NDIS, many communities still face limitations in accessing the Scheme due to geographical location and the limited physical resources to meet demand. Some jurisdictions are receiving additional funding to support NDIS work. The initiative in WA announced by the former Minister for Families and Social Services Minister Fletcher, to invest in a Remote Community Connectors (RCC) Program, has seen people from remote communities employed by local ACCHOs to promote understanding and awareness of the NDIS. The RCCs link

people to access, planning and implementation pathways which assist people in testing their access to the NDIS and, if eligible, support them to build a plan with the NDIA. WA ACCHOs have been funded for Remote Community Connectors, as well as Evidence, Access and Coordination of Planning position (EACP) in local AMS’. This position addresses some of the barriers that confront Aboriginal and Torres Strait Islander peoples to entering the NDIS especially within rural and remote areas. Challenges such as contacting the NDIS and completing the forms to request access, including obtaining appropriate clinical or other assessments can be overcome. The EACP position is based in an AMS, and with the consent of the individual, the EACP is able to work with NDIA National Access Team to facilitate the request for access process, utilising existing medical records and coordinating additional evidence where required. This program effectively addresses a large barrier encountered by many Aboriginal and Torres Strait Islander participants. As of mid-August 2019, in WA, there were contracts with 16 ACCHOs RCCs and another three under negotiation. There were 14 AMS’ with contracts for EACP with a further seven under negotiation.

Case Study: RCC’s often support participants in the planning meeting but also help to get relevant paperwork completed outside of this. In East Pilbara, the capacity of RCC’s is growing and many are starting to take on more responsibilities as their skills and confidence builds. RCC’s also support the EACP (support coordination) – for functional assessments, making sure the participants can attend the functional assessments i.e. arranging transport, communication etc.

In East Pilbara, since June 2019, Puntukurnu Aboriginal Medical Service (PAMS) RCC and EACP

positions have assisted 60 participants in planning meetings/submissions with 35 people now approved to enter the scheme.

Key barriers for remote participants include remoteness, isolation and the mobile and transient nature of peoples which makes it difficult to track possible participants. In WA, this is where the RCCs have assisted, but distance is still a challenge for a small team. Costs increase in remote areas due to numbers of participants, transport and complex needs. The real costs of delivering services to Aboriginal and Torres Strait Islander peoples in remote areas need to be assessed. Due to the additional resources required to engage with Aboriginal and Torres Strait Islander peoples in a culturally competent way, NACCHO believes that ACCHOs (and indeed mainstream providers) should receive a loading for the provision of service to Aboriginal and Torres Strait Islander peoples. This is a feature of other funding models for Aboriginal and Torres Strait Islander service provision in Australia. This weighting should be further increased to account for the costs of service provision in remote Australia. Changes to the funding model to include consideration of the specific needs of Aboriginal and Torres Strait Islander people with a disability would enable a more realistic service delivery business model for those areas currently experiencing thin markets.

NACCHO recommends:

  1. The NDIA in partnership with NACCHO and the Affiliates analyse the real costs of providing NDIS services to Aboriginal and Torres Strait Islander peoples with a disability in urban, regional, remote and very remote locations and provide an appropriate loading to the standard NDIS pricing to recognise this additional cost.

Full list of NACCHO Recommendations

  1. The NDIA, through co-design with community, redesigns the NDIS model to make it appropriate and accessible for Aboriginal and Torres Strait Islander peoples.

  2. Support coordination included in all Aboriginal and Torres Strait Islander peoples NDIS plans.

  3. A stream of funding be provided to ACCHOs for pre-access work undertaken.

  4. NDIA establish, in collaboration with NACCHO and the affiliates ‘Indigenous cultural safety accreditation standards’ for mainstream providers to meet and gain certification.

  5. All NDIS planners and NDIA staff should be required to have completed a minimum level of cultural awareness training, with an accredited certificate being the preferred option.

  6. The NDIA develop a strategy, in partnership with community, for building a workforce of Aboriginal and Torres Strait Islander planners.

  7. The NDIA explore the potential for Indigenous specific LACs (or RCCs) to be established in each jurisdiction.

  8. The NDIA encourage (perhaps incentivise) support and facilitate the building of an Indigenous LAC workforce.

  9. The NDIA in partnership with NACCHO and the affiliates analyse the real costs of providing NDIS services to Aboriginal and Torres Strait Islander peoples with a disability in urban, regional, remote and very remote locations and provide an appropriate loading to the standard NDIS pricing to recognise this additional cost.