Submission 66 — Services for Australian Rural and Remote Allied Health — NDIS Quality and Safeguards Commission | External submission

~~s~,~~tt t / Rural and Remote Allied Health

Submission to the

Joint Standing Committee of the NDIS

NDIS Quality and Safeguards

Commission

2 October 2020

Services for Australian Rural and Remote Allied Health

ABN 92 088 913 517   •    t: (02) 6285 4960  •  e: sarrah@sarrah.org.au   •  w: www.sarrah.org.au

Unit 4, 17 Napier Close, Deakin, ACT, 2600 • PO Box 74, Deakin West, ACT 2600

Contents ……………………………………………………………………………………………………………………………………. 2

Introduction ……………………………………………………………………………………………………………………….. 3
Importance of allied health workforce and services ……………………………………………………….. 7
Addressing the Terms of Reference ………………………………………………………………………………….. 7 a) The monitoring, investigation and enforcement powers available to the Commission, and how those powers are exercised in practice; ……………………………………………………………….. 7

b) The effectiveness of the Commission in responding to concerns, complaints and reportable incidents – including allegations of abuse and neglect of NDIS participants; …… 8

c) The adequacy and effectiveness of the NDIS Code of Conduct and the NDIS Practice Standards; ……………………………………………………………………………………………………………………………… 8

d) The adequacy and effectiveness of provider registration and worker screening arrangements, including the level of transparency and public access to information regarding the decisions and actions taken by the Commission; …………………………………………. 9

e) The effectiveness of communication and engagement between the Commission and state and territory authorities; ……………………………………………………………………………………………….. 9

f) The human and financial resources available to the Commission, and whether these resources are adequate for the Commission to properly execute its functions; ……………….. 10

g) Management of the transition period, including impacts on other Commonwealth and state-based oversight, safeguarding, and community engagement programs; ………. 10

h) Any related matters. ……………………………………………………………………………………………………. 10 Page | 2

Introduction Thank you for the opportunity to provide input to the Joint Standing Committee Inquiry on the NDIS Quality and Safeguards Commission. We provide this submission on behalf of the members of Services for Australian Rural and Remote Allied Health (SARRAH). SARRAH values the in-depth work of the Parliamentary Joint Standing Committee on this key national policy and service priority and the Committee’s role in guiding the evolution, quality and impact of the Scheme. SARRAH welcomes the scope of the Joint Standing Committee’s remit considering the implementation, performance and governance of the NDIS.

SARRAH also fully supports the establishment of the NDIS Quality and Safeguards Commission, which plays a vital, independent, quality assurance and improvement role for the Scheme and the community as a whole.

As the Commission notes in its Annual report 2018-19 Our role is to promote the provision of safe and quality supports and services to people with disability under the National Disability Insurance Scheme (NDIS)1. SARRAH hopes to assist the Commission in this role.

SARRAH is the peak body representing rural and remote allied health professionals (AHPs) working in the public and private sector, across health, disability, aged care and other settings. SARRAH was established in 1995 and advocates on behalf of rural and remote Australian communities in order for them to have access to allied health services that support equitable and sustainable health and well-being. AHPs are tertiary qualified health professionals who apply their clinical skills to diagnose, assess, treat, manage and prevent illness and injury and support people with disability2.

As with previous submissions SARRAH has provided to the Joint Standing Committee previously, our input will focus primarily on ensuring the NDIS as a whole enables participants to access the most appropriate and beneficial allied health services and care, in line with participants’ interests, ambitions and needs. The NDIS Quality and Safeguards Commission has a key role to play in ensuring the Scheme enables optimal access to these services for participants. Put simply, that access often does not occur due to a lack of access and workforce where it is needed. These are long-standing concerns

Allied health professionals provide services to people with a disability, their families and others to achieve goals in their lives’, including daily living, maintaining and building functional capacity and independence, social and community participation, work, leisure, learning and relationships.

SARRAH maintains that every Australian should have access to equitable health and disability services wherever they live and that allied health services are fundamental to the well-being of all Australians.

1 NDIS Quality and Safeguards Commission: Annual Report 2018-2019 – page 8. https://www.ndiscommission.gov.au/document/1771 2 There is no hard and fast definition of allied health. While the term is not rigid and reflects the evolving nature of health and related therapeutic knowledge, treatment and skills development rather than fundamental questions of value, it is also based on recognised health-related scientific and associated knowledge and practice capability. The Australian Health Leadership Forum (AAHLF) describes allied health as Allied Health Professionals are qualified to apply their skills to retain, restore or gain optimal physical, sensory, psychological, cognitive, social and cultural function of clients, groups and populations. Allied Health Professionals hold nationally accredited tertiary qualifications (of at least Australian Qualifications Framework Level 7 or equivalent), enabling eligibility for membership of their national self-regulating professional association or registration with their national board.

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SARRAH is a strong supporter of the NDIS.

The Commission has not been long established, but has a crucial role. It is clear from the functions and responsibilities of the Commission and the Commissioner, that their powers extend well beyond a focus on process, operations and compliance to include the actual impact of the NDIS on peoples’ lives – not only for those who may have reason to complain about a service, but also to consider where the Scheme itself is not serving people who should have a service and do not.

Functions of the NDIS Commission

The NDIS Commissioner has core functions set out in section 181E of the NDIS Act:

 upholding the rights of, and promoting the health, safety and wellbeing of, people with disability receiving supports or services, including those received under the NDIS

 developing a nationally consistent approach to managing quality and safeguards for people with disability receiving supports or services, including those received under the

NDIS

 promoting the provision of advice, information, education and training to NDIS providers and people with disability

 securing compliance with the NDIS Act through effective compliance and enforcement arrangements

 promoting continuous improvement amongst NDIS providers and the delivery of progressively higher standards of supports and services to people with disability

 developing and overseeing the broad policy design for a nationally consistent framework relating to the screening of workers involved in the provision of supports and services to people with disability

 providing advice or recommendations to the NDIA or the NDIA Board in relation to the performance of the NDIA’s functions

 engaging in, promoting and coordinating the sharing of information to achieve the objectives of the NDIS Act

 providing NDIS market oversight, including:

– by monitoring changes in the NDIS market which may indicate emerging risk

– monitoring and mitigating the risks of unplanned service withdrawal.

With regard to the final dot point in the text box above, SARRAH would argue that the absence of adequate allied health service capacity to meet demand (or even enable eligibility, thorough and appropriate needs assessment or delivery) for large elements of the population constitutes a serious risk. It needs to be treated as such.

This gets to the heart of SARRAHs advocacy. Where there are too few allied health professionals to enable access and meet the needs of people in rural and remote Australia, we believe a duty of care exists to develop and deliver policies, systems and structures that enable that access. It must be a proactive approach – as concerned with ensuring people are able to access services as to ensure compliance when it occurs.

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This understanding is also central to the recent work of the National Rural Health Commissioner in recommending action to build allied health service access and capacity in rural and remote communities – sustainably and fit for purpose. SARRAH believes the NDIS Quality and Safeguards Commission has an important role in this regard and we look forward to opportunities to assist in this work.

The role of the NDIS Quality and Safeguards Commission is broad and includes and to meet its objectives must go beyond a process and compliance focus. It is abundantly clear that such a focus in terms of safety and quality does not work.

It is early days – with a challenging establishment context – and good progress has been made.

The presence of an independent Commission, with genuine resource as well as statutory capacity to act is strongly supported, essential to the effective operation and potential benefits of the NDIS.

The work of the Commission must be pro-active capacity and focus – not defined by reactivity / reaction, driven by and swamped by complaints, but designed to identify risk, avert and reduce it systemically, not have capacity overwhelmed by it.

The role goes beyond compliance. It must be able to look at systemic and structural issues – investigate, analyse, raise awareness, monitor and act. It is pleasing to note in this regard (page 3 of the 2018-19 Annual Report) that the Commission has commenced the development if data and analytics framework.

The Commission has potential to operate as a complementary and facilitative body between stakeholders and the NDIA.

Emphasis on services that are provided to anticipate peoples’ needs and avert issues escalating will not only improve outcomes for participants but contain the number of avoidable problems and complaints that might otherwise occur. This could be an explicit component of the Commissions’ strategic and operational planning and performance.

The role must encompass issues which are external to the NDIAs existing footprint, engagement as well as issues to do explicitly with existing delivery. For instance, where people who could reasonably be eligible for NDIS services but have not been picked up the Commission could promote this issue. This applies to many remote communities where individuals’ prior engagement with the disability, health and other service systems have not adequately identified eligibility and/or the potential benefits of engagement.

Similarly, where the outcomes of service are incomplete and/or inadequate and do not optimise or have a substantially beneficial impact on the participant’s life – there is cause for concern and investigation. This may not result in a technical breach but will point to fundamental and potential widespread improvements to the quality, outcomes and genuine cost effectiveness and sustainability of the Scheme.

Our submission focuses on the allied health workforce primarily as a provider of essential services for many NDIS participants. We are also fundamentally concerned about gaps in the NDIS access and services.

 Potentially eligible people not having access / being assessed  The quality of Plans  The utilisation of Plans.

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SARRAH understands that the JSC, and we anticipate the Commission, are very aware of the innate tensions between core Scheme principles (such as choice and control) and how these principles (laudable as they are) can be best exercised where circumstances of geography, population and underlying service support (described as thin markets or otherwise) are clearly not comparable, or even comprehensible, in more developed “markets”. We encourage the JSC and the Commission to work with communities and stakeholders with a demonstrated commitment to address these issues and to ensure access, quality and impact for participants are also imperatives that guide service and system development.

Skilled workforce shortages have inhibited the roll-out and success of the NDIS in some areas. The size and capacity of the pre-NDIS allied health and related service workforce appears to have been seriously overestimated, especially in areas that continue to struggle to assess and meet participant needs.

NDIS staff: understanding of participant need and allied health

SARRAH also commends the JSC for addressing this question with Recommendation 9 of the Inquiry into NDIS Planning, being

The committee recommends that the National Disability insurance agency (NDIA) ensure that additional training and skills development is provided to all persons involved in the planning process (particularly NDIA officers and LACs), to ensure that all such persons:  are familiar with allied health expertise. (among other points)

Lack of knowledge among staff, including NDIS planners and participants about allied health is a major concern and SARRAH welcomed the JSC’s recommendation. SARRAH would welcome and will seek information from the NDIA about how this recommendation is being acted on.

Similarly, informed knowledge and understanding of rural and remote service environments and issues is crucial, not only for Planners and LACs but also NDIA staff in central policy and operational decision-making roles.

As SARRAH argued in our submission to the JSC Inquiry into NDIS Planning:

“Undoubtedly the availability or otherwise of specific allied health services impact the content of some plans when the availability of services does not match an objective and informed appraisal of the participants’ aspirations and needs. This is a separate issue to the knowledge and skills of the planner and may be influenced more by considerations of what services are actually available rather than whether they are optimal, for example. The relationship between the quality and appropriateness of NDIS plans for participants in rural and remote Australia and the limitations of service knowledge and availability is complex and highly iterative.  Plans may include allied health services that are not accessible or available in the participants’ community or region – so go unused.  Planners and participants may have no awareness of interventions that could be of great benefit to the participant – so are missed.  Planners may be aware of beneficial services but not suggest or include them in a plan because they are not aware of suitable service provider for the participant to access. A major factor contributing to plan (and as importantly) service gaps is the shortage of allied health professionals and service capacity in rural and remote Australia….”3

3 Submission 72: https://www.aph.gov.au/Parliamentary_Business/Committees/Joint/National_Disability_Insurance_Scheme/NDISPlan ning/Submissions

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While SARRAH has commended these Recommendations of the JSC specifically, we also appreciate they should be considered and responded to. We note, the Government has provided responses to the Recommendations, with many supported. However, those responses have not always indicated the urgency of action required, the need to work strategically and systematically, and in some cases that the implications of further action or inaction has been taken on board.

There is a duty of care – strongly implied the Commission’s establishing documents.

Importance of allied health workforce and services The mal-distribution of allied health professionals in Australia is severe, long-standing and highly metro-centric, which inhibits awareness of and access to services participants’ would otherwise be able to incorporate in their plans.

SARRAH has described these issues in detail in previous submissions to the Joint Standing Committee, notably in relation to your Inquiries in the NDIS Planning and Workforce.

SARRAH strongly believes that the responsibilities of the NDIS Quality and Safeguards Commission includes identifying and facilitating the effectiveness of the Scheme.

Addressing the Terms of Reference The Terms of Reference for the inquiry are to inquire and report on the operation of the NDIS Quality and Safeguards Commission since it commenced operation on 1 July 2018, with particular reference to:

a. The monitoring, investigation and enforcement powers available to the Commission, and how those powers are exercised in practice;

b. The effectiveness of the Commission in responding to concerns, complaints and reportable incidents – including allegations of abuse and neglect of NDIS participants;

c. The adequacy and effectiveness of the NDIS Code of Conduct and the NDIS Practice Standards;

d. The adequacy and effectiveness of provider registration and worker screening arrangements, including the level of transparency and public access to information regarding the decisions and actions taken by the Commission;

e. The effectiveness of communication and engagement between the Commission and state and territory authorities;

f. The human and financial resources available to the Commission, and whether these resources are adequate for the Commission to properly execute its functions;

g. Management of the transition period, including impacts on other Commonwealth and state-based oversight, safeguarding, and community engagement programs; and

h. Any related matters. a) The monitoring, investigation and enforcement powers available to the Commission, and how those powers are exercised in practice;

As noted above, SARRAH strongly encourages the Commission to exercise the full scope of its mandate and prioritise a pro-active, quality improvement and safeguarding functions in its approach to regulation. SARRAH notes that other stakeholders, concerned about the broader effectiveness of the NDIS and optimising the positive impacts for the community

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recommend a similar stance. For instance, the Submission by the Mental Illness Fellowship of Australia (Submission no. 37) – page 2:

“… urges the Joint standing Committee on the NDIS to recommend to the Commission take a proactive role in assessing the impact of mental health reforms across all domains effecting the health, safety and wellbeing of people with a psychosocial disability”, further noting that

“This is in accordance with the Commission’s core functions:

To uphold the rights of, and promote the health, safety and wellbeing of, people with disability receiving supports or services, including those received under the National

Disability Insurance Scheme….”

Similarly, the Australian Lawyers’ Alliance Submission (Number 4) urges the Committee to recommend strengthening the Commission’s mandate and resourcing if the JSC believes this is required to effect change. SARRAH believes that the Commission must have the capacity and a commitment to prioritise action that goes well beyond the assessment of specific procedural matters and decision-making. One such focus relates to eligibility for the Scheme, the rights of people to have eligibility tested thoroughly, professionally, equitably and objectively and that a duty of care exists to actively facilitate access to the Scheme for potential as well as actual participants.

SARRAH believes a targeted program of independent assessments is warranted to assess a) the extent to which current participants represent the full population of eligible participants, especially in rural and remote areas and b) the degree of variation in existing plans and plan utilisation between location might be attributable to planner knowledge and discretion, service availability and limitations and workforce factors. This analysis might be appropriately managed through the Commission or with their substantial input, with a clear objective of improving systemic, procedural and capacity challenges identified.

b) The effectiveness of the Commission in responding to concerns, complaints and reportable incidents – including allegations of abuse and neglect of NDIS participants;

The scope of the Commission’s activities and resourcing should include/enable independent analysis of issues which may have a major impact on the effectiveness of the Scheme, where innate systemic tensions may exist (e.g. between cost containment and quality and appropriateness of supports) and where such issues have been raised on a wide-spread and repeated basis. A case in point, which is inherently a factor for the Scheme, although preferably at low levels, is the role, knowledge and expertise of NDIS planners in making decisions, especially where such decisions require expert clinical assessment and knowledge. As a matter of quality assurance, the Commission could potentially have a rolling program of independent, random reviews with a view to identifying and working with the NDIA to improve the quality of decision-making and support systems.

c) The adequacy and effectiveness of the NDIS Code of Conduct and the NDIS Practice Standards;

We note the need for these, but not to duplicate unnecessarily compliance action where professionals and other workers engaged in the NDIS are already subject to and have current approval to work with people under nationally acceptable standards of practice and behaviour. Where such assurances do not already exist, they should.

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SARRAH notes that several other submissions point to the absence of in the National Practice Standards of provider responsibilities in supporting participants with complex mental health and psychosocial needs and that quality assessment of high intensity daily personal activities should include quality indicators.

Returning to questions of service quality and access to appropriate care associated with the shortages of relevant allied health professionals in rural and remote Australia, SARRAH notes such shortages negatively impact participants/consumers/patients across all service systems; the NDIS, aged care; health; education and more. For example, if a shortage of psychologists and mental health social workers is identified for health services in a given region, it is very likely that similar shortages are experienced in aged and disability care.

To demonstrate:

 In 2018-19, Health Workforce Queensland (the rural health workforce agency supporting rural and remote health professional recruitment and retention Queensland) identified social workers and psychologists as the health professions in greatest shortage across most Queensland regions4;  The Australian Commission on Safety and Quality in Health Care’s Australian Atlas of Healthcare Variation series5 identifies major variations in treatment and care provided depending on where people live. This variation includes massive variations in the prescription of medications associated with mental illness and psychosocial behaviour. Many factors contribute to variations in treatment, including the availability of different health professionals. There is a risk that the lack of availability of therapists skilled in cognitive or behavioural therapy, for instance, may increase the likelihood of alternative treatments, such as psychotropic medications, being used as it provides treatment that may not be optimal but is available. Similar risks apply across the NDIS and Scheme participants are often subject to the same skilled workforce shortages.

It is imperative, therefore, that the Commission should be in a position to assess crucial contextual information beyond that specific to the NDIS itself in order to identify areas of serious risk to participants and Scheme delivery. This information and the analysis of it is vital if the Commission is to deliver on its purpose and responsibilities.

We point to the AASWs advise on this issue, (page 6), Social Workers are (ideally trained and) eligible to register as support coordinators listed but the costs and processes associated with such registration is a significant obstacle to utilising a workforce whose expert training makes them ideally suited to such roles. Other allied health professionals would be very well equipped to take on such roles but for similar reasons would be deterred from doing so.

e) The effectiveness of communication and engagement between the Commission and state and territory authorities; No specific comments.

4 https://www.healthworkforce.com.au/about-us/. Refer to the 2018-19 Annual Report. 5 https://www.safetyandquality.gov.au/our-work/healthcare-variation===-==-====––==-==-

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f) The human and financial resources available to the Commission, and whether these resources are adequate for the Commission to properly execute its functions;

SARRAH notes important points raised in the submission (No. 32) by the Northern Territory Office of the Public Guardian, which notes “The sparse population, harsh climate and rough terrain mean health and other supports and services in many parts of the Territory are limited” (page 2). These are familiar themes across many service types for people living in rural and remote Australia and can be particularly so for Aboriginal and Torres Strait islander communities, which are specifically referenced in the submission. SARRAH strongly supports the NT Public Guardian’s call for NDIS Quality and Safeguards Commission resourcing levels across jurisdictions to reflect the magnitude and complexity of the jurisdictions needs and to enable acceptable standards of service and access to the residents of the NT, as well as other communities located in remote Australia.

Failing to equip agencies to identify and deliver risks wherever they exitst is clearly false economy and is a theme that underpins many of the findings of Royal Commissions held in recent years.

g) Management of the transition period, including impacts on other Commonwealth and state-based oversight, safeguarding, and community engagement programs; No specific comment.

h) Any related matters. SARRAH believes the JSC on the NDIS and other key bodies of Inquiry, including the Aged Care Royal Commission are identifying serious, core themes that need to be addressed across Australia’s social services systems. In terms of the provision of allied health services, for example, SARRAH would strongly advise that the JSC consider the issues raised by the (former) National Rural Health Commissioner in his report on allied health service access and capacity to Government in July 2020. This outlines why and how coordinated and collaborative action will address major shortfalls across several service systems.

If you require further information please contact me at

Yours Sincerely

Cath Maloney

Chief Executive Officer

2 October 2020

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