Australian Parliament
Joint Standing Committee
on the National Disability Insurance Scheme
Inquiry into the NDIS Workforce
Occupational Therapy Australia submission
April 2020
Occupational Therapy Australia Limited ABN 27 025 075 008 | ACN 127 396 945
5 / 340 Gore St. Fitzroy VIC 3065
Ph: 1300 682 878 | Email: policy@otaus.com.au | Website: www.otaus.com.au
Introduction
Occupational Therapy Australia (OTA) welcomes the opportunity to make a submission to the Joint Standing Committee’s Inquiry into the NDIS Workforce.
OTA is the professional association and peak national body for occupational therapists in Australia. As of March 2020, there were more than 23,000 occupational therapists working across the government, non-government, private and community sectors in Australia. Occupational therapists are allied health professionals whose role is to enable their clients to participate in meaningful and productive activities.
Occupational therapists are allied health professionals whose role is to minimise the functional impairment of their clients to enable them to participate in meaningful and productive activities. Occupational therapists particularly work with people with a disability and their families to maximise outcomes in their life domains including daily living, social and community participation, work, learning and relationships.
As OTA has stated in previous submissions to this Committee, the occupational therapy profession believes that inappropriate plans are the root cause of the challenges and delays that so frustrate occupational therapists and expose their clients to unacceptable risks. But poor plans are themselves symptomatic of a deeper problem: the relative inexperience of many NDIS Planners.
This has always been, and remains, the foremost problem with the NDIS workforce.
The failure of plans to anticipate and make allowance for changes in a participant’s condition is an ongoing concern as it gives rise to the need for a long and frustrating review process.
The role of occupational therapists in the NDIS
Occupational therapists are highly skilled in assessing the degree to which a person’s disability affects their level of function in daily tasks. Based on these assessments, occupational therapists make recommendations for interventions that enhance and maintain an individual’s functional capacity. As a result of these assessments and interventions, occupational therapists are well placed to document the level of formal and informal supports the participant requires to live a meaningful life.
Given their expertise and area of practice, many occupational therapists deliver NDIS funded services to participants. These services include, but are not limited to, functional capacity assessments, interventions to promote participation in daily living skills and independence, minor as well as complex home modifications, and prescribing assistive technology.
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Occupational therapists are frequently asked to complete a functional capacity assessment and/or to provide an update on a participant’s level of function prior to a plan review to enable the Planner to fully understand the level of supports required.
Experience, expertise and qualifications of Planners
OTA members report that the experience, expertise and qualifications of Planners are highly variable. One member likened planning meetings for participants to a lottery, with the quality of outcomes dependent on whether the Planner was experienced and able to facilitate a positive meeting experience, or had little knowledge of disability and the planning process.
This variability in the experience, expertise and qualifications of Planners is reflected in plan variability; some participants have high-quality plans and others have plans with fundamental gaps.
Members have advised OTA that participants often experience difficulties as a result of Planners who do not understand their needs or conditions. One occupational therapist practice reported that participants who have had a difficult experience at their last plan review often turn to staff in that practice for assistance in articulating their needs at upcoming plan reviews. Occupational therapists have therefore found themselves providing participants with the type of assistance that Support Coordinators, Planners and LACs are supposed to provide, despite the participant having access to these. Unfortunately, participants are using therapy support funding for services that other professionals in the scheme are meant to provide. This would not be the case if the expertise and qualifications of Planners were appropriate and consistent.
A key issue is the professional background of many Planners. Too many lack any experience in the disability, health or allied health sectors. As a result, they often recommend highly inappropriate assistive technology; for instance including manual wheelchairs in plans for people with rheumatoid arthritis who have reduced hand function and are unable to self-propel a wheelchair.
The variability in experience and knowledge of Planners is reflected in the hours allocated to supports in plans. Some plans allocate excessive hours to deliver a particular support, while others allocate plainly inadequate time for the same support.
Measures are needed to enhance and standardise the experience, expertise and qualifications of Planners. OTA has previously identified a number of possible avenues to achieving this end. First, requiring Planners to hold a relevant tertiary level qualification, or equivalent skills, would improve the planning experience of participants.
Alternatively, establishing a national basic practice principles framework for Planners would address the inconsistencies noted. Such a framework would ideally align with existing practice frameworks employed by health and allied health professionals who deliver services to clients with disabilities (e.g. using an evidence-based, strengths-based, person-centred approach). Such a framework could be incorporated into the design of the NDIS Participant Service Guarantee, or serve as a stand-alone framework specific to NDIS planning practice.
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Additionally, enhanced collaboration between Planners and allied health professionals would allow knowledge sharing and improved planning processes. Embedding a ‘care-team’ approach within the culture of NDIS planning, one that would facilitate closer collaboration between Planners and other NDIS provider professionals with respect to individual participants, could improve planning.
OTA’s offer to help train Planners
OTA’s offer to help train Planners has been repeatedly rebuffed by the National Disability Insurance Agency (NDIA), on the grounds that occupational therapists are somehow “conflicted”. Being trained in the management of disability, and eminently qualified to recognise the likely progression of disability, occupational therapists are ideally suited to train and encourage newcomers to this often highly complex field. Given many Planners have no experience of disability or disability services, they would surely benefit from such assistance.
As recently as 21 January of this year, OTA renewed its offer to help train Planners, in correspondence to the new Chief Executive Officer of the NDIA, Mr Martin Hoffman.
In this correspondence, it was noted that the Joint Standing Committee on the NDIS, in its interim report arising from its inquiry into NDIS Planning, recommended:
“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.”
The correspondence also noted that access to NDIA funding is underpinned by the participant’s level of functional impairment. Occupational therapists are highly skilled in assessing a person’s level of function and how this affects the extent of informal and formal supports they require. As such, they are ideally positioned to contribute to the education of Planners.
OTA again offered to collaborate with the NDIA in an effort to better acquaint Planners with the nature and the likely progression of disabilities. It also noted that previous offers to help train Planners had been rebuffed by the agency, on the highly questionable grounds that occupational therapists doing such training would be somehow conflicted. And it noted that this argument was given very short shrift by members of the Joint Standing Committee at its hearing on 7 November last year.
In response to this correspondence, Mr Hoffman, expressed a welcome willingness to engage with OTA. Given this was the first time a CEO of the agency had ever responded to correspondence from OTA, we were enormously heartened. Mr Hoffman is also to be commended for meeting with representatives of the member associations of Allied Health Professions Australia (AHPA) on 20
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March; such proactive engagement with the peak bodies of key service providers is a welcome development.
However, and regrettably, it appears there are lingering concerns at the NDIA about the possibility of a perception of conflict of interest if allied health peak bodies were to collaborate with the NDIA in projects aimed at acquainting NDIA Planners with the nature and likely progression of disabilities.
Any such training need not be elaborate, or expensive, and could take the form of online modules or webinars.
In the case of occupational therapy, OTA assures all concerned that there need be no conflict of interest, real or perceived, if all parties work in good faith to educate and support Planners. Moreover, honest collaboration will enable Planners to identify the circumstances which have on occasion given rise to the development of unnecessarily elaborate plans on the part of less experienced occupational therapists.
Anecdotal evidence indicates that some less experienced clinicians lack the necessary confidence to propose realistic plans for their clients, giving rise to possibly unnecessary expense. Such clinicians would benefit from webinars which facilitate two-way communication between Planners and occupational therapists.
We owe it to NDIS participants to make first and subsequent plans work. If a series of informative webinars, developed and presented by highly experienced experts in the field of disability, can help achieve this, the NDIA should support such a project.
As OTA has remarked repeatedly, in the medium to long term a commitment to getting NDIS plans right in the first instance will improve the lives of thousands of NDIS Participants and save the scheme hundreds of millions of dollars.
And, as the Joint Standing Committee has already noted, at its meeting on 7 November last year, concerns around a potential conflict of interest, should not be allowed to prevent such a positive step forward.
It is deeply regrettable that the following two recommendations have already been made by OTA to previous inquiries conducted by the Joint Standing Committee. It is to be hoped they will now be acted on.
Recommendation 1: The NDIA should pursue and promote enhanced collaboration between Planners and allied health professionals to enable knowledge sharing and improved planning processes, and consider ways of embedding a ‘care-team’ approach into planning practices.
Recommendation 2: The NDIA should accept OTA’s offer, repeatedly made, to help train NDIS Planners in the nature, likely progression, and optimal management of disability.
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Overall number of Planners relative to the demand for plans
OTA is advised by its members that in some jurisdictions there is an insufficient number of Planners relative to demand, and that this problem is exacerbated by the amount of time Planners have to devote to process related, rather than clinical, issues. As a result, effective participant planning is being compromised.
It is difficult, of course, to identify the number of Planners required to meet the demand for plans until such time as the planning process is functioning in an optimal manner. Accordingly, there should be increased investment in the design and operation of the planning process, and a commitment to the professional development and training necessary to ensure Planners are well placed to meet the needs of participants in a timely manner.
Planners are often involved in unscheduled plan reviews that might have been avoided if the plan was fit for purpose in the first instance. There must be a renewed effort to ensure first plans do not fail the participant.
Recommendation 3: The NDIA should invest in the design and operation of the planning process, and in the professional development and training of Planners.
Recommendation 4: The NDIA must make a renewed effort to ensure first plans do not fail the participant.
Other matters
OTA would like to take this opportunity to raise an ongoing matter of concern, one which threatens the diverse nature of the workforce providing clinical services to NDIS participants.
Those providers operating as sole providers or in small practices cannot afford the non-clinical time required to keep up with the administrative demands imposed by the NDIS and, in particular, the registration requirements of the NDIS Quality and Safeguards Commission. The demands relate to both ongoing administrative processes and the frequent changes made to these processes.
Large companies employing ten or more allied health professionals can viably manage these demands, as they only need to complete one Commission audit and can afford to employ a person with the dedicated task of arranging the required audit and monitoring changes to administrative requirements. However, for smaller providers – some with less than one Full Time Equivalent employee doing NDIS work – it is not worth the time and effort to undergo verification, let alone certification, with the Commission.
One OTA member working in a regional practice reports that it is common in such areas to have one or two occupational therapists seeing clients across many funding sources (aged care, the state based insurance schemes, etc.) as well as the NDIS. Many of these generalist practices report they do the equivalent of a day a week on NDIS funded work.
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This member writes:
I can already see the outcome of this for small providers in my district. These providers are opting out of services that push them into the need for certification rather than verification (e.g. clinicians have now dropped any behavioural work and work with young children – the two key areas that push them into the higher audit category).
In my own case, I do a day a week working as a contractor for a small OT provider. She has advised that she won’t be doing either certification or verification due to the cost and the preparation time. She is also sick of trying to keep up with all the small changes that come through from both the NDIS and the NDIS Quality and Safeguards Commission.
I fully appreciate that NDIS Quality and Safeguards Commission is there to ensure quality of service but isn’t AHPRA registration already doing that? And If it causes good generalist OTs to stop working for the NDIS, particularly in regional areas that are already short of OTs, hasn’t it totally missed the point!
I have noted it before but I can confirm that I see a lot of experienced specialist disability therapists getting out of the game. They are being replaced by significantly less experienced OTs working for bigger providers. These bigger providers have the time and funding to deal with the NDIS and the Commission. This gets even more concerning when you dig down a layer and find that those less experienced OTs, with the big providers, aren’t getting very good clinical support from their employers.
This member raises two key points already made by OTA on numerous occasions, and repeated here.
First, why does one arm of the Federal Government, the Australian Health Practitioners Regulation Agency, deem an occupational therapist fit to practise, while another arm, the NDIS Quality and Safeguards Commission, calls that fitness into question?
Second, the administrative requirements of the NDIS and the NDIS Quality and Safeguards Commission are placing an intolerably time-consuming burden on smaller providers, driving them from the NDIS and changing forever the nature of those delivering supports to NDIS participants. Moreover, many in the new provider workforce lack the necessary experience, supervision and peer support to deliver optimal care.
This is bad news for the people the NDIS is supposed to support, particularly when you consider that this phenomenon is by no means limited to occupational therapists – it is a discernible development across all the allied health professions.
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Conclusion
OTA thanks the Joint Standing Committee on the NDIS for this opportunity to contribute to its inquiry. Representatives of OTA would be pleased to appear before the Committee and expand on matters raised in this submission if Committee members were to deem that helpful.
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