National NDIS Workforce Plan Joint Standing Committee on the National Disability Insurance Scheme | External submission

ESSA:

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Exercise & Sports Science Australia

Submission

National NDIS Workforce Plan

Joint Standing Committee on the National Disability Insurance Scheme

10 August 2021

Carla Vasoli Anita Hobson-Powell

Policy & Advocacy Advisor Chief Executive Officer

Exercise & Sports Science Australia Exercise & Sports Science Australia

Policy@essa.org.au

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1.0 About Exercise & Sports Science Australia

Exercise & Sports Science Australia (ESSA) is the peak professional association for exercise and sports professionals in Australia, representing over 9,000 members, including university qualified Accredited Exercise Scientists (AESs),

Accredited Exercise Physiologists (AEPs), Accredited Sports Scientists (ASpSs) and Accredited High-Performance

Managers (AHPMs).

AEPs are nationally recognised allied health professionals, with four years of university training and provide clinical exercise interventions aimed at primary and secondary prevention of chronic disease; managing acute, sub-acute and chronic conditions, including physical, intellectual and psychosocial disability; and assist in restoring optimal physical function, health and wellness to people living with disability. In addition to professional recognition under the National Disability Insurance Scheme (NDIS), exercise physiology is a recognised and funded profession under other compensable schemes such as Medicare Benefit Services (MBS), Department of Veteran Affairs (DVA), private health insurance, and state and territory-based workers’ compensation schemes. AEPs typically register with the NDIS Quality and Safeguards Commission under the ‘Exercise Physiology and Personal Well Being Activities’ and ‘Therapeutic Supports’ registration groups and deliver supports in both the ‘Improved Health and Wellbeing’ and ‘Improved Daily Living Skills’ categories of participant plans.

AESs are three-year trained university professionals that apply the science of exercise to design and deliver physical activity and exercise-based interventions to improve physical and mental health, well-being and assist in the prevention of injury and chronic conditions. They coach and motivate to promote self-management of physical activity, exercise and healthy lifestyles and work in the National Disability Insurance Scheme (NDIS) as support workers as personal trainers, therapy assistants and social engagement facilitators under registration groups ‘Innovative Community Participation,’ ‘Development of Daily Living and Life Skills,’ ‘Participation in Community, Social and Civic Activities,’ ‘Early Intervention Supports for Early Childhood,’ ‘Exercise Physiology and Personal Training,’ ‘Therapeutic Supports’ and ‘Group and Centre Based Activities.’ Although AESs are not able to prescribe exercise therapy programs, they often work with AEPs by delivering the exercise therapy programs that an AEP prescribes.

ESSA’s response to the /nquiry into the NDIS Workforce has been prepared in consultation with ESSA members. This submission responds to the Joint Standing Committee on the NDIS’s Terms of Reference, with regard to the new NDIS National Workforce Plan: 2021-2025, and most relevant to the experiences of AEPs and AESs engaging with participants under the NDIS. ESSA welcomes the opportunity to respond to this inquiry and would be delighted to appear before the Committee, if invited.

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2.0 Summary of Recommendations

Recommendation 1: That the NDIA collaborate with ESSA and other allied health peak bodies to co-design employment opportunity promotions for allied health professionals in the NDIS.

Recommendation 2: That the NDIA immediately cease delegation of allied health therapy supports to unqualified support workers and allow delegation to only occur at the discretion and clinical judgement of treating allied health professionals, until an appropriate delegation model can be implemented.

Recommendation 3: That the Department of Social Services consults ESSA throughout the development and implementation of an appropriate delegation model.

Recommendation 4: That the anticipated delegation model formally acknowledges the important delineation between the clinical assessment and ongoing support provided by qualified AEPs (and AESs working as therapy assistants under AEPs) delivering exercise interventions to NDIS participants in contrast to the day-to-day encouragement that carers and support workers should provide to encourage physical activity.

Recommendation 5: That the Department of Social Services monitor the inappropriate delegation of therapy supports and act against NDIA planners that do not comply with the direction in recommendations 2 and 4.

Recommendation 6: That the Minister for the NDIS mandates a minimum level of knowledge of each NDIS therapeutic support and allied health profession for internal NDIA decision making staff, including planners and

Local Area Coordinators

Recommendation 7: That the Minister for the NDIS mandates ongoing planner training to ensure their knowledge of therapeutic supports and allied health professions are regularly updated, in accordance with new and emerging evidence.

Recommendation 8: That the Department of Social Services and the NDIS Commission work with regulatory bodies responsible for other care and support sectors to ensure that their strategies to increase NDIS workforce does not negatively impact workforce availability in other care and support sectors.

Recommendation 9: That the Department of Social Services subsidise the cost of registration for existing unregistered NDIS providers in rural and remote locations.

Recommendation 10: That the Department of Social Services consider the recognition that AEPs receive in comparable schemes when executing initiative 11 of the NDIS National Workforce Plan, relating to improving NDIS pricing, to incentivise AEPs to remain in the NDIS and prevent moving into more competitive schemes.

Recommendation 11: The NDIS Quality and Safeguarding Commission develop and enforce practice standards for plan managers to ensure minimum standards are upheld.

Recommendation 12: That ESSA be consulted during the investigation in to how providers can be supported to increase the number of traineeships and student placements offered in the sector.

Recommendation 13: That ESSA be consulted during the development of a new pricing approach that improves

operation of the market for NDIS services.

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Recommendation 14: That the NDIA and NDIS Quality and Safeguarding Commission work collaboratively to develop clear resources to support new entrants to the NDIS market.

Recommendation 15: That the NDIA be clear and consistent in relation to operational requirements impacting NDIS providers, including reporting expectations, by publishing adequate advice and direction on the NDIA’s website, and provide at least two weeks’ notice to adjust to any changes.

Recommendation 16: That exercise physiology immediately receives recognition as an equal allied health support under the NDIS in both the ‘Improved Daily Living Skills’ category and the ‘Improved Health and Wellbeing’ category, by increasing pricing limits to $193.99 per hour of service to align with all other allied health supports.

Recommendation 17: That ESSA and other allied health peak bodies be well informed and fully involved in meaningful consultation and co-design of any alternative funding models considered by the Australian Government for funding NDIS supports.

Recommendation 18: The NDIA set price limits that are GST exclusive and pay for the GST component in addition to the service delivery costs for exercise physiology services.

Recommendation 19: That the Department of Social Services and the Department of Health commit to mutual recognition of regulation and worker screening processes, by developing and publishing an action plan and timeline for implementation and commencing timely consultation with relevant sector stakeholders to inform this plan, including ESSA.

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3.0 Introduction and Summary of Issues

ESSA’s submission is based on feedback from AEPs delivering services under the National Disability Insurance Scheme (NDIS), and provides responses to the following provider topics:

Areas of concern for reaching projected workforce size and composition projections.
Issues attracting and retaining workforce.
Areas that Commonwealth Government policy may influence. Many initiatives in the new NDIS National Workforce Plan refer to the issues addressed in this submission and in ESSA’s previous workforce submission. While ESSA welcomes this new workforce plan, on the whole, the plan does not sufficiently outline how issues will be addressed or how solutions will be implemented. Initiatives that relate to this submission are indicated and discussed.

Additional areas of concern are discussed below, namely relating to:

Delegation of therapy supports to support workers with regard to the impact this will have on retaining the allied health workforce and reaching projections at full scheme.
Internal NDIA workforce because this workforce is not addressed in the plan, yet it controls many aspects of the operation of the NDIS.
Pricing considerations of the scheme and the importance of recognising AEPs equally, relative to other allied health professions delivering supports under the NDIS.

4.0 Projected workforce size and composition

the current size and composition of the NDIS workforce and projections at full scheme

4.1 Delegating Therapy Interventions (initiative 14)

ESSA notes that the allied health workforce in the NDIS will need to increase by 40% by 2024, or from the current 7.4%, to 7.9% of the entire composition NDIS workforce in 2024’.

While the change in composition to include more allied health professionals in the NDIS is welcome, ESSA is concerned that the NDIA does not value the role of exercise physiology. This concern is based on the increasing trend that AEPs have been reporting to ESSA from across Australia, of planners delegating allied health interventions to untrained and unqualified support workers when not clinically justified. Therefore, the perception that the NDIA does not value the role of allied health could severely deter more professionals from entering this market.

Nevertheless, AEPs are highly qualified and well-equipped to work more prevalently with people with disability. Exercise interventions for people with disability delivered by AEPs have been evidenced to generate multiple positive outcomes in regard to immediate improvements in health and wellbeing, social inclusion, efficacy and long-term health outcomes such as prevention of chronic disease. In addition, ESSA proactively promotes employment opportunities within the disability sector through the provision of resources, continuing professional development (CPD) and specific advice on working within the NDIS. ESSA would be delighted to collaborate with the NDIA to promote employment opportunities for AEPs in the NDIS and co-design campaigns to further augment workforce capacity to meet the imminent demand.

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However, ESSA is concerned that NDIS participant outcomes are being diminished by cost cutting at both the NDIS planning and review stages. ESSA has evidenced a growing trend in NDIA planners cutting, or significantly reducing, participant funding for exercise physiology and requesting that AEPs train unqualified support workers in the delivery of clinical exercise physiology interventions. ESSA advocates for an active Australian population and understands the importance of support workers and carers in encouraging physical activity. However, there is a significant distinction between:

understanding the benefits of physical activity and encouraging incidental exercise day-to-day, and
the assessment, prescription and delivery of clinical physical activity interventions, and monitoring and evaluation of those prescribed interventions for particular outcomes.

ESSA’s concerns are underpinned by the physical and health risks to NDIS participants where unqualified workers are expected to deliver prescribed, clinical exercise treatments. It is inappropriate and dangerous to expect carers or support workers, who do not have the expertise, experience, qualifications, knowledge, or skill of an AEP, to conduct ongoing risk stratification, monitor symptomology, and adjust the prescription of exercise based upon complex interactions of diagnosis, exercise tolerances and changing medication regimes.

Case Study A

A 43-year-old female with progressive Multiple Sclerosis had been seeing her AEP for a 30-minute session twice per week to help improve her muscle control so that she could perform physical tasks independently, such as getting out of bed and getting dressed. Due to the nature of this participant’s condition, the AEP must perform a gentle movement test at the beginning of every session, to guage how her muscles are coping each day. This information was used to determine the most appropriate exercises to deliver each session. As a result of AEP intervention, the participant was able to control leg movement against gravity and safely self-ambulate, when previously unable, and had improved quality of gait when walking.

The participant was also seeing a personal trainer, which the AEP suggested was beneficial for the participant’s social engagement and mental wellbeing. However, the participant would often be unable to get out of bed for up to five days post personal training sessions due to headaches and muscular tightness, as the personal trainer would overwork the participant during sessions. This resulted in higher care needs for the participant after personal training sessions. The AEP attempted to teach the personal trainer movement tests on how to guage the participant’s ability and other strategies on how to conduct and limit exercises so that the participant would not be overworked. Despite this training, the participant was still fatigued and stiff for 3 to 5 days after seeing their personal trainer and unable to independently perform activities of daily living.

At the latest plan review, the AEP provided a progress report highlighting the need for the participant to continue seeing an AEP for at least two sessions per week, as exercise treatment from a lower qualified professional was counterproductive to the participant achieving their goals. Despite this feedback to the NDIA planner, AEP funding was reduced, and the planner indicated that exercise therapy was to be delegated to a support worker.

Case study A raises significant concerns for NDIS participants’ safety and NDIS investment into ineffective and counterproductive supports. This case study evidences that, in some cases, it is not appropriate to delegate therapy to lower qualified professionals. Even after the AEP provided education and training to the personal trainer, the trainer did not have the clinical judgement, experience and reasoning when conducting exercise

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therapy, resulting in negative consequences for the participant. ESSA notes that personal trainers are qualified by a certificate in fitness to operate in the scheme. However, support workers are not required to have any particular qualifications. Therefore, the risk of harm for NDIS participants is significant and needs to be mitigated.

In other circumstances where AEPs have complied with NDIS demands and provided training to support workers, the following has been observed: ¢ Some participants receive supports from more than one allied health professional, which increases the amount of therapy support expected to be delivered by support workers (refer to Case Study B). e Participants do not always receive the same support worker day to day or week to week, making it difficult to train a consistent team of support workers to deliver therapy support (refer to Case Study B). e Support workers who are trained by AEPs often do not follow through on actively supporting participants to engage in prescribed activities. ¢ Group home staff have been known to sign off on records confirming that home exercise services have been provided, but these records often conflict with the advice of participants.

Case Study B

A 17-year-old female had been receiving a range of therapies, including exercise physiology, occupational therapy, physiotherapy, and speech pathology. As part of the review process, funding was reduced across all therapies and the therapists were asked to train the participant’s support workers in the delivery therapy supports. The AEP noted that the participant received support from over 20 different care workers a week, and concerns had been raised about the risks associated with training such a large number of care workers in such a diverse range of therapy supports. The participant’s mother was appealing the decision and expressed fear that her daughter may need to consider residential aged care if her body deteriorated any further.

ESSA notes that it is unclear where the liability rests in these types of scenarios. Many AEPs already express concern about their obligation to cover the professional indemnity insurance of NDIS therapy assistants, whom like support workers, have no minimum qualification requirements under the NDIS. ESSA notes the variability in therapy assistant and support worker qualifications, training and skills can make delegation of an AEP’s duties both challenging and risky.

ESSA acknowledges that in some circumstances there may be a role for unqualified workers to engage participants in physical activity, as seen in case study C below

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Case Study C

Male with a severe intellectual disability has complex behaviours of concern. The participant resides in a group home for participants with high level of behavioural needs. He requires dedicated one-on-one support to engage in any physical activity 100% of the time. Without direction, he spends his days on the couch.

Exercise physiology was given 18 hours of funding in a 12-month plan, which was used for assessment, collaboration with a behaviour support practitioner, monitoring progress, reporting and to assist group home staff, whom he was most familiar and comfortable with, to train them to provide active support for the participant on a daily basis, at multiple regular intervals throughout the day. This included a range of strategies, including the development of a daily task of walking to the shops to buy milk. The participant was particularly fond of iced coffee, so really wanted the milk each day. The participant was so unfit, that this daily walk (approx. 35 mins total) was considered moderate intensity. The participant loved music, so a daily dance was implemented. This resulted in improvement of the participant’s behaviours of concern.

The risk of this exercise therapy (dancing and walking) was relatively low, given the initial assessment was carried out and his assessed cardiovascular risk of exercise is low. The risk of the intervention failing would have been higher if the AEP had conducted, as the participant had already built rapport with group home staff.

Case study C is an example where an AEP was able to delegate exercise therapy, only as it was low level therapy delivered to a low-risk client (i.e., low risk of adverse events due to nature of intervention). The strategies put in place were to increase the participants level of physical activity, which provided behavioural benefits.

However, we note that there is a significant difference between providing support to engage in physical activity and assessing for and delivering a clinically prescribed exercise program designed to achieve a therapeutic outcome. From a workforce perspective, ESSA fears that if AEPs continue to be inappropriately pushed into delegating clinical exercise treatment to unqualified support workers, many AEPs may consider working within the NDIS as a risk rather than a viable employment opportunity.

It is noted that the NDIS National Workforce Plan Initiative 14 aims to explore options to support allied health professionals to work alongside allied health assistants (AHAs) and support workers to increase capacity to respond to participants needs. However, ESSA cautions that there are significant risks associated with delegation to support workers and AHAs that need to be mitigated before any delegation model is implemented. If this model is not appropriate, allied health professionals will be deterred from working within the NDIS, due to risk to participants and their businesses.

Recommendation 1: That the NDIA collaborate with ESSA and other allied health peak bodies to co-design employment opportunity promotions for allied health professionals in the NDIS.

treating allied health professionals, until an appropriate delegation model can be implemented.

Recommendation 3: That the Department of Social Services consults ESSA throughout the development and implementation of an appropriate delegation model.

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4.2 Internal NDIS workforce knowledge of allied health (no initiative)

ESSA is concerned that internal NDIA staff are not addressed in the NDIS National Workforce Plan. This is of particular concern, as internal NDIA staff, such as NDIS planners and Local Area Coordinators (LACs), are responsible for funding decisions and supporting participants to choose their NDIS supports.

Given the allied health NDIS workforce will need to increase by 40% by 20247, it is vital that decision makers in the NDIA recognise the value of allied health. Currently, AEPs must spend additional unpaid time educating individual NDIS planners and LACs on the role of an AEP and benefits of exercise physiology for many of their NDIS participants to be able to access AEP funding in their plans. This has resulted in the NDIS being, economically, an unjustifiable scheme to work in, for many AEPs. The NDIA must ensure these workers are appropriately trained and educated on each support, so that funding allocation and support for decision making will ensure the best possible outcomes for NDIS participants.

ESSA members are concerned about planning decisions for funding supports, noting that planners are refusing to allocate funds for therapy supports recommended by treating allied health professionals, including AEPs.

Case study D

A 9-year-old male with Autism Spectrum Disorder (ASD) presented with communication shut-down, emotional regulation issues, lack of motivation and below average fine and gross motor skills. Short term goals included developing communication and social skills so he can build and maintain friendships and relationships with others, and to recognise and understand emotions, learn strategies to self-regulate his emotions. Medium to long term goals included improving fine and gross motor skills. During the 12-month plan period, as a result of weekly AEP intervention the client had improved confidence in the gym environment; increased engagement and communication with AEP with little to no signs of communication shut down; increased exercise tolerance; increased time engaging within a community environment; improved gross motor skills; and required little to no parental support and supervision during therapy compared to last plan period. The participant’s AEP recommended in progress report to continue to receive ongoing support to progress further towards his goals and recommended that a future goal be to increase his exercise tolerance from 45 minutes to 1 hour per week.

However, at plan review, all AEP funding was removed and only funding for occupational therapy and psychology was provided (costed out for specific number of sessions with each therapy), despite the family’s preference for him to continue seeing his AEP. The planner indicated that funding for AEP was removed, as the child would now be able to get the physical activity they needed from school. After a few months of engaging with the new plan, the child’s parents contacted his AEP to provide feedback that he was disengaging from school due to reduced confidence to participate in social and sporting activities as he did not have the coordination or social skills to participate. The participant was not responding to new allied health therapies, resulting in them being ineffective.

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Refusal to allocate funds to therapeutic supports is consistently occurring in the sector, despite participants and allied health professionals providing all evidence requested by the NDIA to support the need for recommended supports. Evidence provided has included published research and allied health reports demonstrating progress toward participant goals. Insufficient funds for recommended therapeutic supports have resulted in the functional decline of many participants that are seen by AEPs, and other allied health professionals, as seen in case study D. Case study D highlights that the planner was not aware of the value that exercise physiology provides over general physical activity, and the impacts that AEP intervention provides relating to the development of fine and gross motor skills, coordination and increased confidence for social engagement. It also highlights that limiting participant choice and control has negative impacts on participant outcomes and progress toward goals.

Research has demonstrated that movement difficulties impact on a child’s academic and physical performance, social relationships, independence with self-care and community participation, highlighting the need to address movement difficulties in children with ASD?. Children and youth on the autism spectrum are at risk of low levels of physical activity and high levels of sedentary behaviours, putting them at risk of non-communicable diseases associated with inactivity*. There are a number of barriers to physical activity participation for individuals on the autism spectrum, including pragmatic communication differences, sensorimotor impairments and lack of accessible and inclusive programs’. Despite this evidence supporting AEP intervention for people with autism, planners are actively preventing autistic NDIS participants from accessing exercise physiology supports.

Planners and LACs lack understanding of the role, scope of practice and value of various allied health professions and often look to identify lower value alternatives which can be to the detriment of the participant’s functional capacity outcomes.

Planners and LACs who have insufficient knowledge and lack qualifications and experience to determine the allied health needs of a participant, often reduce or eliminate allied health therapy funding against allied health professionals’ clinically justified recommendations, as presented in progress reports. Planners and LACs also do not receive ongoing training or professional development, despite new evidence and research emerging in relation to the impact of therapeutic supports on functional outcomes for people living with disability.

This is currently one of the most significant issues that AEPs report in relation to their ability to successfully provide services to NDIS participants and has been highlighted by many other allied health peak bodies. As such, ESSA advocates that the best way to support allied health professionals in the scheme, and to reach the target of 28,000 allied health professionals by 2024, planners and LACs must be appropriately trained and educated in the role and value of allied health professions.

Local Area Coordinators

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5.0 Attracting and retaining workforce

challenges in attracting and retaining the NDIS workforce, particularly in regional and remote communities

5.1 Registration costs (Initiative 10)

ESSA members report that NDIS registration is a costly and onerous process particularly for small businesses and providers in rural and remote communities. It is difficult for many small businesses to justify the administration time required and the expense, particularly when their business model services a relatively small number of NDIA participants.

AEPs located in rural and remote communities have reported quotes between $6000 and $16,000 for auditing fees, with many suggesting these costs are not financially viable given the small number of NDIS participants they service. AEPs have noted costs associated with auditor travel and accommodation have a significant impact on the price of audits conducted in rural and remote locations. In response to this concern, many AEPs have reported they are considering not registering as a provider or de-registering and only providing services to plan managed and self managed NDIS participants. The decision for businesses not to be registered with the NDIS Quality and Safety Commission will result in limited choice in providers of services for agency managed participants in rural and remote locations, further increasing inequity in access to disability services.

ESSA acknowledges initiative 10, which aims to align provider regulation and worker screening requirements across care and support sectors, including DVA, aged care and NDIS, to allow people to work across multiple schemes. However, given that all care and support sectors have a workforce shortage in rural and remote locations, ESSA suggests that alignment of regulatory requirements alone will not resolve this issue in rural and remote locations.

Implementing initiative 10 alone, may encourage workers from other care and support sectors to work within the NDIS, but will not encourage existing unregistered NDIS providers to become registered if they are not already working in the other sectors. ESSA is concerned that this approach may negatively impact workforce availability in other care sectors. Any approach to increase workforce availability in rural and remote locations should be made in collaboration with the regulatory bodies responsible for the other care and support sectors.

does not negatively impact workforce availability in other care and support sectors.

Recommendation 9: That the Department of Social Services subsidise the cost of registration for existing unregistered NDIS providers in rural and remote locations.

5.2 Remuneration

5.2.1 Comparison with other schemes (Initiative 11)

ESSA notes that AEPs are currently better compensated in schemes other than the NDIS, particularly when considering the additional time involved in dealing with the complexities of working within the NDIS. Further, AEPs are paid equally to other allied health professionals when operating in other schemes, while they are paid 29% less

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under the NDIS when considering GST requirements. Pay parity and GST are discussed further in section 6.0 Commonwealth Government policy influence of this submission.

Exercise physiologists and other NDIS allied health professionals, including audiologists, dietitians, occupational therapists, physiotherapists, podiatrists, psychologists, speech pathologists and social workers are listed as eligible allied health professionals under the Medicare Benefits Schedule (MBS). All MBS eligible allied health professionals, including exercise physiology, receive the same benefit of $53.80 for services that are at least 20 minutes in duration. Under the NDIS each of the above listed MBS eligible allied health professions, receive a significantly higher hourly rate than exercise physiologists. The NDIS also awards a range of other allied health professions not eligible under MBS nor DVA, at a higher rate than exercise physiology.

The Review of Therapy Pricing Arrangements‘ in 2018 identified seven national and state schemes comparable to the NDIS. The Department of Veterans’ Affairs (DVA) insurance scheme, Workcover WA, the Victorian Transport Accident Commission (TAC), WorkSafe Victoria, Sira iCare, Workcover QLD and Return to Work SA were identified as comparable schemes. ESSA has compared the prices that exercise physiology and physiotherapy charge across these seven schemes and revealed that exercise physiology and physiotherapy receive the same rates under DVA, and similar rates across other worker rehabilitation schemes.

Given that AEPs are better compensated and equally recognised with other allied health professions in other schemes, there is less incentive for AEPs to work within the NDIS over other schemes. This is at the detriment to many NDIS participants, who rely on their NDIS funding as their only way to access their AEP.

5.2.2 Plan Management payments (no initiative)

ESSA members have reported that it has become increasingly difficult to recover costs from plan managed participants. Plan managers frequently report that participants do not have the funds required for the payment of invoices. These circumstances arise even in cases where AEPs have contacted the plan managers ahead of time and checked the availability of funds prior to delivering supports.

ESSA members report that they have contacted the NDIA when costs could not be recovered via plan management. The NDIA advised that the plan managers were not at fault and the participants would need to be taken to a debt collector. One ESSA member, a small business owner who refused to send their client to a debt collector, wrote off $5000 in losses in December 2019. This member noted that it did not seem ethical to send a person to a debt collector, when they had engaged a financial administrator to manage their plan funds because they did not have the capacity to do this for themselves.

ESSA considers these practices to be both unethical and a significant risk to the financial viability for allied health professionals to be working within the NDIS. Plan managers are NDIS providers, much like allied health professionals working within the NDIS, and as such, should be required to comply with professional standards and be held accountable by the NDIS Commission for not delivering a quality service in a safe and competent manner in line with their professional standards and the NDIS Code of Conduct®.

Recommendation 11: The NDIS Quality and Safeguarding Commission develop and enforce practice standards for plan managers to ensure minimum standards are upheld.

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5.3 Training and supervision

5.3.1 Student placements (Initiative 9)

ESSA acknowledges that initiative 9 of the NDIS National Workforce Plan should address ESSA’s recommendation in our previous submission to remunerate NDIS service providers for activities associated with supporting a student placement, such as the provision of feedback and assessment of clinical competencies. Initiative 9 recognises the importance of ensuring students have access to placements with effective supervision to encourage entry into the sector and to foster the development of skills required to work in the sector. It also recognises that the ability to make student placements and traineeships available requires resourcing.

Recommendation 12: That ESSA be consulted during the investigation in to how providers can be supported to increase the number of traineeships and student placements offered in the sector.

5.3.2 Retaining New Graduates (Initiative 11)

As stated in ESSA’s previous NDIS workforce submission, research indicates allied health graduates face many challenges in the transition from a being a student to a professional in the workforce. These challenges include having full responsibility for a caseload and for making decisions about a patient’s care for the first time, while having less access to supervision and case discussion®.

ESSA is pleased to see that the NDIS National Workforce Plan acknowledges the need for pricing arrangements to support broader scheme sustainability, including to support workforce development. ESSA suggests that the ability for the pricing approach to include professional supervision and case conferencing is vital to support workforce development.

Recommendation 13: That ESSA be consulted during the development of a new pricing approach that improves operation of the market for NDIS services.

5.4 Scheme complexity (no initiative)

ESSA regularly hears from AEPs who previously have had no dealings with the NDIS and have been approached by an NDIS participant for exercise physiology supports. In these circumstances, the AEPs have generally searched the NDIS website for information about how to onboard an NDIS participant and meet the necessary service provider requirements. A significant number of AEP members contact ESSA for clarity on setting-up their practice to deliver NDIS services due to a lack of clear and easily accessible information, and the time it takes to navigate through the available information and understand how it can apply to their practice environment. Further, there are large numbers of stakeholders often involved in AEP intervention for NDIS participants. In addition to a multidisciplinary health team, AEPs also work with family members, support coordinators, a public trustee and guardian, group home managers, support workers, plan managers, LACs, NDIS planners and more, which is complicated for a new entrant into the NDIS to navigate. ESSA suggests these challenges impact workforce growth, participant choice and the timely delivery NDIS supports. ESSA maintains that this issue could easily be addressed if the NDIA and NDIS Quality and Safeguarding Commission worked collaboratively to develop a range of resources to support new entrants to the NDIS market.

ESSA notes that, as a professional association, we would be happy to consider the allocation of continuing professional development points for training focused on the understanding and working within the NDIS system.

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Recommendation 14: That the NDIA and NDIS Quality and Safeguarding Commission work collaboratively to develop clear resources to support new entrants to the NDIS market.

5.5 Inconsistencies and constant change in the Scheme (no initiative)

ESSA members have reported that inconsistencies and constantly changing requirements of providers add to scheme complexity, making it more difficult for providers to operate effectively. For example, one ESSA member described a time when the NDIA announced a change in support item codes with only two days’ notice. This member and the organisation they worked for were placed under immense pressure to update service agreement templates, back-end coding relating to the new support items and invoices, taking days of unpaid staff time. Not only was this change a burden for the organisation, but a barrier for participants to receive services, as the organisation had to put a hold on invoicing clients and sending out new service agreements until these changes were made.

The most recent release of the updated price guide for financial year 2021-22, was not released by the NDIA until 5 pm on 1 July 2021. While the latest price guide update did not impact AEP service delivery, it highlights the minimal consideration given to provider compliance time and costs.

Further, ESSA members have described inconsistencies in advice on various operational matters from the NDIA, directly. For example, an ESSA member described one planner requesting a 40-page allied health report, while another planner requested only a one-page report. Information on the NDIA’s website in relation to reporting requirements is vague, resulting in ESSA members constantly calling to ask for advice, with no clear understanding of what is expected, both from a provider perspective and a planner perspective. Inconsistencies and changes in provider requirements such as these may deter allied health professionals from continuing to provide services within the scheme.

6.0 Commonwealth Government Policy Influence

the role of Commonwealth Government policy in influencing the remuneration, conditions, working environment (including Workplace Health and Safety), career mobility and training needs of the

6.1 Pay Parity for AEPs (Initiative 11)

Since the introduction of the NDIS, the pricing structure has failed to recognise the exercise physiology profession with the same esteem as other allied health professions. ESSA notes the current price limit for exercise physiology is $43/hour or 29% less than other allied health professionals (after GST is applied) despite AEP qualifications, regulatory requirements, remuneration conditions (via the National Award for Health Workers) and overhead costs being equivalent to other allied health professions delivering supports under the NDIS.

For further detail on how AEPs are equally recognised, qualified and regulated compared with other allied health professions, please see ESSA’s previous submission to the Joint Standing Committee on NDIS Workforce.

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ESSA maintains that the current NDIS price limits imply that the exercise physiology profession provides a lower quality of service and has inferior qualifications to other allied health professions within the scheme, which is not the case, as demonstrated by pay parity experienced by AEPs with other allied health professionals in other schemes, as outlined in section 5.2.1 Comparison with other schemes of this submission. ESSA suggests that this issue will impact on the future growth of the exercise physiology workforce within the NDIS. ESSA argues that the decision to keep exercise physiology price limits lower than other allied health professions inhibits participants potential to reach the full extent of the health and improved daily living outcomes, as it limits the AEP’s scope of practice and the extent to which they can support the participant, both within therapy and within a multidisciplinary allied healthcare team.

ESSA is encouraged by initiative 11 of the NDIS National Workforce Plan, which aims to improve NDIS pricing approaches to ensure effective operation of the market, and sees this as an opportunity for the NDIS to recognise the exercise physiology profession as equal to other allied health professions, as it is already recognised in other schemes. ESSA cautions that changes to the NDIS pricing approach may adversely affect workforce supply, if not implemented correctly. Meaningful consultation and co-design with industries that provide NDIS supports, including the allied health sector, will be the best way to mitigate any issues arising from funding approach changes.

6.2 GST requirements (no initiative)

A range of allied health professions, including audiologists, dieticians, occupational therapists, podiatrists, psychologists, physiotherapists, speech pathologists, and social workers are GST exempt under the NDIS. Exercise physiology services delivered under the NDIS are required to pay GST’.

In line with the requirements set out in the Price Guide 2020-218, AEPs must account for the cost of GST within the price limits set out in the Support Catalogue. This requirement presents additional financial and administrative disadvantages for AEP practitioners and practices. To reiterate, AEPs charging at the maximum price limit of $166.99/hour (non-remote price limit, October 2019) lose $16.69/hour meeting GST requirements. This reduces an AEPs maximum payment to $150.29/hour, $43.70/hour or 29% less than allied health professions delivering GST free NDIS services at the maximum price limit of $193.99/hour. AEPs and businesses providing exercise physiology services face a greater regulatory burden in meeting their GST compliance costs compared to businesses delivering GST exempt health services.

Researchers have found that 58% of internal compliance costs of Australian businesses were due to GST compliance costs®. Further to this exercise physiologists working in NDIS have also experienced enormous challenges when plan managers have assumed that exercise physiology is a GST free supply under the NDIS and refused to pay the GST portion of exercise physiology invoices. Plan managers and GST is discussed further in section 5.2.2 Plan Management payments of this submission, above.

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DVA requires health care providers treating entitled persons to enter into a Recipient Created Tax Invoice (RCTI) Agreement with DVA if they are registered for GST and will be providing services to DVA (for example, reports). The RCTI Agreement permits DHS to automatically add GST to claimed taxable items?°. ESSA suggests that if the NDIA set price limits were made GST exclusive and the NDIA paid for the GST component in addition to the service delivery costs for AEP services, the NDIS would be considered a more attractive to many AEPs considering a career or small business servicing the NDIS.

Recommendation 18: The NDIA set price limits that are GST exclusive and pay for the GST component in addition to the service delivery costs for exercise physiology services.

7.0 Interaction with adjacent sectors

the interaction of NDIS workforce needs with employment in adjacent sectors including health and aged care

7.1 Alignment of provider regulation and worker screening (Initiative 10)

ESSA is pleased to see that initiative 10 of the NDIS National Workforce Plan includes aligning provider regulation and worker screening across the care and support sector. This approach may support continuity of care for people transitioning from one scheme to another. For example, a person living with a disability will be supported under the NDIS until 65 years. Once the person reaches age 65, they will, in principle, transition to the aged care sector, to receive support from new workers. This change in care workers can negatively impact health and wellbeing outcomes, as the participant is forced to rebuild relationships and trust with new care providers. A better solution is for care workers to be easily be recognised across both the NDIS and the aged care sector to enable consistent and continued support for participant. This would mitigate any negative impacts on participant outcomes relating to discontinuity of care.

ESSA notes that the plan indicates a review will be conducted to explore options to achieve alignment. However, the plan does not commit to implementing alignment across sectors. Given that workforce across the NDIS, aged care and health sector overlap, it is essential that a review be completed to ensure alignment. ESSA is concerned that a review without commitment to implement mutual recognition or alignment of regulation and worker screening will result in inaction.

Further, while regulation and worker screening alignment across sectors will support care workers to work across multiple sectors, it does not address workers looking only to work in the NDIS, particularly in rural and remote areas, that are required to pay unjustifiable amounts in auditing expenses. For further details on this, please see section 5.2 Regulation costs of this submission, above.

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8.0 Contact

Thank you for the opportunity to provide feedback into the inquiry into independent assessments.

Please contact ESSA Policy & Advocacy Advisor, Carla Vasoli, for further information or with any questions regarding the content of this submission.

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References

1 Australian Government. Department of Social Services. NDIS National Workforce Plan 2021-2025. [Internet]. June 2021 [cited 2021 August 5]. Available from https://www.dss.gov.au/sites/default/files/documents/06_2021/ndis-national workforce-plan-2021-2025.pdf

Case, L., & Yun, J. (2019). The effect of different intervention approaches on gross motor outcomes of children with autism spectrum disorder: a meta-analysis. Adapted Physical Activity Quarterly, 36(4), 501-526. doi:10.1123/apaq.2018-0174

3 Cynthia, C., Duck, M., McQuillan, R., Brazil, L., Malik, S., Hartman, L., Jachyra, P. (2019). Exploring the Role of Physiotherapists in the Care of Children with Autism Spectrum Disorder. Physical & Occupational Therapy in Paediatrics, 39(6), 614-628. doi:10.1080/01942638.2019.1585405

4 National Disability Insurance Agency (NDIA). Review of Therapy Pricing ARANSETENS, March 2019 [internet]. [place unknown]. NDIA; 2019. Available from https://www.ndis.gov.au i ici ici services.

° NDIS Quality and Safeguards Commission. The NDIS Code of Conduct — Guidance for Service Providers. [Internet]. March 2019 [cited 2021 August 5]. Available from https://www.ndiscommission.gov.au/sites/default/files/documents/202 1-06/code conduct-providers-june-2021.pdf.

® Kazia A, Upton P, Upton D. Supporting the transition from student to practitioner: A scheme to support the development of newly qualified practitioners. International Journal of Therapy and Rehabilitation. 2010 Sep; 17 (9): 494-503. DOI: 10.12968/ijtr.2010.17.9.78039

7 Australian Government. Australian Taxation Office. National Disability Scheme. [Internet]. Australian Government, Australian Taxation Office; 2019 December 18 [cited 2020 Jan 30]. Available from https://www.ato.gov.au/business/gst/in-detail/your industry/gst-and-health/?page=6.

§ National Disability Insurance Agency (NDIA). NDIS Pricing Arrangements and Price Limits 2021-22 (previously the NDIS Price Guide) [Internet]. NDIA; 2021 Jul 1 [cited 2021 Aug 5]. Available from https://www.ndis.gov.au/providers/pricing arrangements.

Evans, C., Hansford, A., Hasseldine, J., Lignier, P., Smulders, S., & Vaillancourt, F. (2014). Small business and tax compliance costs: A cross-country study of managerial benefits and tax concessions. eJTR, 12, 453.

10 Australian Government, Department of Veteran Affairs. Notes for Allied Health Providers, Section 1: General. [Internet]. [place unknown]. Australian Government, Department of Veteran Affairs. 2019 Sep 5. [cited 2020 Jan 30]. Available from https://www.dva.gov.au/sites/default/files/files/providers/alliedhealth/Notes—Allied-Health-Providers--Section-1.pdf

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