Submission to the Joint Standing Committee on NDIS - workforce
Submission by the
Australian Physiotherapy Association
May 2020
Authorised by:
Phil Calvert
National President
Australian Physiotherapy Association
Level 1, 1175 Toorak Rd
Camberwell VIC 3124
Phone: (03) 9092 0888 Fax: (03) 9092 0899 www.physiotherapy.asn.au
Table of Contents
Introduction……………………………………………………………………………………………………………………………………. 3 Summary of Recommendations …………………………………………………………………………………………………. 4 Size and composition of the NDIS workforce ……………………………………………………………………………. 5
NDIA staff ……………………………………………………………………………………………………………………………………………………………………….. 5
Allied health workforce …………………………………………………………………………………………………………………………………………………… 6
Data collection ………………………………………………………………………………………………………………………………………………………………… 7
Research …………………………………………………………………………………………………………………………………………………………………………. 7 Attraction and retention of NDIS workforce ……………………………………………………………………………….. 9
NDIS administrative requirements and processes …………………………………………………………………………………………………………… 9
Challenges of disability work …………………………………………………………………………………………………………………………………………… 9 Conclusion …………………………………………………………………………………………………………………………………… 12 Australian Physiotherapy Association………………………………………………………………………………………. 13
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Introduction
The Australian Physiotherapy Association (APA) welcomes this opportunity to make a submission to the inquiry into National Disability Insurance Scheme (NDIS) workforce by the Joint Standing Committee on the NDIS, on behalf of the physiotherapy profession.
Physiotherapists are movement and participation experts in disability who specialise in improving function, participation and building capacity. Physiotherapists are committed to providing expert, evidence-based, safe and high-quality care to people with disability.
Our profession, at both the level of individual physiotherapists, and collectively, is focused on maximising value in disability – on achieving the best health and related outcomes at the lowest cost whilst maintaining quality of care. We bring this focus to this submission.
Physiotherapy can bring value to the lives of people with disability, however some of the systems and structures of the current system make that difficult to achieve.
We are concerned about the loss of highly experienced clinicians choosing to cease working under the NDIS. Additionally, there is a lack of financial investment and incentivisation to support the professional development and supervision requirements of new and emerging physiotherapists, to ensure the Scheme continues to be underpinned by skilled and experienced providers.
We want to see improvements in access to services, especially for people in rural and regional Australia. Local businesses in rural and remote areas are often ill equipped to provide the expertise required for NDIS participants. The APA recommends funding for experienced physiotherapists to provide training and mentoring to local clinicians in regional, remote and rural areas to build capacity in local workforces and reduce the need, and subsequent cost, of providers travelling further afield.
We would be happy to meet with the Standing Committee on the NDIS on behalf of the physiotherapy profession and have provided a summary of our recommendations in our submission.
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Summary of Recommendations
Recommendation 1
The APA recommends that decision makers for plan and budget allocation have in depth understanding of allied health to ensure decisions are equitable and appropriate for the participant’s needs.
Recommendation 2
The APA recommends that NDIA funding should provide financial incentives to support
student placements and new graduate programs to bolster the development of
physiotherapists in the disability sector and to ensure the ongoing capability of the NDIS workforce.
Recommendation 3
The APA recommends that the NDIA fund the collection of NDIS workforce data in order to gain more understanding of the location of providers, the setting in which they work and the percentage of their work that is NDIS funded. Additionally, capturing the reasons why some NDIS providers are opting to leave the Scheme.
Recommendation 4
The APA recommends that the NDIA fund and collate research into Evidence Based Practice for the NDIS workforce in order to encourage and ensure high value care.
Recommendation 5
The APA recommends that the NDIA incorporate clinical leads into the Scheme to act as centralised points for clinical guidelines and advice. By establishing a clinical lead for physiotherapy, providers can access best practice guidance and reduce unnecessary time developing planned interventions that are then declined by the NDIA.
Recommendation 6
The APA recommend the NDIA collate and streamline their communication material and use simple and sequential messaging to alert providers of changes to the Scheme. We suggest the distribution of regular provider notifications to ensure NDIS providers are aware of any updates to the Scheme, and what they actually mean.
Recommendation 7
The APA recommends that the NDIA establish an urgent pathway to provide a formal approach to reviewing and responding to urgent cases or requests.
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Recommendation 8
The APA recommends the NDIA collaborate with universities to develop and embed learning modules for physiotherapy degrees to provide education around what the NDIS is and how to work within it.
Recommendation 9
The APA recommends developing a workforce capacity building model for physiotherapists to provide training and mentoring to local clinicians in regional, remote and rural areas to build clinical expertise in local workforces.
Size and composition of the NDIS workforce
NDIA staff
Provision of allied health to NDIS participants is a crucial and specialised service. Allied
health practitioners span a myriad of professions and provide a range of treatment
interventions that are based on extensive training and expertise. Access to high quality physiotherapy is essential for a person with disability. Physiotherapists work in partnership with people with disabilities to build on an individual’s strengths and limitations and maximise their participation in social and economic life.
Physiotherapists are experts at the full spectrum of needs assessment, intervention and
evaluation of service provision. A physiotherapist conducts an individualised needs
assessment to determine the level and type of intervention required by a participant as well as implementing the therapy and then assessing outcomes to modify therapy accordingly.
Given NDIA staff do not require any clinical training or experience, there are significant
concerns relating to who makes the decisions for selection and allocation of clinical
resources. Similarly this applies to decision making regarding the approval and allocation of Assistive Technology (AT) with members reporting that the wrong items are being distributed due to lack of knowledge on the part of NDIA planners. At present decisions are being made by unqualified people – this responsibility needs to shift into the hands of trained allied health professionals who can contextualise requests and respond appropriately.
“To have NDIA agents who should understand disability asking if people have been cured of their down syndrome or autism. They cannot advocate if they can’t understand disability.” – APA member
The APA believes decisions relating to the allocation and provision of allied health services should be made by those who understand the clinical justification as well as the gamut of services and interventions available. It is imperative that the advice provided by allied health professionals is incorporated into ensuring feasible and equitable planning decisions.
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Another concern raised by members is the high turnover of NDIA staff, which leads to unwarranted plan changes and inconsistency in decision making. In order to ensure equitable and appropriate distribution of funding and service allocation, it is imperative that decision making follows a consistent and informed approach.
Allied health workforce
Meeting the current need for allied health intervention for NDIS participants is challenging. There are insufficient, appropriately trained allied health professionals to meet the current demand for services. Moreover, there is a mal distribution of suitably trained physiotherapists with rural and remote areas being significantly underserviced. According to an APA member:
“In my experience and conversations with colleagues and participants there is a shortage of paediatric physios and other therapists in rural areas. In many rural areas participants are relying on general private practice physiotherapists who have limited knowledge and experience in paediatrics. There is also difficulty in recruiting paediatric physiotherapists in order to meet the demands of the scheme.”
To ensure participants receive the expert care and service provision they deserve and
require, allied health professionals need to be adequately trained and skilled. Many
experienced and longstanding physiotherapists specialising in the disability sector have left the industry due to financial hardship or other challenges relating to working in this space. As new and emerging physiotherapists begin to work with NDIS participants, it is vital they receive adequate training and mentoring to maintain high value care.
It is unreasonable to expect that the responsibility and financial burden of ensuring the next generation of physiotherapists enter the workforce adequately trained and mentored, falls on existing providers and practice owners. New graduates require significant support and supervision to develop their skills and capabilities in the disability sector. Under an activity based funding scheme, such as the NDIS, time spent upskilling and supporting emerging clinicians detracts from billable hours and carries a notable opportunity cost.
New graduates need to be suitably prepared for the workforce. More onus should be placed on universities to prepare students and provide materials and opportunities for growth and skill development, including appropriate and relevant student placements.
Continual professional development and upskilling of physiotherapists is costly, both in time and education costs. In the case of new clinicians working under the NDIS, the responsibility to develop and upskill staff often falls upon the business owners. As described by an APA member:
“We find it hard to find appropriately skilled, disability workforce ready staff. Training to get them ready for disability is costly.”
In order to sustain a highly skilled and specialised workforce, the overarching structure of the Scheme must empower and facilitate NDIS providers to access suitable and affordable training and optimal professional supervision. The APA believes the NDIA should incorporate
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funding to support and incentivise student placements and new graduate roles in the disability sector, as is done in the public sector. We suggest that fiscal incentives are offered to an organisation to take on a new graduate and provide training and mentoring throughout their first year, when the learning curve is steepest and most time intensive.
Data collection
Commonwealth government policy is imperative to lay the foundation and provide oversight for the NDIS. In order for the Scheme to continue to be viable and effective, government policy must consider the ongoing needs of participants as well as understanding what is required to ensure the sustainability of the workforce.
Ensuring the sustainability and viability of the NDIS workforce relies on sound data. In order to plan for the future of the Scheme we need to understand the composition and operations of the current workforce. Under NDIS funding, the disability workforce now spans NGO, community and private providers with little insight into who is working within the Scheme and to what extent or in which capacity.
We believe it is important to capture some data around the current NDIS workforce in order to extrapolate this data into accurate and meaningful future projections. Data relating to the location of providers, the setting in which they work and the percentage of their work that is NDIS funded, as well as observing how these figures change over time, would provide valuable insights for workforce planning. Potentially data could be gathered and collated according to the use of physiotherapy line items in NDIS plans.
Anecdotally, we can observe and have been told by members, that there has been a significant exodus of highly experienced physiotherapists from the NDIS workforce. Some of the reasons described to us for providers leaving the NDIS relates to the challenges of negotiating budgets and fees. As health professionals who may have previously worked in the health sector, many physiotherapists are not used to having to negotiate fees and find these conversations difficult and unpleasant. Further, every time the NDIA make a change to pricing, the provider is left having to explain the change and budgetary implications to the family, which is challenging. Understanding the range of reasons why people choose to leave the NDIS to work in different sectors or under different funding models would assist in configuring the Scheme to enhance retention of skilled providers.
Research
To encourage and endorse evidence based, best practice and best value interventions, the APA recommends the NDIA fund the creation and collation of research into disability interventions. As demonstrated by other insurance schemes that fund clinical services, the NDIA is well positioned to fund and synthesise resources and advice for providers. We believe the NDIA should ensure appropriate money spend as well as ongoing high value
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care by investing in research and disseminating best practice guidelines and
recommendations to providers.
To support the NDIS workforce and to improve the standard of service provided to participants, the APA recommends that clinical leads are integrated into the Scheme. At present members report having no central line of clinical communication into the NDIA, which results in time and effort being misdirected into the development of planned interventions, that are then declined by the NDIA.
In addition to supporting providers, clinical leads could also incorporate a consultancy function for Local Area Coordinators (LACs) and NDIS Planners, to improve consistency in the planning/ budgeting process. By establishing a clinical lead for physiotherapy within the Scheme, research, guidelines and clinical advice can be distributed to providers to ensure the workforce is supported and encouraged to provide high value care.
Recommendation 1
The APA recommends that decision makers for plan and budget allocation have in depth understanding of allied health to ensure decisions are equitable and appropriate for the participant’s needs.
Recommendation 2
The APA recommends that NDIA funding should provide financial incentives to support
student placements and new graduate programs to bolster the development of
physiotherapists in the disability sector and to ensure the ongoing capability of the NDIS workforce.
Recommendation 3
The APA recommends that the NDIA fund the collection of NDIS workforce data in order to gain more understanding of the location of providers, the setting in which they work and the percentage of their work that is NDIS funded. Additionally, capturing the reasons why some NDIS providers are opting to leave the Scheme.
Recommendation 4
The APA recommends that the NDIA fund and collate research into Evidence Based Practice for the NDIS workforce in order to encourage and ensure high value care.
Recommendation 5
The APA recommends that the NDIA incorporate clinical leads into the Scheme to act as centralised points for clinical guidelines and advice. By establishing a clinical lead for physiotherapy, providers can access best practice guidance and reduce unnecessary time developing planned interventions that are then declined by the NDIA.
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Attraction and retention of NDIS workforce
NDIS administrative requirements and processes
APA members report that extracting valuable information from NDIA websites and resources
is challenging. With regular changes and updates being added alongside existing
information, keeping track of new information and reforms is time consuming for providers and risks important information being missed.
Our members describe a sense of flux in the policies and operations of the NDIS.
Understanding and ensuring adherence to changing policies creates uncertainly and unease amongst providers, leading to some opting not to provide services under the NDIS. Members report that the communication provided by the NDIA is inadequate with one APA member describing:
“I need to trawl through the NDIA website to try to find any new changes or updates – why can’t they alert us when a change is made?”
The APA recommend the NDIA collate and streamline their communication material and use simple and sequential messaging to alert providers of changes to the Scheme. We suggest the distribution of regular provider notifications to ensure NDIS providers are aware of any updates to the Scheme, and what they actually mean.
At present there is no capacity for the NDIA to respond quickly for urgent cases or requests (apart from a specific Covid-19 urgent category that has been recently established). Currently urgent requests are being addressed in an ad hoc basis with no guarantee of a timely response. The APA recommends that the NDIA establish an urgent pathway to provide a formal approach to reviewing and responding to urgent cases or requests.
Further, members refer to the costly and time intensive registration and auditing
requirements that create significant fiscal and opportunity costs. The high burden of
registration and auditing processes coupled with the slow receipt of payment has led to significant frustration within the sector. The APA recommends that payment processing is streamlined to ensure efficient and timely payment of outstanding funds to physiotherapists.
Challenges of disability work
Providing physiotherapy to people with disabilities can be challenging and time consuming. Given the complexities and variability of the caseload, the nature of providing work in the disability sector involves a consistently high caseload with significant work between allocated sessions. Considering the administrative work required outside of designated appointment times, the overall profitability of work in disability is also reduced.
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“The caseload can be complex, there are additional needs outside of therapy sessions and there are complexities for businesses to navigate the system” – APA member
In addition to the complexities of working with people with disabilities, is the ongoing nature of the work. Other streams of physiotherapy involve short periods of intervention and involvement, whereas in the case of disability, conditions are ongoing and often require continual involvement over the course of many years. This means providers may never be able to entirely cease treatment or ‘close a case’ which can be a rewarding sensation.
According to some APA members, the challenge of attracting physiotherapists to work in disability stems from tertiary education and promotion of this segment of the profession. As described by one member:
“Disability is not sexy. The unis do not do enough to show disability in a positive light. We are the best at person centred care and have amazing relationships with the people we work with. We also need more research to increase the attraction.”
New physiotherapists beginning their clinical journey could feel unprepared and
overwhelmed for work in the disability sector. There is a perception that working with people with a disability is complicated from a policy and procedural perspective, and requires
extensive experience and knowledge (which it does). Without adequate training and
development the responsibility to upskill and train physiotherapists to work with disability falls to the sector itself with practice owners needing to invest time and resources into training.
Universities are exposing people to a lot of skills that are required across the physiotherapy profession, including for working in disability. However, students need opportunities to contextualise that learning, which reiterates the APA’s recommendation that more funding and support is required to provide appropriate opportunities for student placements under the NDIS.
Tertiary education is designed to equip students with a range of transferable skills, but these are theoretical until put into practice in ‘real life’ scenarios. The APA recommends the NDIA collaborate with universities to develop and embed learning modules for physiotherapy degrees to provide education around what the NDIS is and how to work within it.
Rural and remote challenges
As per many other components of the health sector, attracting and retaining clinicians is more challenging in the rural and remote settings. Most educational supports and offerings are available in metropolitan regions with less services available to attract the professional workforce to rural and remote areas.
Specifically relating to physiotherapy in disability, that requires ongoing training and upskilling in the clinical and policy level complexities, there is reduced access to experienced clinicians and thus the mentoring required to sustain and propel a strong workforce. In order to instil confidence, assurance and inspiration in providers to work with people with disabilities in rural and remote areas, it is vital that appropriate support channels are in place for ongoing professional development and progression.
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Provision of physiotherapy in rural and remote areas often entails significant travel. In order for a participant to receive high quality and appropriate care from a knowledgeable physiotherapist, providers must travel further afield. This is particularly relevant to rural and remote areas, and thin markets, where suitably experienced provider availability is limited and, for a participant to receive best practice care, significant travel can be involved.
In areas where there is a shortage of suitably trained allied health professionals, most notably in rural and remote locations, we believe that a workforce capacity building approach is required. To ensure participants in regional, rural and remote Australia have access to high quality, best practice care, the APA recommends the NDIA supports physiotherapists to provide training and upskilling to local therapists to build the local workforce.
Small businesses should be bolstered and encouraged to provide services to NDIS
participants in their local communities. One strategy is to enable experienced
physiotherapists to build local capacity, through a train-the-trainer or clinical mentor initiative, thus equipping communities with improved access to skilled clinicians without relying on extensive travel. This would also reduce the opportunity cost of travel and increase availability for physiotherapists to provide more clinical services.
Recommendation 6
The APA recommend the NDIA collate and streamline their communication material and use simple and sequential messaging to alert providers of changes to the Scheme. We suggest the distribution of regular provider notifications to ensure NDIS providers are aware of any updates to the Scheme, and what they actually mean.
Recommendation 7
The APA recommends that the NDIA establish an urgent pathway to provide a formal approach to reviewing and responding to urgent cases or requests.
Recommendation 8
The APA recommends the NDIA collaborate with universities to develop and embed learning modules for physiotherapy degrees to provide education around what the NDIS is and how to work within it.
Recommendation 9
The APA recommends developing a workforce capacity building model for physiotherapists to provide training and mentoring to local clinicians in regional, remote and rural areas to build clinical expertise in local workforces.
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Conclusion
The APA is committed to improving the quality of care provided to people living with disability in Australia. Physiotherapists are vital to enhance the quality of life of NDIS participants and to empower them with the skills and tools to continue to raise their participation and function.
We believe that the NDIS provides a strong framework for the provision of high quality care to the disability sector and offer our recommendations as improvement opportunities to strengthen the impact that the Scheme can create.
We would welcome the opportunity to further contribute to any reforms that emerge.
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Australian Physiotherapy Association
The APA vision is that all Australians will have access to quality physiotherapy, when and where required, to optimise health and wellbeing.
The APA is the peak body representing the interests of Australian physiotherapists and their
patients. It is a national organisation with state and territory branches and specialty
subgroups. The APA represents more than 26,000 members who conduct more than 23 million consultations each year.
The APA corporate structure is one of a company limited by guarantee. The APA is governed by a Board of Directors elected by representatives of all stakeholder groups within the Association.
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