Dietitiar,s
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Joint Standing Committee on the National Disability Insurance Scheme: Inquiry into the NDIS Workforce
Response to consultation August 2021
Recipient
Joint Standing Committee on the National Disability Insurance
Scheme
A 1/8 Phipps Close, Deakin ACT 2600
W dietitiansaustralia.org.au | ABN 34 008 521 480
Dietitians Australia and the associated logo is a trademark of the Dietitians Association of Australia.
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About Dietitians Australia
Dietitians Australia is the national association of the dietetic profession with over 7500 members, and branches in each state and territory. Dietitians Australia is the leading voice in nutrition and dietetics and advocates for food and nutrition for healthier people and healthier communities. Dietitians Australia appreciates the opportunity to provide feedback to the Joint Standing Committee on the National Disability Insurance Scheme regarding the NDIS Workforce.
The Accredited Practising Dietitian (APD) program provides an assurance of safety and quality and is the foundation of self-regulation of the dietetic profession in Australia. APDs are food and nutrition experts who translate the science of nutrition into practical solutions for healthy living. APDs support people with disability to meet their unique food, fluid and nutrition requirements and achieve their goals through full participation in life.
This submission was prepared by Dietitians Australia and members following the Conflict of Interest Management Policy.
Recommendations
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The NDIS Commission collect and disseminate workforce data, to enable workforce mapping and development activities (see part ‘a’ for rationale)
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Address the suite of funding issues that impact the sustainable delivery of ‘reasonable and necessary’ nutrition and dietetic supports (see part ‘b’ for rationale)
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NDIA to develop policy and training to guide NDIA planners/delegates about what is ‘reasonable and necessary’ regarding inclusion of APDs and nutrition support products in NDIS plans (see part ‘b’ for rationale)
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Ensure the NDIS workforce have a basic understanding about food and nutrition and the role of APDs in the NDIS (see part ‘b’ for rationale)
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Change the current NDIA policy so that allied health professionals can supervise students (with participants consent) (see part ‘b’ for rationale)
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NDIS to support the training and use of Allied Health Assistants as Therapy Assistants (see part ‘b’ for rationale)
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Implement a National Food and Nutrition Policy to provide the legislative and policy framework for equitable access to food, fluids and nutrition care across all sectors including the NDIS (see part ‘c’ for rationale)
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State, Territory, Commonwealth Governments should consider targeted workforce development initiatives to address state and local issues (see part ‘d’ for rationale)
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State, Territory, Commonwealth Governments should ensure that the needs of the dietetic workforce are addressed as part of workforce development initiatives (see part ‘d’ for rationale)
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Discussion
a. The current size and composition of the NDIS workforce and projections at full scheme
Dietitians Australia self-reported workforce data shows that there are ~323 APDs registered as NDIS providers nationally. However, the current size and composition of the NDIS workforce cannot be accurately characterised due to lack of available workforce data. Dietitians Australia have requested data from the NDIS Commission on the number of dietitians registered as NDIS providers but were informed that data is not currently collected at the practitioner level.
As common across professions, there are few APDs providing services to NDIS participants in geographically regional and remote locations.
b. Challenges in attracting and retaining the NDIS workforce, particularly in regional and remote communities
There are several barriers to attracting and retaining dietitians within the NDIS workforce. As indicated by the data presented in part a, the NDIS dietetic workforce requires significant growth to meet consumer demand. Workforce issues include market uncertainty, frequent changes to NDIS administrative requirements, problems with planning processes and limited education and training opportunities. Below we highlight several issues frequently raised by members.
Funding and pricing issues
Funding and pricing issues make it difficult for APDs to provide services to NDIS participants in a sustainable manner. Key funding issues include:
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Frequent denial of funding for ‘reasonable and necessary’ nutrition supports and APD services
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Insufficient funding to purchase all the required supports, forcing participants to forgo dietetic services
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Insufficient payment to cover travel costs to deliver APD services, including professional time, vehicle costs and fuel costs
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Overpriced nutrition support products, which limits funding available to purchase other nutrition supports and services
Reasons for these funding issues include insufficient funding allocation for nutrition and dietetic services, insufficient guidelines at the health/disability interface about what is the NDIS responsibility to fund and poor understanding of disability-related nutrition needs outside of the dietetic profession, especially among NDIS planners.
“… I would say about 50% of the time our plans are being funded as per clinical recommendations and then the other 50% of the time its either grossly inadequate funding or
no funding.” (Accredited Practising Dietitian, Dietitians Australia Disability Think Tank,
23/04/2020)
“The horrendous mark-up of nutrition support from companies, when we make recommendations, I have access to HPV [Health Purchasing Victoria] pricing …we get subsidised rates for supplements. Under NDIS it’s very hard for people to access HPV pricing and they have to go to private providers for access and that can really really bump up the quote that we have to add for AT assessment, so for example, I have got someone at the
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moment for a quote for around $9000 for a private provider, under HPV pricing it would be around $6000, so they’re just capitalising on the cost of supplements. So, it just means that when we have to ask for that amount of money out of a plan your even less likely to get it.”
(Accredited Practising Dietitian, Dietitians Australia Disability Think Tank, 23/04/2020)
National Disability Insurance Agency planners and planning ineffectiveness
The NDIA planning processes are inconsistent and ineffective at identifying what is “reasonable and necessary” in relation to access of APD services and nutrition support products. This ongoing issue makes it difficult for APDs to undertake their work and secure reliable funding for their services. Issues with the planning processes and planners include:
NDIA PLANNERS AS GATE KEEPERS TO NUTRITION SUPPORTS AND SERVICES
NDIA planners are gatekeepers to nutrition supports and APD services for people with disability. Planners often have limited knowledge and training regarding nutrition and often lack understanding of the role of APDs in supporting NDIS participants to achieve their goals. This lack of understanding presents a barrier to access of nutrition and dietetic supports, and other health care services.
“…I’m aware of the difficulty that those individuals may have in accessing good health care, in the sense that their access may be dependent on gatekeepers who are supporting them.” (Professor Julian Troller, Royal Commission hearing, 20/02/2020)
PLANNERS REJECT REQUESTS FOR NUTRITION AND DIETETIC SUPPORTS, DESPITE STRONG EVIDENCE THE
SUPPORTS ARE ‘REASONABLE AND NECESSARY’
In a think tank held by Dietitians Australia to identify and address issues impacting the disability sector (23/04/2020), multiple APDs stated that planners consistently reject requests for the inclusion of APD services and nutrition supports in NDIS plans, despite clear evidence that these services meet the ‘reasonable and necessary’ criteria. This demonstrates a lack of understanding about the role of nutrition and dietetic services within the NDIS and lack of understanding about what is reasonable and necessary regarding these supports.
“…I work mainly with paediatrics in Melbourne…since we’ve had the introduction of the health-related disability supports I have seen minimal access, I haven’t had any plans come through with any form of inclusion lately. It’s the self-managed and plan-managed clients that have goals that relate to what we are working on and we’re working side-ways and we are still getting push back from a lot of planners…I have talked at length about how we are responding in letters and advocating back to planners and what we are putting in those early conversations… I’m just being consistently ignored.” (Accredited Practising Dietitian,
Dietitians Australia Disability Think Tank, 23/04/2020)
DIETETICS SEEN AS A ‘HEALTH’ ISSUE
Despite implementation of disability related health supports on 1st October 2019, NDIS planners continue to reject requests for dietetics services, arguing that dietetics should be covered by the health system.
”… they don’t actually get money for dietitians… still pushed back as it’s a health issue, not a disability issue. Even I write in the reports, this eating has absolutely everything to do with their disability, give them information sheets, often from the cerebral palsy or Down Syndrome or whatever about the health issues, feeding issues in that disability and they still just say ‘nup’. Now what I do is I even put in all my qualifications and extra work that I’ve done and experience and all that, saying I do know what I’m talking about, I’m not someone
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who doesn’t know what I’m talking about but then they ultimately have the ultimate decision and they’ve got no qualifications in the field and no experience in that field but they’re the ones making the decisions, it’s very frustrating.” (Accredited Practising Dietitian, Dietitians
Australia Disability Think Tank, 23/04/2020)
PLANNERS RARELY ENGAGE WITH APD SERVICES
APDs in attendance at the Disability Think Tank also stated that planners rarely engage with APD services unless dietitians or NDIS participants push for these services. This demonstrates underutilisation of dietitians by NDIA planners and lack of understanding about the role of food, fluids and nutrition care in assisting participants to achieve their goals. There is also poor understanding of the role and value of APD services.
“…hardly get anyone that’s agency managed, and as [dietitian] was saying most of the time they’re self-managed and the carer or the person will decide that they want to use the money for dietitian themselves” (Accredited Practising Dietitian, Dietitians 7Australia Disability Think Tank, 23/04/2020)
Many of the issues with planners stem from the lack of training provided regarding the role of food, fluids, nutrition and APD services in addressing the functional, social, health and economic outcomes of people with disability.
Dietitians Australia also notes that there is also a lack of clear guidance and transparency regarding how eligibility for disability related health supports is assessed and implemented by the NDIA.
NDIS general workforce, education and training issues
Lack of awareness and understanding of the role of nutrition and dietetics in supporting people with disability to achieve their goals, underlies many of the difficulties APDs face in working in the NDIS setting. All members of the NDIS workforce should have basic training regarding nutrition and the role of APDs in supporting people with disability to achieve their goals, including functional, physical, mental, social and economic.
An additional area of opportunity is for the NDIS to support the training and use of Allied Health Assistants as Therapy Assistants. The current system is opaque and difficult for providers to navigate. Supporting the use of Therapy Assistants would help overcome workforce shortages and with appropriate funding, training and support, assist participants to implement recommendations from multiple therapists/disciplines into a realistic and practical routine for the participant.
Lack of educational opportunities for emerging APDs and new entrants to the NDIS workforce
There are limited opportunities for students and new entrants to the NDIS workforce to gain experience working with people with disability in the NDIS setting. The replacement of block funding for the fee-for-service model, makes it increasingly difficult to find opportunities for student placements. It is essential that NDIA policy is updated to enable allied health professionals to supervise students within the NDIS setting.
“As the course coordinator of a dietetics degree…one of the challenges I’m finding with doing this well is actually giving the students the opportunity to work with people with a disability on placement….That did come up in a capacity building for the NDIA workforce in a rural setting in Victoria, late last year, that working with the NDIA to actually understand that if we want more skilled clinicians in that area, we need to look at how we replace that placement model because we used to have it when we were block funded and now that it’s fee-for
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service we’ve lost a lot of those opportunities and skilled in the area…” (Accredited Practising
Dietitian, Dietitians Australia Think Tank, 23/04/2020)
c. 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 NDIS workforce
Commonwealth Government commitment to implementation of a National Food and Nutrition Policy is part of the solution to addressing NDIS dietetic workforce issues. The last National Food and Nutrition Policy was released in 1992, over 26 years ago, and hence there is no contemporary policy to address the suite of issues regarding food and nutrition in Australia. A comprehensive and contemporary National Food and Nutrition Policy would position food and nutrition as an important factor in the promotion of quality of life and prevention of disease across a broad range of demographics.(1-3) This would ensure prioritisation of nutrition, through screening, assessment, care planning, adequate food and fluid delivery, support during mealtimes and workforce development, education and training.
Lack of awareness of the role and importance of nutrition and dietetics is a fundamental barrier to access of APDs in the NDIS setting. A National Food and Nutrition Policy would address this issue by raising awareness and understanding of the importance and role of nutrition and dietetics across all sectors including the NDIS setting.
d. the role of State, Territory, Commonwealth Governments in providing and implementing a coordinated strategic workforce development plan for the
In addition to an overarching workforce development strategy, State, Territory and Commonwealth Governments should consider targeted workforce development initiatives to address state and local issues.
Dietitians Australia has been advocating for many years to address NDIS workforce concerns for our members. There has been minimal support from State, Territory and Commonwealth governments to address these issues. Governments should explicitly recognise and address the workforce development needs of all sections of the NDIS workforce including dietitians.
References
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Dietitians Association of Australia. Nourish not neglect. Putting health on our nation’s table.
Canberra2019.
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Public Health Association of Australia, Dietitians Association of Australia, Nutrition Australia,
Heart Foundation. Background paper. Supporting documentation for the Joint Position Statement: Towards a National Nutrition Policy for Australia. 2017.
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Public Health Association of Australia, Dietitians Association of Australia, Nutrition Australia,
Heart Foundation. Joint Policy Statement: Towards a National Nutrition Policy for Australia. Canberra: Public Health Association of Australia; 2017.