NACCHO
National Aboriginal Community
Controlled Health Organisation
Aboriginal health in Aboriginal hands www.naccho.org.au
N DIS Workforce
September 2021
About NACCHO
NACCHO is the national peak body representing 143 Aboriginal Community Controlled Health Organisations (ACCHOs) Australia wide on Aboriginal and Torres Strait Islander health and wellbeing issues. NACCHO’s work is focused on liaising with governments, its membership, and other organisations on health and wellbeing policy and planning issues and advocacy relating to health service delivery, health information, research, public health, health financing and health programs. Our members provide about three million episodes of care per year for about 350,000 people across Australia, including about one million episodes of care in very remote regions.
Sector Support Organisations, also known as affiliates, are State based and represent ACCHOs offering a wide range of support services and Aboriginal and Torres Strait Islander health programs to their members including advocacy, governance and the delivery of state, territory and national primary health care policies.
ACCHOs range from large multi-functional services employing several medical practitioners and providing a wide range of services, to small services which rely on Aboriginal Health Workers/Practitioners and/or nurses to provide the bulk of primary health care services, often with a preventive, health education focus. Our 143 ACCHOs operate approximately 700 facilities, including about 450 clinics. ACCHOs and their facilities and clinics contribute to improving Aboriginal and Torres Strait Islander health and wellbeing through the provision of comprehensive holistic primary health care, and by integrating and coordinating care and services. Many provide home and site visits; medical, public health and health promotion services; allied health; nursing services; assistance with making appointments and transport; help accessing childcare or dealing with the justice system; drug and alcohol services; and help with income support.
Collectively, we employ about 6,000 staff, 56 per cent of whom are Indigenous, making us the second largest employer of Aboriginal and Torres Strait Islander people in the country.
Any enquiries about this submission should be directed to:
NACCHO
Level 5, 2 Constitution Avenue
Canberra City ACT 2601
Website: naccho.org.au
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Key Recommendations
NACCHO recommends to the Senate Standing Committee on the National Disability Insurance Scheme inquiry into NDIS Workforce that the Australia Government: Implement recommendations in line with the National Agreement on Closing the Gap (the National Agreement) and the four priority reforms as follows:
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Funding directed to NACCHO to develop flexible care workforce models to trial across urban, regional, and remote Aboriginal Community Controlled Health Organisations (ACCHOs) to address market challenges for Aboriginal and Torres Strait Islander peoples NDIS service provision.
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An analysis of the real costs of delivering services to Aboriginal and Torres Strait Islander peoples in regional and remote areas including the cost of travel, transport, training, and workforce support.
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Development of strategies and funding models to attract, develop and retain Aboriginal and Torres Strait Islander workers for an integrated health and care workforce.
Introduction
NACCHO welcomes the Senate Standing Committee on the National Disability Insurance Scheme inquiry into the NDIS Workforce. NACCHO will respond to the following questions outlined by the terms of reference:
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The current size and composition of the NDIS workforce and projections at full scheme.
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Challenges in attracting and retaining the NDIS workforce, particularly in regional and remote communities.
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The interaction of NDIS workforce needs with employment in adjacent sectors including health and aged care.
Aboriginal and Torres Strait Islander peoples are over twice as likely to experience a disability than other Australians (9% with a severe condition compared to 4% for non - Indigenous1). Currently 6.9% of NDIS participants are Aboriginal and Torres Strait Islander peoples (32,396 active participants as at 30 June
- which is considerably less than the percentage believed to have a significant disability. This percentage of NDIS participants who are Aboriginal and Torres Strait Islander is a measurement of the number of Aboriginal and Torres Strait Islander peoples currently on a plan. This data alone fails to paint a complete picture. Plan utilisation data from the NDIA shows an underutilisation of plans by Aboriginal and Torres Strait Islander people nationally and is considerably less when compared to other Australians3. Furthermore, underutilisation of plans becomes more compounded in rural and remote settings where additional barriers such as thin or in some cases, no markets exist.
Evidence supports the notion that Aboriginal and Torres Strait Islander peoples will only access those services where they feel culturally safe and prefer to use Aboriginal Community Controlled Organisations (ACCO) when available. Community control has its roots in Aboriginal and Torres Strait Islander peoples’ right to self-determination. An ACCO has ongoing community input and ownership
1 AIHW and NIAA (2020a). Aboriginal and Torres Strait Islander Health Performance Framework 2020 report, section 1.14 Disability. 2 NDIA. (2021). NDIS Quarterly Report to disability ministers, 30 June 2021. 3 AIHW and NIAA (2020a). ibid.
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that is initiated by the community and is governed by an Aboriginal and Torres Strait Islander body which is elected by the community and delivers holistic and culturally appropriate services to the Aboriginal and Torres Strait Islander community. Culturally appropriate and holistic primary healthcare is provided by Aboriginal Community Controlled Health Organisations (ACCHOs) who provide about three million episodes of care each year for about 350,000 people4.Other research has shown ACCHOs are best placed to overcome the social and cultural determinants of health which can hinder Aboriginal and Torres Strait Islander peoples accessing the health care they need5.
The current size and composition of the NDIS workforce and projections at full scheme
There is a clear preference for Aboriginal and Torres Strait Islander peoples to access community-controlled services for disability, aged-care, health or otherwise and will bypass mainstream services to access one where they are confident their cultural safety is guaranteed. More concerning is that Aboriginal and Torres Strait Islander peoples will not access a service (or at least defer accessing) if they perceive that, or have an experience, where their cultural safety is compromised6. For this reason, ACCOs, including ACCHOs, are critical to the successful uptake and delivery of NDIS services to Aboriginal and Torres Strait Islander peoples. To ensure the successful uptake and utilisation of NDIA disability, a multidisciplinary and culturally competent workforce is needed to support and provide services to Aboriginal and Torres Strait Islander peoples.
The Aboriginal and Torres Strait Islander community-controlled care sector is facing major workforce challenges where demand will outstrip supply of suitably skilled and job ready Aboriginal and Torres Strait Islander employees. This shortage will impact access to culturally appropriate, effective, and efficient support and assistance needed for Aboriginal and Torres Strait Islander people. Without an overall increase in the number of Aboriginal and Torres Strait Islander people participating in the care workforce, services will be competing for workers who are a limited resource across all health and care sectors.
Growth needs for the entire care workforce is estimated to be in the order of 14.2% to 2025, a requirement for an additional 249,500 workers7. For Aboriginal and Torres Strait Islander workers to make up a modest proportionate component (say 3.3%) of the forecast increase, an additional 8,233 Aboriginal and Torres Strait Islander workers are required by 2025. But we know that Aboriginal and Torres Strait Islander people make up a far greater proportion of the people who need care, so this number is an underestimate. Our established network of 143 ACCHOs with their 550 clinics are a well established national resource. But our existing services are already experiencing severe workforce shortages.
Expansion of the Aboriginal and Torres Strait Islander workforce ensures the care sector can address the needs of Aboriginal and Torres Strait Islander NDIS participants. Aboriginal and Torres Strait Islander workers can align their unique sociocultural skills and cultural knowledge to improve patient care,
4 AIHW (2018). Australia’s health 2018. Australia’s health series no. 16. AUS 221. Canberra: AIHW. 5 Davy, C. et al., (2016). Access to primary health care services for Indigenous people: A framework synthesis.
International Journal for Equity in Health.,15:163
6 Aspin., C. et al., (2012). Strategic approaches to enhanced health service delivery for Aboriginal and Torres Strait Islander people with chronic illness: a qualitative study. BMC health Services Research., 12: 14
7 National Skills Commission. (2020). Industry Employment Outlook, Employment Projections
https://lmip.gov.au/default.aspx?LMIP/GainInsights/EmploymentProjections
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improve access to services, and support the provision of culturally appropriate care and service provision8.
The current disability system (the NDIS) is not accessible to Aboriginal and Torres Strait Islander people with a disability for numerous reasons. The needs, situation, and culture of Aboriginal and Torres Strait Islander people were not taken into consideration when developing the NDIS, creating a system with accessibility and service gaps at best and exploitation at worst for Aboriginal and Torres Strait Islander people.
Aboriginal and Torres Strait Islander peoples are under-represented in the NDIS. Even if Aboriginal and Torres Strait Islander people are successful in applying for, and meeting the eligibility criteria for the NDIS, many communities still face limitations in accessing the NDIS due to geographical location and the limited physical resources to meet demand. The most effective way for Aboriginal and Torres Strait Islander people to participate in the NDIS is to provide them with culturally appropriate information and system navigation (e.g., such as Community Connectors) to ensure their understanding of the NDIS, together with increasing the number of Aboriginal and Torres Strait Islander community-controlled providers. This includes understanding the real costs of delivering services to Aboriginal and Torres Strait Islander people.
Supporting the Aboriginal and Torres Strait Islander care workforce to grow will have long-term benefits for Aboriginal and Torres Strait Islander NDIS participants. A study by Gilroy and colleagues (2017) found the importance of Aboriginal and Torres Strait Islander workers to support people with a disability, especially in rural and remote areas and proposed ways to support this important workforce9. Specifically:
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strategies to attract, develop and retain Aboriginal and Torres Strait Islander workers for the NDIS workforce;
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the importance of culturally safe NDIS services and community-centred principles;
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identification of strategies such as cultural training for workforce development10. In 2019, the COAG Disability Reform Council agreed to use a more flexible approach to address market challenges in the NDIS and recognised a ‘one size fits all’ approach to deliver NDIS is not suitable to address market gaps faced by geographic location, particular cohorts, and certain disability types.
As we speak, the NDIS system is failing Aboriginal and Torres Strait Islander people. Any attempt to implement a more flexible approach for our sector has been ad hoc and short-term, resulting in interrupted service delivery, and an inability to build a sustainable care workforce. It has also resulted in some cases of unintended consequences of community losing trust in their ACCHO.
8 AIHW and NIAA (2020b). Aboriginal and Torres Strait Islander Health Performance Framework 2020 report, section 3.12 Aboriginal and Torres Strait Islander people in the health workforce.
9 Gilroy. J., et al. (2017). Need for an Australian Indigenous disability workforce strategy: review of the literature. Disability and Rehabilitation 39:1664-73. 10 Gilroy, J., et al (2017). Ibid.
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To help our people with a disability we need far greater integration across the service system so that it can respond to the whole family in a way that avoids disruption. We need Aboriginal and Torres Strait Islander led solutions that are enabled to focus on addressing needs at the community level.
The ACCHO sector is best placed to support innovative solutions in developing and delivering an integrated care service delivery model that aligns with their holistic comprehensive primary health care model. Integral to this, is a sustainable and strong multidisciplinary care workforce that are embedded within ACCHOs who are best placed to deliver culturally competent care for all Aboriginal and Torres Strait Islander people nationally.
Challenges in attracting and retaining the NDIS workforce, particularly in regional and remote communities.
Aboriginal and Torres Strait Islander NDIS participants are more likely to live in remote areas compared to other Australians (11% compared with 1%, respectively)11 which indicates a higher need for an NDIS workforce in these areas to support Aboriginal and Torres Strait Islander NDIS participants, families, and communities.
The costs of delivering services to Aboriginal and Torres Strait Islander communities in rural, regional, remote, and very remote can be enormous when compared with urban locations. This can be for a number of reasons including, long distances between communities and urban hubs, limited resources within communities, and workforce shortages that are constantly experienced by our services across Australia. Due to these issues, and the resulting high cost of service delivery, many Aboriginal and Torres Strait Islander peoples have limited access to the NDIS and when on the plans, limited opportunity to utilise their disability supports.
Aboriginal and Torres Strait Islander peoples who live in regional and remote Australia often live long distances from centres providing disability services and often rely on infrequent outreach services for appropriate support. This is complicated by difficulties for services in attracting and retaining workers and insufficient resources being provided to services to upskill within organisations. For ACCHOs to employ health professionals for delivery of disability supports, there would need to be enough NDIS participants paying fees to fund these roles. Consequently, there is a reliance on fly-in fly-out (FIFO) and drive-in drive out (DIDO) arrangements to provide services in these communities. This is very expensive, represents little value for money, and may also not be the best for the participants. Research into the short-and long-term economic effects of FIFO and DIDO practices is limited but what has been conducted shows there is a poor understanding of the impact of these practices on the liveability of regional communities12. The cultural safety of the community is also at risk with new health professionals coming in and out with new checks and balances on the appropriateness of these individuals. Importantly, within a cultural context, it also prohibits staff from building trusting relationships with participants.
Some WA ACCHOs have been funded for Remote Community Connectors (RCCs), as well as Evidence, Access, and Coordination of Planning positions (EACP) in local ACCHOs. These positions address some of the barriers that prevent Aboriginal and Torres Strait Islander people entering the NDIS especially within rural and remote areas. Challenges such as contacting the NDIS and completing the forms to request
11 AIHW and NIAA (2020a). ibid. 12 Weeramanthri, T. & Jancey, J. (2013). Fly-in, fly-out (FIFO) work in Australia: the need for research and a health promotion framework. Heath Promotion Journal of Australia.
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access, including obtaining appropriate clinical or other assessments can be overcome with the right support. The EACP position is based in an AMS, and with the consent of the individual, the EACP is able to work with NDIA National Access Team to facilitate the request for access process, utilising existing medical records and coordinating additional evidence where required. This program effectively addresses a large barrier encountered by many Aboriginal and Torres Strait Islander NDIS participants
Key barriers for remote participants include remoteness, isolation, and the mobile and transient nature of peoples which makes it difficult to track possible participants. In WA, this is where the RCCs have assisted, but distance is still a challenge for a small team. Costs increase in remote areas due to numbers of participants, transport, and complex needs. The real costs of delivering services to Aboriginal and Torres Strait Islander peoples in remote areas need to be assessed.
The interaction of NDIS workforce needs with employment in adjacent sectors including health and aged care
Structural reform is needed in the care space to ensure Aboriginal and Torres Strait Islander people with disability can access culturally safe NDIS services and older Aboriginal and Torres Strait Islander people can access aged care services. Currently the separation of health, disability, and aged care, creates barriers and access issues which has a flow-on effect to the workforce and the number (and competency) of employees available to support some of the most disadvantaged people in Australia.
The ACCHO sector has started branching out into supporting Aboriginal and Torres Strait Islander NDIS participants. However, it must be remembered ACCHOs are foremost, comprehensive primary health care providers. In addition to frontline workers, we need to build the workforce capacity of our sector to keep up with the Aboriginal and Torres Strait Islander NDIS participant demand and capacity building to support ACCHOs to succeed as registered NDIS providers. ACCHOs are also branching out into other areas of the care sector, including support for aged care to ensure all Aboriginal and Torres Strait Islander people have access to culturally appropriate competent care. To effectively support growing demand, we need to leverage the current ACCHO workforce and draw from local communities to build a multi-disciplinary care workforce that includes both cultural and clinical experts. Clear and supported entry pathways into the care workforce targeting school leavers, older workers wanting to return and/or transition and existing care (often unpaid) community members are also required to meet projected workforce growth demands. The Aboriginal and Torres Strait Islander community-controlled RTO Sector are best placed to provide accredited and non-accredited training to ensure a well-qualified and expert workforce is built.
Evidence from the Royal Commission report into Aged Care Quality and Safety supports the need for culturally appropriate, flexible care services that the ACCHO sector are best paced to deliver13. Integration of aged care with other care and health services including disability, mental health, and primary health care is recommended to ensure seamless care for all Aboriginal and Torres Strait Islander people regardless of their health and care needs.
13 Australian Government. (2021). Royal Commission into Aged Care Quality and Safety. Final Report: Care, Dignity and Respect.
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To achieve this, a focus on up-skilling, re-training, and utilisation of the existing Aboriginal and Torres Strait Islander ACCHO workforce is required. In line with the care workforce more broadly, Aboriginal and Torres Strait Islander people working in this space experience burn out and workplace fatigue.
To ensure a long-term sustainable workforce is built and supported to meet the needs of Aboriginal and Torres Strait Islander people holistically a number of strategies need to employed including: -co-worker support and peer mentoring; workplace cultural safety and culturally competent human resources policy and practices embedded in mainstream organisations; role recognition and clear definition of roles; job security and adequate remuneration; and support for expanded roles and career progression14.
14 AIHW and NIAA (2020b). ibid.
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