Concerns with the ECEI Approach for Aboriginal Children in the NT | External submission

Submission to the Joint Standing Committee on NDIS: Inquiry into the provision of services under the NDIS

Early Childhood Early Intervention (ECEI) approach

August 2017

About AMSANT

The Aboriginal Medical Services Alliance of the NT is the peak body for the community controlled Aboriginal primary health care (PHC) sector in the Northern Territory (NT). We have 25 members providing Aboriginal comprehensive primary health care (PHC) right across the NT from Darwin to the most remote regions. AMSANT has been established for 20 years and has a major policy and advocacy role at the NT and national levels, including as a partner with the Commonwealth and NT governments in the Northern Territory Aboriginal Health Forum (NTAHF).

The  Aboriginal Community  Controlled  Health  Services (ACCHSs)  sector  in  the NT  is

comparatively more significant than in other jurisdictions, being the largest provider of Aboriginal primary health care services to Aboriginal people in the NT. Over half of all the episodes of care (53%) and contacts (55%) in the Aboriginal PHC sector in the Northern Territory are provided by ACCHSs. Moreover, ACCHS deliver comprehensive primary health care that incorporates social and emotional wellbeing, mental health and AOD services, family support services and early childhood services, delivered by multidisciplinary teams within a holistic service model.

Background

Extensive research over many years has provided evidence that the early years of life are fundamental to both the physical and emotional health of children, for their social and cognitive development, and for later educational achievement and life chances. Adverse childhood events have been causally linked to poorer long-term outcomes.

Children are cherished in Aboriginal cultures and nurtured within broad family networks. However, a history of colonisation and ongoing policies stemming from that history have resulted in many Aboriginal children in the Northern Territory growing up in disadvantaged communities with much poorer health, education levels and social and emotional wellbeing (SEWB) compared to the non Aboriginal population.

The Australian Early Development Census (AEDC) measure of early childhood development at school entry clearly reveals the extent of disadvantage for young Aboriginal children. On average 37% of children in the NT are developmentally vulnerable in one or more domains and 23% across two or more domains - significantly higher than the national average. However, for many children

in remote areas the reality is far worse, with data in some communities identifying more than 50% of children as developmentally vulnerable, with only slight improvement between 2009 and 2012 (AEDC 2015). Furthermore, national ABS data from 2012 identified that Aboriginal and Torres Strait Islander children aged 0–14 years were more than twice as likely as non-Indigenous children to have a disability (15.2% compared with 6.6%).

Despite these concerning statistics, evidence shows that early intervention, and specifically intervention in early childhood, can help to break cycles of intergenerational disadvantage and trauma, improving long-term outcomes across a range of areas including education, employment, health and wellbeing.

Knowledge accumulated over the past 40 years supports the conclusion that children whose mothers received high quality antenatal and postnatal care, who then go on to participate in high quality early childhood programs including preschool, experience a range of immediate and longer term health, social and educational benefits (Braveman et al. 2014). Cost analysis has also shown that investing in early childhood offers the best return on dollars spent for disadvantaged people, with high quality programs producing a 6-10% per annum return on investment – substantially higher than later education, employment and policing interventions (Heckman 2006).

Concerns with the ECEI Approach

AMSANT is concerned that the ‘key research pieces’ identified as forming the basis of the ECEI approach in NDIS Early Childhood Early Intervention (ECEI) Approach (2016) do not adequately identify or address many of the issues, concerns and constraints related to providing early childhood intervention to Aboriginal children in the NT, and the particular challenges for service delivery in regional and remote areas. These documents focus on mainstream service delivery, contain only cursory mention of Aboriginal children or consideration of remoteness factors, and make no reference at all to the Aboriginal community controlled sector.

Similarly, while the principles behind the National Standards: Best-practice in early childhood intervention (2016) are sound, we are concerned that these principles will not be translated into reality for Aboriginal children with disability in the NT. The experience of many of our member services in their interactions with the NDIS to date suggest that we will not see improved outcomes through the Scheme without a far more comprehensive understanding of the unique cultural circumstances and service delivery constraints that are present in Aboriginal communities in the NT.

In light of this we refer this inquiry to the Northern Territory Aboriginal Health Forum’s document

Progress and Possibilities: What Are the Key Core Services Needed to Improve Aboriginal

Childhood Outcomes in the NT? (NTAHF 2016) and recommend that this document be a foundational reference for the NDIA in the development and implementation of the ECEI approach in the NT.

This document outlines the core services required to improve childhood outcomes, as identified by delegates with local expertise in early childhood development at a two-day workshop in Darwin in June 2015. Importantly, it also identifies a number key policy considerations for implementing this model which AMSANT strongly recommends the NDIA integrate into the ECEI approach. These are:

Current systems provide fractured and often ineffective service delivery to children and their families and this must change if we are to close the gap. Sector reform is required to better integrate child health, education and other early childhood services.
Only evidence-based programs or those working to build evidence should be funded and evaluation must be an integral component of early childhood funding and programs.
Programs and services must be culturally appropriate, consultative and inclusive of the community at all stages, including co-design and Aboriginal leadership where possible. Programs should be family centred and male inclusive.
Programs need to be of sufficient duration and intensity to have an optimal effect, and start early.
Competitive funding processes should be reviewed as they are driving a fragmented and inequitable service system that lacks real engagement with Aboriginal communities.
Needs-based equitable resource allocation should be a core funding principle and the Aboriginal primary health care sector must be adequately resourced to meet increasing need.
A localised approach to building the Aboriginal workforce and providing well-trained staff is a priority.
Inter-sectoral cooperation and coordination is required for optimal outcomes, particularly between education and health sectors.

In addition to these overarching considerations we also identify below a number of specific concerns with the provision of services under the NDIS ECEI Approach which we ask the Inquiry to consider.

Accessibility and Eligibility

A pervasive lack of access to services is often a compounding factor for many Aboriginal children with disability and their families, particularly for those who live in remote areas. While some larger ACCHSs are already providing early childhood and family support programs, smaller ACCHSs and government remote clinics often do not have the economies of scale to implement these programs and are often inadequately serviced through visiting outreach programs delivered centrally or via fly-in-fly-out NGO providers.

Of particular concern is the lack of specialist services, including clinical psychologists, on the ground throughout the NT to conduct diagnoses, and a lack of definitive and culturally appropriate diagnostic tools for Aboriginal children. The inadequacy of existing assessment tools may result in the exclusion of many children requiring early intervention from accessing these services via the NDIS. This impacts particularly on children with permanent impairments such as FASD and autism where delays in diagnosis can mean that crucial opportunities for action to improve long term life outcomes can be lost. Ensuring equitable access to ECEI for Aboriginal children will

require  significant  additional investments and planning  to secure an appropriately  skilled

workforce to deliver services in remote areas.

Critically, we have received reports from our member services that there are currently NDIS participants with plans in place who are reported to be receiving no services at all within remote Aboriginal communities. This raises real concerns regarding the ‘quality of life’ for children with profound disabilities and/or limited life expectancy who might be eligible for ECEI services under the NDIS.

Clear recognition must be given that not all children with disability will be eligible for the NDIS and assurances must be made that appropriate companion schemes and services are available and accessible for these children and their families over the long term.

Workforce

The Productivity Commission’s Position Paper on NDIS costs (2017) identified that ‘it is unlikely that the disability care workforce will be sufficient to deliver the supports expected to be allocated by the NDIA by 2020’. Given the existing difficulties in remote Aboriginal communities to find and retain appropriately skilled staff, it is likely that workforce issues will be particularly acute in these areas.

As outlined above, a lack of access to specialist services for children with disability is a major issue for many remote Aboriginal communities and AMSANT has serious concerns that the speed

of the NDIS  roll-out does not allow  sufficient time  for necessary workforce  training and

development to meet demand within the Scheme. Particular consideration should be given to the development of an Aboriginal workforce strategy which focuses on building capacity within local communities to ensure the long-term sustainability of ECEI within the NDIS.

Use of a competitive market mechanism

Increased competition is not the answer to improved outcomes in remote communities in Aboriginal Australia. In fact, past experience has shown that increased competition in remote Aboriginal communities can lead to worse outcomes by undermining the effectiveness and potential development of existing Aboriginal service providers through the introduction of new external non-Indigenous providers. This has the effect of increasing service fragmentation, providing less culturally-safe service delivery, and compromising the ability for service integration at a local and regional level (AMSANT 2016).

The community controlled sector provides unique benefits which are highly valued by their clients, including ease of access, proactive service provision, cultural safety and the personalised, comprehensive nature of care provided (Gomersall et al 2017). AMSANT is concerned that the

current NDIS model makes  little  or no investment  in  the  viability and  sustainability  of

organisations, which  will  limit the  ability of our member services to offer early childhood

intervention services within the current Scheme.

In this regard, AMSANT also draws the inquiry’s attention to the Aboriginal Peak Organisations NT (APO NT) Partnership Principles, which outline an approach to building the capacity of Aboriginal organisations in service delivery through partnerships with appropriate NGO and other providers. Support for these Principles can increase the number of local Aboriginal organisations involved in providing services under the NDIS, with significant benefits in terms of local Aboriginal employment and career pathways and more culturally-safe services.

Cultural safety, quality and effectiveness

The lack of cultural competency within NDIS has so far proved to be a major barrier to participants

engaging  with  the Scheme and  with non-Indigenous  organisations who  deliver  support

coordination services. There are currently few if any incentives for service providers to actively work to build community capacity or show that they are able to respond to the unique health and wellbeing needs of Aboriginal people.

The comprehensive model of service delivery delivered by ACCHSs has been shown to be particularly effective in the Northern Territory and recognised as foundational in the reduction of mortality rates and progress towards ‘closing the gap’ in health between Aboriginal and non Aboriginal communities (AIHW, 2015). It has been shown that where ACCHSs exist they are preferred providers for Aboriginal people. The 2014 ATSI Health Performance Framework revealed that 73% of Aboriginal Australians would prefer to go to and AMS or community clinic (AIHW 2014).

Social determinants

Social determinants – including nutrition, housing quality, and community- or family-related factors such as safety – are strongly linked to child health. Children from disadvantaged backgrounds often face multiple physical, psychological and emotional hardships. The combined effects of these hardships can take a heavy toll on children’s health, leading to high levels of toxic stress and suboptimal development. Aboriginal children in the Northern Territory have a greater chance of exposure to the cumulative impacts of multiple stressors than do non-Aboriginal children.

Unless we see improvements across all of the social determinants of health, improvements in the lives of Aboriginal people with disability in the NT through the NDIS will be limited. This will require

a  coherent,  overarching  strategy  which  connects  related  policy  in a  coordinated and

complementary way across departments and institutions.

References

ABS 2012, Aboriginal and Torres Strait Islander People with a Disability, 2012, cat. no. 4433.0.55.005 http://www.abs.gov.au/ausstats/abs@.nsf/productsbytopic/176B7899CCE3B173CA257D9E00112463?OpenDocument [Accessed August 2017]

AEDC 2015, AEDC data explorer, Australian Early Development Census, Commonwealth of Australia. https://www.aedc.gov.au/communities/accessing-community-results [accessed August 2016]

AMSANT 2016, Response to The Productivity Commission’s Introducing Competition and

Informed User Choice into Human Services: Identifying Sectors for Reform - Preliminary

Findings Report.

Braveman P, Egerter S, Arena K & Aslam R 2014, Early Childhood Experiences Shape Health

and Well-Being Throughout Life, University of California, San Francisco Centre on Disparities in

Health.

Gomersall J, Gibson O, Dwyer J, O’Donnell K, Stephenson M, Carter D, Canuto K, Munn K, Aromataris E, Brown A 2017, What Indigenous Australian clients value about PHC: a systematic review of qualitative evidence, Australian and New Zealand Journal of Public Health

Heckman J 2006, Skill Formation and the Economics of Investing in Disadvantaged Children, Science, vol. 312, 30 June 2006.