AHPA Response to the Joint Standing
Committee on the National Disability
Insurance Scheme (NDIS)
Transitional arrangements for the NDIS
August 2017
Allied Health Professions Australia
Level 13, 257 Collins Street
Melbourne VIC 3000
Phone: 03 8662 6620 Email: office@ahpa.com.au Website: www.ahpa.com.au
AHPA interest in this consultation
Allied Health Professions Australia (AHPA) represents 22 national allied health associations and collectively works on behalf of their 100,000 allied health profession members. Many of those allied health professionals are involved in providing services to people experiencing disability, people who may or may not be participants in the National Disability Insurance Scheme (NDIS). AHPA and its member associations are committed to ensuring that all Australians, regardless of disability, can access safe, evidence-based services to support them to realise their potential for physical, social, emotional and intellectual development.
This submission has been developed in consultation with AHPA’s allied health association members. However, it does not represent a summary view of individual member association’s submissions. As such it is recommended their detailed submissions be carefully considered.
Introduction
The announcement of the National Disability Insurance Scheme (NDIS) was met with significant enthusiasm by the allied health sector. A significant proportion of allied health practitioners work with participants and the allied health sector is highly cognizant of the issues participants and their families have in accessing care they need as well as the long wait times that have typically been associated with accessing funding and supports. Allied health practitioners are also highly focused on supporting participants to identify and achieve life goals as identified as key goals of the NDIS. The allied health approach aligns very closely with those goals with a strong focus on reablement and wellbeing.
However, the early stages of transition to the NDIS have revealed a range of issues that impact on participants and the allied health providers who provide services for them. These issues are limiting the ability of allied health providers to deliver the support and care participants need. These issues are described in greater detail below with specific commentary to each of the terms of reference.
Terms of reference
The AHPA response includes specific commentary to the following of the Terms of Reference:
a. the boundaries and interface of NDIS service provision, and other non-NDIS service provision, with particular reference to health, education and transport services;
b. the consistency of NDIS plans and delivery of NDIS and other services for people with disabilities across Australia;
d. any other related matters. Allied Health Professions Australia | www.ahpa.com.au 2
Commentary to the Terms of Reference
A. The boundaries and interface of NDIS service provision, and other non-NDIS service provision, with particular reference to health, education and transport services.
Defining the boundaries of the National Disability Insurance Scheme (NDIS) is rightly seen as a crucial challenge that must be addressed as part of its large scale implementation. Achieving appropriate coverage is essential as is the long-term sustainability of the scheme. AHPA recognises that despite the size of the scheme, it is only part of the complex set of systems in place to provide for the needs of people experiencing disability in Australia. AHPA and its allied health profession members also recognise the challenges involved in achieving this task but note significant concerns at this stage of the rollout. There is strong evidence to suggest that there a range of cases where a lack of coordinated interaction between systems is resulting in cost - and responsibility shifting and participants being left without the services they require.
Intersection with the health sector AHPA and its members recognise the importance of effective interaction with the health system and that there are a range of legitimate situations in which a participant may be fully supported within the health system. However, we note that the question of eligibility for the NDIS remains a significant issue and many participants are finding themselves in a grey area where neither system takes responsibility for their needs. The lack of clarity or oversight in terms of the intersection with the health sector is exacerbating this issue for many participants and their families. Information and guidance around eligibility criteria is contradictory and incorrect information is circulating regarding the eligibility of participants with some conditions, including auditory and balance disorders. Audiology Australia reports that issues around eligibility for hearing and related disorders have been exacerbated by delays in the release of the NDIA’s access (eligibility) work package which was originally planned to be released in the first half of 2016 and by the varied and contradictory information provided by NDIS Planners and other NDIS staff regarding the eligibility criteria for people with hearing loss. Audiologists also report that the NDIA is enforcing threshold criteria such as the Hearing Services Voucher Scheme Minimum Hearing Loss Threshold, which is limiting eligibility for people who may experience significant personal and psychosocial factors as well as hearing loss that should be considered when determining eligibility.
AHPA has also had reports that people with chronic health conditions resulting in a functional disability are experiencing inconsistent eligibility assessments. One recent example is a person with obesity who requires the use of a powered wheelchair and who had their application declined on the basis that their condition was considered a temporary one. AHPA believes the NDIS access requirements should be refined to provide greater clarity for prospective participants to reduce the scope for inconsistent decisions around eligibility. The access requirements need to clearly articulate situations where are person would be eligible for the NDIS (such as particular conditions, severity level and degree of functional impairment), and where they would be better supported through an
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alternative funding source. Appropriate training is also crucial to ensure that these access requirements are consistently applied across different regions.
The Dietitians Association of Australia (DAA) reports that planners are frequently denying the inclusion of dietetic services by APDs in participant packages despite requests from participants and families in direct contradiction with the legislated intent of ‘choice and control’. Instead planners are frequently directing participants to seek access to dietetics services through the health system and Medicare CDM items. AHPA believes this approach is inappropriate when the nutrition issues of participants are grounded in their disability, and therefore access to APDs is reasonable and necessary. Both DAA and Speech Pathology Australia (SPA) report that this issue is being further exacerbated by a recent decision that participants requiring support to eat are to be directed to the health system for access. Closely related to this issue is that of access to assistive technology, which remains an issue for many participants and their families. Allied health practitioners are reporting that participants are not being able to access products and services in a timely and consistent way, and at an acceptable price. Dietitians Association of Australia (DAA) is working with industry and other stakeholders in a Disability Nutrition Support Network to identify problems and develop solutions to some of these issues and is seeking to work more formally with the NDIA to properly map out and address these issues.
Audiology Australia has also noted inconsistency between schemes, with NDIS participants sometimes receiving lower levels of funding than available through the Australian Government’s Hearing Services Program Community Services Obligations (CSO) scheme. The outcome is that there is an incentive for participants and families to ‘shop around’ for the best funded program.
One of the outcomes of these boundaries issues between the NDIS and the health system is that practitioners are reporting frequent examples of participants and their family being bounced between the two systems with neither side taking responsibility. This is leaving the participant without the services they require with significant potential consequences. It also particularly impacts on more vulnerable families and participants that are not in a position to undertake self-advocacy.
RECOMMENDATION
AHPA understands that NSW is setting up local and higher level structures for the purpose of dealing with issues around the intersection between health and disability services. AHPA strongly encourages the establishment of resolution structures in each jurisdiction and recommends a consistent approach is taken across all jurisdictions. AHPA also recommends greater clarity is provided for participants and providers about eligibility and the interaction with the health and education sectors and for clear information to be provided about how to access resolution mechanisms where issues arise. AHPA additionally believes work should be undertaken to ensure consistency across government funded schemes and to ensure participants access the right service without fear of disadvantage.
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Access for people with psychosocial needs AHPA and its members have significant concerns about the limited capacity of NDIS eligibility criteria to address the needs of people with psychosocial needs, dual diagnoses or co-morbidities, autism spectrum disorder and chronic conditions resulting in functional disabilities. Occupational Therapy Australia has noted that current eligibility criteria do not take into account the relapsing/remitting nature of mental illness due to the requirement to ‘have an impairment or condition that is likely to be permanent’. This directly conflicts with principles of recovery oriented mental health practice.
Allied health professionals involved in supporting people with mental health issues note that the significant changes being undertaken in the mental health sector are causing a significant impact on participants and their families. Potential NDIS funding of services is only one part of a complex system that includes different levels of government, various non-government organisations as well as Primary Health Networks. One challenge is that people with mental illness may experience significant variation in the level of disability caused by their condition over the course of a lifetime and it may not meet the eligibility criteria for the NDIS. However there also remains confusion around the provision of services for people who have been diagnosed with multiple conditions—for example, autism spectrum disorder and depression—resulting in questions around where funding should come from and potential shifting of responsibility rather than a holistic care approach. The intersection between these services is complex and unclear and is causing significant risk that people will be deemed ineligible for the NDIS at the same time as state-based programs are transitioning to being delivered under the NDIS resulting in gaps in service provision.
RECOMMENDATION
Additional work will be needed to determine and make clear to the community where eligibility boundaries exist for psychosocial needs. In addition, the NDIA should work closely with state and territory governments, as well as non-government services, to map out potential gaps during the transition and full implementation of the NDIS.
Transition of State and Territory services The transition of services is often unclear and where there is uncertainty about whether services fall within the scope of NDIS funded supports or whether those supports fit within an organisation’s existing mandate, significant delays are occurring in access to plans for participants. This appears to be a particular issue for state-Government operated services. Closely related to this issue is the inability to access NDIS funded supports where scheme rules attempt to force the cost on to other schemes such as when a person is hospitalised. The intention in such a case appears to be to make all care the obligation of the hospital in such a case, however the hospital may lack the capacity or expertise, particularly around routine activities of daily living.
The current interface between NDIS and mainstream services is not working effectively and there is significant scope for failures in the handover process between services and resulting safety risks for participants.
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The Australian Physiotherapy Association (APA) reports that practitioners are encountering situations where poor communication between the public system and the chosen NDIS provider results in inadequate preparation of the NDIS-funded service provider. This can be further exacerbated when rigid eligibility rules result in services being ceased by non-NDIS providers (often in the public sector) before new services are in place. These issues are particularly concerning in those regions where State- and Territory-funded services have transitioned, or are expected to transition, to the private sector as part of the shift to the NDIS.
Practitioners have reported that some State Governments have announced that they will be withdrawing from their role as a service provider, raising uncertainty around whether existing services will continue. In New South Wales, a number of staff from the Department of Family and Community Services (FACS) have moved across to the private sector following the transfer of the Home Care Service of NSW to Australian Unity. This can result in uncertainty and a reduction in the availability of services and service continuity.
RECOMMENDATION
It is important to ensure that providers and participants are given time to prepare for transition and to ensure that services are not disrupted. It is also important to ensure that providers are not left waiting for bills to be paid. The NDIA as the lead agency will need to ensure it works closely with state and territory governments and oversees appropriate transition arrangements for service providers as well as the effectiveness of quality controls in the private and not-for-profit sectors.
School support services AHPA and its members are concerned that there is insufficient clarity around the split between NDIS and mainstream education services. A number of allied health practitioners have noted the impact of the NDIS on access to therapy supports in the education sector. For example occupational or speech therapy services often integrate school participation and activities that assist students to access the curriculum with support for participation in activities outside school. However there is currently no policy and funding clarity around how the implementation of the NDIS in educational/school settings will work and risking lack of continuity of services.
Occupational Therapy Australia notes that therapy supports, including behavioural strategies, environmental adaptations, and assistive technologies, typically have application in a range of life areas but that certain therapeutic interventions (such as assistance with handwriting) have not been funded by the NDIS because they are considered to be ‘school skills’ rather than ‘life skills’. This carries significant risks that participant requirements will fail to be covered with both NDIA planners and education providers claiming responsibility lies elsewhere.
RECOMMENDATION
AHPA believes that a specialist taskforce should be appointed to determine how a consistent therapy approach can work across NDIS-specific and education-specific goals and to ensure
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consistent access to assistive technologies used across these different settings. Choice and control for the child and family in both the education and broader NDIS settings must be a guiding principle for the work of the taskforce.
B. The consistency of NDIS plans and delivery of NDIS and other services for people with disabilities across Australia
AHPA and its members have found that there is significant variation both within particular regions and across the different NDIS sites in how plans are designed and levels of funding. NDIS plans appear to be dependent on many factors that do not relate to individual participants’ needs and goals. These factors typically include:
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The level of advocacy families and individual NDIS participants can undertake and their knowledge of the disability sector
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The NDIS planner’s knowledge of, and attitudes towards, various allied health services and their role for people with disabilities
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The location/jurisdiction of the participant. Inconsistent training and experience levels among planners Extensive feedback from across AHPA’s membership suggests that there is a high degree of inconsistency across the planning workforce. The quality of NDIS plans varies considerably from person to person even where support needs are similar. The supports identified in a plan are proving to be highly dependent on the planner’s level of experience and understanding of the different services available to participants. This is particularly the case with allied health services and practitioners are consistently reporting that understanding of allied health professions is poor among planners, leading these supports to be absent from participant packages. This lack of knowledge extends across even professions such as occupational therapy. Planners also frequently underestimate the hours of therapy required for a participant to achieve their goals, which subsequently affects the quality of their plan.
For example, Audiology Australia’s practitioner members have noted significant funding discrepancies for participants with similar needs and goals with some participants receiving funding for higher technology hearing aids or assistive technology to meet their needs at work or university while others do not. Similarly only some participants were funded for aural rehabilitation aimed at capacity building. The Australian Music Therapy Association has received numerous reports of participants being told they could not receive funding for music therapy due to a lack of understanding among planners about music therapy’s eligibility and efficacy. This resulted in participants losing access to a service or specifically requested leading them to hold off transition to NDIS funding packages until this was rectified.
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AHPA also notes that participants and their families are reporting significant frustration about the extent to which planning meetings are conducted by phone and the overall difficulty in accessing planners. Allied health service providers are reporting having to advocate on behalf of participants directly with planners and needing to request plan reviews where insufficient funds have been allocated to meet support needs. These reviews are currently taking weeks and even months to complete, resulting in added frustration for families and potential service gaps. These issues are likely to be the result of overly large caseloads and additional work should be undertaken by the NDIA to ensure planners are skilled to properly engage with their clients.
AHPA and its members note that appropriate involvement of allied health professionals in the planning process either directly or through appropriate assessments would be an effective means of ensuring that packages are appropriately designed. Audiology Australia notes that it is inefficient and inappropriate for plans to be approved which specify the funding available to hearing aids and equipment before a holistic assessment of the client’s audiological needs has been conducted by an audiologist. Issues around conflicts of interest in such an approach can easily be managed by seeking additional opinions in the case that the planner or participant feel that the advice was incorrect or insufficient.
AHPA and its members also believe there is a need to develop more effective methods to resolve issues such as the quality of a participant plan. Current processes are slow and inefficient with practitioners repeatedly reporting a lack of response to phone calls and emails. This is resulting in providers having to invest significant time and energy to chase NDIA staff for responses. There is also some evidence to suggest staff involved in reviewing complaints may at times make mistakes in their decision-making due to a lack of knowledge about the eligibility of services.
RECOMMENDATION
AHPA believes it will is necessary to improve on the training of NDIS planners and that allied health professionals will need to be involved in the development of training materials. We further recommend the appointment of discipline experts, an approach that has been successfully employed for the Department of Veterans Affairs. AHPA further proposes the development of a formal process through which providers can submit supporting documentation and make recommendations about participant supports. This process should have clearly defined response time requirements and may need to be supported by the establishment of expert review panels.
Inconsistent provider registration requirements AHPA and its members note that unclear and inconsistent provider registration requirements are a significant barrier to entry into the NDIS marketplace for allied health providers. Third party verification in particular has been a frequent issue reported by providers with ongoing issues in NSW and similar issues now occurring in Victoria. Allied health practitioners face significant bureaucratic burdens as a result of these requirements, which carry significant costs for smaller providers in particular. The application of a mutual recognition model, as proposed in the NDIS Quality and
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Safeguarding Framework, that recognises the certification provided by the allied health professional peak bodies and registration boards along with a tiered system of provider requirements proportionate to the support risk-level and the size of the provider is a clear means of addressing current state-based systems that may be overly onerous, particularly for small providers of low-risk services. This approach should recognise not only registration with an Australian Health Practitioner Regulation Agency Board, but also recognise the practitioner certification provided by self-regulating allied health professions including such as the eight members of the National Alliance of Self Regulating Health Professions (NASRHP).
RECOMMENDATION
Accreditation is a key issue that impacts on the size and availability of the allied health workforce and must be fully considered now to ensure that it does not become structural during the full national rollout. Existing certification processes should be reviewed and utilised unless evidence reveals that these are insufficient.
Conflicts of interest for Local Area Coordinators One issue AHPA remains concerned about is the potential for conflicts of interest to arise when the Local Area Coordinators (LACs) that provide planning support for participants are employed by service providers. The potential issues arising from this potential conflict are exacerbated for participants with less ability to drive their own care and decision-making. A number of allied health practitioners have raised concerns about the extent to which participants are able to provide informed consent as feedback from participants and families suggests participants were not informed about their level of choice and control with regards to choosing a different provider to deliver services under their NDIS packages. Where the LAC ‘managing’ their funds is employed by an NGO providing some or all of the other services they need this is a serious potential issues and may have the impact of reducing choice and diversity in the market, particularly in terms of the involvement of private practices.
RECOMMENDATION
The NDIA should review the appropriateness of the guidance provided by LACs by undertaking regular audits and supporting participants and families to have access to clear information about the level of choice and control that they have in choosing their providers.
D. Any other related matters Transition from residential facilities to NDIS-funded supported accommodation services A significant number of participants are likely to move into supported accommodation after having previously lived in residential facilities as part of the transition to the NDIS. This move carries a risk that adequate supports and systems may not be in place to ensure that special dietary needs are addressed. AHPA has received reports that while food services and other care systems in residential facilities are well equipped to consider and meet the needs of people with special dietary needs (such
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as low protein diets and amino acid supplements where the participant experiences an inborn error of metabolism), supported accommodation services do not necessarily have support workers trained to understand and meet those needs. A key factor in this is that NDIS funding is limited to service delivery and does not cover training costs. Support workers generally have limited nutrition knowledge or food skills, even those with a certificate III or IV, and are unlikely to know about basic support for their clients or when to seek further assistance from allied health professionals. This is particularly relevant given that at least 50% of people with intellectual disability have chronic disease, and it is that which shortens their lives. (NSW Ombudsman Report 2012-13).
RECOMMENDATION
The NDIA will need to ensure adequate training for support workers delivering accommodation services as well as consider the adequacy of support accommodation service facilities to be able to meet the dietary needs of participants.
Workforce training and supply AHPA and its members do not believe it will be possible to increase the NDIS workforce to that which is projected as being required without changes that address both the previously identified registration and accreditation issues and workforce planning, education and training issues. Particularly as demand for services is already exceeding the available supply of allied health providers.
The availability of mentoring and clinical supervision for undergraduate students and new graduates is critical. Clinicians who have recently entered the workforce require access to professional development opportunities to enable them to build and maintain the specialised needed within the NDIS market environment. The lack availability of allied health professionals as mentors and clinical supervisors is a major issue flowing from the closure of many state-based services which it is essential that the NDIS address. Ensuring access to learning and development opportunities will require the continued delivery of workforce readiness initiatives in the form of workshops and training programmes that promote evidence based interventions for people with disability. Initiatives such as the Sector Development Fund (SDF) and Innovative Workforce Fund (IWF), which allow individuals and organisations to apply for grants to support the development of the disability workforce, are valuable ways to ensure a ready and appropriately skilled workforce.
AHPA recognises the crucial importance of a system that is financially sustainable and the careful balance that must be struck between current and future needs. But AHPA is also acutely aware of the potential risks associated with too great a focus on cost minimization, signs of which are already present in the decision not to apply any increase in rebate levels to therapy services in the recent NDIS costs review as well as some reports of rationing of allied health services focused around life goals. The Australian Physiotherapy Association has noted that in other insurance schemes across Australia, price setting has involved the ‘bundling’ of a number of different service elements into the price. These elements can vary between travel (which includes the opportunity cost of providing other services and the direct cost of the transport), extensive report preparation for third parties,
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transaction costs involved in communications with the insurance scheme, and professional services costs such as liaison with other services. As such the time involved in the actual consultation may be reduced appropriately to allow for the time involved for the practitioner to undertake these other activities. A similar balance will need to be struck with NDIS services and participants and their families appropriately informed to ensure sustainable service delivery and minimize complaints. If these factors are not sufficiently addressed then it risks making the provision of NDIS services unsustainable for providers. This issue is particularly critical in light of the need to address a potential shortfall of allied health professionals available to meet the demands of this growing sector. Ensuring that practitioners are adequately funded for their services and able to manage sustainable businesses will be essential to the ongoing viability of providing allied health services to the disability sector.
RECOMMENDATION
AHPA and its members strongly supports initiatives such as the Sector Development and Innovative Workforce Funds as a way to support workforce training and development. These initiatives will need to ensure that they can support not only larger NGO models but also the small and solo provider model common in the allied health sector. AHPA also strongly encourages a focus on ensuring adequate funding for therapy services. While these services represent a higher cost, they are an essential source of support for participants and cannot be replaced by lower cost alternatives.
Role of technology AHPA believes telehealth and other online-based services should be fully funded where the provision of these services has been determined to be appropriate, safe and of good value. Other initiatives such as My Health Record provide scope for better communication and improved decision making for the different health providers involved in delivering care for people with disabilities. It also has the potential to allow participants and their families to more actively involve themselves in the health of the participant. However, many of the providers providing services for people with disabilities do not currently have the necessary infrastructure and systems to utilise digital technology. It will be up to the NDIA or Government to ensure smaller practices are supported to address the significant disadvantage they are likely to experience in the high proportional cost of the adoption of technology, particularly in light of uncertainty about income.
RECOMMENDATION
The allied health sector requires a genuine commitment from government in providing the funding, support and training to help it fully utilise and deliver the benefits of digital systems to participants. AHPA believes it will be essential for government health, human services and digital health departments to work together to provide the support the sector needs.
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