NDIA Accountability Project

Submission 379 — National Rural Health Alliance — Inquiry into the Thriving Kids initiative

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Submission to the House of Representatives
Standing Committee on Health, Aged Care and
Disability Inquiry into the Thriving Kids initiative

October 2025

Healthy and
sustainable rural,
regional and remote
Communities
across Australia.

National
Rural Health
Alliance

Postal Address: PO Box 475 Curtin ACT 2605
Phone: 02 6285 4660
Email: nrha@ruralhealth.org.au

Introduction

The National Rural Health Alliance (the Alliance) is pleased to provide a submission to the House of Representatives Standing Committee on Health, Aged Care and Disability inquiry into the Thriving Kids initiative.

The Alliance is the peak body for regional, rural and remote health in Australia, comprising 54 member organisations which include healthcare professionals, service providers, health and medical educators, researchers, medical and health practitioner students and the Aboriginal and Torres Strait Islander health sector.

Our vision is for healthy and sustainable rural communities, which make up the over 7 million people residing outside our major cities, or approximately 30% of the Australian population. We are focused on advancing rural health reform to achieve equitable health funding to that of urban per capita spending and equitable health outcomes for rural communities.

Given the findings from The Forgotten Health Spend: A Report on the Expenditure Deficit in Rural Australia, as well as feedback from our members, the Alliance’s submission focuses on aspects of the Inquiry’s terms of reference (ToR) that have an impact on people living in rural, remote and regional (hereafter rural) areas, specifically:

  • Examine evidence-based information and resources that could assist parents identify if their child has mild to moderate development delay and support parents to provide support to these children.
  • Identify equity and intersectional issues, in particular, children who identify as First Nations and culturally and linguistically diverse.
  • Identify gaps in workforce support and training required to deliver Thriving Kids.
  • Identify mechanisms that would allow a seamless transition through mainstream systems for all children with for children with mild to moderate support needs.

Rural context

As part of its advocacy to improve health access and equity in regional, rural and remote rural Australia, the Alliance recently published The Forgotten Health Spend Report undertaken by NOUS Group which provides estimates of government funded healthcare, pharmaceuticals, aged care and National Disability Insurance Scheme (NDIS) expenditure and usage patterns across Australia based on geographical remoteness

One of the key findings in The Forgotten Health Spend Report is that the underspend is most pronounced in rural to remote areas (MMM 5–7), where the annual per capita expenditure is now $4,701 lower than in metropolitan areas. The report underscores that while targeted programs improve access in some regions, systemic issues such as service shortages, workforce challenges, cost and limited infrastructure, inflexible policy and funding continue to drive inequity, pointing to the need for coordinated, regionally tailored solutions.

The Forgotten Health Spend Report also found that in rural and remote areas those with need struggle to access NDIS funding. MMM 5 and 7 regions, in particular, show the largest gaps in NDIS expenditure, both per person and per person in need, with a third of long-term participants in remote communities not accessing daily supports. These areas also have the lowest numbers of key health professionals such as occupational therapists and physiotherapists, which can affect the level of support available to people with disability.

The Alliance acknowledges the importance of early intervention for children in rural and remote Australia. Early and comprehensive screening is a basic health need for assessing children’s ability to learn, including hearing and vision checks, as well as dental checks, and for identifying disorders that will affect children’s ability to participate fully in the school environment. These are imperative, given

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travel distances, higher costs and lack of service provision encountered in rural areas. Limited choice of schools for rural students compounds the issues. For those with specific learning needs, choice is compromised further.

Accordingly, the Alliance welcomes the proposed Thriving Kids initiative targeting children in the early years (under the age of 9) to provide early identification of health and developmental concerns. We also welcome the focus on foundational supports through child and maternal health, GPs, playgroups, early childhood education and care and schools, as well as digital and phone-based supports.

It is hoped that Thriving Kids will create a better national support system for children with mild to moderate developmental delay and their families that is more responsive, sustainable and equitable, no matter the postcode. At the same time, we recognise that the NDIS remains essential for children and adults with significant, lifelong disabilities.

Evidence-based information and resources

The National Framework for assessing children’s functional strengths and support needs in Australia (the Framework) developed by Autism CRC (of which the Alliance was a Reference Group member) sets out an evidence-based, culturally appropriate approach for assessment, differentiation, and written reporting of children’s functional strengths and support needs (Fitzpatrick et al 2024).

The Framework can be used across relevant health, education, disability and community services to support all children, irrespective of whether they have a diagnosed condition or may receive a diagnosis in the future, and includes, but is not limited to, children with developmental delay. The Framework is intended to sit at the centre of a range of future initiatives to improve the approach, experience, and outcomes of services and supports provided to children and their families, grounded in human rights (Fitzpatrick et al 2024) and the rights of all children, no matter where they live in Australia.

The Alliance recommends consideration of the Framework as part of the design and development of Thriving Kids. The primary intended beneficiaries of the Framework are children and families, indeed clinicians, who can use the Framework to know what best practice is.

Equity and intersectional issues

The roll-out of Thriving Kids must carefully address equity, parity and intersectional issues to ensure that all children—regardless of background, location, or identity—can access timely and appropriate support. This is critical for children, given their functional strengths and support needs change over time as they grow, as do the preferences and priorities of children and families (Fitzpatrick et al 2024). We must not leave rural children out, just because they are outside of urban centres.

Current estimates from Australian Early Development Census (AEDC) data suggest that approximately 60% of children in remote and very remote are not developmentally on track to start school, and more than 20% are vulnerable in 2 or more areas of development – almost 3 times the rate seen in major cities (AEDC 2018). This ‘vulnerability gap’ between urban and rural children is widening, with complexity increasing (Royal Far West 2017). As a result, children in rural and remote areas are needing significantly more support for their developmental and mental health and at a younger age (Royal Far West 2025). Across regional Australia, families are trying to navigate an over-stretched and fragmented health and early education and care system (Emery 2025). The consequence is that children miss critical windows for intervention.

Systematic reviews have demonstrated that multi-disciplinary therapies (such as physical therapy, occupational therapy, speech therapy, and psychological therapy) are most effective when delivered in a family-centred manner. Programs that address specific developmental needs, family socio-economic circumstances, and environmental factors have been found to be more effective (Liu et al 2025).

However, known difficulties of seeking support for rural and remote children with developmental challenges include; long waiting times for assessment, diagnosis and treatment, a lack of appropriate services in their community; the costs of privately provided services; and of travelling to access those services (Arefadib and Moore 2017).

There are also potential confounding factors that can affect the outcomes and long-term results of early rehabilitation interventions for children with developmental delays, such as the impact of a family’s socioeconomic status and cultural differences in the area (Liu et al 2025). Rural people are disproportionately affected by poorer social determinants and often have lower incomes, lower educational attainment, and significant challenges with homelessness and overcrowded housing (National Rural Health Alliance 2024). Accordingly, families with lower socioeconomic status may not be able to afford expensive rehabilitation costs, access high-quality medical and educational resources, afford to travel long distances, or spend time away from work and family. These factors directly affect their access to early rehabilitation services (McManus et al 2018).

Other factors include attitudinal and cultural barriers. Examples reported to the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability (the Royal Commission) regarding difficulties experienced by Aboriginal and Torres Strait Islander people living with disability in rural areas included racism. For those living in remote areas, the lack of access to medical disability services meant the need to leave Country to access care or, alternatively, go without appropriate health care (National Disability Insurance Agency 2019).

Digital connectivity, reliability, accessibility, affordability and digital health literacy continue to be enduring barriers to enabling rural communities to fully participate in digital health and in many other areas which are key tenets in thriving economies and societies. There is an ongoing need to address the digital access divide for rural communities, and this holds true for people with disability.

In terms of the education system, the 2024 survey undertaken by Children and Young People with Disability Australia (CYDA) shows that the educational experiences of students with disability have seen little meaningful improvement in recent years. Improvement in key areas such as inclusive practice and educational support remain largely stagnant, indicating persistent systemic gaps and the absence of strategic progress towards genuinely inclusive education (Riessen 2025).

Early childhood education centres (ECECs) and schools, often the only consistent support, are under-resourced and overwhelmed. Without timely, specialised support, these children risk falling further behind academically, socially and emotionally (Casburn et al 2025).

The Alliance recommends several features for the roll-out of Thriving Kids Care to ensure equity and intersectional issues in rural and remote areas are not exacerbated, including but not limited to:

  • Bringing together professionals from different sectors to provide early coordinated, holistic, wrap-around support in rural areas- multidisciplinary care teams can include a variety of health professionals, from general practice, dentists, allied health, education professionals and social and community workers offering comprehensive care for patients with complex needs. This may require a navigator for this to occur.
  • There should also be an emphasis on the importance of integrating the individual, family, and environment, e.g. school setting, into the intervention design.
  • Financial support for accessing mainstream settings, e.g. GPs/Rural Generalists who are often the first and main consistent point of contact for families concerned with their child’s development and can link families to other services.
  • Federal, state, territory and local governments should work together to improve the experience and outcomes of development, learning and education for children with disability, in line with CDYA’s 2024 youth education survey report.
  • Telehealth and hybrid service models supported by local facilitators and outreach programs may complement (not replace) face-to-face contact and address the tyranny of distance, allow timely screening, and facilitate continuity of care, especially for workforce-scarce areas.
  • Investing in a range of technologies and channels to improve digital inclusion for participants. This includes digital literacy and delivering a digital experience tailored to the diverse needs of people with disability.

The Alliance supports Recommendation 9 of the NDIS Review in relation to delivering a diverse and innovative range of inclusive housing and living support.

Gaps in workforce support and training

The success of Thriving Kids hinges on the capacity of Australia’s health, education, and community services to work together and for the workforce to deliver timely, inclusive, and developmentally appropriate support to children with mild to moderate developmental delay.

When concerns arise regarding a child’s development or behaviour, many families seek care from their GP or allied health provider. Research shows that engagement of primary care providers and healthcare systems in the community is one of the identified critical contextual factors in early intervention success (Liu et al 2025). The family GP/Rural Generalist can support the family to clarify developmental concerns, identify appropriate medical investigations, as well as identify the need for allied or other health assessment or intervention. Wherever there is an overlap in components of care between primary care and allied health clinicians, there is an opportunity for collaboration (NSW Agency for Clinical Innovation 2024).

However, the available workforce declines with remoteness, impacting the ability of providers to deliver care and support in some areas. In addition, the numbers of audiologists, speech pathologists, occupational therapists, dentists, psychologists, paediatricians and social workers are lower in rural, remote and very remote areas (National Rural Health Alliance 2019). Rural Australians also face longer wait times to see a GP, with 36.3% of regional, remote and very remote communities reporting in the 2023-24 financial year that they waited longer than they felt acceptable to see a GP compared to 26% in major cities (Australian Bureau of Statistics 2024). There is also a significant shortage of disability support workers across Australia and there is limited data available indicating the number and distribution by Modified Monash Model (MMM) area (Mavromaras et al 2019) (Daly N 2022).

Paediatricians are a highly specialised workforce that form a crucial component of the child health workforce (Royal Australian College of Physicians 2023). Studies demonstrate that there is an upward trajectory in the proportion of children that are accessing paediatric services related to developmental, behavioural and psychosocial concerns in Australia and around the world (Kardell et al 2022). Rural paediatricians report high percentages of developmental and behavioural conditions in their caseloads.

In addition, a recent study of rural paediatric services found that children living in rural and remote areas more likely to be developmentally vulnerable than their metropolitan counterparts (Kardell et al 2022). Paediatricians participating in the study reported that the high demand for these services in rural areas, alongside the complexity of the conditions that children faced and the limited access to multidisciplinary services to refer patients, leads to long waitlists and delays in children receiving diagnoses and management. Due to the skillset required to manage these conditions, the paediatricians participating in the study noted that they were often the only clinicians available to manage many of the conditions they were presented with in rural areas (Kardell et al 2022).

According to Royal Far West, the waitlist for paediatric assessments in some locations can range between 18 months and six years and paediatric waitlist concerns continue to grow in many rural communities (Royal Far West 2024).

Therefore, the foreseen challenges with the roll-out of Thriving Kids in rural and remote communities include access to the workforce who can provide screening and mainstream services outside of the NDIS system.

Besides the number and distribution of the workforce in rural Australia, the Alliance has heard that providing mainstream services for children under 9 with mild to moderate developmental delay requires a different skill set compared to delivery of clinical services under the NDIS. For example, Thriving Kids will require working effectively within the mainstream system such as schools, early childhood education and primary care. In addition, training will be required to provide delivery of foundational supports, including but not limited to, early identification and screening, and adapting therapy models to universal and targeted settings, such as classroom-based interventions or parent coaching. Interventions and support through the education system have not progressed over the years, as noted previously (Riessen 2025) (Casburn et al 2025), particularly in rural ECECs and schools.

The workforce involved in Thriving Kids must be able to support the needs of children in a coordinated way with other relevant service providers to provide integrated care. This may involve working with the child’s educators/school, health professionals, welfare and disability workers, and other individuals or professions from across the child’s life contexts (Fitzpatrick et al 2024).

For healthcare workers, training may be achieved through targeted Continuous Professional Development (CPD) training for health professionals. Notably, the Australian College of Rural and Remote Medicine (ACRRM) offer Autism in Rural and Remote General Practice education to develop registrars’ knowledge of autism in the context of life in rural and remote communities (Australian College of Rural and Remote Medicine 2025).

The Alliance has received feedback that the recent changes in the NDIS Pricing Arrangements and Price Limits 2025-26 to cap the travel reimbursement rate for therapists and reduce the prices for rural and remote-specific support types will create significant financial disincentives for allied health providers and further threaten the viability of services in thin markets.

Therapy providers located in rural Australia are considering reducing or withdrawing their services from small rural communities, while those willing and able to support will burn out, leaving vulnerable Australians further isolated and unsupported. These changes will exacerbate the fragile market, and negative rural workforce trend, particularly in towns with limited infrastructure. These will result in families travelling long distances or forgoing support entirely, and worsen the health inequity for people in rural Australia living with disability. Policies must address these systemic and financial sustainability drivers, to ensure we do not further reduce the access for rural children.

The Alliance recommends the following measures to address gaps in workforce support and training:

  • Build workforce capacity and provide targeted and training support for mainstream services. These services must be trained and equipped to screen, identify and respond to mild to moderate developmental delay in children and refer them to navigators (discussed under the next heading) and/or the right information to help them get the supports they need.
  • Service providers should work in ways that provide families in rural and remote areas with access to sustainable and flexible services, taking into consideration available resources and adapting their approach accordingly to ensure the process is fit for purpose within the local context (Fitzpatrick et al 2024).
  • Provide clear referral pathways and service directories. These must be mapped out to facilitate collaboration and care across mainstreams services as well as guide the patient’s journey.
  • Travel support/reimbursements must be adequate and appropriate for the distances covered by the rural workforce with rural loadings increasing with remoteness.

Mechanisms for a seamless transition of children with mild to moderate support needs to mainstream systems

The Alliance shares the vision of the NDIS Review that all people with disability and their families should have access to a Navigator who acts as their trusted guide across systems. To support the reform blueprint outlined in the NDIS Review, particularly Recommendation 4, the Navigator function should be complemented by foundational supports, and expansion of universally available child development checks. These would ensure early identification of children with developmental concerns and disability and enable early intervention. Navigators will also have an important role in amplifying and giving voice to people with disability.

The Navigator should be appropriately funded and at a minimum include:

  • Helping families navigate complex systems and providing accessible information and advice on the right support, whether to mainstream services, foundational supports or NDIS-funded services, thereby bridging the gap between families and services.
  • Importantly for rural and remote areas, be locally embedded with strong knowledge and connections of existing support and services and understanding of the local context including barriers to access, e.g. services, education system.
  • Coordinating the right mix of support and provide continuity of support as children move between services or life stages. This includes an understanding of federal vs state funded programs.
  • Assisting people before they access the NDIS, through proactive screening, outreach and support, including accessing mental health services.
  • Report on demand for services and unmet need, including gaps in local service systems.

Research has found that parents often have to divert their time and resources away from their child to navigate complex health and education services, such as understanding different referral systems (Home et al 2015). An effective Navigator is one that provides a coordinated, inclusive, and flexible support, and would potentially reduce reliance on the NDIS by helping direct families to the appropriate support elsewhere.

The Alliance urges Government to adopt the recommendations of the NDIS Review to establish the Navigator function. In particular:

  • In line with Action 1.1 of the NDIS Review, the Foundational Supports Statement of Intent should be agreed upon as a commitment from all governments to all people with disability that foundational support will be developed and funded as a critical part of an effective and sustainable disability ecosystem.
  • Importantly, funding for Navigators should be provided outside of individual budgets to ensure participants do not need to choose between a Navigator and other much needed support.
  • The Alliance supports Action 4.4 of the NDIS Review report suggesting the staged approach to transitioning the existing Support Coordinators to Navigator supports to allow continuity of support.
  • In addition, there should be a national framework for the Navigator function to ensure consistent delivery, developed in partnership with relevant Australian government and state and territory government agencies, incorporating local design to capture the unique needs of different locations.

Other considerations – data

As there is no single solution to improve access to care and support services for children with disability in rural Australia, a range of flexible policy levers are needed to address the complex and

multifaceted issues, including ensuring governments collaborate on consistent eligibility and service models.

As the NDIS Review noted, building the quality, availability and use of disability data is essential to increasing our understanding, improving transparency and making evidence-based decisions about the future of the disability ecosystem.

Thriving Kids will require meaningful data to facilitate insights and inform policy, reform and evaluation. The disability ecosystem, more broadly, needs to be supported by comprehensive disability data and data improvements that reflect the experience of all people with disability. As noted by the NDIS Review, investment in integrated and longitudinal data is needed now so we can respond to the needs of children with developmental needs. This will also require cross-portfolio understanding and collaboration in the health, disability and education sectors.

The Alliance supports Recommendation 23 of the NDIS Review, that we measure what matters, build an evidence base of what works, and create a learning system.

The evidence-base should include data on prevalence, service, equity (rural vs urban) indicators relating to children with disability living in rural Australia, broken down by geographic location using classification systems such as the MMM.

Conclusion

The Thriving Kids initiative is a vital opportunity to build a more inclusive, sustainable, and equitable system for children with developmental needs. By investing in foundational supports, empowering families, and embedding services in everyday settings, we can ensure that all children—not just those eligible for the NDIS—have the chance to thrive. If Australia is to build a thriving, productive economy and society long term, we need to invest in our children.

As recommended by the NDIS Review, significant investment by governments in foundational supports outside the NDIS for children in the early years (under the age of 9) will be needed. Thriving Kids will need to have in place better screening to pick up developmental and health concerns as early as possible in mainstream settings, and early intervention services based on best practice principles and evidence will be needed. These are much-needed investments for our country that can lead to significant long-term benefits for individuals and their communities.

As a signatory to the United Nations (UN) Convention on the Rights of Persons with Disabilities and the UN Convention on the Rights of the Child, Australia is legally bound to implement a human rights approach to disability in children – to ensure they have the right to enjoy a full and decent life, receive special care, and participate in community.

As a wealthy western country, we also need to ensure that all children, including those outside of urban centres, have the best chance to grow and thrive. These children also have a right to access to coordinated, accessible and culturally appropriate disability support.

The Alliance urges the Committee to recommend to the Australian Government a fully funded, nationally consistent, and community-led rollout of Thriving Kids, with strong accountability and a focus on equity. Indeed, equity and parity for rural, remote and regional children.

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