pa | HE AUSTRALIAN ORTHOTIC PROSTHETIC ASSOCIATION

Orthotics and Prosthetics in Australia

Orthotist/prosthetists assess the physical and functional limitations of people resulting from disease, illness, trauma and disability, including limb amputation, diabetes, arthritis and neuromuscular conditions, such as stroke. Orthotic and prosthetic services may involve the provision of orthoses and prostheses to restore function, prevent deterioration, and improve quality of life. Orthotist/prosthetists are commonly employed in Australian hospitals, private clinics, research institutions as well as rural and remote regions, working independently and as part of multidisciplinary healthcare teams to support the Australian community.

Orthotist/prosthetists are tertiary qualified allied health professionals. An Australian Qualification Framework level 7 is required to practice as an orthotist/prosthetist in Australia, consistent with education standards for other allied health professions. Orthotic/prosthetic students complete training alongside physiotherapy,podiatry and occupational therapy students.

The Australian Orthotic Prosthetic Association (AOPA) is the peak professional body for orthotist/prosthetists in Australia, with certified practitioners comprising 89% of the practicing profession. AOPA is responsible for regulating the profession and is a founding member of the National Alliance of Self Regulating Health Professions (NASRHP) in partnership with other professional organisations, including Speech Pathology Australia,the Australian Association of Social Workers and Exercise and Sports Science Australia. AOPA is recognised by the Commonwealth Government as the assessing authority responsible for conducting migration skill assessments for orthotist/prosthetists.

Contact

The Australian Orthotic Prosthetic Association P.O. Box 1132 Hartwell, Victoria 3124 (03) 9816 4620 | www.aopa.org.au

Leigh Clarke – Chief Executive Officer leigh.clarke@aopa.org.au

Executive Summary

AOPA would like to thank the Joint Standing Committee (JSC) on the National Disability Insurance Scheme (NDIS) for the opportunity to provide comment on the NDIS National Workforce Plan 2021-2025 (the Workforce Plan)

AOPA welcomes the opportunity to support the work of the JSC through strengthening the NDIS workforce and improving access to clinical services.

This submission addresses the following JSC inquiries: a. The current size and composition of the NDIS workforce and projections at full scheme, b. Challenges in attracting and retaining the NDIS workforce, particularly in regional and remote communities,c. The role of Commonwealth Government policy in influencing the remuneration, conditions, working environment (including Workplace Health and Safety), career mobility and training needs of the NDIS workforce,d. The role of State, Territory, Commonwealth Governments in providing and implementing a coordinated strategic workforce development plan for the NDIS workforce,e. The interaction of NDIS workforce needs with employment in adjacent sectors including health and aged care,g. Other matters.

By way of summary:

Only 14% of the orthotist/prosthetist workforce are located in regional and remote areas of Australia. Difficulty accessing mentoring and continual professional development as well as professional isolation likely contribute to this low prevalence of practitioners,
The NDIS provider travel policy is a Commonwealth Government policy that negatively affects remuneration of orthotic/prosthetic clinical services. This policy is difficult to implement administratively and financially burdensome, and a barrier to the provision of sustainable clinical services,
Effective workforce development relies on State, Territory and Commonwealth Governments applying a coordinated, strategic and nationally consistent workforce strategy,
An underdeveloped orthotic/prosthetic private sector drives participants to public health services. Conflicts arise as health services are triaged ahead of disability services,
Building a complimentary workforce, including technicians and allied health assistants will increase capacity of the existing orthotic/prosthetic workforce.

Examples in this submission consist of real-life reported examples, as well as fictitious scenarios. Effort has been made to ensure all examples are accurate.

AOPA is grateful for the opportunity to provide this additional context describing the orthotist/prosthetist workforce and other workforce issues relating to the JSC Terms of Reference. We are available for further comment and look forward to assisting the JSC to implement initiatives that will help grow the NDIS workforce.

a) The current size and composition of the NDIS

workforce and projections at full scheme

The orthotic/prosthetic workforce is small and has poor geographic dispersion. Workforce projections suggest that the orthotic/prosthetic workforce cannot support the needs of NDIS participants at full scheme

The size and composition of the

orthotic/prosthetic workforce

AOPA certified orthotist/prosthetists represent approximately 89%2 of the total number of orthotist/prosthetists working in Australia.

While the exact proportion of orthotic/prosthetic practitioners that contribute to the NDIS workforce is not known, AOPA estimate that the vast majority likely provide orthotic/prosthetic services to NDIS participants. Therefore, the characteristics of the AOPA certified orthotist/prosthetist workforce presented Figure 1. Number of orthotist/prosthetists per 100 000 herein can be considered to be a fair reflection of the population characteristics of the NDIS orthotic/prosthetic workforce.

In 20193, the national orthotic/prosthetic workforce comprised of 410 certified practitioners, with a practitioner prevalence of 1.62 orthotist/prosthetists per 100 000 population. There is only one published recommendation for orthotist/prosthetist practitioner prevalence – which recommends 3.0 orthotists per 100 000 population4. The Australian national average practitioner prevalence (Figure 1) is therefore just over half of the international recommendation.

The orthotic/prosthetic workforce is also geographically unevenly dispersed. 46% of the workforce is concentrated in Victoria where there are 2.85 practitioners per 100 000 population3 (Figure 1). Victoria (2.85) and Tasmania (2.43) have the highest practitioner prevalence whilst New South Wales (0.99) and the Northern Territory (0.81) have the lowest practitioner prevalence3. Only 14% of practitioners work outside of major cities (NB: this includes all of Tasmania and the Northern Territory), which results in a practitioner prevalence of 0.84 practitioners per 100 000 population; nearly half that of metropolitan areas. Geographical

Orthotic/Prosthetic Workforce Projections

dispersion relating to regional/remote areas will be
Orthotic/prosthetic workforce projections

discussed further in section B) challenges in attracting and retaining the NDS workforce, particularly in
The orthotic/prosthetic workforce has grown steadily regional and remote communities.

The number of AOPA certified practitioners has increased at over the past ten years, the a steady rate of approximately 7% per year. While this growth has outpaced population growth and has growth has outpaced population growth and has therefore translated into more practitioners per 100 000 therefore translated into more practitioners per 100 000 population, current practitioner prevalence in Australia population, current practitioner prevalence in Australia remains below international recommendations. It is remains below international recommendations. It is likely that without targeted initiatives to increase or likely that without targeted initiatives to increase or expand the existing workforce, this shortage of expand the existing workforce, this shortage of orthotist/prosthetists in Australia, is likely to continue. northotist/prosthetists in Australia, is likely to continue.

Since 2007, the Australian orthotic/prosthetic workforce has become significantly feminised (p<0.05)3 with the proportion of female orthotist/prosthetists increasing from 30% in 2007 to 49% in 2019 (Figure 2).

Figure 2. Proportion of male and female orthotist/prosthetists

b) Challenges in attracting and retaining the NDS workforce, particularly in regional and remote communities

Poor access to mentoring and professional development coupled with professional isolation likely contribute to the low prevalence of orthotist/prosthetists in regional and remote Australia. Low orthotist/prosthetist prevalence in and remote areas must travel to metropolitan areas to access orthotic/prosthetic services, while those who do not or cannot travel, experience substantial delays given they must wait for a satellite or outreach service. Only 14% of the orthotic/prosthetic workforce are located in regional and remote areas of Australia, including all of Tasmania and the Northern Territory, equating to 0.84 orthotist/prosthetists per 100 0003. This is less than half the number of practitioners per 100 000 population located in metropolitan areas of Australia (i.e., 1.92) 3, and only one third of the international recommendation of 3.0 orthotists per 100, 000 population 4. The proportion of the orthotic/prosthetic workforce in regional and remote areas is similar to many other allied health disciplines experiencing workforce shortages, including occupational therapists5 physiotherapists6 and podiatrists7. With barriers such as lack of mentorship possibilities, difficulty accessing professional development and professional isolation, AOPA suggest that low numbers of practitioners in regional and remote areas is unlikely to substantially change in the future. Low orthotist/prosthetist prevalence in regional and remote areas make it difficult for NDIS participants to access orthotic/prosthetic services. For example, AOPA believe that the majority of participants living in regional

Example: Molly needs to travel 8 hours for service Molly is an NDIS participant and needs a new pair of ankle foot orthoses with modified footwear to help her walk at school, at her part-time job and around the community. Unfortunately, Molly lives 8 hours away from her nearest orthotist. This means Molly’s mother needs to take two days off work to drive Molly to her appointment and back. As it is such a long trip, Molly and her mother also must stay overnight for this appointment. Molly and her mother will need to make this trip again for a fitting appointment in 4 weeks’ time, and again in another 2 weeks for a review.

Low orthotist/prosthetist prevalence in regional and remote areas make it difficult for NDIS participants to access orthotic/prosthetic services. For example, AOPA believe that the majority of participants living in regional

Barriers to recruiting and retaining

practitioners in regional and remote settings

Take more time from work to travel to the CPD activity,
Pay additional transportation and accommodation costs. There are barriers inhibiting recruitment and retention of orthotist/prosthetists in regional and remote settings. Given there are so few practitioners providing services into regional/remote areas of Australia, practitioners often work in isolation or in services with few practitioners. It is often not possible for more than one practitioner to be absent from work at the same time. This is particularly problematic for very small allied health professions such as orthotist/prosthetists, who also have access to fewer relevant CPD activities each year, compared to many of their larger allied health counterparts.

Furthermore, experienced practitioners accepting multiple requests for mentorship from junior practitioners have increased risk of burnout given the balance required to manage a high clinical load and allocate sufficient time to mentoring activities. Lack of mentorship opportunities is disadvantageous to junior practitioners given the practical and context-specific knowledge and support that could be provide through these professional relationships.

Example: Harry’s difficulty upskilling

Harry is an orthotist based in Whyalla. He is hoping to attend the AOPA National Congress held in Melbourne this year. Harry has looked over the program and is excited to note a number of presentations and workshops are relevant to the services he provides Unfortunately, as the congress is in Melbourne, Harry is unable to attend as he cannot cover the costs of flights and accommodation, and the two days off work.

Example: John can’t keep up

John is an experienced certified orthotist/prosthetist working in rural Queensland. He has over 45 years’ experience across several major clinical areas. John is looking forward to reducing his clinical hours to part-time, so he is able to spend more time with his grandchildren. John now mentors three junior practitioners; however, the strain of mentoring whilst trying to reduce to part-time work means John is having less time to keep up with his own clinical load. This stress causes John to make plans to retire earlier than he had anticipated.

Lack of mentorship opportunities and difficulty accessing CPD can lead to professional isolation and increased risk of intent to leave the profession. Given opportunities to connect and network with professional counterparts are so limited, practitioners in regional/remote areas must either forgo opportunities or take them on at a greater cost compared with their metropolitan counterparts.

A key barrier to orthotist/prosthetists working in a regional/remote area is difficulty accessing continuing professional development (CPD). Although practitioners can take part in web-based CPD such as live and pre-recorded webinars, the majority of profession-specific CPD activities such as national conferences and workshops are located in metropolitan areas. This means practitioners in regional/remote areas are not only required to take time off work to attend the CPD activity but they must:

Take more time from work to travel to the CPD activity,
Pay additional transportation and accommodation costs.

Workforce Plan proposal

The Workforce Plan proposes an initiative to combat some of the difficulties facing regional/remote practitioners: “Enable allied health professionals in rural and remote areas to access professional support via telehealth” (Priority Action 3; initiative 15)^1. AOPA welcomes this initiative given it offers valuable support to practitioners working in regional/remote

Submission to the Joint Standing Committee on the NDIS: NDIS Workforce 2021

areas of Australia. For example, since 2015, AOPA has offered high-quality and relevant webinars to our national membership, with feedback suggesting these webinars are highly valued by our regional/remote practitioners, given they offer support and resources that would otherwise be inaccessible.

However, this initiative alone is unlikely to make a substantial difference to practitioner recruitment and retention. For this initiative to appropriately support an orthotic/prosthetic workforce that is stretched thin and becoming progressively younger, professional support (i.e., mentoring) offered via telehealth could be offered in a group setting. This would capitalise on the knowledge and expertise of the experienced practitioner and would reduce travel barriers associated with geographic dispersion. Practitioners working in regional/remote areas would feel more connected to their profession and colleagues.

AOPA is looking forward to learning more about this initiative and is available to advise on how orthotist/prosthetists in regional and remote areas could access professional support such as group mentoring, via telehealth.

c) The role of Commonwealth Government policy in

influencing the remuneration, conditions, working environment (including Workplace Health and Safety), career mobility and training needs of the NDIS workforce

The NDIS provider travel policy is a Commonwealth Government policy that negatively affects remuneration of orthotic/prosthetic clinical services. This policy is: difficult to implement, administratively and financially burdensome, and a barrier to the provision of sustainable clinical services. Current policy is not fit for purpose • Ensure each participant has provider travel in their plan,

The NDIS provider travel policy is intended to promote • Obtain consent from each participant to invoice practitioner and service dispersion across Australia. provider travel, Unfortunately, the NDIS provider travel policies are difficult to implement and present significant • Negotiate provider travel hourly rates with each participant, administrative and financial burden which means they administartive steps involved in these administrative tasks.invoicing provider travel time to the NDIS. Because funding for provider travel is accessed through a participant’s individual plan, these administrative steps must be completed prior to service provision, and for every participant.
Financial burden Each administrative step attracts a financiale consequence. It takes hours to organise the necessities for clinics and out-reach services (e.g., staffing, location, rent, equipment and inventory). Adding to this, the timeorthotic/prosthetic providers are required to: required to individually contact participants, including confirmation and/or re-negotiation of appointments.

Administrative Time and NDIS Provider Travel Policy

This administrative time translates directly into administrative costs.

The current NDIS provider travel policy requires individual participant negotiation, and as a consequence, is financially burdensome. AOPA is aware of numerous service providers who rely on state-based funding to deliver clinics and out-reach services, which is not a long-term or sustainable solution for the delivery of services t NDIS participants in regional and remote areas. Example one below is one such example.

Example One: When multiple participants are seen in a Port Lincoln Clinic

These clinical services are provided in Port Lincoln, South Australia. According to the geographic classification system defined by the Modified Monash Model Six, Port Lincoln is an MM6 area. Because Port Lincoln is an MM6 area, the service provider cannot invoice any more than $271.59 per hour, for provider travel.

The Port Lincoln clinic is a 3-hour (one-way), drive from the provider’s regular place of business. On average, the provider will see four NDIS participants per Port Lincoln clinic (and four Community Health Patients). The clinic operates once a month, with two orthotist/prosthetists attending each clinic.

The provider can invoice each NDIS participant for the percentage of travel related to NDIS participant services at the clinic. In this example, this is 50%, given NDIS participants represent 50% of the clinic caseload. The provider can invoice each NDIS participant the proportion of provider travel time that is attributable to their service (25%), as long as: e Each participant has provider travel listed in their plan e Each participant has agreed to the provider invoicing for travel time e Eachparticipant has agreed the provider can apportion their travel time across all NDIS participants.

The total time to travel to and from the clinic is 6 hours. As the clinic is servicing 4 NDIS participants out of 8 clients, once 50% (3 hours) of the travel time may be invoiced to the NDIS participants. The three hours of provider travel time comes to a total of $814.77. This figure is then apportioned across the 4 NDIS participants ($203.69 per participant). ® |f one of the participants doesn’t have provider travel in their plan, or has depleted the funds from their plan,the participant will need to undergo a plan review.* [f one participant wants to negotiate a different price (which they are entitled to) the provider must thenapportion the travel time differently against the remaining NDIS participants.* The administrative time spent obtaining consent, confirming provider travel funds in a participant’s plan andnegotiating hourly rates, cannot be claimed.[t is important to note that the service provider described in this example, is based in a state hospital department andtherefore has increased levels of administrative support that would not be available to smaller, private providers.

NDIA geographic classifications do not reflect orthotic/prosthetic workforce

As seen in example one, the NDIA use a geographic classification system called the Modified Monash Model(MMM). This classification system is intended to assist the NDIA in funding supports fairly across metropolitan, regional and remote areas of Australia. Essentially, participants in more remote areas of Australia receiveadditional funding to support the increased cost of provider travel.

Unfortunately, funding provider travel using a geographical classification system based on population,does not take into account the nuances of provider travel based on workforce distribution.

For example; Launceston is classified as MM2 (Regional Centre) which offers two permanent orthotic/prosthetic service providers, with seven certifiedorthotist/prosthetists. In contrast, Rockhampton is also an MM2 location, but in contrast to Launceston,Rockhampton has no permanent orthotic/prosthetic service provider. Instead, participants living inRockhampton receive orthotic/prosthetic services via

Impact

Provider Travel Policy Challenges

Out-reach clinics offered by two orthotic/prosthetic service providers, who each offer one clinic twice per month. Service providers travelling into Rockhampton will need to charge provider travel time. Despite this being a 3-hour journey for some providers, they are limited to billing a maximum of 30 minutes travel time at the regular support cost of $193.99. This means that service providers must absorb the cost of the additional travel time, creating a barrier to offer these services and reducing long-term sustainability.

This provider travel policy results in two participants, who live in the same MMM geographic classification (for example Launceston or Rockhampton), and require the same funding supports, will not receive equitable access, given the participant in Rockhampton will experience increased service wait times.

The impact

Given provider travel costs are allocated based on a geographic classification that does not reflect the required provider travel, it is not surprising that orthotic/prosthetic providers travel into these areas only where alternative arrangements are in place (i.e., state funding received). For example, some private service providers report community-based funding is provided to support airfares and associated travel costs.

Current NDIA provider travel policy means it is difficult for providers to establish provider travel efficiently. Some providers must absorb the majority of the costs associated with provider travel - a practice that is highly unsustainable and problematic. Current provider travel policy has also resulted in some providers:

Reducing the number of outreach clinics,
Refusing to operate any outreach clinics,
Relying on state-based support to operate clinics. None of these outcomes are sustainable or enable participants to access services in a timely manner.

Workforce Plan to Reduce Red Tape

AOPA support the Workforce Plan’s 11th initiative to “continue to improve NDIS pricing approaches to ensure effective operation of the market, including in thin markets”. The plan proposes that the Australian Government run a “pricing project to consider approaches to improve pricing practices” and support “workforce development”.

d) The role of State, Territory, Commonwealth Governments in providing and implementing a coordinated strategic workforce development plan for the NDIS workforce

Effective workforce development relies on State, Territory and Commonwealth Governments applying a coordinated, strategic and nationally consistent workforce strategy.

State/territory equipment funding policies inhibit growth of private sector Similar market-growth issues occur in other states/territories. For example, the Queensland Artificial Limb Service (QALS) and Western Australian Limb Service for Amputees (WALSA) only recognise service providers who are contracted suppliers. Becoming a contracted supplier is administratively burdensome. It also prevents new providers entering the market easily.

As a result, workforce growth is inhibited in these states, and other states with similar funding policies. Practitioners are attracted to open private practice in other states with less restrictive policies, thus practitioner prevalence decreases and access to services is made more difficult.

An under-developed private sector forces NDIS participants to the public sector With a small and unevenly dispersed orthotic/prosthetic workforce, the lack of private practice providers in many states steers NDIS participants to access orthotic/prosthetic services in the public sector. Where the public sector is unable to meet this outpatient disability service demand, long waiting lists are emerging. This is typically because public sector services are required to prioritise inpatient health services over outpatient disability services.

Waitlists are highly problematic for people requiring orthoses and prostheses. Orthoses and prostheses are vital assistive technology that enable people to safely ambulate, administer self-care tasks and activities of daily living, and participate in school, work and social

Life.

When waitlisted, a person may be denied access to this vital assistive technology and may be therefore unable to participate in home, school or work life. They may also face an increased risk of falls, injury or an escalation in care needs.

Workforce Growth

Workforce growth in the private sector depends on the removal of barriers currently inhibiting private practice set-up. This includes the reviewing of contractual arrangements with state-based equipment schemes to make it easier for new service providers to enter the market. States and territories need to uniformly remove these barriers to encourage workforce growth across the sector.

e) The interaction of NDIS workforce needs with

employment in adjacent sectors including health and aged care

An underdeveloped private sector drives participants to public health services. Conflicts arise as health services prioritise inpatient services over out-patient disability services. The conflict between health and disability workforce and under-developed private sector in many states, NDIS participants are often driven to the public Orthotist/prosthetists work across a range of sectors sector to access orthotic/prosthetic services. including health, aged care, and disability. With a small and unevenly dispersed profession, As the public sector must prioritise health services, orthotist/prosthetists must provide services across all disability caseloads are often waitlisted and downgraded in their priority. This conflict often results in NDIS participants needing to wait longer to receive their service. This is particularly problematic in regional and remote areas where there are low workforce numbers and even fewer private practices. Given the low numbers of orthotist/prosthetists in regional and remote areas, and in several state/territories, a number of public orthotic/prosthetic providers are also NDIS providers. Given the small

Example: Health and disability services in a regional area

Angela lives in regional area. She uses an ankle foot orthosis (AFO) to ambulate at home and in the community. There are no private providers for Angela to access in her region, therefore she attends the local hospital orthotic/prosthetic department for outpatient services.

Angela has a scheduled review appointment to see her orthotist. She made this appointment after she noticed a small crack in her AFO. On the day of the appointment her orthotist is running late as they have been called into surgery to fit a post-operative orthosis and has also been required to attend the emergency department to fit a cervical orthosis to someone who has a spinal fracture.

Angela is unable to wait any longer than an hour. She has had to reschedule her orthotic appointment for the following week. Two days later, as Angela is walking down the steps at her front door, her AFO develops a large crack in her AFO at the ankle. Angela falls down two steps. She has injured herself and is unable to use her AFO as it is unsafe.

g) Any other matters

Building a complimentary workforce, including technicians and allied health assistants will increase capacity of the existing orthotic/prosthetic workforce. Orthotic/prosthetic technicians in Australia. However, technicians are not employed across all orthotic/prosthetic service providers, which one strategy to combat a small workforce size and suggests potential for meaningful workforce growth of geographical dispersion, is to strengthen the this complimentary workforce.complimentary workforce which in turn increases the capacity of the existing workforce by allowing practitioners to work at top of scope.

How the workforce plan can support technician training

A key complimentary workforce for the orthotic/prosthetic profession is the orthotic/prosthetic technician workforce. While orthotist/prosthetists are trained and qualified to assess, prescribe, design, manufacture, fit and review orthoses and prostheses, orthotic/prosthetic technicians have expertise in the manufacturing and repairing orthoses and prostheses. The technician workforce is an integral part of the orthotic/prosthetic workforce. With technicians providing expertise and skills in manufacturing and repairing orthoses and prostheses, practitioners have increased capacity to be able to work at the top of the scope, consult with more clients and provide more clinical services, which effectively expands the existing workforce.

For example, a practitioner is attending a busy rehabilitation clinic, with several clients requiring refurbishments to their orthoses. The practitioner assesses the first client and notices an orthotic knee joint on a knee ankle foot orthosis is showing signs of malfunction. After assessing the need for a new orthotic knee joint, the practitioner takes the orthosis to the technician in the workshop. The technician replaces the knee joint according to the practitioner’s specifications. Whilst the technician completes this, the practitioner is able to consult with their next client. Technicians are a vital part of the orthotic/prosthetic profession and must be considered when implementing the Workforce Plan. AOPA estimates there are 200 technicians employed by public and private orthotic/prosthetic service providers

Allied Health Assistants

Allied health assistants are a complimentary workforce that could be utilised to increase the capacity of the existing orthotist/prosthetist workforce, by allowing them to work top of scope.

While the number of allied health assistants employed within the orthotic/prosthetic profession is not known, AOPA believe there are currently no allied health assistance employed in the private orthotic/prosthetic sector.

Allied health assistants are generally employed by public health services and are understood to be used only occasionally in the public sector to support orthotic/prosthetic service provision.

Initiative 14 of the Workforce Plan will support allied health assistant training and mobilisation within the orthotic/prosthetic profession.

AOPA is aware of the Victorian Government’s allied health workforce plan and training institutions like Skills IQ, working to ensure competencies and training packages are fit for purpose. The Workforce Plan can further promote disability training for allied health assistants.

Example:

e.g., A practitioner is attending a busy rehabilitation clinic with several clients requiring casting and refurbishments to their orthoses. The practitioner assessed one client needing a new orthotic knee joint on their knee ankle foot orthosis (KAFO). The practitioner has instructed the allied health assistant to help the client put on their KAFO after the technician has replaced the knee joint. Whilst the allied health assistant helps the client put on their KAFO, the practitioner can commence casting another client. After the practitioner has completed casting, they return the first client and instruct the allied health assistant to prepare the casting room for the next client. The practitioner can now assess if the new orthotic knee joint is achieving its purpose.

The Australian Orthotic Prosthetic Association

P.O. Box 1132 Hartwell, Victoria 3124 (03) 9816 4620 | www.aopa.org.au