Exercise & Sports Science Australia

Submission to the Joint Standing Committee on the National Disability Insurance Scheme

Inquiry into NDIS Workforce

Date: 08 May 2020

Phone: PH 07 3171 3335 Email: E info@essa.org.au Address: A Locked Bag 102, Albion DC. 4010 Website: W www.essa.org.au

1.0 ABOUT EXERCISE & SPORTS SCIENCE AUSTRALIA

Exercise & Sports Science Australia (ESSA) is the peak professional association for exercise and sports professionals in Australia, representing over 8,000 members, including university qualified Accredited Exercise Physiologists (AEP), Accredited Sports Scientists (ASpS), Accredited High Performance Managers (AHPM) and Accredited Exercise Scientists (AES).

AEPs are recognised allied health professionals who provide clinical exercise interventions aimed at primary and secondary prevention; managing sub-acute and chronic disease or injury; and assist in restoring optimal physical function, health, and wellness.

1.1 EXERCISE PHYSIOLOGY AND EXERCISE SCIENCE IN THE NATIONAL DISABILITY INSURANCE

SCHEME

AEPs are university qualified allied health professionals who provide clinical exercise interventions aimed at primary and secondary prevention; managing sub-acute and chronic disease or injury; and assist in restoring optimal physical function, health and wellness. With a primary focus on improving health and functional independence.

There is compelling evidence that clinical exercise interventions, as delivered by AEPs, provide a range of physical, mental and psychosocial benefits to people with a disabilityi ii. AEPs develop a range of exercise- based activities that empower National Disability Insurance Scheme (NDIS) participants and support them to achieve goals in the areas of daily living, social inclusion and functional well-being.

AEPs can currently register under the ‘Exercise Physiology and Personal Well Being Activities’ and ‘Therapeutic Supports’ registration groups and can deliver supports under the ‘Improved Health and Wellbeing’ and ‘Improved Daily Living’ categories of participant plans. The Council of Australian Governments (COAG) Disability Reform Council’s Quarterly Reportiii revealed that as of June 2019, 2,557 approved providers are registered under the Exercise Physiology and Personal Well Being Activities registration group.

AESs are university qualified professionals with high level training in exercise and sports science. AESs specialise in the assessment, design and delivery of exercise and physical activity programs as interventions

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to improve health and wellbeing and prevent chronic conditions, with a strong focus on achieving

behavioural change. AES can be instrumental in preventing chronic disease by supporting people with

disabilities to be and stay physically active at an individual, community and population level. AES can register

under the Exercise Physiology and Personal Well Being Activities registration group as personal trainers. AES

are also engaged as Therapy Assistants, often supporting AEPs to deliver clinical exercise programs to both

individuals and groups of NDIS participants. NDIS participants also use funds in the Increased social and

community participation categories of their plans to engage in sporting activities and camps.

2.0 ESSA’S SUBMISSION TO THE INQUIRY INTO THE NDIS WORKFORCE

ESSA welcomes the opportunity to provide input into to the Joint Standing Committee on the National

Disability Insurance Scheme’s (the Joint Standing Committee) Inquiry into the NDIS Workforce (the Inquiry).

ESSA’s submission is based on feedback from AEPs and AESs delivering services under the NDIS and

responds to following Inquiry themes:

challenges in attracting and retaining the NDIS workforce, particularly in regional and remote
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 communities
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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

the role of State, Territory, Commonwealth Governments in providing and implementing a
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 coordinated strategic workforce development plan for the NDIS workforce
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the interaction of NDIS workforce needs with employment in adjacent sectors including health and
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 aged care.

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3.0 SUMMARY OF RECOMMENDATIONS

Recommendation 1: The NDIA work with allied health professional associations and universities to promote the NDIS as a future career pathway.
Recommendation 2: Remunerate NDIS service providers for additional activities associated with supporting a student placement, such as the provision of feedback and assessment of clinical competencies.
Recommendation 3: Adjust the current NDIS pricing model to make provisions for professional supervision and case discussion.
Recommendation 4: The NDIA review the price limits for exercise physiology and align exercise physiology rates with the price limits awarded to other NDIS allied health professionals.
Recommendation 5: The NDIA set price limits that are GST exclusive and pay for the GST component in addition to the service delivery costs for exercise physiology services to align with other allied health professionals.
Recommendation 6: The NDIA and NDIS Quality and Safeguarding Commission work collaboratively to develop a range of resources to support new entrants to the NDIS market.
Recommendation 7: Introduce training programs designed to upskill allied health professionals on overcoming communication barriers and understanding the rights of people with disabilities.
Recommendation 8: That the NDIS Quality and Safeguarding Commission develop an operational framework for plan managers to ensure minimum standards are upheld.
Recommendation 9: Reduce the cost and red tape of certification audits for small allied health practices servicing rural and remote communities.
Recommendation 10: Compensate health professionals for the time they spend providing NDIS information and support in rural and remote communities where the NDIA planning workforce does not have a presence.

Recommendation 11: That the NDIA formally acknowledge the important delineation between the clinical assessment and ongoing support provided by qualified AEPs and AES delivering exercise interventions to

NDIS participants in contrast to the day-to-day encouragement that Carers and Support Workers should provide to encourage physical activity.

4.0 CHALLENGES IN ATTRACTING AND RETAINING THE NDIS WORKFORCE, PARTICULARLY IN REGIONAL AND REMOTE COMMUNITIES.

4.1 Attracting New Graduates

ESSA encourages the Joint Standing Committee to consider how the NDIS could improve the attraction and retention of new allied health graduates, noting that new graduates are an available workforce that are actively seeking employment opportunities.

The Australian Government Report titled Growing the NDIS Workforce and Marketiv indicates that some of the barriers associated with attracting people into the NDIS workforce include low public awareness of NDIS job opportunities, misperceptions about working in the sector, and competition from similar sectors.

ESSA suggests that the NDIA work with professional associations and universities to address some of these barriers with students, whilst they are still considering their practical placement options and future career pathways.

ESSA considers some of the benefits associated with the NDIS that could be promoted amongst exercise physiology and exercise science students include:

The NDIS is one of few compensable schemes that allow students on placement to deliver services rather than just observe (under the supervision of an allied health professional and with the permission of participants).
The NDIS provides an opportunity for new practitioners to gain experience across a diverse range of age groups and conditions.
The NDIS is a growing market and presents one of the largest job opportunities in Australian history. The allied health workforce alone needs to grow by 12% to meet future demand.
The NDIS will introduce new practitioners to a range of quality improvement business processes that will be incredibly valuable should they choose to establish their own practice in the future.

The NDIS is one of the few compensable schemes that supports ongoing use of telehealth, providing

practitioners with the opportunity to gain experience in the delivery of services via phone or web-

to platforms.

Working with NDIS participants and supporting them to achieve their goals and improve their

independence, function, social engagement, and quality of life through exercise interventions can

be an incredibly rewarding experience for practitioners.

ESSA notes that professional associations often have student members and established communication

channels that could potentially be used to promote these types of messages amongst students. ESSA for

example has over 700 student members. ESSA’s student members currently receive a monthly eNewsletter

and have access to a dedicated group on Facebook where resources and information can be shared.

Recommendation 1: The NDIA work with allied health professional associations and universities to promote

the NDIS as future career pathways.

   **4.2 Student Placements**

ESSA suggests that student placements are a valuable way to grow the NDIS workforce and introduce new, skilled allied health professionals into the sector. ESSA notes that access to appropriate supervision is key to

the success of student placement programs. Effective supervision during practicum placement provides a

safe, effective, and essential opportunity for students to consolidate learning and develop practical skills

relevant to future work as an entry level practitioner.

ESSA notes that for many AEPs running private practices and operating off the NDIS fee-for-service funding model, supporting student placements is not economically viable. Whilst the NDIS allows service providers

to charge for sessions conducted with a student, there are no arrangements in place to remunerate

supervising professionals for additional activities such as provision of feedback and assessment of clinical competencies.

Recommendation 2: Remunerate NDIS service providers for additional activities associated with supporting a student placement, such as the provision of feedback and assessment of clinical competencies.

4.3 Retaining New Graduates

Research indicates that allied health graduates face many challenges in the transition from being a student to a professional in the workforce. These challenges include: having full responsibility for a caseload and for making decisions about a patient’s care for the first time; adjusting to full-time work and balancing a full caseload with other competing demands; having less access to supervision and case discussion; and understanding and navigating new service systemsv vi.

ESSA suggests that new graduates entering the NDIS face additional challenges due to the complexity of the NDIS system and the varied and complex nature of NDIS caseloads. For many new graduates, the NDIS will provide them with their first experiences in delivering services to people who have complex needs, communication disorders, cognitive disabilities, or mental illness. It may also provide them with their first experience in navigating aggressive behaviours and complex family dynamics.

ESSA is aware that there are high rates of burn out amongst new allied health graduates entering the NDIS Workforce. In response to this ESSA suggests that greater effort should be directed towards ensuring that all new graduates have access to professional support and supervision to assist with the transition from student to NDIS practitioner. ESSA maintains that this cannot be achieved under the current pricing arrangements.

The NDIS needs to consider how the current pricing model can make provisions for professional supervision and case discussion. ESSA considers the funding for these types of measures to be essential in securing a quality NDIS workforce for the future.

Recommendation 3: Adjust the current NDIS pricing model to make provisions for professional supervision and case discussion.

5.0 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.

5.1 Pay Parity for AEPs

Since the introduction of the NDIS, the pricing structure has failed to recognise the exercise physiology profession with the same esteem as other allied health professions. ESSA notes the current price limit for exercise physiology is $43/hour or 29% less than other allied health professionals (after GST is applied)

despite AEP qualifications, regulatory requirements and remuneration conditions (via the National Award for Health Workers) and overhead costs being comparable to other allied health professions delivering supports under the NDIS.

ESSA maintains that the current NDIS price limits imply that the AEP profession provides a lower quality of service and has inferior qualifications within the scheme, which is not factual. ESSA suggests that this issue, if left unaddressed will impact on future growth of the exercise physiology workforce within the NDIS.

In the July 2018 Price Guidevii, exercise physiology was subject to a price limit of $148.69/hour. A rate 20.5% lower than other allied health professionals eligible to claim a rate of $179.26/hour under the support item of Individual assessment, therapy and/or training.

In December 2018, the NDIA commenced The Review of Therapy Pricing Arrangementsviii (the Therapy Review). The Therapy Review examined whether existing price controls and other market settings under the NDIS were appropriate in relation to therapy services.

The Therapy Review examined therapists delivering supports under the provider registration groups of Therapeutic Support, Early Intervention Supports for Early Childhood, Specialist Positive Behaviour Support and Community Nursing Care. At the time of the Therapy Review, accredited exercise physiologists were not eligible to register under the Therapeutic Supports registration group and were not considered as part of the review process.

The Therapy Review benchmarked the cost and price of therapy across Australia by analysing comparable insurance schemes, private billing rates for therapy and awards and enterprise bargaining agreements used by allied health professionals around Australia.

As a result of the Therapy Review, new pricing structures and price caps were introduced for therapy services. In July 2019ix, the support item Individual assessment, therapy and/or training was renamed Individual assessment, recommendation, therapy and/or training and was split into three categories- psychology, physiotherapy and other therapies. The rate for physiotherapy (ACT/NSW/QLD/VIC) and other therapies increased by 8.2% to $193.99/hour ix.

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At the same time, the rate for exercise physiology increased by 12.3% to $166.99/hour. ESSA received verbal advice from the NDIA that this increase incorporated annual indexation and recognised the GST obligations exercise physiologists must adhere to under the NDIS. Exercise physiologists are one of the few allied health professions subject to GST under the NDIS (Refer to section 5.1.6). Whilst ESSA welcomed this increase, the reality was that the rates for exercise physiology remained 16.6% lower than other allied health professions delivering support under the NDIS. When GST is considered, the exercise physiology rate is reduced to $150.29/hour, $43/hour or 29% less than other allied health professionals, including the less recognised professions of music therapy and art therapy.

For some time, ESSA advocated for exercise physiology to be recognised within the Improved Daily Living category of participant plans, as well as inclusion in Therapeutic Supports registration group. As part of these advocacy efforts, ESSA produced an Evidence Report titled Accredited Exercise Physiologist Professional Standards for NDIS Registration -Category Change “Daily Living”.x This report provided evidence demonstrating how exercise physiology interventions utilised evidence-based practice to improve the functional capacity of people with disability and support them to achieve goals relating to 1) independence, 2) community involvement, and 3) education and employment.

In October 2019, ESSA was pleased to receive news that exercise physiology had been accepted into the Therapeutic Supports registration group. A move that ESSA had assumed would finally see exercise physiology awarded the same recognition and rates of pay received by other allied health professions delivering NDIS supports.

The following exercise physiology support items were introduced to the Support Cataloguexi as new items under the Therapeutic Supports Registration group:

Therapeutic Supports - Improved health and wellbeing - Exercise Physiology - 12_027_0128_1_3
Therapeutic Supports – Improved health and wellbeing – Exercise Physiology in a Group- 12_028_0128_1_3
Therapeutic Supports - Improved daily living skills - Exercise Physiology - 15_200_0128_1_3
Therapeutic Supports - Improved daily living skills Exercise Physiology in A Group - 15_201_0128_1_3

Price Limits for Exercise Physiology Items

The price limits for these exercise physiology items remained at $166.99/hour for individual sessions and $55.66/hour for group sessions. ESSA enquired as to whether Accredited Exercise Physiologists registered under Therapeutic Support would also be considered as “other therapy” as per the support items below:

01_741_0128_1_3 Assistance with Daily Life: Assessment, recommendation, therapy and/or training – other therapy
15_056_0128_1_3 Improved Daily Living Skills: Assessment, recommendation, therapy and/or training – other therapy
15_059_0128_1_3 Improved Daily Living Skills: Group Therapy- Group of 3 – Other therapy
15_049_0128_1_3 Improved Daily Skills: Multidisciplinary Team

despite the above-mentioned support items being well within the scope of an accredited exercise physiologist; the NDIA advised ESSA that exercise physiologists cannot claim from the Other Therapy or Multidisciplinary line items. The justification for this decision was that the exercise physiologist support items had a different description and price limits compared to those of the other therapy and multidisciplinary support line items. However, ESSA argues that this decision inhibits the full extent of the health outcomes and benefits for NDIS participants because it limits the AEP’s scope of practice and extent to which they can support the participant, both within therapy and within a multi-disciplinary allied healthcare team.

ESSA strongly recommends that the NDIA review the price limits for exercise physiology and align exercise physiology rates with the price limits awarded to other NDIS allied health professions. ESSA has outlined evidence below to highlight the rationale and reasons why pay parity needs to exist between exercise physiology and other allied health professions:

Qualifications

AEP qualifications are comparable to other allied health professions delivering supports under the NDIS. AEPs undertake a minimum of 4 years equivalent study at an Australian Qualification Framework (AQF) Level 7 or above in the area of clinical exercise physiology and are required to meet an extensive accreditation process that includes practicum experience in a range of settings and environments. Some AEPs are dual qualified (physiotherapy/exercise physiology, dietetics/exercise physiology, podiatry/exercise physiology). Pay disparity across allied health professions presents unique challenges for dual qualified professions.

5.1.2 Regulation

AEPs are subject to practice standards that are comparable to other allied health professions delivering supports under the NDIS. ESSA takes steps to ensure that AEPs are aligned with other self- regulating professions (e.g. dietetics speech pathology, audiology) through membership with the National Alliance of Self-Regulating Health Professions (NASRHP).

The NASRHP is an independent body providing a quality framework for self-regulating health professions. NASRHP has a set of standards for membership that have been closely modelled on the standards that health professions regulated by Australian Health Practitioner Regulation Agency (AHPRA) are required to meet. ESSA has achieved 100% of the required self-regulating standards.

The standards developed by NASRHP relate to:

Scope (Areas) of Practice
Code of Ethics/Practice and/or Professional Conduct
Complaints procedure
Mandatory Declarations
Professional Indemnity Insurance
Competency Standards
Practitioner Certification Requirements
Course Accreditation
Recency and Resumption of Practice Requirements
English Language Requirements
Continuing Professional Developmentxii

Like other allied health professionals delivering supports under the NDIS, AEPs are required to maintain ongoing annual professional practice and successfully attain professional development requirements to uphold their professional accreditation.

Yearly professional development requirements for maintaining AEP accreditation includes:

1.  Undertaking a minimum of 20 approved continuing professional development (CPD) points
   per membership year (1 January – 31 December).

2.  Meeting recency of practice requirements.

3.  Holding a current cardiopulmonary resuscitation certificate.

4.  Holding a current first aid certificate.

5.1.3 EBAs and award wages

AEPs are employed under the same national and state awards as other health professionals delivering supports under the NDS. AEPs delivering NDTS supports are typically employed under an EBA or the national Health Professionals and Support Services Award 2010 whilst AEPs working in the hospital setting or public sector, typically fall under one of the following state-based awards:

Health Industry Status of Employment (State) Award 2019
NSW Health Service Health Professionals (State) Award 2019
Public Hospitals (Professional and Associated Staff) Conditions of Employment (State) Award 2019
Health Practitioners and Dental Officers (Queensland Health) Certified Agreement (no. 2) 2016
Allied Health Professionals (Victorian Public Health Sector) Single interest Enterprise Agreement 2016-2020
WA Health – HSUWA – PACTS Industrial Agreement 2016
SA Public Sector Wages Parity Enterprise Agreement Salaried 2014
Allied Health Professionals Public Sector Unions Wages Agreement 2014

The Therapy Review analysed national and state awards and EBAs from 48 top providers, evaluating the differences between the awards and EBAS, as well as differences at the state level. The Therapy Review found most providers did not support price differentiation based on type of therapy because identical wage rates in most EBAs and awards mean that input costs do not vary by type of therapy. viii. ESSA notes that exercise physiologists are often employed within multidisciplinary teams and are paid under the same EBA’s as other allied health professions. Price disparities between allied health professionals creates significant challenges for employers who employ multidisciplinary teams under a common award or EBA.

5.1.4 Medicare Benefits Schedule

Exercise physiologists and other NDIS eligible allied health professionals including audiologists, dietitians, occupational therapists, physiotherapists, podiatrists, psychologists, speech pathologists and social workers are listed as eligible allied health professionals under the Medicare Benefits Schedule (MBS). All MBS eligible allied health professionals, including exercise physiology, receive the same benefit of $53.80 for services that are at least 20 minutes in duration. Under the NDTS each

Fee schedules

Other comparable schemes

The Therapy Review identified seven national and state schemes comparable to the NDS. The Department of Veterans’ Affairs (DVA) insurance scheme was identified as a comparable national scheme, and WorkCover WA, the Victorian Transport Accident Commission (TAC), WorkSafe Victoria, Sira iCare, WorkCover QLD and Return to Work SA were identified as comparable state schemes. ESSA has compared the prices that exercise physiology and physiotherapy charge across these seven schemes (refer to Appendix A). The comparison revealed that exercise physiology and physiotherapy receive the same rates under DVA, and similar rates across other worker rehabilitation schemes. In some cases, the exercise physiology rate was higher than the rate for physiotherapy.

Services

Researchers have found that 58% of internal compliance costs of Australian businesses were due to GST compliance costsxv.

Further to this exercise physiologists working in NDIS have also experienced huge challenges when plan managers have assumed that exercise physiology is a GST free supply under the NDIS and refused to pay the GST portion of exercise physiology invoices. Only persistent lobbying by ESSA to the both the ATO and the NDIA to update resources and information has alleviated most of these concerns. The ATO now has an Example: Supply of when exercise physiology is not GST-free on its websitexvi and the NDIA recently featured exercise physiology in an article Tax Office requirements for GST-free NDIS supports in its 2 December, 2019 newsletterxvii.

ESSA notes that other comparable schemes, including Worksafe Victoria, Return to Work SA, Workcover WA, SIRA and DVA set fees that are GST exclusive and pay for the GST component in addition to the maximum fee, as evidenced below.

If GST is applicable, WorkSafe Victoria will pay the GST component in addition to the maximum fee. (Worksafe Victoria)xviii
All amounts listed in this fee schedule are exclusive of GST. If applicable, the insurer will pay to the provider an amount on account of the provider’s GST liability in addition to the GST exclusive fee. (Return to Work South Australia)xix
If GST is payable on a service listed in these regulations, the fee for the service is the applicable fee increased by 10 per cent. (Workcover WA)xx.
An amount fixed by this Order is exclusive of GST. An amount fixed by this Order may be increased by the amount of any GST payable in respect of the service to which the cost relates, and the cost so increased is taken to be the amount fixed by this Order. This clause does not permit an Accredited Exercise Physiologist to charge or recover more than the amount of GST payable in respect of the service to which the cost relates. (SIRA)xxi

DVA requires health care providers treating entitled persons to enter into

a Recipient Created Tax Invoice (RCTI) Agreement with DVA if they are

registered for GST and will be providing services to DVA (for example,

reports). [See clause 155 for contact details on where to send the

Agreement.] 110. The RCTI Agreement permits DHS to automatically add

GST to claimed taxable items. (DVA)xxii

ESSA suggests that if the NDIA set price limits were made GST exclusive and the NDIA paid for the GST component in addition to the service delivery costs for AEP services, the NDIS would be considered a more attractive to many AEPs considering a career or small business servicing the NDIS.

Recommendation 4: The NDIA review the price limits for exercise physiology and align exercise physiology rates with the price limits awarded to other NDIS allied health professionals.

Recommendation 5: The NDIA set price limits that are GST exclusive and pay for the GST component in addition to the service delivery costs for exercise physiology services.

5.2 Navigating the NDIS system

ESSA regularly hears from AEPs who previously have had no dealings with the NDIS and have been approached by an NDIS participant for exercise physiology supports. In these circumstances, the AEPs have generally searched the NDIS website for information about how to onboard an NDIS participant and meet the necessary service provider requirements. A significant number of AEP members contact ESSA for clarity on setting-up their practice to deliver NDIS services due to a lack of clear and easily accessible information, and the time it takes to navigate through the available information and understand how it can apply to their practice environment.

ESSA suggests these challenges impact workforce growth, participant choice and the timely delivery NDIS supports. ESSA maintains that this issue could easily be addressed if the NDIA and NDIS Quality and Safeguarding Commission worked collaboratively to develop a range of resources to support new entrants to the NDIS market. ESSA notes that as a professional association we would be happy to consider the allocation of continuing professional development points for training focused understanding and working within the NDIS system.

Recommendation 6

The NDIA and NDIS Quality and Safeguarding Commission work collaboratively to develop a range of resource to support new entrants to the NDIS market.

   5.3 Training requirements

ESSA suggests that there is a need for training programs aimed at upskilling allied health professionals on engaging with people with disabilities. ESSA notes that tertiary level curriculum often educates health professionals on the nature of and interventions for specific disabilities and associated conditions, but rarely provides education on overcoming communicating barriers and understanding the rights of people with disabilities.

For example, most health professionals receive very little training through their tertiary education, on how to communicate effectively and respectfully with people with a cognitive disability or communication disorders. Effective communication is essential to the process of obtaining informed consent, documenting medical histories, conducting accurate health assessments, prescribing safe and appropriate interventions and measuring the success of said interventions. Health professionals that are not appropriately equipped to communicate with people with a cognitive disability or communication disorders risk of bias influencing their assessment and treatment of conditions. Further to this, they are not supporting the individual to exercise a basic human right, that is, to be informed and involved in decisions regarding their health care.

Similarly, ESSA suggests health professionals may benefit from training on working with substitute decision makers, understanding the rights of individuals with cognitive disability, encouraging supported decision making where possible and options for obtaining consent when there is no formal decision maker in place.

As a peak professional association, ESSA would be willing to consider assigning continuing professional development points to training of this nature.

Recommendation 7

Introduce training programs designed to upskill allied health professionals on overcoming communication barriers and respecting the rights of people with disabilities.

6.0 Other matters

6.1 Plan Management payments

ESSA members have reported that it has become increasingly difficult to recover costs from plan managed participants. Plan mangers frequently report that participants do not have the funds required for the payment of invoices. These circumstances arise even in cases where AEPs have contacted the plan managers ahead of time and checked the availability of funds prior to delivering supports.

ESSA members report that they have contacted the NDIA when costs could not be recovered via plan management. The NDIA advised that the plan managers were not at fault and the participants would need to be taken to a debt collector.

One ESSA member, a small business owner who refused to send their client to a debt collector, wrote off $5000 in losses in December 2019. This member noted that it did not seem ethical to send a person to a debt collector, when they had engaged a financial administrator to manage their plan funds because they did not have the capacity to do this for themselves.

ESSA considers these practices to be both unethical and a significant risk to the financial viability of the NDIS therapy market. The NDIA should be holding these financial administrators accountable.

Recommendation 8: The NDIS Quality and Safeguarding Commission development an operational framework for plan managers to ensure minimum standards are upheld.

6.2 Supporting practitioners in rural and remote locations

ESSA notes that the NDIS registration process and associated auditing costs can have a significant impact on the growth the NDIS market and workforce in rural and remote areas. ESSA acknowledges that recent and legislative changes have resulted in a decrease in the number of high cost certification audits amongst many allied health professionals including AEPs. However, it must be noted that it is not unusual for a small AEP or allied health practice to be the only practice servicing a large rural and remote communities covering large geographical areas. In many circumstances, these practices may be the only local service that has the potential to provide therapy under the higher risk registration group of Early Intervention supports for Early Childhood (EIEC) but may be reluctant to take on this role given high cost associated with registration in the EIEC registration group.

AEPs located in rural and remote communities have reported that they have been quoted between $6000

and $16,000 for auditing fees, with many suggesting that these costs are not financially viable given the

small number of NDS participants they service. AEPs have noted costs associated with auditor travel and

accommodation have a significant impact on the price of an audit conducted in rural and remote locations.

In response to this concern, many AEPs have reported they are considering not registering as a provider or

de-registering and only providing services to plan managed and self-managed NDIS participants.

Another concern impacting on the AEP workforce in rural and remote locations is an apparent shortage of

local NDIS planners in rural and remote locations.

ESSA members report that NDIS planning in rural and remote areas is often conducted via the phone, where

a local presence is not available. ESSA has several concerns relating to telephone planning including:

the inability of planners to assess and incorporate environmental factors into a plan
the limited ability of planners to engage with participants with communication disorders in a
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     meaningful and inclusive way
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cultural barriers faced, particularly for those who identify as Culturally and Linguistically Diverse
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    and Aboriginal and/or Torres Strait Islander
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a reported lack of clarity amongst participants that a telephone conversation with the NDIA is in

       fact a planning meeting limiting the ability of participants to pre-plan and engage planning

     support from family members, carers, representatives, and other supporters.

The absence of a local NDIA presence also sees many NDS participants/potential participants seeking face- to-face supports from health professionals and community organisations with offices situated in the local

area. Service providers in these communities often spend a substantial amount of time answering questions about the NDIS and planning process and are rarely compensated for information and supports they provide

Recommendation 9: Reduce the cost and red tape of certification audits for small allied health practices servicing rural and remote communities.

Recommendation 10: Compensate health professionals for the time they spend providing NDIS information and support in rural and remote communities where the NDIA planning workforce does not have a presence.

6.3 Delegating Therapy Interventions

ESSA is concerned about cost cutting measures that occur at both the NDIS planning and review stages. ESSA has observed a growing trend in NDIA planners reducing participant funding for exercise physiology and requesting that AEPs train unqualified support workers in the delivery of exercise physiology interventions.

ESSA advocates for an active Australian population and understands the importance of support workers and carers in encouraging physically activity. However, there is a significant distinction between understanding the benefits of physical activity and encouraging incidental exercise day-to-day, and the assessment, delivery and monitoring of clinical interventions that prescribe physical activity for particular outcomes. As such, AEPs have significant concerns about the risk associated with unqualified workers delivering exercise treatment programs. These concerns are justified by the level of associated risk of unqualified workers who do not have the expertise, experience, qualifications, knowledge or skill to conduct ongoing risk stratification, monitor symptomology, and adjust the prescription of exercise based upon complex interactions of diagnosis, exercise tolerances and changing medication regimes.

It is apparent that some of the disability organisations employing support workers share these concerns, with AEPs reporting that some have been known to restrict their employees from engaging in the delivery of therapy supports, citing duty of care concerns.

In circumstances where AEPs have complied with NDIS demands and provided training to support workers, the following has been observed:

Some participants receive supports from more than one allied health professional which increases the amount of therapy support expected to be delivered by support workers (refer to Case Study A).
Participants do not always receive the same support worker day to day or week to week, making it difficult to train a consistent team off support workers to deliver therapy support (refer to Case Study A).
Support workers who are trained by AEPs often do not follow through on actively supporting participants to engage in prescribed activities.
Group home staff have been known to sign off on records confirming that home exercise services have been provided but these records often conflict with the advice of participants.

ESSA notes that it is unclear where liability lies in these types of scenarios. Many AEPs already express concern about their obligation to cover the professional indemnity insurance of NDIS therapy assistants,

ESSA notes the variability in therapy assistant and support worker workforce qualifications, training and skills can make delegation of an accredited exercise physiologist’s duties both challenging and risky.

ESSA acknowledges that in some circumstances there may be a role for unqualified workers to engage self-managed participants in physical activity. However, we note that there is a significant difference between providing support to engage physical activity and assessing for and delivering a clinically prescribed exercise program designed to achieve a therapeutic outcome. From a workforce perspective ESSA fears that if AEPs continue to be inappropriately pushed into delegating clinical exercise treatment to unqualified support workers, many AEPs may consider working within the NDIS as a risk rather than a viable employment opportunity.

ESSA is open to working with the NDIA and relevant carers’ associations, such as the Australian Industry Community Alliance, to co-develop professional development education delivered by AESs or AEPs to inform support workers and carers on the benefits of physical activity, the role of AEPs and the prescription of exercise programs, and how to safely encourage incidental physical activity. This could:

result in quality health and wellbeing outcomes for NDIS participants
provide workforce opportunities for qualified allied health professionals
upskill
increase cohesion between the day-to-day role of carers and support workers in encouraging physical activity and the role of the AEP under the NDIS
ensure clear understanding of the difference between the clinical support provided by qualified AEPs in delivering exercise interventions and the role that a carer or support worker may take to facilitate self-management overtime.

Case Study A

A 17-year-old female had been receiving a range of therapies including exercise physiology, occupational therapy, physiotherapy and speech pathology. As part of the review process, funding was reduced across all therapies and the therapists were asked to train the participant’s support workers in the delivery therapy supports. The AEP noted that the participant received support from over 20 different care workers a week and concerns had been raised about the risks associated with training such a large number of care workers in such a diverse range of therapy supports. The participant’s mother was appealing the

Recommendation

Decision and Fear Regarding Residential Care

decision and expressed fear that her daughter may need to consider residential aged care if

her body deteriorates any further.

Recommendation 11:

That the NDIA formally acknowledge the important delineation between the clinical assessment and ongoing support provided by qualified AEPs and AES delivering exercise interventions to NDIS participants in contrast to the day-to-day encouragement that carers and support workers should provide to encourage physical activity.

7.0 Contact ESSA

Thank you for the opportunity to provide feedback into the Inquiry into the NDIS Workforce.

Please contact our Policy and Advocacy Team on for further detail or any questions regarding the content of this submission

Appendix A: Price comparison across comparable insurance schemes

DVA	Exercise Physiology	Physiotherapy	Speech Pathology	Occupational Therapy
Initial consultation - Rooms	$65.30	$65.30	$109.10	$89.70
20 minutes minimum
Initial consultation - Home	$70.15	$70.15	$109.10	$112.15
20 minutes minimum
Subsequent consultation - Rooms	$65.30		$109.10	$89.70
20 minutes minimum
Subsequent consultation - Home	$65.30		$109.10	$112.15
20 minutes minimum
Standard consultation – Rooms		$65.30	$109.10
Standard consultation - Home		$65.30	$109.10
Group sessions	$29.15	$29.15
30 minutes minimum

Workcover QLD

Exercise Physiology	Physiotherapy	Speech Pathology	Occupational Therapy
Initial assessment	$183/hr.
Initial consultation		$87/hr.	$183/hr.
Complex assessment		$183/hr.
Complex intervention		$183/hr.
Subsequent consultation	$183/hr.	Level A- D	$183/hr.
		$58 -$108 /hr.
Group session	$47/hr./person	$47/hr./person

SIRA

Exercise Physiology	Physiotherapy	Speech Pathology
Initial consultation	$12.80/ 5 minutes	$96.10 – practice
	$153.60/ hr. (max 1 hr.)	$118.30 – home visit
(Standard consultation and treatment)	$12.80/ 5 minutes	$81.40 – practice
	$153.60/ hour (max	$94.60 – home visit
1hr.)
(Complex treatment)		$162.60 - practice
		$197 – home visit
(max 1 hr.)
(Group/class intervention)	$48.80/person	$57.70/person

Worksafe Vic

Exercise Physiology	Physiotherapy	Speech Pathology	Occupational Therapy
Initial assessment	$110.23/hr.
Individual session	$110.23/hr.
Initial comprehensive consultation – new patient		$116.67/hour	$59.90
Standard consultation		$58.33/hour	$48.51
Restricted consultation		$116.67/hour
Group session	$19.09 per person/ hr. (max 6 people)	$29.17 per person/ hr. (max 6 people)

ESSI:

TAC VIC Initial consultation $104.21 Out of Room* (1 Hour) Standard Consultation $83.38 Out of Room*(1hr.) Group Consultation 30 min) Return to Work South Australia Initial assessment Individual session Initial consultation . (max 2.5hrs) Subsequent consultation . (max 1 hr.) Long subsequent consultation Restricted consultation (max 1 hr.) Group session/exercise people) (max 8 people) Workcover WA Pathology Therapy Initial consultation/assessment including 1hr.) Subsequent consultation/assessment Standard consultation (> one hr) Group consultation Specific physiotherapy asessment Specific physiotherapy tervention *The fees for Exercise Physiology Physiotherapy Speech Occupational Pathology Therapy - $73.01 Room - $60.64 (1 Hour) $97.37 (1 hr.) $55.63 Room - $48.52 (up to 30 min) $24.38/person (1 hr.) $33.76/person (up to - 29.19 Exercise Physiology Physiotherapy Speech Occupational Pathology Therapy $147/hr. (max 1 hr.) - - - $147/hour (max 1 hr.) - - - - $83.50 flat rate $185.40/hr $185.40/hr. - $68.00 flat rate $185.40/hr $185.40/hr. - $92.90 flat rate - - - $185.40/hr. - - $24.50/ person (max 6 $19.20/ person - - Exercise Physiology Physiotherapy Speech Occupational $200.25/hr. (max 2 $87.85 flat rate $183.10 - hours) (up to and $200.25/hr. (max 1hr.) $200.25/hr (max 1 hrs) $139.95 - (> 1hr.) - $70.55/hr - $198.20 - $21.75/hr - - - $200.25/hr - - - $200.25/hr (max 2hrs) - - these items include travel

References

i Tweedy, S. M., Beckman, E. M., Geraghty, T. J., Theisen, D., Perret, C., Harvey, L. A., & Vanlandewijck, Y. C. (2017). Exercise and sports science Australia (ESSA) position statement on exercise and spinal cord injury. Journal of Science and Medicine in Sport, 20(2), 108-115.

ii Willis. C. (2018). Exercise and Paediatric Disability Case Study. Retrieved on 22 May, 2018 from http://activenation.org.au/wp-content/uploads/2018/03/case-study_Exercise-andpaediatric-disability_final.pdf3

iii National Disability Insurance Agency, COAG Disability Reform Council Quarterly Report 30 June 2019 [Internet]. [place unknown]: National Disability Insurance Agency; 2019 [cited 3 Sep 19]. Available from https://www.ndis.gov.au/about-us/publications/quarterly-reports .

iv Commonwealth of Australia. Growing the NDIS Market and Workforce [Internet]. [Place unknown]: Department of Social Services; 2015 [cited 2020 May 4]. Available from https://www.dss.gov.au/sites/default/files/documents/03_2019/220319-ndis-market-and-workforce-strategyacc-ij5665.pdf .

v Smith RA, Pilling S. Allied health graduate program - supporting the transition from student to professional in an interdisciplinary program. Journal of Interprofessional Care. 2007 Jun;21(3):265-276. DOI: 10.1080/13561820701259116.

vi Kazia A, Upton P, Upton D. Supporting the transition from student to practitioner: A scheme to support the development of newly qualified practitioners. International Journal of Therapy and Rehabilitation. 2010 Sep; 17 (9): 494-503. DOI: 10.12968/ijtr.2010.17.9.78039

vii National Disability Insurance Agency (NDIA). NDIS Price Guide: New South Wales, Queensland, Victoria, Tasmania [Internet]. [Place unknown]: NDIA; 2018 [cited 2020 Jan 30]. Available from https://www.ndis.gov.au/providers/price-guides-and-pricing/price-guide-archive .

viii National Disability Insurance Agency (NDIA). Review of Therapy Pricing Arrangements, March 2019 [Internet]. [place unknown]. NDIA; 2019 [cited 2020 Jan 30]. Available from https://www.ndis.gov.au.providers.priceguidesandpricing.pricingreviewtherapy.services

ix National Disability Insurance Agency (NDIA). NDIS Support Catalogue 2019-20: Valid from 1 July 2019. [Internet]. [place unknown]. NDIA; 2019 [cited 2020 Jan 30]. Available from https://www.ndis.gov.au.providers.priceguidesandpricing.priceguidearchive#20-priceguideseffective1-july- 2019-to-30-september-2019 .

x Exercise & Sports Science Australia (ESSA). Accredited Exercise Physiologist Professional Standards for NDIS Registration -Category Change “Daily Living”. [Internet]. (AU). ESSA; 2019. [cited 2020 Jan 30]. Available from https://www.essa.org.au.Public.Advocacy.Submissions___Lobbying.Public.Advocacy.Submissions___Lobbying.aspx?hkey=a641d3b5-9198-4a92- 8869-6f4c80c08ffe .

xi National Disability Insurance Agency (NDIA). NDIS Support Catalogue 2019-20: Valid from 1 October 2019. [Internet]. [place unknown]. NDIA; 2019 [cited 2020 Jan 30]. Available from https://www.ndis.gov.au/providers/price-guides-and-pricing/price-guide-archive#20-price-guides-effective-1-july-2019-to-30-september-2019

xii National Alliance of Self-Regulating Health Professions (NASRHP). About NASRHP [Internet]. 2017 [cited 30 Jan 2020]. Available from https://nasrhp.org.au.about-us/

xiii Australian Government. Australian Taxation Office. National Disability Scheme. [Internet]. [place unknown]. Australian Government,Australian Taxation Office; 2019 December 18 [cited 2020 Jan 30]. Available from https://www.ato.gov.au.business.gst.in-detail.your-industry.gst-and-health/?page=6 .

xiv National Disability Insurance Agency (NDIA). NDIS Price Guide 2019-20 [Internet]. [Place unknown]: NDIA; 2019 Dec 1 [cited 2020 Jan 30]. Available from https://www.ndis.gov.au.providers.priceguidesandpricing.

xv Evans, C., Hansford, A., Hasseldine, J., Lignier, P., Smulders, S., & Vaillancourt, F. (2014). Small business and tax compliance costs: A cross-country study of managerial benefits and tax concessions. eJTR, 12, 453.

xvi ATO. (2019). Example: Supply of when exercise physiology is not GST-free. Retrieved from: https://www.ato.gov.au/business/gst/in-detail/your-industry/gst-and-health/?page=6

xvii NDIA. (2019). Tax Office requirements for GST-free NDIS supports in 2 December newsletter. Retrieved from: hhttps://mailchi.mp/ndis/marketsandprovidersenewsnov2019?e=2ccf57bbfd

xviii Worksafe Victoria. Exercise physiology services fee schedule. [Internet]. [place unknown]. Worksafe Victoria. 2020 Jan 22. [cited 2020 Jan 30]. Available from https://www.worksafe.vic.gov.au/exercise-physiology-services-fee-schedule .

xix Return to Work South Australia. Exercise physiology fee schedule and policy. [Internet]. [Adelaide AU]. Return to Work South Australia. 2019 Jul 1. [cited 2020 Jan 30]. Available from https://www.rtwsa.com/__data/assets/pdf_file/0010/99406/Exercise-Physiology-Fee-Schedule.pdf

xx Workcover Western Australia. GST Information. [Internet]. [place unknown]. Workcover Western Australia. 2016 Jan 29. [cited 2020 Jan 30]. Available from https://www.workcover.wa.gov.au/resources/rates-fees-payments/gst-information/

xxi State Insurance Regulatory Authority. Workers Compensation (Accredited Exercise Physiology Fees) Order 2020. [Internet]. [Sydney AU] State Insurance Regulatory Authority; 2019 Dec 11. [cited 2020 Jan 30]. Available from https://www.sira.nsw.gov.au/__data/assets/pdf_file/0009/586755/Accredited-Exercise-Physiology-Fees-Order-2020.pdf .

xxii Australian Government, Department of Veteran Affairs. Notes for Allied Health Providers, Section 1: General. [Internet]. [place unknown]. Australian Government, Department of Veteran Affairs. 2019 Sep 5. [cited 2020 Jan 30]. Available from https://www.dva.gov.au/sites/default/files/files/providers/alliedhealth/Notes–Allied-Health-Providers–Section-1.pdf