Australian Psychological Society | Submission, May 2020

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Contact

Dr Tony McHugh MAPS Senior Policy Advisor t.mchugh@psychology.org.au

The Australian Psychological Society Ltd Level 13, 257 Collins Street Melbourne, VIC 3000 Phone: 03 8662 3300 Email: contactus@psychology.org.au Web: psychology.org.au

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This resource is provided under licence by the Australian Psychological Society. Full terms are available at psychology.org.au/Special-pages/Terms-and-Conditions. In summary, you must not edit or adapt it or use it for any commercial purposes. You must acknowledge the Australian Psychological Society as the owner.

We acknowledge the Traditional Custodians of the lands and seas on which we work and live, and pay our respects to Elders, past, present and future, for they hold the dreams of Indigenous Australia.

© 2020 The Australian Psychological Society

Contents

The Australian Psychological Society . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

APS Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

The APS Response to the Inquiry’s Terms of Reference . . . . . . . . . . . . . . . . . . 8

Term of Reference (a): The current and future size and composition of the NDIS workforce 10

Term of Reference (b): Workforce attraction and retention challenges . . . . . . . . . . . 11

Term of Reference (c): The impact of Commonwealth Government policy on the NDIS working environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Term of Reference (d): Government’s role in NDIS workforce development planning . . . . .15

Term of Reference (e): The interaction of NDIS workforce needs with employment in adjacent sectors including health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Term of Reference (g): Other matters . . . . . . . . . . . . . . . . . . . . . . . . . .19

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

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The Australian Psychological Society

The Australian Psychological Society (APS) is the largest national professional organisation for psychologists, with over 24,000 members across Australia. It seeks to help people achieve positive change, so they can confidently contribute to the community.

Psychologists are experts in human behaviour and The APS has a long history of working collaboratively with the Australian Government, State and Territory governments and other agencies to help address major social, emotional, and health issues for local communities and ensure healthcare is equitable and accessible to all members of the Australian community.

Economic evaluations highlight the cost-effectiveness of psychological interventions to support functioning, prevent people from becoming mentally unwell, and to treat a range of mental health symptoms and disorders when they do occur.

Executive summary

The APS welcomes the opportunity provided by the Joint Standing Committee on the National Disability Insurance Scheme (NDIS/the Scheme) to provide feedback on the Scheme’s workforce and guide improvements that will support the lives of many Australians living with disability and the communities in which they reside.

The APS offers the following recommendations in relation to the Terms of Reference set out by the Joint Standing Committee.

APS Recommendations

needs analysis and conducted with input from key stakeholders (including the peak professional bodies) across the disability sector.

The current and future size and composition of the NDIS workforce

Workforce attraction and retention challenges

of the NDIS workforce

The APS recommends that the Australian Government takes the necessary steps through the NDIA to address the workforce attraction and retention challenges facing the Scheme. In particular, it recommends that the NDIA:

• Ensure NDIS planners, Local Area Co-ordinators (LACs) and support co-ordinators recommend the use of psychologists as the preferred providers of psychology interventions for NDIS participants for neurocognitive, behavioural and mental health and psychosocial disabilities.
• Address the cost of Third-Party Verification (TPV), especially for small practices with small customer bases.
• Reduce unnecessary “red tape” and the burden of administration in service delivery.

Impact of Commonwealth Government policy on the NDIS working environment changes to auditing/registration requirements on provider workforce numbers, and impact on eligible participant access to psychologist providers.

3. Development of workforce benchmarks for successful service delivery predicated on the NDIA and NDIS take the necessary steps to:

Other matters

7. Fully assist the NDS workforce to develop to its optimal potential. This includes developing

The APS recommends that the Australian Government takes the necessary steps to ensure that the NDIA and NDIS act to:

• Operational policies that are supportive of the needs of staff and providing training targeted to workers and NDIS staff (including planners and LACs) and

8. Appropriately engage with professional bodies.

9. Improve the quality of communications with professionals, practitioners, industry representatives and peak organisations in the development and implementation of NDIS targeted programs of education and training.

10. Review the role of NDIS planners for their impact on the NDIS workforce and the availability and quality of service delivery through the NDIS Quality and Safety Commission.

Government’s role in NDIS workforce development planning

The APS recommends that the Australian Government takes the necessary steps through the NDIA and NDIS to develop a comprehensive strategic workforce development plan. To facilitate this, the APS recommends the:

• Development of workforce benchmarks for successful service delivery predicated upon a needs analysis and conducted with input from key stakeholders (including the peak professional bodies) across the disability sector and the close involvement of the Quality and Safeguards Commission.

The interaction of NDIS workforce needs with employment in adjacent sectors including health

The APS recommends that the Australian Government takes the necessary steps through the NDIA and NDIS to better design the arrangements that apply to interaction of NDIS workforce needs with employment in adjacent sectors. To facilitate this, the APS recommends that:

• The NDS/NDIA commence high level government, industry and peak association consultations aimed at clarifying the best set of working relationships of the Scheme to all adjacent sectors for their workforce and service delivery implications and impacts.

Introduction

The APS welcomes the opportunity to provide a submission to the Joint Standing Committee (JSC) inquiry into the Workforce of the National Disability Insurance Scheme (NDIS).

The market-place environment in which the NDIS operates has potentially profound consequences for participants and practitioners through the NDIS workforce. Ongoing scrutiny of the NDIS workforce is essential in ensuring that the best possible outcomes for participants are being targeted and delivered.

Based on APS member comment, this submission focuses on the Terms of Reference set out by the JSC Inquiry into the:

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;

f. the opportunities available to, and challenges experienced by, people with disability currently employed, or wanting to be employed, within the NDIS workforce; and

g. any other matters.

Psychologists are an important part of the workforce involved in providing support to people with disability in Australia. In making this submission, the APS liaised with members who are working or have worked in the NDIS environment as sole practitioners, staff members of service provider organisations or members of other entities. The APS believes it is critical that the workforce issues it identifies in this submission are addressed if the NDIS is to operate as the originally envisaged landscape-altering scheme for the provision of care to Australians with a physical, intellectual, sensory and/or psychosocial disability.

The operation of the NDIS is underpinned by a philosophy that places autonomy (though choice and control in decision making about services). It decentralises service delivery from state government providers to the non-government and private sectors via various funding mechanisms that aim to improve the quality of life of Australians living with disability.

The APS Response to the Inquiry’s Terms of Reference

Term of Reference (a): The current provide a variety of supports and interventions and future size and composition of to participants. This includes services related to assessment (e.g., of neuro-cognitive disorders), early childhood disabilities (e.g., in intellectual function and learning disorders), complex behavioural deficiencies, developmental issues (e.g., sexual maturation), the co-ordination of life stage transitions (e.g. from special to mainstream schools and vice versa and from school to adult day care programs) and capacity building (e.g., for community participation). Individuals who require care and support under the NDIS can be affected by a range of sensory, sensory, intellectual, developmental and/or behavioural impairments and disabilities. Importantly, research demonstrates that people with a disability have a higher prevalence of mental health disorders compared to those without a disability. In mid-2018, the NDIS predicted that 64,000 Australians with severe and persistent mental illness will be eligible to access the Scheme by the time it is in full operation (NDIS, 2018). Around a year later, it was identified that the Scheme is likely to fund plans for over 500,000 Australians over the next five years (NDIS Ministerial statement; August 2019), many of whom will also experience psychosocial disability. In the face of this demand, the NDIS in August 2019 projected that up to 90,000 FTE equivalent NDIS workers will be employed in the field in Australia by 2023. As the APS understands it, this is twice the current disability workforce. Given the projected number of NDIS participants with mental illness (13% of the total NDIS population) and that those with psychosocial disability arising from or associated with disability are not included in this, the demand for psychology interventions that is facing the NDIS is, and will continue to be, significant. The impairments and disabilities experienced by NDIS participants and the psycho-social disability associated with them impact significantly on their capacity to function within the community. Scheme participants are, therefore, among the most disadvantaged Australians and the challenges involved in working with them are considerable. Scheme participants are entitled to best-practice care and interventions for their disabilities. For this to occur efficiently and effectively, however, two things are required:

• Clarity of scope: There must be clarity about what disabilities are within the scope of the Scheme. APS member feedback indicates a serious lack of clarity among planners about the mental health conditions accepted under the NDIS and whether psychosocial disabilities will be funded for intervention. The APS stresses the critical importance of addressing this issue as it creates significant uncertainty for participants and providers. As at 31 January 2020, there were approximately 1000 psychology practices (most of which likely employ more than one psychologist) registered to provide services under the Scheme across Australia (NDIS, 2020). Based on this data, there is uncertainty regarding the capacity of the current psychology workforce to meet current demand, and even more uncertainty regarding its capacity to meet expected future demand. The psychology workforce must increase if the supply and availability of psychology services is to cope into the future. The work required to address participants’ psychological needs under the NDIS is specialised and often complex in nature. The role of psychologists in providing assessment, care and interventions to participants is vital to assisting them and their families, guardians and carers, to cope with their disability. Psychologists working under the Scheme have an important role in delivering best practice care and interventions to NDIS participants. Psychologists working under the Scheme The work required to address participants’ personal needs under the NDIS is specialised and often complex in nature. The role of psychologists in providing assessment, care and interventions to participants is vital to assisting them and their families, guardians and carers, to cope with their disability. Psychologists working under the Scheme have an important role in delivering best practice care and interventions to NDIS participants.

Gaps

In the absence of any hard data provided by the scope (eg. to provide psychological services without the requisite training) or encourages growth in unregistered providers at the expense of registered providers via unregulated price incentives is a risk to the appropriateness and quality of services. The composition of the workforce and the balance between registered and unregistered providers is incredibly important and as the APS has previously observed there is a paramount need to APS member feedback also highlights that the current supply and demand ratio may be worsening and that, contrary to any idea that the psychology workforce will increase, practitioners are reluctantly deciding to leave the Scheme and, in some cases, the field. Illustrative of this, a March 2020 APS member survey about the NDIS, to which there were 963 respondents who indicated they intended, were As the APS argues in relation to Term of Reference (b), ten per cent of those surveyed indicated their intention there is a need to remove workforce barriers to discontinue providing services under the Scheme. and undertake a campaign to attract and retain These practitioners were very experienced, with 29 psychologists within the NDIS. As the APS argues in and 26 per cent of them having respectively worked relation to Term of Reference (d) this can only be done for more than 10 or 20 years in the disability field. on the back of a comprehensive workforce plan that gives due prominence to psychology. If the current supply of psychologists as a proportion of the NDIS workforce was maintained, this Recommendations would provide for a doubling of the number of The APS recommends that the Australian psychologists under the Scheme over the next three Government takes the necessary steps through years. However, such an increase in the psychology the NDIA and NDIS to ensure that a viable and workforce would simply maintain parity with the sustainable NDIS workforce of the requisite current supply and demand ratio which, as noted quality is established as a matter of priority. above, appears insufficient to meet the current This will be enabled by: needs of many participants in the Scheme and would 1. A thorough participant-care needs analysis, certainly be insufficient to address the likely increase conducted with input from key stakeholders in demand for psychology interventions in the future. (including peak professional associations) included across the disability and other relevant (e.g., health and mental health) sectors. The development of an NDIS disability workforce 2. An analysis of the workforce supply and plan (see Term of Reference (d)) which provides demand. This analysis should specifically for a proper matching of the supply of psychology seek to establish (a) the number of NDIS providers against demand for psychology services participants with a mental illness and/or a has been a glaring omission in the operation of the psychosocial disability, (b) what proportion Scheme to the present time. of those participants with such needs have current plans that include psychological goals
and (c) which professionals are providing
the required services which professionals
demand curve. The APS is not aware of any plan by the the impact of recent changes to auditing/ NDIA to address this and meaningfully grow the registration requirements on provider psychology workforce and accelerate the supply of workforce numbers, and impact on eligible psychology services. participant access to psychologist providers. The APS has expressed its concerns to a range of 3. Development of workforce benchmarks for of market forces on the capacity to ensure quality inquiries (e.g., those conducted by JSC and Australian services. The importance of developing the correct Productivity Commission (APC)) about the impact workforcetrajectory for the NDIS cannot be of market forces on the capacity to ensure quality overstated. Any strategy that deskills the workforce, services. encourages practitioners to work outside their

Term of Reference (b): Workforce attraction and retention challenges

High need participant groups

No less important, but often less visible, is the problem of inadequate workforce supply for, and service delivery to, specific high need participant sub-populations.

Members of the APS have identified several areas where workforce deficiencies are acute:

(i) in the treatment of Autism and other Neurodevelopmental disorders (like Intellectual Developmental Disorder, Global Developmental Delay, Learning Disorders, Attention Deficit/Hyperactivity Disorder, Other Specified Attention-Deficit/Hyperactivity Disorder, Unspecified Attention-Deficit/Hyperactivity Disorder, Specific Learning Disorder and Stereotypic Movement Disorder).

(ii) in the provision of Early Childhood Support (ECS) and Behaviour Support Service, where there are indications that providers - who often have provided a highly-dedicated and expert service - are choosing to not do this work because Scheme-driven difficulties markets and timely, creative solutions are required if workforce-related service shortfalls are to be successfully addressed.

(iii) in services to participants with mental health issues and/or psychosocial disability, where they, their families, carers and practitioners are continually referred to the MBS for assistance. The NDIA is urged to consider mechanisms to expand capacity rather than leave it to market forces (with all of the implications that this would create for rising prices and unit costs).

faces participants, their families and carers and

feedback strongly suggests that planners in some practitioners in the psychology space. It involves: a 36 yo male client who lives in supported accommodation. He has a moderate intellectual disability and ASD and has a substantial NDIS package. He was displaying increasingly erratic behaviours leading to four admissions to a mental health facility over a short period of time. The mental health facility eventually deemed him to be “unsuitable” for their care due to his intellectual disability. The NDIS planner was contacted to obtain emergency respite but because there was no funding specifically allocated to emergency respite, the request was rejected by the planner. Thus, the mainstream mental health service rejected the client due to his intellectual disability but the NDIS planner was also unable to provide suitable care for the client

As this example demonstrates, the absence of a clear definition of scope results in decisions that directly affect the care provided to participants. (ii) Issues in the planning process There are several patterns of planner decision-making behaviour that result from the lack of clarity around scope, which affect service delivery and as a consequence affect the experience of psychologists working in the Scheme. These issues have been identified by members as contributing factors to their decisions to review – and in some cases discontinue – their involvement in the Scheme. The Institute for Applied Behaviour Analysis – internationally acclaimed service providers for children and adults with disability – estimates that it can take over 80 hours to adequately complete a behavioural analysis3. This contrasts with the experience of an APS member providing psychological care to a 58 yo male participant who is an amputee with an acquired brain injury, high medical support needs, high-need support for all activities of daily living and who exhibits high levels of physical and verbal aggression, has inappropriate sexualised behaviour towards other residents and staff in community-located supported accommodation who frequently returns to the facility in an intoxicated state. She reported that despite the enormity of his needs, his NDIS plan included only 6 hours of behaviour support, when [in line with best-practice] he needed a … functional behaviour analysis, baseline cognitive assessment and (associated) adaptive measures … BSP and an (implementation) instruction for the staff of the residential facility. The psychologist also needed to be available for monitoring and review of the BSP over 12 months.

In its 2017 submission to the APC, the APS observed that If an individual has significant anxiety and/or mood and/or behavioural issues as a result of their disability and this is contributing to their inability to function within the community, should services be provided under the NDIS or via the health system? The experience of members is that this depends on what planner is working with the participant, or the location of the participant. Some participants are provided psychological services via the NDIS, yet for the same issue or circumstances, other participants are told to obtain a GP Mental Health Plan and see a psychologist under Medicare. This anomaly cannot be explained by participant choice. Member

e3 see www.iaba.com

This attempt to push participants to Medicare has

This is because the NDIS inadequately distinguishes between the high-level knowledge, skills and experience of psychologists in behaviour management (especially complex behaviour management) and those of the less qualified workforce who are currently delivering behaviour support under the NDS. (such as OT assistants). The APS has been advised by members over some time that there is evidence of active advocating by planners against the inclusion of psychology interventions in plans and/or in favour of the provision of interventions by other providers, who lack the expert skills for the delivery of specialist psychology interventions for the conditions and behaviours involved on the basis of cost. The overall result of such planner decision-making in developing plans for participants is that it directly influences the care, services and interventions that are made available to participants. This inappropriate restriction on the provision of psychology interventions in relation to neuro-cognitive disorders, ECS needs, mental health problems and psychosocial disability has unequivocal consequences for workforce retention and attraction. There is also evidence that participants with behaviour support needs (especially those with complex needs) are being denied the opportunity to make choices and exercise control over the services they need. Member feedback suggests that this is primarily due to the development of plans by planners that do not reflect what is needed for behaviour management plans for clients with complex needs (in terms of both cost and time). The APS is aware that highly credentialed psychologists with long histories of delivering best practice interventions to the disability sector have left or are intending to leave the NDIS because of the inability to deliver best practice interventions to clients.

Despite the APS having consistently raised these concerns in submissions and in direct communication with the NDIA, there appears to have been little change for the better and the feedback is that, to the contrary, the incidence of such advice is increasing. Several members have suggested that planners are following an NDIS operating protocol or directive to direct psychology services to Medicare. The APS has not been able to establish the accuracy of this assertion but would be very concerned if it were the case. Further detailed comments from members are appended to this submission.

These planning deficiencies are common and are particularly problematic for participants with multiple or complex needs, who are among the most disadvantaged members of our community. Such deficiencies have the potential to place the safety of participants, and their families, guardians and carers at risk through the provision of sub-optimal care. Ultimately, such planner decision-making has the potential for very significant impacts on participants. If psychologists de-register their services, depriving vulnerable NDIS participants of true choice, then default services are likely to be less appropriate for their condition(s) and needs.

Non-psychologists delivering psychology interventions A further concern of the APS relates to the preference of planners to advocate for non-psychologists to deliver mental health interventions where psychosocial disability is accepted as a target for interventions. The APS is firmly of the view that decisions about who is best to deliver interventions cannot be left to the marketplace, as there is significant potential for the market to operate to meet service demand via for-profit organisations and large Non-Government Organisations (NGOs) using a low cost and low capacity workforce.

To summarise, the APS’s view is that there are serious

structural and behavioural deficiencies in the NDIS planning process as it has operated in relation to the approval of psychology interventions in participant plans. Given it is acting as a deterrent to the continued involvement of some practitioners in the Scheme, the APS believes is critical that planner decision-making behaviour be addressed for their impact on workforce availability development. Also affecting the attraction to and retention of psychological practitioners in the NDIS are the barriers and costs involved in being a registered provider for psychologists under the Scheme. Psychologists are remunerated for their work across a range of third-party payment systems (e.g., in workers compensation, traffic accident and victims of crime and services systems related to current and ex-serving military personnel) and primary health care systems. None of those systems has a comparable level of administrative burden and cost although some (e.g., Comcare) provide for similar rates of remuneration. The APS acknowledges the need for only suitably credentialed and experienced practitioners to deliver services. It believes, however, that the cost of registration and the necessity of re-registration needs to be addressed to reduce its deterrent value. The APS is of the view that it is not enough to assume that the business model of large provider entities can be applied to the whole workforce without deleterious impacts on engagement. The attached appendix of sample comments about the impact of TPV from the recent APS survey of practitioners in the disability field is illustrative of this. Another area of concern relates to the cost of travel. It is often not only highly desirable, but clinically necessary for psychologist practitioners to travel to deliver interventions to NDIS participants. Remuneration for travel has long been considered insufficient by practitioners who operate to deliver services in a client-located manner. This is a particularly acute problem in the dormitory suburbs of Australia, where practitioners can travel long distances to provide participants with services. Third party verification (TPV) of particular concern to members is the introduction of costly Third-Party Verification (TPV) and particularly certification (as applies in relation to work with children or participants with challenging behaviours). They have indicated that it has either made it unaffordable or cost ineffective for smaller (including sole practitioner) practices to take on children under the age of seven years. This is particularly concerning, given evidence that smaller, quieter and less sensorially stimulating environments are what is required for these participant groups. The APS recommends that the Australian Government takes the necessary steps through the NDIA and NDIS to address the workforce attraction and retention challenges facing the Scheme. In particular, it recommends that the NDIA: 4. Ensure NDIS planners, Local Area Coordinators (LACs) and support co-ordinators recommend the use of psychologists as the preferred providers of psychology interventions for NDIS participants for neurocognitive, behavioural and mental health and psychosocial disabilities. 5. Address the cost of TPV, especially for small practices with small customer bases. 6. Reduce unnecessary “red tape” and the burden of administration in service delivery.

Term of Reference (c): The impact of

Commonwealth Government policy Recommendations on the NDIS working environment The APS recommends that the Australian Government develops comprehensive policies in relation to the NDIS working environment regarding education and training of NDIS staff, fee setting and regulation of providers, and that via such policies the NDIA and NDIS take the necessary steps to: There is an obvious and significant role for government policy in price setting, defining what conditions and impairments are within Scheme, and safeguarding quality and safety by regulating the behaviour of providers and workers and NDIS staff. However, the environment in which the NDIS workforce operates extends beyond government policy settings. It is also necessary that the NDIS/NDIA sets supportive operational policies and develops competency-based education, training and supervision to build workforce expertise across the sector that supports the Scheme’s vision. A factor that should not be overlooked in the NDIS working environment is the potential for caring professionals and workers in disability and mental health field to “suffer because they care”. This is not uncommon in such workforces and carries a significant personal cost (Sabin-Farrell & Turpin, 2003). The NDIS requires a workforce with good mental health literacy and that is supported by management and peers who are aware of the principles of trauma informed care. It also requires access to Psychological First Aid (PFA) which permits safety, calm, connectedness, self-efficacy and group efficacy, and hope. To this end, it is important that the NDIS partners with professional organisations to help drive change in the planning process via targeted programs of education and training for provider organisations, workers and NDIS (especially planners and LACs).

7. Fully assist the NDIS workforce to develop to its optimal potential. This includes developing operational policies that are supportive of the needs of staff and providing training targeted to workers and NDIS staff (including planners and LACs) and
8. Appropriately engage with professional organisations in the development and implementation of NDIS targeted programs of education and training.

Term of Reference (d): Government’s role in NDIS workforce development

The APS acknowledges that the NDIS has commissioned considerable work around the role of allied health assistants in the NDIS. The APS has contributed to this work and looks forward to working with the NDIS and governments across Australia to ensure that best practice arrangements are identified and implemented.

The APS believes that it is critical that a comprehensive strategic workforce development plan (Plan) be developed as a matter of priority to enable the delivery of best-practice care and interventions to NDS participants. Such a Plan is fundamental to defining the appropriate workforce to deliver the services required under the NDIS. It is critically important that it clarifies who is best qualified and safest to deliver the services required for participants.

To accommodate situations where it is not clear which health professionals are best placed to deliver certain types of services, or where less complex services may be delivered by a non-or lesser-qualified worker, the Plan must articulate closely managed delegations with appropriate protocols and provide for easily auditable paper trails.

Benchmarks that assure the quality of interventions are central to proper workforce planning. The APS suggests that the establishment of effective benchmarks be facilitated by a range of actions; for example,

• the development of prototypical industry position descriptions for workers that articulate Key Selection Criteria and required and desirable experience

As the APS has previously observed in its submission to the JSC and again reiterates in this submission, the NDIS is complex in its operation. Often it is difficult for participants, their families and carers to navigate the system with its diverse workforce of NGO providers, workers and health professionals, each with different enterprise agreements/fee schedules, skill levels and professional roles and capacities.

Recovery coaches may be able to assist participants with that navigation. They may also play an important role in the implementation of plans and co-ordination of the care provided by the variety of practitioners, workers and organisation who may be involved in the delivery of care. They could also fruitfully be involved in the linking and coordination of that care and the “Team” that sits around participants.

The APS is strongly of the view, however, that recovery coaches must not operate to deliver interventions under the NDIS. This is because they do not possess the required qualifications, experiences or capacities. Rather, they must act under the direction of LACs and support coordinators to assist Participants to access

Workforce Plan Monitoring

best-practice care and interventions. Given the role In this context, this workforce plan must be subject difference and capabilities involved, allied health to monitoring by an independent agency. That fits assistants, LACs, support coordinators and recovery well with the mandate of the NDS Quality and coaches, must each have clear job descriptions and Safeguards Commission and it appears well placed to will need to worker under clear delegations and oversee the ongoing operation and maintenance of a supervision with clear audit trails. viable NDIS workforce.

The APS recognises the need for workforce development at the low intensity end of the support Recommendations spectrum and acknowledges the potential for allied health assistants and recovery coaches to play a The APS recommends that the Australian valuable role. However, the APS is concerned that Government takes the necessary steps through both will be seen inappropriately as solutions to the NDIA and NDIS to develop a comprehensive psychology workforce issues in the NDIS and may strategic workforce development plan. To introduce new complexities. Issues of accountability, facilitate this, the APS recommends the: supervision, delegation and potentially loss of service 9. Development of workforce benchmarks for quality will need to be addressed. The introduction successful service delivery predicated upon of recovery coaches has the potential for adding a needs analysis and conducted with input further complexity and confusion into the system; from key stakeholders (including the peak unless practice in all parts of the system shifts professional bodies) across the disability to assume a recovery focus, there is potential for sector and the close involvement of the inconsistent messaging, confusion and ultimately Quality and Safeguards Commission. harms to NDIS participants. Issues such as what team care arrangements will be in place to support this (this cannot be undertaken via the MBS) will need to be addressed. How these issues will be mitigated appears not to have been considered by the NDSIS.

The insights of the 2019 Victorian Royal Commission into mental health and the APS submission support this view and should be considered. The APS submission strongly emphasised the need for skilled clinicians providing evidence-based care to be an integral focus within that system. For case coordination and supporting roles (such as recovery coaches), provisional psychologists (who work under supervision) could be considered.

The NDIs has developed a range of critical guidance documents including practice standards, business rules, codes of conduct for providers and workers and NDI Codes of Conduct for Service Providers and Workers and the Guidelines associated with each. Such documentation is well supported by Federal and State Government Disability Plans and state government practice frameworks and advisory statements (such as the Victoria Government’s allied health capability framework) and by professional association Codes of Ethics (such as the AP Code of Ethics, which has been adopted as a matter of National law, and its associated Ethical Guidelines). The development of a comprehensive workforce development plan represents a missing link in the documentation required to fully support the Scheme.

Term of Reference

(e):The interaction through the mainstream and community sectors of NDIS workforce needs with (e.g., referral to the public mental health system and private mental health service providers including employment in adjacent sectors psychiatrists and psychologists). including health Although this is a process identified as necessary by the NDS, there has been no reporting (e.g., by the gublic release of data) to date of its success. While it is the responsibility of support co-ordinators and LACs to assist participants/families in the planning process, and to identify suitable service providers, the effectiveness of this is open to dispute. Additionally, where they coordinate with non-plan related services is unclear. The APS is strongly of the view that the current arrangements at the interface of systems are not working. The archetypal example of this relates to psychosocial disability. Given its nature, psychosocial disability requires a mixture of evidence-based psychological interventions and broader social supports to enable functioning. Some individuals with psychosocial disability will also require psychiatric interventions. This will often hinge on whether evidence-based treatments have been applied with effect and whether the individual’s condition has become stable (i.e., no more improvement can reasonably be expected). Psychosocial disability, however, can have its roots in intellectual, sensory or physical disabilities; for example, an individual with permanent severe physical disability derived from stroke is likely to experience psychosocial disability (e.g., depression, anxiety and irritability) directly related to their disability. To the APS’s knowledge there are, as yet, very few cases of participants with chronic pain Additionally, many NDIS participants with mental health conditions or psychosocial disability may not have been formally psychiatrically diagnosed. This does not mean, nevertheless, that their psychological state does not affect their wellbeing and functionality and – based on the intention of the Scheme – they are legitimately entitled to mental health and capacity building interventions under the NDS. The APS continues to have significant concerns about the intersection of the health and disability sectors around psychosocial disability. Evidence provided by members suggests that gaps in services for Scheme participants with psychosocial disabilities are not narrowing and may be widening. Up until the age of 65 (when the aged care system assumes responsibility for the (non-health-related) care of people with disability) or where individuals are no longer eligible for care and interventions under other Schemes and their impairment and disability is judged to permanent, the NDIS is responsible for the care of those individuals. However, there is a grey area where judgments are made regarding whether support needs are or are not a function of disability. Where the NDIS deems an individual is not eligible for funding in relation to some aspect of their care – for example, because they have mental health issues that are neither permanent nor related to their disability – there is a need to assist those persons to find support Given this, the APS draws the JSC’s attention to the need for the Government to definitively reinforce

Recommendations

to the NDIA and the NDIS that for participants with either mental health conditions and/or psychosocial disabilities requiring inventions, that they be ruled as fitting within the Scheme’s scope in the absence of evidence that their conditions and difficulties are in no way connected with either a physical and sensory or psychosocial disability. This will effectively redirect the Scheme from the “opt out” decision-making that has become the defacto norm under the Scheme in relation to mental health and psycho-social disability. A well-functioning process would see fewer complaints of people ineligible for NDIS funding struggling to source alternative options. This is not the case and there is an urgent need to resolve the current lack of clarity regarding where to distinguish a person who should be treated under the NDIS from those whose care should be funded by another system. This is best to occur at peak government level, involving agencies, councils (especially the Disability Reform Council and the National Mental Health Commission), industry representatives, associations (including the APS) and “think tanks” (such as Safe Work Australia) and state and federal government departments. The insights of the 2019 Victorian Royal Commission into mental health and the APS submission to it are noteworthy.

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Term of Reference (g): Other matters

The APS has consistently expressed concern about the impact of planners on the delivery of services to participants with mental health and/or psychosocial disability. Further, the APS is strongly of the view (based on interactions with its members) that the role of planners has a deterrent effect on psychologists entering or remaining within the Scheme as registered providers.

Communication with stakeholders

and its members that the NDIS does not provide timely responses to practitioner enquiries about or clarifications of decisions about psychology care, support and interventions. There are significant potential benefits in having the NDIS Quality and Safeguards Commission accept responsibility for addressing this by creating mechanisms for planning oversight. Such mechanisms will ensure that plans developed for individuals with a disability in need of psychological assessment or intervention are appropriate and enable them to receive such care.

participant plans is very difficult

• there is difficulty obtaining clarification about anything!
• when matters are formally raised with the NDIS – for example, by posting an entry on the NDIS Providers page on the NDIS portal – these entries have been removed by NDIS staff without the permission of the author of that post
• NDIS staff have a poor grasp of the challenges that face practitioners outside of provider organisations and the pressures upon individual practitioners.

It is important that the NDIS establishes appropriate consultation mechanisms not only with participants (which the APS recognises as fundamental to the proper operation of the Scheme) and health providers, but also other stakeholders, such as the APS, at both peak representative and day-to-day levels of communication, so that early advice is sought from providers in a collaborative top-down and bottom-up manner. The development of the Workforce Plan discussed in Term of Reference (d) provides an excellent opportunity for demonstrating a change of approach.

The role of Planners

wellbeing of participants and their choice and control in decision-making about what will be included in their NDIS plan(s). However, the need for central planning can result in a variety of issues for the participant and practitioner as it impedes progress and creates roadblocks in the delivery of care. When this occurs, practitioners lose trust and can become disillusioned and participants’ aspirations are thwarted.

Recommendations

The APS recommends that the Australian Government takes the necessary steps to ensure that the NDIA and NDIS act to:

11. Improve the quality of communications with practitioners, industry representatives and peak professional bodies.

12. Review the role of NDIS planners for their impact on the NDIS workforce and the availability and quality of service delivery through the NDIS Quality and Safeguards Commission.

Summary

The APS again thanks the Joint Standing Committee for the opportunity to submit to this Inquiry. This submission raises various important areas of consideration for the Committee’s review. The APS seeks to convey to the Committee that several of the observations made and the associated recommendations relate to issues that have been brought to the attention of the NDIA and NDIS before via a range of channels. The APS calls for government action on each issue identified and the propositions made. It does so on the basis that now is the time for action.

References

DHHS (2020) Allied health capability framework: Victorian Government https://providers.dhhs.vic.gov.au/workforce-capability-framework-implementation

Littlefield, L. & Roufeil, L. (2015). APS Response: Proposal for a National Disability Insurance Scheme Quality & Safeguarding Framework. APS: Melbourne. DOI 30/04/2015.

McHugh, T (2019). APS Submission to the Royal Commission into Victoria’s Mental Health System APA: Melbourne. https://www.psychology.org.au/getmedia/d809397b-fa55-4e2d-9801-c72be582aaa0/19APS-Victorian-Royal-Commision.pdf

McHugh, T., Clarke, J. & Mundy, G. (2019). APS Response: Joint Standing Committee on the National Disability Insurance Scheme: NDIS Planning. APS: Melbourne. DOI 09/2019.

Meadows, G., Brophy, L., Shawyer, F., Enticott, J. C., Fossey, E., Thornton, C. D., … & Slade, M. (2019). REFOCUS-PULSAR recovery- oriented practice training in specialist mental health care: a stepped-wedge cluster randomised controlled trial. The Lancet Psychiatry, 6(2), 103-114.

NDIS (2020). Growing the NDIS Market and Workforce: Based on Commonwealth of Australia (Department of Social Services) data. https://www.dss.gov.au/sites/default/files/documents/03_2019/220319-ndis-market-and-workforce-strategyacc-ij5665.pdf

Media Release. NDIS Workforce Funding. The Hon Stuart Robert MP. https://ministers.dss.gov.au/media-releases/5036

Roufeil, L. (2017). APS Response: National Disability Insurance Scheme (NDIS) Costs: Productivity Commission Issues Paper, February 2017. APS: Melbourne. DOI 23/03/2017.

Roufeil, L. & Li, B. (2017). APS Response: Provision of services for people with psychosocial disabilities related to mental health conditions under the National Disability Insurance Scheme. APS: Melbourne. DOI 02/2017.

Roufeil, L. & McHugh, T. (2018). APS Response: Inquiry into the Implementation of the National Disability Insurance Scheme and the Provision of Disability Service. APS: Melbourne. DOI 26/09/2018.

Sabin-Farrell, R., & Turpin, G. (2003). Vicarious traumatization: implications for the mental health of health workers? Clinical psychology review, 23(3), 449-480.

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APS Response to Joint Standing Committee on the National Disability Insurance Scheme: NDIS Workforce

Appendix

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Appendix

APS Member comments about the cost-shifting to Medicare

I am very concerned about what is being told to clients by NDIS planner about psychology and how it should be funded. Many clients would not be able to advocate for themselves very well nor would they have the knowledge or professional background that I have and would likely just accept what they are being told.

• I attended a meeting with my brother and his primary support worker funded by the NDIS funds. I did not introduce myself as a psychologist nor was anything said during the meeting that indicated my profession, as I was attending as my brother’s endorsed plan nominee and at that stage, I was self-managing his funds. When I raised the issue of funding for psychological services for him the planners response was so prompt and delivered so authoritatively that I had no doubt that it was established policy, albeit a policy that I was confident was incorrect, in which the assessors had been well drilled. That response was, “Have you a Mental Health Care Plan for B?” . I indicated we didn’t and said that it was my understanding that Medicare was not intended nor appropriate for the psychological outcomes my brother required. She indicated that he wouldn’t get weekly or fortnightly funding for psychological services under the NDIS and we should get a MHCP. She further stated you might get monthly funding for psychology. Given the assessor’s confidence in her advice, there seemed to be no point in discussing it further with her.
• The difficult and expensive process of maintaining registration status as an NDIS registered provider.

She stated again, “you can get a Medicare referral for that too.” I replied that from my understanding the Chronic Diseases Medicare (EPC) referral only gave 5 sessions and did not pay the whole fee for any service used so it was unlikely to go very far for his needs. The planner then stated that we wouldn’t receive all of what was requested and would have to prioritise what we used it on.

Member comments about the cost and impact of Third-Party Verification

Having to go through a very costly audit which means I will not be renewing my NDIS registration

• As a sole practitioner I deemed the requirement way too onerous and the auditing process too expensive to complete (especially as NDIS participants make up a relatively small part of my case load). I did not renew my registration
• We were registered as providers and we have now unregistered due to the auditing requirements being unmanageable for a sole practitioner clinic.
• The difficult and expensive process of maintaining registration status as an NDIS registered provider. (I was registered with them until Feb 2020 when it ran out. I did not re-register due to the exorbitant costs of preparing for audit, etc.).
• Openness of the audit process, particularly the costs involved. These are significant and could be termed crippling for a small Psychology practice.
• I used to be registered with the NDIA but the audit process has made it unworkable. Why would I pay thousands of $$ to get registered for one or two clients?
• The audit required to remain a registered provider is extremely onerous and expensive and for this reason after April 2020 I do not plan to remain

registered with the NDIS

one day to go through the policies and procedures

• It became apparent that the auditing process and explain how you interact with clients and conduct your work). I have several issues with my vulnerable client group being asked to interact directly with the auditor.

The audit process involves checking that you have a work involves long hours of communication with range of policies and procedures in place – to ensure the school, other providers, teachers and parents, The paperwork hours (no fee) far exceed therapy hours, and together with the cost of auditing it has made seeing clients of the NDIS an act of charity At every opportunity during the audit process I and not sustainable for a small business have directed the auditor to the existing Code of Conduct and APS suite of policies that I adhere to as a registered psychologist. I also refer to these in my self-developed policies and procedures. I estimate the I have self-developed approximately 20 policies and procedures especially to satisfy the NDIS registration requirements.

As a registered psychologist, who has provided • I am a small business provider and these expenses specialist behaviour support since 1995, it seems are not viable. amazing that no credit is given for this in the • I have consequently knocked back several NDIS registration / audit requirements. It seems a range referrals of unqualified people are being allowed to register • The NDIS Commission audit process was too as providers of specialist behaviour support, or be expensive and burdensome. As such, I ceased employed by people / organisations under their providing Specialist Behaviour Management Specialist Behaviour Support registration. and Early Childhood Support and only provide

• We are likely to remove our registration next year therapeutic support because the cost of audit is well above what is • I am registered for psychological therapy until feasible for a small practice. March, when I shall no longer be registered as the audit and process involved is too time consuming and expensive for a sole practitioner. Similarly, despite decades of behaviour intervention work, I was unable to register with the NDIA due to onerous requirements.

• The time and cost involved to undergo the audit process are excessive. For a 3-year audit cycle, I need to pay approximately $16000, and this does not include the time spent preparing (i.e., creating, reviewing and updating policies and procedures, contacting clients to ensure some can be available for direct contact with the auditor, and being available to sit with the auditor for a minimum of

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