Submission to the Joint Standing Committee on NDIS:

Inquiry into the provision of services under the NDIS Early Childhood Early Intervention (ECEI) approach

August 2017

About AMSANT

The Aboriginal Medical Services Alliance of the NT is the peak body for the community controlled Aboriginal primary health care (PHC) sector in the Northern Territory (NT). We have 25 members providing Aboriginal comprehensive primary health care (PHC) right across the NT from Darwin to the most remote regions. AMSANT has been established for 20 years and has a major policy and advocacy role at the NT and national levels, including as a partner with the Commonwealth and NT governments in the Northern Territory Aboriginal Health Forum (NTAHF).

The Aboriginal Community Controlled Health Services (ACCHSs) sector in the NT is comparatively more significant than in other jurisdictions, being the largest provider of Aboriginal primary health care services to Aboriginal people in the NT. Over half of all the episodes of care (53%) and contacts (55%) in the Aboriginal PHC sector in the Northern Territory are provided by ACCHSs. Moreover, ACCHS deliver comprehensive primary health care that incorporates social and emotional wellbeing, mental health and AOD services, family support services and early childhood services, delivered by multidisciplinary teams within a holistic service model.

Background

Extensive research over many years has provided evidence that the early years of life are fundamental to both the physical and emotional health of children, for their social and cognitive development, and for later educational achievement and life chances. Adverse childhood events have been causally linked to poorer long-term outcomes.

Children are cherished in Aboriginal cultures and nurtured within broad family networks. However, a history of colonisation and ongoing policies stemming from that history have resulted in many Aboriginal children in the Northern Territory growing up in disadvantaged communities with much poorer health, education levels and social and emotional wellbeing (SEWB) compared to the non-Aboriginal population.

The Australian Early Development Census (AEDC) measure of early childhood development at school entry clearly reveals the extent of disadvantage for young Aboriginal children. On average 37% of children in the NT are developmentally vulnerable in one or more domains and 23% across two or more domains - significantly higher than the national average. However, for many children

Concerns with the ECEI Approach

AMSANT is concerned that the ‘key research pieces’ identified as forming the basis of the ECEI approach in NDIS Early Childhood Early Intervention (ECEI) Approach (2016) do not adequately identify or address many of the issues, concerns and constraints related to providing early childhood intervention to Aboriginal children in the NT, and the particular challenges for service delivery in regional and remote areas. These documents focus on mainstream service delivery, contain only cursory mention of Aboriginal children or consideration of remoteness factors, and make no reference at all to the Aboriginal community controlled sector.

Similarly, while the principles behind the National Standards: Best-practice in early childhood intervention (2016) are sound, we are concerned that these principles will not be translated into reality for Aboriginal children with disability in the NT. The experience of many of our member services in their interactions with the NDIS to date suggest that we will not see improved outcomes through the Scheme without a far more comprehensive understanding of the unique cultural circumstances and service delivery constraints that are present in Aboriginal communities in the NT.

In light of this we refer this inquiry to the Northern Territory Aboriginal Health Forum’s document Progress and Possibilities: What Are the Key Core Services Needed to Improve Aboriginal Childhood Outcomes in the NT? (NTAHF 2016) and recommend that this document be a foundational reference for the NDIA in the development and implementation of the ECEI approach in the NT.

Core Services Required to Improve Childhood Outcomes

This document outlines the core services required to improve childhood outcomes, as identified by delegates with local expertise in early childhood development at a two-day workshop in Darwin in June 2015. Importantly, it also identifies a number key policy considerations for implementing this model which AMSANT strongly recommends the NDIA integrate into the ECEI approach.

These are:

Current systems provide fractured and often ineffective service delivery to children and their families and this must change if we are to close the gap. Sector reform is required to better integrate child health, education and other early childhood services.
Only evidence-based programs or those working to build evidence should be funded and evaluation must be an integral component of early childhood funding and programs.
Programs and services must be culturally appropriate, consultative and inclusive of the community at all stages, including co-design and Aboriginal leadership where possible. Programs should be family centred and male inclusive.
Programs need to be of sufficient duration and intensity to have an optimal effect, and start early.
Competitive funding processes should be reviewed as they are driving a fragmented and inequitable service system that lacks real engagement with Aboriginal communities.
Needs-based equitable resource allocation should be a core funding principle and the Aboriginal primary health care sector must be adequately resourced to meet increasing need.
A localised approach to building the Aboriginal workforce and providing well-trained staff is a priority.
Inter-sectoral cooperation and coordination is required for optimal outcomes, particularly between education and health sectors.

In addition to these overarching considerations we also identify below a number of specific concerns with the provision of services under the NDIS ECEI Approach which we ask the Inquiry to consider.

Workforce

The Productivity Commission’s Position Paper on NDIS costs (2017) identified that ‘it is unlikely that the disability care workforce will be sufficient to deliver the supports expected to be allocated by the NDIA by 2020’. Given the existing difficulties in remote Aboriginal communities to find and retain appropriately skilled staff, it is likely that workforce issues will be particularly acute in these areas.

As outlined above, a lack of access to specialist services for children with disability is a major issue for many remote Aboriginal communities and AMSANT has serious concerns that the speed of the NDIS roll-out does not allow sufficient time for necessary workforce training and development to meet demand within the Scheme. Particular consideration should be given to the development of an Aboriginal workforce strategy which focuses on building capacity within local communities to ensure the long-term sustainability of ECEI within the NDIS.

Use of a competitive market mechanism

Increased competition is not the answer to improved outcomes in remote communities in Aboriginal Australia. In fact, past experience has shown that increased competition in remote Aboriginal communities can lead to worse outcomes by undermining the effectiveness and potential development of existing Aboriginal service providers through the introduction of new external non-Indigenous providers. This has the effect of increasing service fragmentation, providing less culturally-safe service delivery, and compromising the ability for service integration at a local and regional level (AMSANT 2016).

Cultural Safety, Quality and Effectiveness

The lack of cultural competency within NDIS has so far proved to be a major barrier to participants engaging with the Scheme and with non-Indigenous organisations who deliver support coordination services. There are currently few if any incentives for service providers to actively work to build community capacity or show that they are able to respond to the unique health and wellbeing needs of Aboriginal people.

Social determinants – including nutrition, housing quality, and community- or family-related factors such as safety – are strongly linked to child health. Children from disadvantaged backgrounds often face multiple physical, psychological and emotional hardships. The combined effects of these hardships can take a heavy toll on children’s health, leading to high levels of toxic stress and suboptimal development. Aboriginal children in the Northern Territory have a greater chance of exposure to the cumulative impacts of multiple stressors than do non-Aboriginal children.

Unless we see improvements across all of the social determinants of health, improvements in the lives of Aboriginal people with disability in the NT through the NDIS will be limited. This will require a coherent, overarching strategy which connects related policy in a coordinated and complementary way across departments and institutions.

References

ABS 2012, Aboriginal and Torres Strait Islander People with a Disability, 2012, cat. no. 4433.0.55.005 http://www.abs.gov.au/ausstats/abs@.nsf/productsbytopic/176B7899CCE3B173CA257D9E00112463?OpenDocument [Accessed August 2017]

AEDC 2015, AEDC data explorer, Australian Early Development Census, Commonwealth of Australia. https://www.aedc.gov.au/communities/accessing-community-results [accessed August 2016]

AMSANT 2016, Response to The Productivity Commission’s Introducing Competition and Informed User Choice into Human Services: Identifying Sectors for Reform - Preliminary Findings Report.

Braveman P, Egerter S, Arena K & Aslam R 2014, Early Childhood Experiences Shape Health and Well-Being Throughout Life, University of California, San Francisco Centre on Disparities in Health.

Gomersall J, Gibson O, Dwyer J, O’Donnell K, Stephenson M, Carter D, Canuto K, Munn K, Aromataris E, Brown A 2017, What Indigenous Australian clients value about PHC: a systematic review of qualitative evidence, Australian and New Zealand Journal of Public Health

Heckman J 2006, Skill Formation and the Economics of Investing in Disadvantaged Children, Science, vol. 312, 30 June 2006.