The NDIS – from then to now
In today's post, Dr Raelene West (@raelene_west) discusses the history and current state of Australia's National Disability Insurance Scheme. She argues that the NDIS is at a critical juncture, and that its success hinges on people with disability having a more significant role in its design and delivery. Dr West is a sociologist based at the Melbourne Disability Institute at the University of Melbourne, and she has lived experience of disability.
The NDIS: both momentous and radical
The NDIS was a momentous and radical policy response to the needs of Australians with a disability. What have we learned thus far from its implementation? Photo by Cliff Booth from Pexels
Australia’s implementation of its National Disability Insurance Scheme (NDIS) following the passing of the NDIS Act in March 2013 was both momentous and radical in terms of how formalised disability services were to be provided to people with disability across Australia. The passing of the NDIS Act legislation established both the National Disability Insurance Scheme (NDIS) and the National Disability Insurance Agency (NDIA), the agency commissioned to run and administer the scheme.
The implementation of the scheme was momentous in that it amalgamated together 8 separate state and territory state-based disability service schemes into one centralised and national service scheme. This also included, at a late stage, the amalgamation of each of the state and territories’ mental health service schemes into the NDIS.
The implementation of the scheme was also radical in that all block funding arrangements to service providers, based on historical, institutionalised and charity model of disability services, ended. In its place, a wide-scale, market-based scheme was introduced, comprised of individualised funding packages provided directly to the scheme ‘participants’ (the scheme’s service users) who then purchased services in an open market as required based on their individualised plan. The principles of the new radical scheme were enhanced ‘choice and control’ for the participants themselves, based on principles of individualism, neo-liberalism and human rights, and a scheme that would reflect the principles of the then newly developed United Nation’s Convention of Persons with Disability (CRPD) in 2008.
As such, these legislative changes marked a dramatic shift at all levels government and for all stakeholders in terms of the provision of disability services Australia wide.
Initial piloting raised shortcomings
The NDIS scheme formally began on 1 July 2013. The first phase ran from 2013-2016 with a number of trial sites across Australia. The trial sites provided testing in various areas of the individualised funding packages such as how these worked (or didn’t) within local markets, what technologies would be needed in terms of a service payment structures, potential innovations, service provider capacity to respond to the individualised funding model, how plan assessments could be conducted by NDIS staff (and needed frequency of assessments), workforce issues and then the building of the bureaucratic scaffolding required to support the running of the scheme.
The trial site phase demonstrated that related government structures and all stakeholders (including participants themselves) required significant capacity building to more effectively interact with the scheme. A particular issue was unit pricing of services. Under the previous block funding model, services providers had simply been handed a block of money by government each year, based on the number of clients they had, and then provided services to their clients from this funding allocation (a charity model in itself).
Little auditing, quality assessment or meeting of key indicators were linked to the receipt of any of this government funding. Rather, funding was handed out year after year to service providers regardless of the quality of service, characterised by rationing and under-resourcing of funding allocation to meet the requirement client need. Under an individualised funding package model, service providers were now being asked to individually itemize each day or hour of service (including workforce costs) provided to each participant. During the NDIS trial phase it became evident that many service providers did not have the IT requirements or back-end structures to even generate an individualised invoice to an individual participant, let alone determine accurate hourly costs for services given; they did not have any historical reference points for costs of service per hour or day.
It was also evident from the trial sites that participants were struggling with choice of services, having not in many cases had decision-making capacity in many of their life areas before. The trial sites also demonstrated that the bureaucratic scaffolding was struggling with the new scheme, and that many policy areas would require significant development to get the scheme running to scale, such as an efficient payment system between participant funding packages to service providers.
Scaling up was ‘turbulent’
From 2016-2020, with completion of the trial sites, the second phase of the scheme focused on the widescale national onboarding of participants onto the scheme and significant industry/service provider capacity building. Onboarding involved a scaled roll-out, based on local government areas, of individualised funding packages to all Australians with a disability. This was a highly resource-intensive process for the sector (including for the government, which was required to individually complete each individual participant plan assessment and determine eligibility). For the sector, it involved the development of pre-planning processes by service providers and potential participants. For participants, this involved gathering relevant medical and allied health reports at their own cost, to prove their level and permanency of disability and hence eligibility into the scheme; and itemising all requirements such as equipment, services and modifications that may be needed over a single year. Once eligible and on the scheme, there was a sharp learning curve for many participants in managing budgetary processes of running a plan and learning to interact with the NDIS portal to make claims for invoiced services from their funding package budget.
This phase of the NDIS was a highly turbulent phase for both government and stakeholders. Arguments on eligibility into scheme – the ‘uninsurables’ – were sharp. There were also high numbers of appeals from participants who were unhappy with their plan scope or who had missing items. Many LACs and NDIA planners were over-worked, inexperienced and under-resourced, leading to delays with plan approvals and appeals, and as a consequence there was a high turnover of LACs and NDIA planners; this in turn led to loss of scheme knowledge capital and high use of consultants in the bureaucracy. Additional issues were an IT portal that was clunky to use for both participants and service providers, which made payment claims difficult and caused delays.
Further, some of the weaknesses of a marketised scheme were now being exposed. These included an inadequate number of service providers prepared to operate in more difficult regional and rural areas because of low client numbers, creating ‘thin markets’. It exposed problems with client decision-making when many had a lifetime of little or no choice offered to them, and therefore many had reduced capability. It also exposed problems with the workforce with poor working conditions often amplified within the marketised scheme. Despite controls, the competitive nature of the market system also encouraged providers to undercut their prices to attract clients. The state as the provider of last resort also emerged as an issue, in that highly complex clients were not taken on by service providers, who preferred clients that were easier to service, which would achieve an adequate profit margin.
Some innovations occurred in this phase. A number of online platform service providers emerged, along with a number of IT resources to help with budgeting. A direct employment of worker model, an innovation modified from previous DHS versions in Victoria, was also formalised.
The only moderate use of full self-management by participants was a particular finding - possibly reflecting the 70% to 80% of clients on the scheme with an intellectual disability having problems independently running their budgets. Issues with an oversupply of support coordination developed with a burgeoning number of non-qualified and exploitative individuals creating new start-up organisations to the detriment of many vulnerable participants, and quality of care and scheme safeguarding became significant issues based on a number of high-profile abuse cases such as that of Anne Marie Smith based on service provider neglect.
The current state of the NDIS
The third and current phase of the NDIS, 2020-2027, is that of an ongoing improvement and maintenance of the scheme, with the intention of getting the scheme running well for both government and stakeholders. Now that the bulk of qualifying Australians with disability are onboarded onto the scheme, innovation and any needed reform within the scheme will require systems thinking and logic to get the scheme running at a good level and ensuring participants have all their rights and needs met to a high standard - that the NDIS is underpinning the provision of quality services that are supporting wellbeing and life opportunities for participants.
What should also be flagged as a recent but unsuccessful innovation by the NDIA agency, directed from the top down, is that of the attempted introduction of independent assessments. Citing difficulties with plan consistency across the nation, the NDIA attempted to introduce a process where an external consultant would assess a participant’s needs based on a number of clinical tools over a 2-3 hour session and using 460 characterised profiles developed by the NDIS (that isn’t a typo). Despite claims by the NDIA of consultation with the sector, the clinical and depersonalised nature of the Independent Assessments, rejection of allied health referrals and assessments already provided to the NDIS, and need for all participants to effectively repeat an eligibility assessment meant participants and advocates campaigned strongly and successfully for rejecting implementation of the Independent Assessments. Significant concern about the introduction of Independent Assessment mechanism was also provided to the NDIA board by the participant representation body the Independent Advisory Council.
Scheme innovation moving forward must involve participants having adequate voice within the system and co-participation in terms of how the scheme is operationalised.
Posted by @Olney_Sue