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Chapter 2

The application process

2.1        This chapter describes the issues faced by participants and providers as they navigate through the Assistive Technology (AT) process. It considers the equity and accessibility of the process, as well as examining the evidence around delays and inconsistencies in the length of time it takes the NDIA to assess and deliver AT.

AT applications

2.2        Effective information is the first step to achieving the vision outlined in the NDIS AT Strategy set out in Chapter 1. Clear information ensures common understanding, efficiency of resources, and manages participants' expectations. The committee repeatedly heard of the frustration felt by individuals, their families, carers, service providers, and suppliers, who are attempting to navigate the process.[1]

2.3        A lack of information about what constitutes a sound application (including what can and cannot be funded) was a common issue raised. The committee received numerous reports there are inconsistencies between AT decisions, even in cases where participants' circumstances, needs, and goals appear similar.[2]

2.4        Specifically there is confusion as to:

1. the method to submit an AT application;[3]
2. who can submit an application;[4]
3. what constitutes a sound AT application;[5]
4. who considers AT applications;[6]
5. how to alter an application;[7] and
6. how the results of applications are communicated.[8]

2.5        Complaints to the Commonwealth Ombudsman Office indicate that participants find the AT process confusing. Participants are uncertain as to what information is required with applications and what form this information should take:

The NDIA refused to consider a quote submitted by the participant's occupational therapist as the therapist had not completed the required NDIA training. After submitting another two quotes from NDIA-trained therapists, NDIA staff told the participant they could not accept either quote as they were not itemised.[9]

2.6        Limbs 4 Life argued that the lack of information has a flow-on effect to organisations, whose resources become absorbed developing material to assist participants to navigate the Scheme.[10]

2.7        The Benevolent Society argued that transparency in each stage of the application process is vital to managing participants' expectations.[11]

Inequity between application methods

2.8        Submitters raised concerns about how the method by which applications are submitted can affect the speed with which they are resolved.[12]

2.9        There are three ways individuals can apply for AT under the Scheme:

1. Prior to a planning meeting:
   1. the individual pays for an AT assessment, and trials of equipment, and takes the assessment report, and quotes, to their planning meeting. The planner allocates a monetary value for AT on the participant's plan and the item can be ordered once the plan is approved;[13]
2. During a planning meeting:
   1. the participant identifies a need for AT and the planner records AT on the plan but does not allocate a monetary value while the participant undergoes assessments and trials. When the participant has obtained an assessment report and quotes, they request a partial plan review for the AT component of their plan. When the partial plan review for AT is approved, the item can be ordered;[14]
3. During an active plan that does not contain an AT component:
   1. the individual completes an AT assessment and equipment trials and obtains an assessment report and quotes. The participant submits a request for a full plan review, and can order the AT item once the full review has been completed and the AT component approved.[15]

2.10      Therapy for Kids et al raised concerns that the speed of decisions on equipment requests were to some degree dependent on how and when they were raised:

If justification report and quotes are all presented at a face-to-face planning meeting, they are generally actioned within one month and if they are approved then the funds are in a participant's plan between one and 3 months after the planning meeting. If they are presented at any time around this meeting or required within the time period of the plan, there are great delays being experienced.[16]

2.11      In addition to concerns around varying processing speeds, the probability that applications are less likely to be rejected when considered in-person rather than online was also raised:

If assistive technology requests are lodged during a planning meeting there is the opportunity for a verbal discussion to be had. This is clearly a better form of communication then email, and is a way for planners and participants to ask questions and ensure there is an understanding of the request. When an assistive technology application is made outside of the planning meeting, it can only be lodged via email to the NDIA or through the relevant state based AT program. There is no opportunity for further discussion or questions with the NDIA employee who is actioning the request.[17]

Administrative requirements for replacement items   

2.12      The committee received numerous submissions that there are onerous administrative requirements being placed on prescribing therapists as a result of inefficiencies in the application process.[18]

2.13      For example, several submitters were critical of the need to complete a full AT application for direct replacement AT,  arguing that the process is inefficient, time consuming, and unnecessary.[19] The committee also heard that items outgrown by participants and require one size up require a full AT application form to be submitted.[20]

2.14      Cerebral Palsy Alliance argued that the requirement can cause delays for AT for participants, waste funding and therapists' time, and affect the development of children in particular.[21] One submitter provided an example of this process in action:

A 15-year-old girl with a chromosomal syndrome, severe intellectual disability and very low muscle tone requires specialist orthotics in her shoes. These need to be assessed and replaced every 12 to 18 months. The girl required an intensive early intervention program to get her walking and many people with the same condition us a wheelchair.[...] Every year the planner agrees the orthotics are reasonable and necessary, however, the family is still required to submit an assistive technology request, costing $500 in paper work for orthotics that cost between $800 to $1200 and can take 3 to 6 months for an approval.[22]

2.15      The Agency said it is working to address this issue in Q2 2018–19 by allowing replacement items to be sourced quickly without needing reassessment.[23] It has developed a form for participants, providers and planners to outline what criteria must be met for replacement items to be added to plans without further assessment. The approach has recently commenced testing in several sites in NSW.[24]

Duplication of paperwork to meet state and federal requirements

2.16      Submitters argued there is duplication of paperwork when AT items are requested through NDIS plans but are obtained through state based equipment programs, and that this is is further delaying participants' access to AT.[25]

2.17      OTA questioned why applications are required to pass through two approval systems for the same equipment:

Occupational therapists are faced with a system where each agency blames the other for blockages...It is not clear why there is this requirement in Victoria for AT requests to pass through two systems of checking, with all of the expensive delay this entails....The system is challenging at best, and broken at worst. The involvement of two agencies, and the unnecessary duplication of bureaucratic requirements, is adding further delays to an already protracted process. This is frustrating for our members and tragic for their clients.[26]

2.18      Therapy for Kids et al argued that the SWEP process comprehensively considers AT applications and that participants should not be subjected to an additional NDIS process: 

SWEP receives applications for assistive technology for people in Victoria [and] approves the items based on their thorough prescription forms providers are required to provide. However, the NDIS participants' applications now go through an additional approval process direct with the NDIA...[27]

2.19      OTA argued that the interaction of systems is placing excessive administrative burden on therapists:

One occupational therapy practice reports that its clinicians are each having to devote at least one hour a week to following up SWEP applications. The practice does not bill participants for this time, as its clinicians do not believe this is fair. Across this organisation, with more than 50 therapists, it is estimated that AT-related problems amount to 100 hours per week of non-billable time. This is 100 hours that would otherwise be spent helping NDIS participants achieve outcomes. It also, of course, undermines the financial viability of the practice.[28]

2.20      The NDIA advised that it is continuing to streamline its arrangements, and highlighted that, in the case of SWEP in Victoria, the state equipment program altered its online submission tool to receive NDIS related assessments as part of their assistance in providing quality assurance before passing to the NDIA for decision.[29]

AT assessment and trials

2.21      Before funding for AT can be included in a participant's plan, an assessment must be conducted by an AT assessor. Depending on the type and complexity of the AT and the needs of the individual, an assessor may be an AT Mentor, allied health practitioner, continence nurse, registered dietician, psychologist, or rehabilitation engineer.[30]

2.22      Not all AT requires an assessment to be conducted. The NDIA uses four complexity levels to identify participants' needs. Complexity Levels 2, 3 and 4 typically require an appropriate assessment form to be completed by, or with the oversight of, an AT assessor with suitable experience in that AT. No assessment is required for Level 1 as these items are easy to purchase, low risk, and require little or no assistance to set up.[31] 

2.23      Where assessment is compulsory, assessors are required to:

• trial AT with the participant to ensure it is best fit for their needs and used correctly and safely;
• recommend appropriate AT for the individual's needs;
• provide a recommendation report (including quotes) to the NDIA;
• assist the participant to select and purchase AT once funding has been approved; and
• set up and provide training on how to use the equipment.[32]

Assessment paperwork

2.24      The assessment forms attracted substantial criticism from submitters. AT assessors are required to complete assessment templates provided by the Agency. The forms provide information on the participant's goals, needs, equipment options trialled, and recommended AT.[33] However the templates were criticised for duplicating sections, and being time-consuming to write, counter-intuitive, and unfit-for-purpose.[34]

2.25      Permobil argued there is inadequate scope on the forms to convey how essential the AT is for the participant:

...therapists are reporting frustration with the report templates they are required to fill out and submit. The format does not allow adequate scope for providing information resulting in therapists feeling they can answer all the questions but still feel like they have not been given adequate opportunity to highlight how essential the Assistive Technology is. The report needs to be redesigned with consultation from therapists.[35]

2.26      Cerebral Palsy Alliance argued that some sections are poorly formatted and not clear on what information is being sought.[36] Noah's Ark argued that the application phase is taking 'at least twice as long as previously' in order to provide sufficient evidence that demonstrates need for AT.[37] Spinal Life Australia argued that AT report writing under the NDIS is arduous, not user friendly, and places clinicians under unnecessary stress.[38]

2.27      The NDIA acknowledged that further improvements to its templates are required and advised that it is working to improve its templates to make them simpler and easier to use.[39]

Assessment for complex cases

2.28      For participants who require more complex AT, assessments and equipment trials are required. Following purchase, assessors assist by setting up equipment and training the participant in how to use the AT.[40] Each stage of the process is critical to ensuring participants have appropriate AT and are using it correctly.

2.29      AT assessments often require a considerable amount of time for the assessor to travel to the individual's home, develop an understanding of the participant's and family's needs, order and assess pieces of trial equipment, obtain quotes from suppliers, and write a recommendation report for the on Agency's template.[41] In some cases this can take up to 20–30 hours required for liaison, trial, reporting, delivery, and set up.[42]

2.30      Families who cannot afford to source assessments and reports for AT are reliant on the funding allocated in their plans to understand what AT solutions are most appropriate. Without an effective assessment, participants are at risk of missing out on key AT items. The committee heard that most of the steps in AT provision are not product-related,[43] and that 90 per cent of work is done prior to providing a quote.[44]

2.31      Submitters also reported that not all elements of the assessment and trial process were funded,[45] particularly around the travel time required to conduct trials, and to set up equipment and devices.[46] For example, Therapy for Kids et al pointed out that therapists are often not within close range of participants and that multiple trips to the participant's home are usually needed.[47] The committee heard that one participant was unable to undertake any training with his AT because the funding allocated for his AT trial had been drained by traffic delays in Sydney.[48]

2.32      Submitters drew attention to the lack of additional loading for therapists to travel to participants in regional and remote areas, and for associated trial and fitting costs.[49] Evidence from the family of Tim Rubenach identified that significant underfunding of the remote travel cost component of his plan contributed to unnecessary, stressful, and extensive delays for AT.[50]

Funding for AT, and repairs and maintenance

2.33      Several submitters argued that funding for AT equipment or devices is also frequently insufficient.^[51] Therapy for Kids et al argued that some plans underestimate the cost of AT items even despite provision of a quote or estimate.[52]

2.34      The committee also heard that some plans include insufficient funding for repairs and maintenance,[53] causing unnecessary delays while an unscheduled plan review process is undertaken.[54] 

2.35      With regard to the repairs and maintenance issues, the NDIA has been attempting to address the funding, and access, for participants.  According to their response to questions on notice, they are calculating an appropriate budget for repair and maintenance coverage, as well engaging with AT repairs and maintenance services nationally to explore market-based arrangements to meet demand.[55] Changes to the process following this work are expected from Q2 2018–19.[56]

Multiple trials and quotes

2.36      Submitters expressed frustration that some participants were asked to undertake several trials and provide multiple quotes in order to demonstrate cost effectiveness of the selected AT.[57] The Australian Rehabilitation and Assistive Technology Association (ARATA) argued it is unreasonable to require assessors, participants, and suppliers to undertake numerous trials simply to obtain cost comparisons, as each trial takes up considerable time, resources, and NDIS funding.[58] Spinal Life Australia argued that comparative quotes cannot be guaranteed to be like-for-like due to differences in trial equipment and changes to prescriptions following second assessments.[59]

2.37      The committee heard that some practitioners were asked to trial lower cost equipment even in complex cases where low cost equipment was not appropriate.[60]

2.38      ILC Tasmania pointed out that that the multiple trial and quote requirement results in increased report writing time, creating a convoluted and inefficient process:

NDIS requires multiple trials of AT and the therapist to demonstrate transparency in their clinical justification. This may then result in additional time/inefficiencies sourcing AT from interstate and increased report writing time to provide evidence about AT trialled and reasons for discounting various options.[...] OTs undertake the same trial process which can take several hours using NDIS plan funds. At the basic AT (Level 2) we still need to provide 2 quotes which takes time.[61]

2.39      Likewise, Noah's Ark was concerned that a significant amount of providers' time is spent contacting suppliers which can reduce the participant's funding for other supports.[62] The inefficiency of the system was underscored by evidence from this NDIS participant:

As a wheelchair user for more than 38 years, with some experience of scripting wheelchairs, I filled out the wheelchair script and used the therapists as a check to ensure I had measured correctly. Then we spend 4-5 hours wasting the time of suppliers and the therapist's time so that we could say we had tried different brands of chairs and had quotes. The therapist cost of the equipment trials and quotes was around $900, and of course had to happen over several days due to coordination of dealers and the therapist and my time.[63]

2.40      Submitters argued that, in some circumstances, it may also be inappropriate to require participants to undertake trials of equipment before AT can be included in their plans for logistical reasons.[64] For example, some AT equipment is manufactured and supplied from overseas and may not be available for participants to trial before purchasing. In one case, the requirement resulted in perverse outcome for the participant and the Scheme: 

We had an example of a participant who required titanium heavy duty crutches for mobility which could only be supplied from the US. Trial was not possible, however trials were completed of other products which were not suitable. The NDIA planner did not approve this equipment as we couldn't trial it, and chose to fund less suitable crutches despite the high likelihood that they would require much more frequent replacement and greater long term cost.[65]

2.41      For participants in regional, rural, and remote areas, accessing trial equipment presents additional difficulties.[66] The Benevolent Society explained that some suppliers may only visit remote areas every few months: 

It is particularly difficult for practitioners in regional and remote areas to comply with the trialling requirement and ensure that equipment is provided to clients in a timely manner. In some regional areas, equipment suppliers may only visit the area every four months so opportunities to trial equipment is limited. When the practitioners and the family have done their research and are certain that the equipment they are requesting is what is needed to support the participant to function, being asked to trial other equipment which the practitioner and participant know is unsuitable is time consuming, costly and appears unnecessary.[67]

2.42      Assessors' ability to conduct trials may also be impacted by a limited number of suppliers in some regions.[68] Northcott argued that therapists in regional NSW have limited access to equipment and it is often impossible for them to organise more than one trial.[69] In Tasmania, the ILC pointed out that often only one supplier may stock the item.[70]

2.43      Even in cases where suppliers stock the required equipment, the ability to trial can be impacted by the limited number of items available.[71] In Melbourne, Therapy for Kids et al reported that items are often not available for trial at the time they are needed which can prolong delays for participants.[72]

2.44      Other submitters highlighted that some suppliers are reluctant to cover freight costs, which can further limit access to trial equipment.[73]

2.45      WA OTA argued that coordinating availability of equipment with the required health professional can also complicate and delay the process.[74] Noah's Ark reported that typical wait times in Victoria were 3–4 weeks for an appointment and 3–4 weeks to receive a quote.[75]

Impact of quote shopping

2.46      Submitters raised concerns that AT suppliers who have taken the time to provide trials and quotes to participants are being penalised for doing so.[76]

2.47      Mr David Sinclair, Executive Officer, Assistive Technology Suppliers Australia, explained that suppliers expend considerable resources to provide a quote, which is provided to the NDIA, however, some planners will then carry out a 'desktop shop' for a competing price and another company will benefit for undercutting the original price.[77]

2.48      Special Needs Solutions drew attention to suppliers' inability to claim for trial services under the NDIS:

We, as a highly specialised service provider, cannot charge for our services at the moment. We predominantly cover Queensland and northern New South Wales. I currently have two of our team on a trip from Brisbane and Hervey Bay to Bundaberg, Gladstone, Rockhampton and return. We are not paid any fees for actually going out and doing those trials and those assessments with the occupational therapists and the physiotherapists. For our business to remain sustainable, we need to be able to charge a fee for our service. Under the NDIA there is a rental line which the NDIA have advised us that we can draw a fee for our service from. However, this is very rarely allowed in a plan, so it's simply not working...The general cost of a week-long road trip is about $15,000...under the state-based scheme, when we had a tender system, that cost was built into that. But we were fairly much guaranteed that we were the preferred supplier under that tender system, so that cost would be recuperated...At the moment we cannot recuperate those costs at all.[78]

2.49      Assistive Technology Suppliers Australia argued that the quote shopping process has potential to affect market sustainability, and that some businesses were beginning to protect themselves by charging participants for quotes:

The current approach by the NDIA insisting on multiple quotations has created an unsustainable market for quote shopping and under-cutting. Decisions to work with an AT supplier are being based on price, rather than who has invested time and expertise working with a participant...In the quoting process, the supply of trial equipment is common, and historically this has been provided by the supplier at no charge. However due to the quote shopping that is current with the NDIA, these costs will need to be charged as businesses cannot sustain hours of work with a risk of missing out on the order.[79]

2.50      The Agency has submitted that it is working to introduce a new funding tool to calculate appropriate funding for AT supports to replace the current reliance on quotes. The new tool is expected to be introduced progressively starting with the most common AT items from Q2 2018-19.^[80]

2.51      A further development is that the threshold for when quotes are required was raised from $1000 to $1500 in the last quarter of 2017–18, which will apparently impact 50 per cent of AT applications.[81]

Tracking application status

2.52      As discussed at the start of this chapter, effective communication is essential to empowering participants, and their families, providers, and suppliers, throughout the AT process. The committee heard that a lack of communication throughout the AT process is a cause of considerable stress for individuals who are waiting for essential equipment.[82] Applicants are continually calling and emailing the Agency to seek updates on the status of their applications in the absence of any communication.[83]  Evidence indicates that the Agency frequently fails to provide verbal or written advice to applicants on:

• receipt of applications;[84]
• progress of applications;[85]
• when applications are likely to be considered;[86] and
• the outcome of applications.[87]

2.53      The Commonwealth Ombudsman received similar complaints from participants encountered by participants in finding out about the progress of their AT request, despite having contacted the NDIA multiple times.[88] In one case cited by the Ombudsman, a participant was never notified of the outcome of their application:

[T]he complainant had made an assistive technology request for a prosthetic arm in mid-2017. In March 2018, the NDIA accepted quotes for the prosthetic arm and added funding to the participant's plan at the time of conducting a scheduled plan review. However, the NDIA did not notify the participant of the outcome. In June 2018, the participant complained to our Office about the apparent delay in his assistive technology request being decided. Our investigation revealed a decision had been made, but that it had not been clearly communicated to the participant.[89]

2.54      Other submitters reported similar situations.[90]

2.55      Lifestart pointed out that Enable NSW would provide written confirmation of the outcomes of applications to both prescriber and participant, and contact both of them again when funding became available.[91]

2.56      Ms Melissa Noonan, CEO, Limbs 4 Life, argued that replicating the practice in use at the Transport Accident Commission (TAC) in Victoria might be beneficial for the NDIS:

I am actually a TAC client...When I meet with my clinician and discuss my needs and what I need to achieve an independent life, I have timelines of when that is submitted and when it's accepted. I'm also corresponded with quite frequently during the review process, and there are timelines in place. It might be a 28-day process. When the quote is approved, I receive a copy of that quote. It outlines all of the pricing and everything else related to the assistive technology I'm going to receive. That could be similar if I require—if I'm changing devices or upgrading a device and I request a number of days of training sessions from a physiotherapist, I get exactly the same information.[92]

2.57      Submitters argued that participants should be able to track the progress of their AT requests through the myplace portal. For example, the portal could indicate: receipt of application, with delegate, referred to technical advisory team, awaiting further information, rejected/approved.[93]

2.58      According to responses to questions on notice the Agency has designed a method to track participant and provider AT requests in its business systems, and that, when implemented, participants and providers will be able to view the status of individual applications in the myplace portal. It is expected to be incorporated into the system in the first half 2019.[94]

Committee view

2.59      The committee heard that a lack of clear consistent information on the AT application process is contributing to confusion for participants and their prescribing therapists. Whilst the information on the website outlines the process generally, that process does not appear to be delivered once participants actually enter the system and go through the application and assessment process.

2.60      Further clear information is required on assessment, trial, and quote phases, as well as on the methods by which applications can be submitted, what constitutes a sound application, and who can submit them. The Agency should also clarify when trials of equipment and quotes will be required and what format quotes and other information should take.

Recommendation 1

2.61      The committee recommends that the Agency revise the AT information on its website to improve clarity around all aspects of the AT process, and ensure training and guidance is provided to NDIA staff to improve consistency in the information provided to participants, providers and AT assessors.

2.62      All submitters, including the Agency itself, agree that the ability to track the progress of an AT request would assist everyone. It is a basic requirement, and the committee welcomes steps taken by the Agency to incorporate it into the myplace portal. It will also provide valuable data which will assist the Agency in providing further improvement to the AT process at a systemic level, while alleviating some stress on participants that a lack, or inconsistency of, information brings. The committee will monitor the introduction of the capability with interest.

2.63      The committee also heard from AT providers on the prohibitive costs of providing trial items to participants, especially in an outreach context in regional and rural areas. This service is crucial to participants, and despite the NDIA advising that there is a 'rental line' item available to pay for such costs, the committee is of the view that a specific line item for trial costs should be available for participants in receipt of AT.

Recommendation 2

2.64      The committee recommends that a line item for trial costs of AT equipment be created and included in the plans of all relevant participants. 

Delays in AT decisions

2.65      Nearly every submitter to the inquiry raised concerns about the length of time it takes the Agency to process AT applications. The committee repeatedly heard that it can take several months, and in some cases over a year, for the NDIA to process applications.[95]

2.66      The most common issue raised in complaints about AT to the Commonwealth Ombudsman in 2017–18 related to the time taken by the NDIA to decide an AT request.[96] Some participants who had approached the Office had waited 12 months with no decision having been made by the NDIA on their request for particular equipment, such as power wheelchairs, while other participants who requested AT in the form of home modifications or prosthetics, waited 24 months for an outcome.[97]

Impact of delays to participants

2.67      AT items typically restore function, prevent deterioration, and improve quality of life. As such, delays for approvals can significantly impact participants and their families. The committee heard some participants cannot be discharged from hospital, others cannot access their own bathroom, and some have no means of communicating without the requested AT or modifications.[98]

2.68      The committee heard there is widespread frustration amongst individuals, families, carers, service providers, and suppliers, who do not know when funding will become available.[99]

2.69      Amputees awaiting prosthetic limbs are at increased risk of pressure areas and resulting wounds, infections, and risk of falls which could result in preventable hospital admissions, and the potential for carer injuries was also raised.[100] The committee heard that damage can be caused to the remaining limb when sockets do not confirm perfectly to the individual's body.[101] ECIA drew attention to the impact that these delays are having on children who miss developmental milestones for lack of essential equipment.[102]

2.70      Some families purchased equipment with their own funds in order to avoid the Scheme' delays for approvals:

If we had to delay surgery whilst waiting for the NDIS to approve orthotics, our daughter's mobility would have continued to decline, she would quite likely have gone "off her feet", her muscles would have lost more strength, she would have done more damage to her joints and it would have been more difficult for her to regain her mobility post-surgery...[103]

2.71      In NSW, the state government intervened to mitigate the impact of AT approval delays on participants:

As at 7 September 2018 at least 990 participant requests reviewed by EnableNSW at the request of the NDIA are yet to be finalised by the NDIA and have been in the system for longer than three months awaiting a 'reasonable and necessary' decision for plan finalisation...Consequently, EnableNSW has provided equipment for 567 NDIS participants who are waiting on approval of AT in their plans. While AT is now the responsibility of the NDIS, NSW Health is aware that delays in the provision of aids and equipment are adversely impacting participant's health and has intervened to minimise the impact from these delays.[104]

2.72      A side-effect of delays for approvals was highlighted by The Benevolent Society, in that the person who requested the equipment may no longer be involved with the client or that funding in the plan may be exhausted by that time. In these cases, there may no longer be a practitioner or funding available to set up the equipment.[105]

Lengthy plan reviews

2.73      Inadequate plans not only have potential to compromise participants' outcomes, but they can result in the need for participants and their families to undergo an unscheduled plan review or appeal process which can further delay access to AT.

2.74      MS Australia reported that over 80 per cent of participants the organisation is providing support to have required a plan review due to errors in plans, underfunding of supports, or unmet needs not addressed during plan design.[106]

2.75      Submitters were critical of the need for participants to undergo unscheduled plan reviews in order to correct insufficient funding or errors in plans.[107] Submitters argued that the process is inefficient and there are often significant delays before a resolution is reached.[108] Attention was drawn to the additional stress the appeal process takes on participants and their families.[109]

2.76      MS Australia pointed out that undergoing an appeal process does not guarantee that a satisfactory result will be achieved:

The process for submitting and waiting for a response from the NDIA is just another cause of stress for those people that are most vulnerable. The fact that a total plan reset is required to change a single item in a plan or to amend an error by the Agency is causing a strain on the resources within the Agency which is then transferring to participants and the MS support staff involved. Once reviewed, changes to those support areas which were not included in the plan review leads to reductions in funding for core supports. These reductions then lead to yet another review and the cycle begins anew.[110]

2.77      The Benevolent Society argued that appeals drain funding from participant's plans and there may be insufficient funding for therapists to assist with the process.[111]

2.78      The committee heard that some families are choosing to avoid the process altogether by paying for AT themselves, and those who cannot afford to do so are simply going without:

...in many cases, clients or parents/carers of clients are taking it upon themselves to fund repairs to equipment because they cannot wait for the NDIS approval or review process for essential equipment. But in cases where clients are not able to cover the cost of the equipment or repairs themselves they are simply going without necessary equipment, which impacts on the quality of their life.[112]

2.79      The lack of communication from the Agency on the progress of reviews was also criticised:

A major concern is the lack of communication from the NDIA to participants regarding the progress of a review. This is especially frustrating for participants waiting for aids and equipment or home modifications.[113]

2.80      The Benevolent Society highlighted that a flow-on impact of unscheduled plan reviews is that service providers are unable to continue to deliver services to the client while the plan is placed on hold:

Given that NDIS plans do not include flexible or contingency funding, whenever funding in a plan is insufficient and additional funding is needed for new equipment, equipment upgrades or repairs a plan review is required. Whenever a plan is being reviewed, the plan is placed on hold and service providers are unable to continue to deliver services to the client, or to bill for services already delivered. Anytime an adjustment is required to the AT line item in a plan- the plan is placed on hold, and clients and providers are often not advised that the plan review is underway.[114]

2.81      The Commonwealth Ombudsman's May 2018 report into the NDIA's handling of reviews identified that the Agency had around 8100 reviews on hand, was receiving around 620 new review requests each week (at February 2018), and some reviews are taking up to nine months to be completed.[115]

Causes of delays

2.82      Evidence indicates there could be a number of reasons why participants are experiencing delays for an AT application outcome.

• NDIA staffing pressures; [116]
• Minor changes require a full plan review. [117]

Specific language required

2.83      The committee received feedback that some therapists are uncertain how to write AT reports in a way that meets the requirements of the Scheme.[118] Permobil argued that therapists are used to writing from a clinical perspective rather than in a way that links requested equipment to goals:

We have found that often the reports therapists put together do not link the Assistive Technology to the goals of the participant. Many therapists are still writing the reports with a focus on "clinical requirements" without linking the equipment to goals, which results in the applications being rejected by the NDIA. When the reports are rewritten linking the equipment to the participants goals the review approves the equipment. However, this process can take months.[119]

2.84      Mrs Julienne, Physiotherapist, Australian Physiotherapy Association, told the committee that prescribing therapists are learning to write their reports and recommendations in a way the NDIS requires:

They're non-clinical; they don't understand jargon. Gone are the days when we could talk to people who understood the disability and what we were saying. As physios, we dumb it down. We're taking out anything of clinical significance and putting really basic words in it in the hope that the person understands it...That's what we're all trying to work towards: what is the language we need to use; and how do we use NDIS language in our communications to the agency?[120]

Lack of assessors

2.85      Several submitters reported that participants are experiencing considerable delays accessing AT assessors[121] and that many professionals are heavily booked and managing lengthy waiting lists.[122] Moreover, the committee heard that some therapists automatically decline NDIS assessment work due to the delays involved.[123]  

2.86      PDCN reported that participants who require therapists to prescribe complex AT are experiencing additional delays that can add weeks or months to the process.[124] Similar feedback was provided by this NDIS participant:

This was the big hold up for me. The shortage of prescribing therapists with the skills to deal with a customised wheelchair script meant that it took about a month to be able to have an appointment with a therapist I trusted. Her feedback was that she is inundated due to the lack of therapists...It then took approximately 6 weeks for the therapist to do the report. Followed up several times but again she said she was flat out and was working through the assessments systematically.[125]

2.87      Able Australia drew attention to the difficulties faced by certain cohorts, for example, those with combined vision and hearing loss, who face additional complexity finding an appropriately experienced and qualified allied health professional who can recommend suitable specialised AT.[126]

2.88      There are additional concerns for participants living in regional, rural and remote areas. Independent Living Centre WA reported that participants in rural and regional WA are having AT assessments completed by the Health Department's therapy services as there are no private providers in the region.[127]

Lack of priority system for urgent cases

2.89      A common concern in submissions was the lack of a priority system to escalate urgent AT requests.[128] According to feedback from stakeholders, there is no way for applicants to distinguish urgent or dangerous situations for the Agency.[129]

2.90      APA drew attention to the lack of a public risk management system in use by the team processing AT applications:

Decisions and wait times appear to be inconsistent and do not follow any clear pattern (or documented process) around cost of equipment, needs, outcomes or risks to the participant. There appears to be no business rules for when applications will be responded to (approved / declined). There appears to be no published risk matrix or clear information available around how to request an urgent application where health or safety risks are imminent'.[130]

2.91      Indeed, the committee received feedback that some applications were not appropriately escalated. In the case of Timothy Rubenach, the urgency of his situation was communicated at several points; however, the requests failed to trigger an urgent  response:

Urgency was identified in many emails...regarding Tim's health and wellbeing and this was repeatedly ignored/not acted upon/not even acknowledged by return email from NDIS, and our 8th March letter, sent the NDIS and to the Disability Minister was ignored as well...Out of desperation, media (Fairfax and ABC) was contacted in early May...A final plea was made to politicians the day before Tim passed away...[131]

2.92      Similarly, the AT request for this participant was not escalated:

In one case, our team member watched powerlessly as recommended equipment requests bounced around between NDIA staff and suppliers, as the man's condition deteriorated. He eventually passed away, 12 months after the date of the initial assessment, and the emotional strain caused our team member to resign.[132]

2.93      The committee understands that the Agency has guidance to prioritise certain requests, including for: children with a rate of developmental changes that affects need; people with broken equipment in urgent need of replacement due to risk; and people with progressive neurological conditions where support needs change rapidly.[133]

2.94      The Agency has also advised that it has placed guidance on its website on how applicants can indicate urgency of requests. It also advised that a central team of planners is trying to respond to escalations within two business days.[134]

Impact of delays to providers and suppliers

2.95      Evidence indicates that approval delays can have considerable consequences on AT suppliers and providers. Most quotes are only valid for three months and expire by the time the NDIA approves them, meaning suppliers have to continually requote AT for participants which requires considerable resources on behalf of the supplier, participant, and assessor.[135] The committee heard that delays can sometimes be so extensive that a new assessment of the participant is required.[136] 

2.96      Submitters argued that delays in approval have potential to impact sustainability of suppliers.[137] PDCN argued that repeat consultations and quotes is inefficient and uneconomical, especially for smaller businesses:

Suppliers frequently find they are required to re-do consultations, for example in situations where the initial assessment and quote was provided up to 12 months prior. This impacts on the viability of businesses and may edge smaller suppliers out of the market, reducing the level of choice for consumers.[138]

2.97      Likewise, ILC Tasmania argued that it is unreasonable to expect suppliers to place items on hold for prolonged periods of time:

This is placing pressure on businesses as they run a trial for the AT, hold the items for the participant for approval, and due to delays, cash flow suffers. When this is the case for multiple orders, it can create major problems for a small specialised business.[139]

2.98      A common issue raised in submissions was the erosion of the client-provider relationship as a result of delays for AT.[140] Indeed, OTA argued that reputational risk has become a genuine concern for many prescribing therapists despite their innocuous role in the AT process:

A related and very serious issue for OTA members is reputational. Participants frequently develop a negative view of our members because of delays in the delivery of AT; delays which are attributable to existing arrangements for AT provision, and over which our members have no control. This has also impacted adversely on longstanding business relationships and given rise to a situation where the prescription of AT and home modifications, an integral part of the occupational therapist's role, has now become a business risk.[141]

Committee view

2.99      The Agency does not currently have specific KPIs in place across the Scheme for the consideration, and delivery, of Assistive Technology. The committee is strongly of the view that what you can measure, you can improve. The length of time that some people have had to wait for decisions around AT is unacceptable, especially in light of the length of time people had to wait under previous state and territory schemes.  

2.100         The committee heard that it can take months, even years in some cases, to receive requested equipment or devices. Delays for AT place can have profound effects on the development of young children, those who require prosthetics or orthotics, and those with degenerative conditions. The committee welcomes steps taken by the Agency to address delays, however, it is of the view that the Agency should set KPIs for the length of time in which staff must consider and process applications. This will improve inconsistencies in the Scheme and help to manage the expectation of participants and their providers.

Recommendation 3

2.101         The committee recommends that the NDIA prescribe KPIs for the length of time in which staff must consider and process AT applications.

2.102         The committee also heard that therapists are having to amend their language in order to meet the requirements of planners, and the administration of the Scheme. The Committee is concerned that if planners do not have the knowledge or training to understand clinical language, how can they be in a position to make decisions about the clinical needs of participants.

2.103         The committee urges the Agency to ensure that all delegates responsible for deciding which AT equipment a recipient may receive, have all the necessary skills and training to make those decisions.

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