Funding and delivery of services

4.1        This chapter examines the funding and delivery of ECEI services, and reviews issues raised by families, carers and service providers. The chapter considers Participant views on the costs of assessment and diagnosis, the adequacy for support needs and reported delays in service delivery. The chapter also considers service providers' views on service costs; regulated pricing, gaps in funding and workforce issues.

Assessment and diagnosis reports

4.2        Submitters[1] reported that families have to partially, and sometimes fully, fund assessment and diagnosis reports to provide evidence of their child's need for support and access the funding they need. The costs of these reports can be significant and are, at best, only partially subsidised. As highlighted in the evidence below, the issue of sourcing assessment reports is particularly relevant to families with children on the autism spectrum.

4.3        In its submission, the Victorian Autism Specific Early Learning and Care Centre noted that 'families often report feeling pressured to source a private assessment team, at great cost, to get a diagnosis and access the funding they need'.[2]

4.4        In 2017, AMAZE, the peak body in Victoria for people with autism and their supporters, conducted a survey of parents and carers of NDIS ECEI Participants. The survey found 36 per cent of respondents incurred costs to access the NDIS ECEI pathway (that is, costs for initial diagnosis and providing evidence of reasonable and necessary supports).[3]

4.5        At a public hearing in Melbourne, Mr Braedan Hogan, Manager, Public Affairs and NDIS Transition at AMAZE, reported that some people with an existing diagnosis are asked to obtain an up-to-date diagnosis at a personal cost.[4]

Public health system

4.6        The committee heard that, due to long waiting lists in the public health system and limited Medicare rebates and services, families are self-funding assessment and diagnosis reports. For example, the grandmother of a boy with autism stated she 'borrowed money to pay for an assessment of [name of grandson withheld] as the public wait time was around 1 year'.[5] Similarly a family 'self-funded occupational therapist, psychologist and speech pathologist assessments as the NSW Health waiting list was too long—12 months plus'.[6] The Australian Psychological Society Limited also reported that 'waiting lists for assessment in the public sector are lengthy (commonly 1–2 years, but often longer) and are not available in many parts of Australia'.[7]

4.7        There are only limited rebates under Medicare for these assessments. The Australian Psychological Society Limited explained:

Only some children will meet criteria for an assessment to be done under Medicare, and even then there is likely to be a substantial gap fee.[8]

[...] some children may be eligible for a Medicare rebate for an assessment for ASD. However, the rebate only supports a limited assessment and is significantly below the fees recommended by the APS. This means that many families pay full fees or a significant gap fee if the child is eligible for a Medicare rebate.[9]

4.8        Some diagnosis testings are not covered at all by Medicare. For example, the cost of genetic testing for SWAN Children (children with Syndromes Without A Name) is expensive and not covered by Medicare. SWAN Australia reported that the approximate cost for a singleton Whole Exome Sequencing (WES) is $2500, and $5000 for a trio WES Syndromes.[10]

Costs incurred

4.9        RDI Consultants Australia, an association representing and supporting RDI Certified Consultants and Trainees who provide the RDI (Relationship Development Intervention) Program, reported that assessments can cost $450 to $1500.[11]

4.10      One of AMAZE's survey respondents reported spending a total of $1200 on paediatrician reports.[12]

4.11      The costs of private diagnosis for Autism Spectrum Disorder (ASD) are high. According to the Australian Psychological Society, it is at least $2000 to $3000[13] and is not covered by private insurance.[14]

4.12      Dr Jessica Paynter, a Member of the Australian Psychological Society described the situation and consequences for families:

We're also seeing then that there is a gap where there is no funding for things like an intellectual assessment to demonstrate cognitive impairment. And a private assessment for a cognitive assessment or for an ASD assessment can be upwards of $2,000 to $3,000 per child. That's a substantial cost that is either borne by families—or they're coming in to Planners without evidence of their child's level of need, which makes it challenging to advocate for the supports that they require.[15]

4.13      Occupational Therapy Australia argued that it is placing families who cannot afford assessments at a significant disadvantage.[16]

Annual assessment when on a plan

4.14      Current NDIS Plans cover the cost of an annual assessment. However, best practice in early intervention for children with hearing loss is to undertake biannual assessments, to allow clinicians to review a child's progress and adjust services as appropriate in order for a child to achieve optimal results.[17] Hear and Say recommended that the assessment protocol be updated to allow Plans to include funded biannual assessments for children with hearing loss.[18]

Committee view

4.15      The committee is concerned that some families have had to fully or partially fund assessment and diagnosis reports to ensure their child could access ECEI services and have adequately funded Plans. The committee is also greatly concerned that some families feel pressured to pay for costly assessments to access funding and services.

4.16      As discussed in chapter 2, there should be no need for families to provide these costly assessment and diagnosis reports at the time of lodging the access request for ECEI services with the NDIA or during the Planning process. Furthermore, if the NDIS has made a request that a prospective Participant undergo an assessment or examination, the NDIS operational guidelines and the NDIS Act stipulate 'the NDIA will support the prospective Participant to comply with the request by providing assistance, including financial assistance where appropriate'.[19] The NDIA needs to clearly communicate to families, Planners and ECEI Partners that assessment reports are not needed unless requested by the NDIA. The NDIA should pay for the costs of assessment and diagnosis it requests from prospective and existing Participants.

4.17      The committee believes that adequate provision of funding for assessments should be made available in Plans if considered necessary by clinicians, and not be limited to funding for an annual assessment if better results can be achieved with more frequent assessments.

Recommendation 9

4.18      The committee recommends the NDIA clearly communicate to families, Planners and ECEI Partners that assessment reports are not needed unless requested by the NDIA.

Recommendation 10

4.19      The committee recommends the NDIA ensures provision of funding for assessments in Plans is based on the Participant's needs and is not arbitrarily restricted to a yearly assessment.

Funding in plans

Overall funding  

4.20      Some inquiry participants reported significant funding shortfalls in Plans under the ECEI Approach.[20]

4.21      In response to AMAZE's ECEI survey, only 54 per cent of respondents felt satisfied that the amount of funding provided was adequate to meet their child's early intervention support needs.[21] One of the survey respondents estimated 'that the funding is 40 per cent to 50 per cent below requirements'.[22]

4.22      Children and Young People with Disability Australia (CYDA), provided examples of some family experiences that highlight issues of significant funding shortfalls in Plans:

Lack of funding has limited the access to supports in general and excluded some others. Our child's plan was cut from $32000 to $16000 in the second year and this has had a major impact.

We have just applied for the NDIS and received a first package which is half of what we applied for. We are currently launching an appeal.[23]

4.23      The committee also heard from the grandmother of a three year old boy that his Plan is currently underfunded by $50 000.[24]

Underfunded plans for children with autism

4.24      Submitters expressed concerns about the inadequate level of funding ECEI Participants with autism are commonly receiving.

4.25      The Australian Psychological Society indicated that NDIS funding levels are lower than previous national funding models such as Helping Children with Autism (HCWA).[25]

4.26      The Australian Psychological Society pointed out that current funding levels make it difficult to achieve good outcomes:

Current funding levels are not commensurate with recommended best/good practice guidelines in Autism Spectrum Disorder (ASD) of 15-25 hours per week making it difficult for consumers to obtain good outcomes.[26]

4.27      Similarly, Victorian Autism Specific Early Learning and Care Centre submitted:

The funding ECEI Participants with autism have received does not align with evidence-based practice. The NDIS publication, Autism spectrum disorder: Evidence-based/evidence-informed good practice for supports provided to preschool children, their families and carers (Roberts and Williams, 2016), recommends 15-25 hours per week of evidence based, early intervention for children with autism. However, thus far, NDIS Plans have only supported such intensity for children who are severely impaired. Children with mild-moderate autism have received limited funding and do not enable them to access the recommended intensity of intervention.[27]

4.28      At a public hearing in Sydney, Mrs Tina Skapetis, a mother of a girl diagnosed with autism, reported:

In late November 2016 the NDIS advised that Emanuella's plan had been approved for $22,000 for 12 months. This was $38,000 short of what we needed. We were devastated. There was no way that we could afford to fund the shortfall. I expressed my disappointment, only to be told by the planner that I should be grateful for what I have gotten, as other families got only $17,000.[28]

4.29      In its submission, the Victorian Autism Specific Early Learning and Care Centre relayed stories from parents of children with autism who received inadequate funding in their child's Plan:

Parent 2: [...] Funding was not enough to cover everything we needed. [...]We had to cut therapies to make the funding we had last. We are still going to run out before review, and are having to obtain loans to bridge the gap.

Parent 4: [...] Her plan was approved in May, for 39 hours, or $6900, which is woefully inadequate for what she needs.[...] Next year, I will have to pay for private therapy (OT, speech and psych) to supplement funded therapy if we have the same amount.[29]

Underfunded Plans for deaf and hard of hearing children

4.30      The committee recently reported on the issue of underfunded Plans for deaf and hard of hearing children in its interim report Provision of Hearing Services under the National Disability Insurance Scheme,[30] released in September 2017.

4.31      During the course of the inquiry, submitters from the hearing sector[31] continued to report that Plans for deaf and hard of hearing children are generally underfunded and not meeting children's reasonable and necessary support needs.

4.32      First Voice and its members reported that families customarily receive NDIS funded Plans that are $6000–$10 000 per child per year less than the actual costs of services.[32]

4.33      Mr Michael Forwood, Chair of First Voice noted:

So, most children who are entering into the specialist language development programs are now getting $6,000, against a cost of between $18,000 and $22,000 for a comprehensive multidisciplinary program.[33]

4.34      Mr Bart Cavaletto from the Royal Institute for Deaf and Blind Children told the committee that 'the plans that families are getting in no way reflect the cost of delivering services'.[34]

Inconsistencies in funding

4.35      As with other cohorts in the Scheme, variations in types and amounts of funded support in NDIS Plans for children with similar needs remain a significant concern.[35]

4.36      The Commonwealth Ombudsman reported that 'ECEI providers expressed frustration and concern that children in very similar situations could receive NDIS Plans with vastly different types and amounts of support'.[36]

4.37      The Royal Institute for Deaf and Blind Children found that 'the scope of supports provided to Participants in their Plans is highly variable despite similarities in needs'.[37]

4.38      Early Childhood Intervention Australia Victoria/Tasmania and others[38] suggested that variations in funding can be attributed to parents' ability to advocate for their child's needs:

Inequities have been identified by service providers in many plans indicating parents who are better able to advocate for their child's needs or those who are supported through the process are receiving better supports and funding.[39]

4.39      Variations and inconsistencies in funding have also been attributed to the lack of knowledge and expertise of NDIS Planners.[40]

Assistive technology

4.40      The issue of funding for assistive technology in Plans was raised by many participants.[41] Submitters noted inconsistencies in funding, approval and rejection of assistive technology, which can lead to suboptimal or inappropriate equipment being given to children.

4.41      Ms Gail Mulcair, CEO of Speech Pathology Australia, reported that some Participants are given inappropriate assisted technology equipment in their Plans to reduce costs:

We certainly see these decisions occurring around trying to limit the cost, in the situation of an AAC device or a communication aid, as an example, or other assisted technology equipment, that there is a cap on the expense. Decisions are being made around defaulting to something which may be more affordable but may not be appropriate, or certainly that has been recommended as not being appropriate for that child or in the case of adults.[42]

4.42      Participants expressed concerns about funding for non-specialised technology, such as tablets being rejected in Plans despite being relatively low cost, to meet the needs of some NDIS Participants.[43]

4.43      Deaf Services Queensland explained how tablets can reduce expenses to the NDIA over the short and long term by 'enabling children to participate in therapy or Teacher of the Deaf services via tele-practice, thereby increasing efficiencies and decreasing the impact of travel distances'.[44]

4.44      Ms Michelle Crozier, NDIS Project Manager, Deaf Services Queensland, said:

We want to be able to deliver our services remotely through videoconferencing, and people need tablets for that—particularly for interpreting. We have arrangements with hospitals like Townsville Hospital, where they have an iPad and we do remote interpreting. But we can't do that under the NDIS for individual participants because a tablet or device that will support that can't be funded.[45]

4.45      Mrs Rachel Tosh, General Manager at Therapy Alliance Group, reported the following case:

Just this week, we had a child where the therapist had recommended an iPad with a specific app for communication. The child's already familiar with the app from school, so it would provide a cost-effective alternative and augmentative communication method for this child. We were informed not to put in an AT request for the iPad, because it wouldn't be funded, because it's not a disability specific support.[46]

4.46      Deaf Services Queensland noted that tablets were previously funded under Commonwealth schemes such as a Better Start and Helping Children with Autism (HCWA).[47]

4.47      Similarly, Myhorizon noted that therapy resources such as Sensory Aids (weighted blankets, vests, and mini-trampolines) and Assistive Technology (iPads) are not being approved, but that 'these therapy resources are funded via Better Start and HCWA'.[48]

4.48      A respondent to AMAZE's ECEI survey also reported that 'the NDIA refuses to fund sensory equipment that would make a big difference to my child's behaviour'.[49]

Interpreters

4.49      Many submitters raised concern about the lack of funding in Plans for interpreters and translators.[50]

4.50      Noah's Ark Inc explained:

The NDIS has a rule that it will not support the cost of translators. This means that non-English-speaking families cannot understand, gain information from services about their child's condition or the supports they need to provide. This rule undermines the purpose of early intervention.[51]

4.51      Occupational Therapy Australia reported that 'concerns have also been raised about the decision to no longer fund interpreters, and how this will affect service providers who are unable to afford the fees for an interpreter to communicate with parents from culturally and linguistically diverse (CALD) backgrounds'.[52]

4.52      The Victorian Government is also concerned about the lack of funding for interpreter services and how this may affect the quality of services provided to Participants.[53] They submitted that the NDIS 'should fund interpreter services for culturally appropriate service provision'.[54]

4.53      Similarly, Autism Spectrum Australia recommended 'funding for interpreters and translators as part of NDIS packages (not just for the Planning process) as this cost is not able to be met from NDIS funding'.[55]

Support for families, carers and siblings

4.54      The lack of funding and support available for families, carers and siblings was raised by several inquiry participants.[56]

4.55      Syndromes Without A Name (SWAN) Australia is of the view that 'funding needs to be directed into supporting families when they are first told there is an issue with their child's development'.[57] It recommended funding for counselling be made available for families and carers who care for a child newly diagnosed.

4.56      KU Children's services pointed out that because the NDIS focuses on individual supports, group support programs which supported families are no longer adequately funded to operate.[58]

Sibling support

4.57      Submitters argued that the needs of siblings are being overlooked in the ECEI Approach and highlighted that siblings of children with a disability or developmental delay can experience a range of challenges, such as ongoing stress, which can affect their health, well-being, and contribution to society.[59]

4.58      At a public hearing in Adelaide, Ms Kate Strohm, Founder and Director of Siblings Australia, explained the important role of siblings:

Siblings are also a key component of the sustainability of the NDIS. They are a major part of the informal support for a person with disability. But, again, there is no support for them. They are a key part succession planning as parents become older. Often, siblings will step in and take over that role.[60]

4.59      Ms Strohm also pointed out the lack of dedicated policy or funding for sibling support under the NDIS:

Siblings are not in policy anywhere. There is a lot of rhetoric about families, but, unfortunately, here there is no mention of siblings. This is unlike in the UK, where the Children Act states that the needs of brothers and sisters should not be overlooked—they should be provided for as part of a package of services for the child with a disability.[61]

4.60      One submission provided a number of practical examples of how siblings could be supported, including through therapist facilitated sibling support groups or through individual therapy and counselling.[62]

4.61      In response to the committee's question on supports available for siblings, the NDIA stated:

The National Disability Insurance Scheme funds supports that families need as a result of a family member's disability, such as:

• family support and counselling due to a family member's disability;
• building the skills and capacity of other family members to manage the impact of a Participant's disability on family life;
• supports that increase the Participant's independence, as well as supports that enable the Participant to enjoy social and community activities independent of their informal carers; and
• supports aimed at increasing the sustainability of family caring arrangement, including personal care and domestic assistance related to the person's disability.[63]

Committee view

Plans

4.62      The committee is concerned with the numerous reports of significantly underfunded Plans for ECEI Participants. The committee notes that the funding shortfalls and inconsistencies in Plans appear to particularly affect children with autism and those with hearing impairments.

Underfunded plans for children with autism

4.63      The committee received concerning evidence in relation to recurring funding shortfalls in Plans for children with autism. It appears that the level of funding granted in many Plans does not meet Participants' needs and does not align with recommended evidence-based practice guidelines. This is resulting in those children not accessing the right level of support and therapies to achieve optimal outcomes.

4.64      Alarmingly, the committee heard that NDIS funding levels are often lower than previous national funding models such as Helping Children with Autism. It is concerning that some Participants and their families are potentially worse off than under previous funding models.

4.65      With almost 40 per cent of NDIS Participants age 0–6 years having autism as their primary disability, it is of paramount importance that the NDIA urgently addresses the issues of scope and level of funding in Plans for children with autism.

Recommendation 11

4.66      The committee recommends the NDIA urgently address the issues of scope and level of funding in Plans for children with autism with a view to ensuring that recommended evidence-based supports and therapies are fully funded.

Underfunded plans for deaf and hard of hearing children

4.67      The committee has already made a number of recommendations in its interim report Provision of Hearing services Under the National Disability Insurance Scheme[64] to address funding shortfalls in Plans for deaf and hard of hearing children.

4.68      The committee reiterates its concerns regarding funding levels in Plans for deaf and hard of hearing children. The committee urges the NDIA to implement the Provision of Hearing Services Under the National Disability Insurance Scheme recommendation 5 in relation to early intervention packages.

Recommendation 12

4.69      The committee recommends the NDIA implement the Provision of Hearing Services under the National Disability Insurance Scheme recommendation 5 in relation to early intervention packages which says:

The committee recommends NDIA ensures that the early intervention packages take a holistic approach to the needs of Participants and include:

• scaled funding, depending on need;
• funding provision for additional services beyond core supports, depending on need; and
• retrospective payment of the costs borne by approved service providers for the provision of necessary and reasonable supports between time of diagnosis and Plan enactment.

Assistive technology

4.70      The committee believes that approval of funding for assistive technology should be systematically and consistently based on the Participant's individual needs to achieve optimal outcomes. The funding decision should not be based on minimising costs. As a result, the committee is concerned that some submitters suggested that Participants were given inappropriate assisted technology equipment to reduce costs. The committee acknowledges the existing NDIS operational guidelines on funding assistive technology available on the NDIS website.[65] The committee recommends the NDIA further clarifies in its guidelines its definition and interpretation of minimum necessary and standard level to determine funding for equipment in a Participant's Plan.[66]

4.71      A major source of concern for families is the rejection of funding requests for certain items such as iPads, despite being recommended by therapists. According to the NDIS operational guidelines, the committee believes there is no reason for rejecting a request for a tablet or sensory equipment if it meets the following criteria:

[...]allows a Participant to perform tasks that they would otherwise be unable to do, or which increases the ease and safety with which tasks can be performed. [...] In addition to enabling Participants to be more independent or participate more fully in daily activities, assistive technology may:

• reduce the need for assistance;
• make assistance safe and sustainable; or
• prevent or slow the development of further impairment.[67]

4.72      The committee believes the NDIA should clarify its guidelines in relation to funding non-specialised equipment.

Recommendation 13

4.73      The committee recommends the NDIA reviews and clarifies its Operational Guidelines on funding for assistive technology with the view of ensuring that Participants can access the most appropriate equipment to meet their needs.

Interpreters

4.74      The committee is concerned that costs for interpreters for families who need them appear not to be appropriately covered in Plans. The committee notes there is no specific information in the NDIS Operational Guidelines about supports in Plans for interpreters. However, there is a factsheet about Translation and Interpreting Services (TIS) available for Participants or their parents or carers which states that Participants with a Plan from a CALD background can access assistance from the National Translation and Interpreter Services when engaging with NDIA registered service providers.[68]

4.75      The committee believes the NDIA needs to clarify its Operational Guidelines and ensures provision of funding for interpreters to enable efficient communication with Participants and their families.

Recommendation 14

4.76      The committee recommends funding be made available in Plans for interpreters, including funding an interpreter to communicate with the Participant's parents or carers.

Supports for families and carers

4.77      The committee believes access to supports for families and carers should be integral to the ECEI Approach. The committee agrees that, to date, the role of siblings of children with disability has been overlooked within the framework of the NDIS and its ECEI Approach. The committee believes that the NDIA should consider the development of sibling specific supports and how these could be integrated into the ECEI Approach. Development of tailored programs should be considered and delivered through the Information, Linkages and Capacity Building (ILC).

Recommendation 15

4.78      The committee recommends the NDIA consider allocating specific funding for the development and provision of tailored support programs for parents, carers and siblings of children with disability through the ILC.

Delays in accessing and receiving services

4.79      As described by CYDA, 'early childhood is a well-established pivotal time for development and it is critical that children and families have timely access to expertise, services and supports during this time'.[69]

4.80      Many submitters are thus concerned about the delays in receiving services under the ECEI Approach and the negative impacts these delays can have on the success of therapies and the future of their children and families.[70]

4.81      Delays are not just occurring during the process to determine access to ECEI services and Planning phase to devise a first Plan but also once a child has a Plan.[71]

4.82      Ms Fleur Beaupert, Policy Officer at CYDA, reported that families experienced 'lengthy delays in accessing services' with some families 'waiting up to 18 months before accessing services'.[72]

4.83      Similarly, Ms Teigan Leonard, Team Manager/Psychologist at Kalparrin Early Childhood Intervention Program Inc commented that they had 'families who have had to wait in excess of 90 days to be able to access any of their funds'.[73]

4.84      The Royal Australasian College of Physicians expressed concern over long delays in South Australia for vulnerable children. This includes 'children in South Australia under the Guardianship of the Minister (GOM) waiting around 12 months between enrolment in the NDIS and therapy commencing'.[74]

4.85      First Voice gave the following example from a service provider in South Australia:

Cora Barclay Centre statistics show there have been 48 new ECI referrals since the NDIS started of whom 11 (23%) commenced services with us 12 months or longer after confirmation of diagnosis. These include 3 who have taken longer than 2 years.[75]

4.86      Other submitters[76] reported similar concerns, including Deaf Services Queensland, which attributes some of the delays in provision of services to provider availability, limited service options in some areas, and limited awareness from relevant Access Partner on possible pathways and services.[77]

4.87      Long waiting lists to access relevant services are a common issue,[78] with one family reporting:

It took a whole year to access supports, but everything was booked out so my son's first plan was wasted. He used hardly any of his first plan because of waiting list times![79]

4.88      Disability sector staff shortages were identified as one of the contributing factors to delays in delivering services.[80]

4.89      SDN Children's Services believes that 'the demand for ECEI support had been underestimated and this has increased waiting lists for new children'.[81]

4.90      As described by Deaf Services Queensland, issues of service delays are 'obviously exacerbated through the tyranny of distance and limited options of specialist providers within certain locations'.[82]

Committee view

4.91      The committee is concerned with widespread reports of delays in accessing and receiving services for ECEI Participants with a Plan. This can significantly impact on the success of therapies and the ability of Participants to achieve optimal outcomes.

4.92      The committee noted that contributing factors to delays in accessing and receiving services for Participants are part of a broader range of issues across the Scheme, which include: overall disability staff shortages, underestimation of the demand for support, and the limited options of providers.

Costs of delivering services for service providers

4.93      Throughout the inquiry, ECEI service providers raised a number of issues regarding additional burdens and costs associated with operating as an ECEI service provider, the pricing of services and emerging gaps in funding.

Registration process and costs

4.94      Some service providers[83] expressed concerns about the registration process and the costs associated with becoming an NDIS service provider.

4.95      The Commonwealth Ombudsman stated:

Many smaller service providers, and even some larger ones, have also complained about the costs and administration associated with registering with the NDIS, claiming the arrangements are more onerous than the previous state requirements.[84]

4.96      Speech Pathology Australia noted 'significant barriers to NDIS provider registration to deliver ECEI supports in some states and territories'.[85]

4.97      Occupational Therapy Australia reported that 'The NDIA's apparent inability to engage meaningfully with service providers, and the difficulties involved in navigating the NDIA website, act as disincentives to registration as an NDIS provider'.[86]

4.98      This has led to some services providers indicating they will not register as an NDIS provider and may mean that only larger service providers will remain in the market; reducing supply, decreasing competition and limiting choices for families.[87]

4.99      For example, a small service provider explained:

To register for NDIS Early Childhood Supports as a new Provider is overly onerous; particularly for sole traders and small organisations [...] I need to make a business decision about whether I can absorb the costs associated with registration for NDIS. It is difficult to do this when I can't determine roughly what these costs will be. Many of my colleagues have decided not to register as the process is too onerous.[88]

4.100         Speech Pathology Australia anticipates unmet need for speech pathology ECEI services unless issues with provider registration are addressed.[89]

4.101         The Dietitians Association of Australia drew the committee's attention to the issue of the exclusion of Accredited Practising Dietitians (APDs) from the Early Supports for Early Intervention Professional Registration Group.[90]

4.102         Some submitters[91] recommended streamlining the registration process for providers.

Administration costs

4.103         Submitters raised concerns about the pricing structure used by the NDIS. Significant new costs, including organisational overheads, are not reflected in the NDIS pricing structure.[92]

4.104         The Victorian Autism Specific Early Learning and Care Centre noted that the NDIS Price Guide rates are often inadequate to cover the true costs of quality service provision as 'they do not allow for the necessary overheads of a well-coordinated (transdisciplinary) service'.[93]

4.105         Similarly, Noah's Ark Inc argued:

The pricing structures being used by the NDIS are not realistic in a number of areas, including organisational overheads. There are significant new costs being introduced under the NDIS, including for marketing, administration (e.g. highly complex financial processes) and IT systems.[94]

4.106         The Cora Barclay Centre reported absorbing significantly increased administration costs:

Under the NDIS, most of the very substantial burden of administration is borne by service providers and families/participants, not by the NDIA.[95]

4.107         Ms Dee Hofman-Nicholls, Director at Enhanced Health Therapy Services, described the situation:

[...] for every one clinician we have on the ground we need a 0.6 FTE to support the administration costs of NDIA, which are exorbitant. Effectively, for $175.57 we're paying two people's wages, not just one person's. When the new price guide came out with no increase to therapy cost because 'you are paid quite well,' it was quite insulting, because we aren't lining our pockets. There are actual costs to administering the scheme. A lot of costs aren't being billed onto the client.[96]

4.108         As a consequence, Mrs Hofman-Nicholls concluded that small businesses will stop operating:

Long term, small business will not be able to play in this field and it will return to what we had: several big service providers with long waiting lists and reduced or very little choice and control. There are some very, very, very fatal flaws that will affect small business continuing in this scheme.[97]

Non-attendance at appointments

4.109         Occupational Therapy Australia and other submitters[98] reported that service providers are financially disadvantaged by clients who fail to keep appointments despite some recent adjustments to arrangements that partially compensate providers for non-attendance.

4.110         Until 30 June 2017, the NDIS price policy prohibited cancellation charges. The policy was amended, and from 1 July 2017, the NDIA advised that:

Providers may charge for up to 2 participant cancellations for therapeutic supports per annum. Each cancellation charge must be for no more than 2 hours of support, and may only be applied where the participant has failed to give 24 hours' notice.[99]

4.111         Noah's Ark Inc noted that the NDIS rule on cancellation has been modified but considers that it is not enough for service providers supporting young children:

Young children, as is generally understood in the community, become ill more quickly and more frequently than older children and adults. As a result, the cancellations policy has a more adverse effect on service providers supporting young children.[100]

4.112         According to Occupational Therapy Australia, the lack of compensation for cancellations is a contributing factor to providers not being able to have a reliable income and ultimately leaving the sector, especially in regional, rural and remote areas.[101]

Peer and group therapy

4.113         Pricing guidelines also impacted the provision of peer and group therapy services. Occupational Therapy Australia told the committee that:

The NDIS is currently not providing funding options for young children to attend small social group therapy. Currently, group therapy is funded at a rate that is not viable for clinics to implement, with rigid therapist to child ratios that do not take into account the needs of the child.[102]

4.114         Some submitters argued that changes to the NDIS Price Guide are needed to reflect the costs of providing peer therapy to children with developmental disabilities who are transitioning from individual to group therapy.[103]

Committee view

4.115         The evidence received to date about the registration process suggests that the current system is not operating as well and effectively as it should be. The committee also noted the issues around increased administration costs borne by providers and pricing issues. All these issues are threatening the sustainability of providers, especially sole traders and small organisations to operate in the NDIS environment. This has the potential to further limit choices for Participants and further extend delays in accessing and receiving services.

4.116         The committee acknowledges that, in response to the wide range of issues raised in the FY2017–18 Price Review, the NDIA has commissioned an Independent Pricing Review, which is currently being undertaken by McKinsey & Company. The committee understands that the Review will deliver its Final Report by the end of 2017.[104]

4.117         The committee also notes finding 8.1 of the Productivity Commission in its recently released Study Report on NDIS Costs, which states that 'the benefits of the NDIS will not be fully realised if the Agency continues with its current pricing approach'.[105]

4.118         Once released, the committee will consider the Independent Pricing Review report within the broader context of the NDIS market readiness.

Provision of ECEI services in rural and remote areas

4.119         Accessing and delivering services in rural and remote areas presents some challenging issues. Issues raised by service providers include lack of funding for travel and use of innovative technologies to deliver appropriate services.

Transport

4.120         Transport costs for service providers to deliver services in rural and remote areas are high. Dr Jennifer Fitzgerald, CEO, Scope Australia described the situation:

Transport, particularly for us in rural and regional Victoria, is a major problem. We are unable to bill between services. We can bill for the first 40 minutes of the day. Our practitioners see approximately five or six children a day, if they're out on the road, particularly in rural and regional Victoria. All of that time and the actual cost of the vehicle—mileage cost, depreciation, maintenance and purchase—is unfunded.[106]

4.121         Mrs Amanda Mather from Hear and Say reported that, due to lack of specialist services in rural and remote communities, Hear and Say has to travel to adequately support families and noted that 'the travel allowances that are currently provided for in the NDIS are inadequate and not satisfactory for the size and nature of Queensland'.[107]

4.122         Deaf Services Queensland described travel as being the 'single most complex issue in terms of adequate funding to provide support, particularly in locations where the Participant does not live close to services'.[108] Their submission highlighted that 'the $1000 a year limit on travel for therapists (across all therapy support delivered) does not provide fair and equitable access to supports and services for clients living in more regional areas or clients who are financially challenged and don't have access to transport to attend sessions'.[109]

4.123         Similarly, Speech Pathology Australia highlighted that the limits for payment for provider travel can restrict access to specialised supports:

Rulings regarding NDIS payment for travel by providers further restricts access to these specialised speech pathology services to NDIS Participants who need them. Defining strict limits for payment for provider travel in all Participants plans and not allowing flexibility in travel expenses for individual Participants means that children who required the services of a speech pathologist with specialised expertise may not be viable to purchase within the parameters of the funded plan if that practitioner is located a significant distance away from the child.[110]

4.124         Vision Australia believes it is unfair for families and service providers to be put in a situation where they are required to draw down on Participants' support budgets for purposes of travel as this may impede them receiving adequate supports.[111]

4.125         At a public hearing in Melbourne, Mr Scott Jacobs from Vision Australia further explained:

When you do bill for travel, it comes out of the support budget for the participants. In theory the participant is given an allocation within that budget that is intended for travel. It's not separated out, and the justification or rationale that leads to how much travel might be included in that support budget is not ever clear. If you have multiple providers billing travel, the limits are different for adults and children, but you are drawing down on what could potentially be your support budget for service delivery, which from a provider perspective is an ethical quandary and is not a particularly pleasant one. What would be ideal would be to have a specific limited budget for provider travel to be able to have the access that doesn't touch the support budget for families.[112]

4.126         Many submitters recommended allocation of additional funding, on top of the loading currently provided, for travel to address the significant challenges for families and service providers in rural and remote areas.[113]

Technology

4.127         AMAZE submitted that emerging research supports the efficacy of delivery of therapeutic services to remote locations via videoconferencing facilities.[114]

4.128         Speech Pathology Australia recommended greater use of videoconferencing to communicate with clients and families living in rural and remote areas.[115] Similarly, Connect and Relate for Autism Inc argued that a telehealth service model can significantly reduce the demands and costs associated with families needing to travel long distances to access services.[116]

4.129         However, Early Childhood Intervention Australia reported 'inadequate resourcing of technology to enable collaboration and access to remote areas and consultations' and recommended 'funding for ICT infrastructure and technology solutions to enable case-conferencing, skype/online consultations and chat rooms and e-referral'.[117]

4.130         Lifestart suggested that 'investment in the use of technology for some ECEI service provision is one way to resolve accessibility issues in some rural and remote areas'.[118] Hear and Say also recommended 'improving funding for technology to assist with access to tele practice services.[119] Similarly, AMAZE called for the Australian Government and the NDIA to consider 'innovative service delivery methods such as telehealth models to mitigate potential market failure'.[120]

4.131          Overall, Participants recommended a review of costs of service provision in regional, rural and remote areas.[121]

Committee view

4.132         The committee understands there can be significant additional costs to deliver services in rural and remote areas, including costs associated with travel. The committee noted that the new NDIA Price Guide, introduced on 1 July 2017, incorporates a series of changes, including an increased price loading to apply for the delivery of supports to Participants in remote and very remote parts of Australia.[122] However, it appears that the issue of travel costs remains a significant cause of concern for services providers. The committee believes it is too early to evaluate the impact of the recently introduced increased price loading for delivery of supports in remote areas.

4.133          The committee notes with interest the call for a greater use of technology, especially videoconferencing for delivering services in rural and remote Australia. Submitters identified videoconferencing as an efficient and cost effective way to deliver some types of services. The committee believes technological solutions to deliver services should be encouraged as long as the quality of services is not compromised. The NDIA should, as part of progressing its rural and remote strategy, investigates how it can better support Participants and service providers to use technology.

Recommendation 16

4.134         The committee recommends the NDIA develop a strategy to foster greater use of technology to deliver services in regional, rural and remote areas.

Workforce availability, remuneration and training

4.135         ECEI service providers expressed concerns around the availability of a suitably qualified and experienced workforce.[123] Inadequate remuneration and lack of training and professional development opportunities were identified by submitters[124] as major contributors to current staff shortages.

Workforce remuneration

4.136         SDN Children's Services highlighted the inability for service providers to recruit and retain staff due to the limited funding available under the ECEI Approach.[125]

4.137         Early Childhood Intervention Australia Victoria/Tasmania raised concern about funding constraints that 'will lead to the employment of graduates with lower qualifications and/or less experience'.[126]

4.138         Carers Australia stated that specialists are 'often in short supply, especially when they may have more attractive employment conditions in the health sector'.[127]

4.139         Occupational Therapy Australia argued that the ECEI Approach should ensure the viability of providers who work in a variety of capacities (as sole providers, in multi-disciplinary private practices, as part of NGOs) 'by recognising the costs of delivering services and ensuring these are offset by appropriate remuneration'.[128]

Workforce training

4.140         National Disability Services and others[129] expressed concerns about the NDIS pricing model, which limits opportunities for training and professional development. This could contribute to workforce shortages in the future.

4.141         Noah's Ark Inc noted 'there is little indication that the NDIS costing has considered the recruitment and training of new staff or the need to provide careers for allied health professionals and teachers, who have other career opportunities in health and education'.[130]

4.142         Early Childhood Intervention Australia NSW/ACT expressed the view that 'the ECEI Approach needs to assist with the mentoring of the future ECI workforce. This has cost implications and the funding should support the development of our future workforce'.[131]

4.143         National Disability Services and others[132] recommended the development of a strategy for responding to skilled practitioner shortages.[133] Similarly AMAZE identified the need for 'a concentrated effort by Government to stimulate growth in the skilled disability workforce'.[134]

Committee view

4.144         Workforce shortages are well documented. As described by the Productivity Commission in its recent Study Report on NDIS costs,[135] the disability sector workforce will need to double and in some regions triple or more over the transition period to meet demand. It is not surprising, therefore, that this issue was raised in the context of this inquiry.

4.145         The committee received evidence that workforce remuneration, training and professional development issues contribute to current challenges. The committee believes these important issues warrant further work and analysis, and be considered within the broader context of market and workforce readiness.

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