8.1
This chapter examines issues for the National Disability Insurance Scheme (NDIS) and its workforce associated with thin markets, and makes preliminary recommendations to address identified concerns.
8.2
Key issues considered in this chapter include:
challenges for regional, rural and remote communities;
local workforce development;
workforce concerns for Aboriginal and Torres Strait Islander peoples;
the maldistribution of allied health services;
concerns associated with travel; and
NDIS costs and administrative burden.
Challenges for regional, rural and remote communities
8.3
The committee heard that regional and remote communities face particular challenges in recruiting and retaining a suitably qualified workforce. In many cases, these mirror the challenges faced by the workforce more generally, exacerbated by the additional cost and administrative burden associated with remoteness and professional isolation.
8.4
National Disability Services (NDS) provided a comprehensive—though non-exhaustive—list of the factors that contribute to market failure in regional, rural and remote areas. According to NDS, these include:
price caps which are not sufficient to cover the higher costs of service delivery in regional, rural and remote areas;
a small number of active service providers;
high travel costs which are not adequately covered by NDIS funding;
inconsistency in the National Disability Insurance Agency's (NDIA) approach to funding transport;
the time needed to establish relationships of trust with remote communities;
inadequate crisis management or provider of last resort arrangements;
tension between individualised and community approaches to care and service delivery; and
the cultural capacity of staff.
8.5
According to NDS, the difficulties of providing quality disability support are compounded in some areas by problems including inadequate or overcrowded housing; poor community infrastructure; inadequate and expensive transport; and shortages of income to meet basic needs.
8.6
Lifestyle Solutions observed that regional and remote areas have smaller pools of candidates and more competition for them—both from adjacent sectors such as health and aged care and unrelated sectors such as mining. These and other factors play out in higher costs in terms of recruitment, orientation, cultural induction and training, and may lead to increased turnover.
Challenges for particular states
8.7
The committee heard that jurisdictions have discrete workforce challenges that must be taken into account as part of workforce planning at the national level.
8.8
For example, the Northern Territory Office of the Public Guardian (NT OPG) noted that the NT's transient population impacts workforce retention, as skilled workers often have alternate employment options in other jurisdictions. In addition, a high proportion of Territorians identify as Aboriginal and Torres Strait Islander. The NT OPG noted that Aboriginal and Torres Strait Islander peoples often experience significant difficulties receiving appropriate support services in remote and very remote communities.
8.9
Dr Emma Campbell, Chief Executive Officer (CEO), ACT Council of Social Services (ACTCOSS), highlighted characteristics of the Australian Capital Territory (ACT) that should be considered as part of workforce development:
We have significant competition in terms of employment from both the federal and the ACT public service, which are relatively well paid. I think also that the average levels of, and types of, qualifications in the ACT don't necessarily match with the available jobs in the disability sector, the broader community sector and the healthcare sector.
Inability to specialise in regional, rural and remote areas
8.10
The committee heard that it is often not viable for allied health professionals to deliver only NDIS-funded services in regional, rural and remote areas. For example, Ms Claire Hewat, CEO, Allied Health Professions Australia (AHPA), observed that:
[A] lot of allied health…can't survive on just NDIS practice. Particularly in more rural and remote areas, they have to have mixed practice, so they have to have a practice which is viable in, perhaps, providing a day service to a private hospital, a day service to a GP clinic and a day service to an aged-care home, and then the balance is done with [the] NDIS.
8.11
This view was echoed by Services for Australian Rural and Remote Allied Health (SARRAH), which suggested that the allied health workforce in rural and remote areas should be conceptualised as 'allied health professionals who deliver NDIS services', rather than as an 'NDIS workforce'. Ms Catherine Maloney, CEO, SARRAH, asserted that this lack of capacity to specialise in rural or remote areas means workforce development requires a cross-agency, cross-sector approach. Ms Maloney noted that that at present, multiple agencies are focussing on different strategies to improve the local workforce—leading to fragmentation.
8.12
SARRAH highlighted the Allied Health Rural Generalist Pathway (AHRGP) as a potential avenue to increase the capacity, recruitment and retention of allied health professionals in rural and remote Australia, noting that:
The AHRGP is a multijurisdictional workforce development initiative that aims to support the growth, sustainability and value of the rural and remote allied health workforce and the proliferation of rural generalist service models that deliver accessible, safe, effective and efficient health services for rural and remote health consumers.
8.13
SARRAH also noted that—with the success of the AHRGP—it is working with a range of stakeholders to expand the program into private practice and community health settings.
Local workforce development
8.14
Several submitters and witnesses observed that strategies to attract local people to the disability sector are crucial to growing the NDIS workforce in regional, rural and remote areas, noting that local workforce development initiatives should be built in to an overarching national framework.
8.15
SARRAH expressed its strong support for such an approach, noting that this may be enabled by using existing pathway approaches which leverage and—as appropriate—supplement existing vocational education and training (VET) and university courses and infrastructure.
8.16
Mental Health Australian (MHA), Community Mental Health Australia (CMHA) and the Mental Health Fellowship of Australia (MIFA) similarly noted that part of the solution to workforce issues in thin markets is to tap into local workforces, and to train and support people from local communities instead of relying on workers to relocate. MHA, CMHA and MIFA observed that recruitment could initially be targeted to people with existing health or social services skills, and progress from there. Regarding the workforce supporting participants with psychosocial disability, they also stated that:
We know that people of rural origin are more likely to work in rural areas in the future. In addition to sustainability, growing the local workforce is… essential for place-based approaches and utilisation of staff who are able to understand and connect with the community's culture and experiences. There are examples in other health and social service programs of developing preferential selection, scholarship and supports for people to train and work locally.
8.17
Indigenous Allied Health Australia (IAHA) expressed strong support for initiatives to grow the local workforce, stating there should be additional investment to support training hubs outside of urban centres that provide education and career pathways for local people to work across the human services sector, including disability and aged care. IAHA recommended a cross-government approach to investment which:
ensures that the workforce is safe and respectful when working with people with disability, and culturally safe and responsive when working with Aboriginal and Torres Strait Islander peoples;
considers the interrelated social determinations of health, education and disability, to empower Aboriginal and Torres Strait Islander peoples with disability to achieve their goals, good health and wellbeing; and
addresses gaps in infrastructure, health care delivery and housing, noting that otherwise the NDIS cannot deliver on its objectives for Aboriginal and Torres Strait Islander peoples living in isolated communities.
Workforce concerns for Aboriginal and Torres Strait Islander peoples
8.18
According to data from the 2014–15 National Aboriginal and Torres Strait Islander Social Survey (NATSISS), 45 per cent of Aboriginal and Torres Strait Islander peoples reported living with disability or long-term health condition, with 7.7 per cent living with severe and profound disability. This is twice the rate for non-Aboriginal and Torres Strait Islander people.
8.19
The committee heard that positive outcomes for Aboriginal and Torres Strait Islander peoples with disability require that supports be delivered on country, in a culturally safe and appropriate manner—ideally by a member of the community:
Wherever possible NDIS supports should be provided to Aboriginal people on country and must be delivered in strong partnership and collaboration with Aboriginal leaders of the community. NDIS service providers and any NDIS worker, who is not already a member of the Aboriginal community, must recognise the unique needs, histories and strengths of the community they are working within.
8.20
Evidence before the committee indicated that Aboriginal and Torres Strait Islander peoples are significantly underserved by the NDIS. Submitters and witnesses observed that this is due to the acute shortage of culturally safe, affordable services—particularly in rural and remote areas. Compounding this issue is that the NDIA may not appreciate the unique needs of Aboriginal and Torres Strait Islander peoples with disability or their communities.
8.21
Ms Liza Balmer, CEO, Ngaanyatjarra Pitjantjatjara Yankunytjatjara (NPY) Women's Council, observed at that there is a shortage of disability support workers in Aboriginal and Torres Strait Islander communities, stating that:
The workforce is another area where there needs to be a lot of work done. There are people in communities who could potentially be really good disability support workers, but they will require a lot of support in order to meet the expectations of those roles. There needs to be a lot of training done. There needs to be ongoing management of those people on a
day-to-day basis. There needs to be a lot of flexibility.
8.22
Ms Balmer asserted that teams should be established in remote communities to support workforce growth. The teams should be drawn from within the communities they serve, and their functions should be funded separately from participant supports. Ms Balmer suggested that a block funding aproach may be appropriate for this initiative.
8.23
IAHA noted that while Aboriginal and Torres Strait Islander peoples comprise 3 per cent of the population, they comprise just 0.5 per cent of the allied health workforce. IAHA stated that:
[This] disparity…requires an approximate six-fold increase to reach population parity and considerably more to address the health, disability and related needs of Aboriginal and Torres Strait Islander people.
8.24
IAHA stated that strategies must be developed to grow the allied health workforce in remote communities, emphasising that these strategies must focus on growing a workforce from the community itself; ensuring cultural safety; and increasing investment in capacity-building. IAHA expressed concern that workforce development initiatives often assume (wrongly) that service models designed for metropolitan areas can be directly transposed to rural and remote Aboriginal and Torres Strait Islander community settings.
8.25
Ms Donna Murray, CEO, IAHA, elaborated on this matter as follows:
It is essential to ensure that Aboriginal and Torres Strait Islander people who are eligible to receive NDIS services are able to access services that meet their immediate and long-term needs. Services must be delivered in a culturally safe and responsive manner, which requires transformation in the way that we work and the way that we deliver our workforce to Aboriginal and Torres Strait Islander people and communities.
Right now, we know that that is not the case, with a significant underspend reported on the NDIS despite continuing levels of unmet need…among Aboriginal and Torres Strait Islander people with disability. This reflects a lack of access to services and a lack of communication by the NDIS within our communities, let alone the services that understand the culture and the circumstances of our communities and how we work in a safe and effective manner, which can be provided by an Aboriginal and Torres Strait Islander workforce.
8.26
Ms Beth Walker, Public Guardian, NT OPG, similarly noted that growing the local workforce will require capacity-building of Aboriginal community-controlled organisations to ensure they are resourced to deliver NDIS supports and to train and support the local workforce, stating that:
[W]e need to get…the council or the Aboriginal controlled organisation or someone who will put their hand up to say, 'Yes, we want to get involved with the scheme, and we're going to take carriage of providing these services in community'…
[I]f they do opt in, there's the set-up, start-up, establishment, development and then upskilling individual workers. I have a vision which is people on community operating in services because those jobs and those needs are there, but there seem to be these barriers which aren't being addressed, which means that those work opportunities and those services that people with a disability desperately need aren't coming to fruition.
Existing and proposed initiatives
8.27
The committee heard that there have been a number of successful initiatives aimed at growing the Aboriginal and Torres Strait Islander workforce. For example, Ms Donna Murray, CEO, IAHA, drew attention to the National Aboriginal and Torres Strait Islander Health Academy (NATIHA), which is operating in several jurisdictions in partnership with the Institute for Urban and Indigenous Health (IUIH). Ms Murray explained the role and functions of the program as follows:
This is really about providing a Cert II and Cert III training pathway to young Aboriginal and Torres Strait Islander people but also for others in our community that may be carers, that may be looking at part-time work but are very interested in working with people with disability, as they already have the experience. Allied health assistance is one of those areas that people are very interested in attaining, to either provide allied health assistance work or go on to be an allied health professional.
Wrapping the support services of scholarship, further traineeships for apprenticeships, support and providing the mentoring and the
role-modelling of our members who are already in the allied health sector has become quite a successful approach to building that locally-driven need for workforce.
8.28
Ms Murray noted that IAHA is also working with stakeholders to identify the demand for jobs and future opportunities for Aboriginal and Torres Strait Islander peoples in the allied health workforce. However, Ms Murray raised concern that there is a lack of government investment in such initiatives, noting that IAHA is strongly advocating for additional investment.
Maldistribution of allied health services
8.29
A substantial number of submitters and witnesses noted that a key workforce issue is maldistribution of allied health professionals, favouring metropolitan and inner regional areas. The committee heard that this issue is affecting all allied health professionals in regional, rural and remote areas, as well as in metropolitan areas experiencing socioeconomic disadvantage.
8.30
Submitters representing specific allied health professions provided examples of maldistribution. The Australian Orthotic Prosthetic Association (AOPA) observed that:
To give an indication of the size of the orthotic/prosthetic workforce working in regional and remote areas, in 2019, this comprised only 14% of the national orthotic/prosthetic workforce. On average, the number of orthotist/prosthetists per 100 000 population in regional and remote areas was 0.84, compared to 1.92 in major cities.
8.31
The committee heard that there is an urgent need to address the maldistribution of allied health services, to ensure that NDIS participants can access the supports they need in a timely manner, and exercise an adequate level of choice and control.
8.32
IAHA observed that the maldistribution of allied health professionals severely limits the quality of NDIS assessments and the availability, efficacy and cultural safety of services. IAHA also stated that issues associated with the maldistribution of health professionals are compounded by limitations on services that may be funded under the NDIS, stating that:
[T]he [NDIS] Act and its operational guidelines prevent [allied health professionals] from providing their full accredited and registered scope of practice (or range of services). This is despite the aim of the Scheme being to provide a range of innovative person-centred services, to enable NDIS participants to choose the best services to meet their individual needs.
8.33
This concern was echoed in submissions from members of specific allied health professions. For example, Audiology Australia (AudA) stated that the NDIS should fund a full range of rehabilitation services for hearing loss, and should recognise the skills and services that audiologists provide to participants—especially in behaviour management, counselling and aural rehabilitation.
8.34
SARRAH observed that chronic shortages of allied health services predate the NDIS, stating that:
The NDIS was therefore rolled out into 'thin markets' which lacked not only the capacity to service many NDIA participant needs, but to provide the baseline allied health services required to maintain health and wellbeing or to recover well from illness and accident.
8.35
As regards the factors that contribute to the maldistribution of allied health services in Australia, SARRAH further observed that there are an increasingly low number of publicly funded allied health roles as remoteness increases, as well as a lack of service subsidy arrangements that enable private and community-based practice in regional, rural and remote areas.
Challenges for supervision and mentoring
8.36
The committee heard that a consequence of the maldistribution of allied health services is professional isolation, which can create difficulties in supervising early career practitioners and in providing effective professional support. For example, the Australian Physiotherapy Association (APA) noted that a lack of qualified allied health professionals in regional, rural and remote areas limits access to the mentoring required to sustain a strong workforce. It asserted that in areas where there is a shortage of trained professionals, capacity-building is required.
8.37
AOPA noted that professional isolation, poor access to supervision and limited opportunities for professional development are common negative motivators impacting job satisfaction and retention in the regional and remote allied health sector. Ultimately, these issues make it more difficult to attract qualified professionals to regional and remote areas, and lead to greater staff turnover. AOPA provided a case study to illustrate this concern:
Abdul graduated with a Master in Clinical Orthotics and Prosthetics
2 years ago and works in a clinic in regional South Australia. Of the 410 Australian certified practitioners, there are 31 in South Australia but only 3 outside of Adelaide.
Abdul works with two part-time senior practitioners and often practices with minimal supervision. Abdul leaves this position after just 6 months and looks for another job where he feels more supported and can receive regular supervision.
Potential solutions
8.38
A number of submitters and witnesses indicated that incentives may need to be considered to address issues associated with thin markets—particularly the maldistribution of allied health services. For example, Mr Ross Joyce, CEO, Australian Federation of Disability Organisations, observed that:
[T]he NDIA has to have a key role as a lead market steward to ensure that we have appropriate supply of services. It must do that and it can do that by a range of mechanisms such as incentives for providers to go into areas where there are thin markets or no markets or only one provider of choice available.
8.39
The Disability Council NSW suggested the NDIS could provide incentives for providers to establish long-term outreach relationships with rural towns, noting that businesses are unlikely to provide services in thin market areas unless appropriately funded. For example, the Disability Council NSW suggested that grants could be given to providers that make a minimum three-year commitment to delivering services to a town, with a minimum of four visits per year. Providers could deliver specialist face-to face services via outreach visits, and build relationships with and educate local professionals.
8.40
Vision Australia proposed incentives for service providers with staff based in regional and remote communities over and above the current regional loading provided by the NDIS—to cover the costs of supervision and training.
8.41
Lifestyle Solutions asserted that the NDIA should consider developing strategic contract arrangements with providers with a proven record of service delivery in regional, rural and remote areas, noting that such arrangements may contemplate recruitment, training and shared 'back up' arrangements to ensure continuity of support during absences or emergencies. The Disability Council NSW expressed its support for similar arrangements:
Another incentive could be a longer-term contract or permanent working conditions at competitive rates of remuneration, with applicable benefits such as personal leave, along with additional transport and travel subsidies for those working in rural areas.
8.42
Speech Pathology Australia (SPA) observed that there are several incentives that might be implemented to increase the number of providers, including free training; paid administrative time; paid time for professional development; and a surcharge for expertise in certain skillsets.
8.43
As regards mentoring opportunities, the Disability Council NSW noted that professional support could be enhanced by having specialist urban providers receive grants for mentoring practitioners in isolated areas. It suggested that conditions for grants could be monthly mentoring over videoconference, with less frequent in-person visits each year. The APA similarly suggested that experienced physiotherapists could build local capacity through mentoring initiatives—thereby equipping communities with improved access to skilled clinicians without relying on extensive travel.
8.44
SARRAH asserted that the maldistribution of allied health professionals, and implications for service access, is ultimately a matter for the National Cabinet. It called on the committee to recommend that the National Cabinet conduct a cross-portfolio, cross-sector and intra-governmental review of allied health workforce capacity, with a view to improving distribution, sustainability and growth. The review should include an assessment of:
current and potential NDIS eligible populations, service demand, location and capacity of crucial workforce and supports—informed by participant profiles, thorough assessments and participant preferences; and
whether payment arrangements and structures that apply in rural and remote service locations require further structural change or adjustment to facilitate access equivalent to that achieved in metropolitan settings.
8.45
Some submitters also suggested that telehealth may be a viable means of increasing access to services in regional, rural and remote areas; addressing issues with the maldistribution of allied health services; and supporting mentoring and professional development.
8.46
For example, Audiology Australia (AudA) observed issues associated with the availability of audiologists and other health professionals could be addressed (at least in part) through the use of telehealth, stating that:
[T]elepractice is an appropriate model of service delivery for the audiology profession. Teleaudiology is already used in Australia…for fitting hearing aids…in assisting children [to] develop their listening, spoken language and social skills…and in the programming of cochlear implants.
8.47
The Australian Orthotic Prosthetic Association (AOPA) noted that demands on already over-extended services in rural locations might be addressed through the use of alternative delivery models such as telehealth. It also observed that telehealth offers increased opportunities to enhance multidisciplinary care in rural and remote regions, and to provide practitioner support and mentoring.
8.48
The committee also heard there may be merit in the government incentivising use of tele-practice by meeting certain costs. For example, the Disability Council NSW observed that government assistance could be provided for the costs of technology and wi-fi.
8.49
The committee also heard that that telehealth may not be an appropriate means of supporting some cohorts of people with disability, and for people experiencing socioeconomic disadvantage. In relation to remote Aboriginal and Torres Strait Islander communities, Ms Kim McRae, Tjungu (Disability & Aged Care) Team Manager, NPY Women's Council, stated that:
For people who don't have English as a first language, it's largely incomprehensible. They need to have a lot of support and help to access and to try and understand the scheme. If they don't have access to a personal computer or if they don't have computer literacy, then, of course, they're even further disadvantaged, and many of our families don't have access to a computer or don't have computer literacy.
8.50
Deafblind Australia noted that people with deafblindness in rural and remote areas are at increased risk of under-servicing, particularly as telepractice is less viable for this group due to the tactile nature of learning and communication.
Travel
8.51
The committee heard that the high costs of travel are a key barrier to attracting and retaining a suitably skilled and qualified workforce in regional, rural and remote areas. For example, the Disability Council NSW stated that:
Travel is one of the major costs faced by support workers working in rural areas, as well as by clients living in these areas. As a result, service providers can be reluctant to establish offices in areas outside major regional centres, both due to distance, and because there is a comparatively small client base in these areas.
8.52
The Australian Psychological Society (APS) stated that it is not only desirable but often clinically necessary for psychologists to travel to participants. According to the APS, remuneration for travel is considered to be insufficient by practitioners who operate to deliver services in this client-located manner. This is particularly acute in 'dormitory suburbs', where practitioners can travel long distances to provide participants with services.
8.53
National Disability Services (NDS) noted that funding for travel costs is one of the most common issues raised by providers, and is a particular concern with regard to accessing supports outside of metropolitan areas. NDS observed that the NDIA only allows providers to claim for up to 30 minutes of travel time in metropolitan areas and 60 minutes in regional areas. Moreover, the NDIS does not cover the costs to a worker of using the vehicle.
8.54
SPA observed that the lack of an additional, dedicated travel budget in NDIS plans effectively discriminates against participants in rural and remote areas. It noted that participants may not be able to access the funding necessary to transport themselves to therapists, and therapists may not choose to travel to more remote areas. This is often because they cannot recoup costs associated with travel—even if multiple participants are seen during the same visit. SPA expressed concern that little is being done to address this issue at the agency level, noting that it is aware of participants being encouraged to move closer to services rather than having additional funds allocated.
Potential solutions
8.55
Some submitters suggested specific means of addressing issues associated with high travel costs in regional, rural and remote areas. For example, SPA stated that the NDIS could allocate specific travel budgets in participants' plans, or make one-off payments to participants for visits to providers. Other potential solutions include classifying travel to service providers as a 'basic and essential service'; paying providers hourly rates for travel in rural and remote areas; and funding the establishment of regional 'hubs' to which participants could travel in order to receive services.
Costs and administrative burden
8.56
A number of submitters and witnesses observed that cost and administrative burden are a substantial barrier to providers considering delivering services under the NDIS, and are leading to existing providers choosing to de-register or—in some cases—choosing to reduce their service offerings or to leave the NDIS altogether. Ultimately, this is leading to a reduction in the availability of quality supports for people with disability.
8.57
The Disability Council NSW stated that the administrative burdens associated with the NDIS are 'huge', and expressed concern that these burdens lead to experienced workers leaving the sector. At one of the committee's hearings, representatives of the Council noted that financial and administrative burdens are a particular challenge for smaller providers, stating that:
Sometimes…smaller organisations have very highly qualified people, but they cannot keep up with the administrative burden and so their organisations are cannibalised, if you will. We lose those excellent highly qualified service providers for, perhaps, less experienced…providers.
8.58
Submitters and witnesses also observed that administrative burdens add to the challenges faced by providers in regional, rural and remote areas. For example, SARRAH noted that the viability of allied health services in rural and remote locations may depend as much on reducing administrative burdens as on any other factor. Similar views were expressed by representatives of AHPA:
[I]f it's too hard to work in the NDIS, people will find other areas in which they can work. Particularly as new markets open up, and we anticipate that it's very likely new markets will open up as with aged-care reform, that's going to put even more pressure on where people are working.
8.59
The committee also heard that financial and administrative burdens associated with the NDIS are higher than those associated with other service systems and funding schemes. For example, the APS noted that while psychologists are remunerated across a range of schemes, none has a level of administrative burden and costs comparable to the NDIS. This is despite the fact that some of these systems—such as Comcare—provide for similar levels of remuneration.
Registration and auditing
8.60
The committee heard that audit and registration requirements are unduly onerous, and are leading to providers deregistering or choosing not to register. This is of particular concern to agency-managed participants, who must use registered providers for supports. Submitters and witnesses acknowledged the value in ensuring suitably credentialed and experienced practitioners deliver services. However, they emphasised that the cost and necessity of registration should be addressed to reduce its deterrent effect.
8.61
AHPA noted that the audit requirements for registration can be particularly onerous for smaller providers in rural and remote areas. This is exacerbated by the additional audit costs for providers based outside of metropolitan areas, who may need to pay travel and accommodation costs for auditors.
8.62
Exercise and Sports Science Australia (ESSA) observed that NDIS registration processes and associated auditing costs can have a significant impact on the growth of the NDIS market and workforce in rural and remote areas. It provided an illustrative example:
[Accredited Exercise Physiologists (AEPs)] located in rural and remote communities have reported that they have been quoted between $6000 and $16,000 for auditing fees, with many suggesting that these costs are not financially viable given the small number of NDIS participants they service. AEPs have noted [that] costs associated with auditor travel and accommodation have a significant impact on the price of an audit conducted in rural and remote locations.
8.63
Submitters also queried whether NDIS registration and auditing requirements deliver improvements over accreditation with professional regulatory bodies. For example, Occupational Therapy Australia stated that it is unclear why one 'arm' of Government (the Australian Health Practitioners Regulation Agency) would deem a therapist fit to practice, while another (the NDIS Quality and Safeguards Commission) would call that fitness into question.
8.64
Some submitters also raised concerns in relation to the cost and administrative burden of third-party verification (TPV)—particularly for smaller providers. For example the APS observed that TPV processes have made it unaffordable for smaller providers to take on children under the age of seven years.
8.65
Submitters observed that these issues are exacerbated by poor communication within the NDIA, and dysfunction within the agency's IT system. For example, Maurice Blackburn Lawyers observed that:
Many providers that we work with have found the registration process a matter of great complexity. The IT dysfunction within the NDIA, which has plagued the NDIS since the outset, has been regarded by most service providers as inexcusable. We have heard many reports of difficulties experienced in using the provider portal.
8.66
In addition submitters noted that there is little useful, accessible information on the NDIA's website, and expressed concern that policy and process changes are not communicated to providers in a clear and timely manner.
Potential solutions
8.67
Some submitters suggested potential solutions to issues with administrative and financial burden. The Disability Council NSW suggested that the NDIS may wish to consider funding administrative support in thin market areas. Administrative assistants might work across multiple providers, and could be funded to assist with the administration of NDIS matters and to keep abreast of changes to the scheme. Providers may access portions of the assistant's time depending on the number of participants on their caseload.
8.68
Catholic Social Services Australia (CSSA) suggested that providers explore increased uptake of new technology to assist with administrative tasks, freeing time to provide additional care and support. It also asserted that technological solutions should be considered as part of workforce planning.
8.69
SPA noted that providers may be encouraged to register if audit costs were better regulated, and discounts were provided to in rural, regional and remote areas. It also suggested that there may be merit in changing the classification of certain registration groups, such as early childhood, to 'high risk'.
Existing Commonwealth initiatives
Thin markets project
8.70
In its submission to the inquiry, the Department of Social Services (DSS) stated that it and the NDIA are working on the NDIS Thin Markets Project to address areas of potential market failure—including addressing challenges across specific locations, cohorts and support types. DSS released a discussion paper in relation to the project in April 2019, with consultation from 5 April to
30 August 2019. The discussion paper asked respondents to agree on how to identify thin markets, their causes, and where they are particularly acute, and to identify ways in which the government should respond to thin markets.
8.71
According to the NDIA's June 2020 Quarterly Report, the NDIA is 'developing a Market Commissioning Strategy and comprehensive roll out plan in consultation with state, territory and Commonwealth governments to support a flexible approach to addressing market challenges'. This strategy will involve trial projects in all jurisdictions in the second half of 2020 to collect 'evidential insights' and test 'the NDIA approach to market challenges'.
8.72
In its response to the committee's inquiry into Supported Independent Living, the Government stated that the NDIA is considering a number of projects to address thin markets in rural and remote locations. According to the response, these include providing information about levels of participant need, locations of demand, and number of participants residing in cities who may relocate to regional communities if they can access the required supports.
8.73
In October 2020, Mr Martin Hoffman, CEO, NDIA, observed that the NDIA is undertaking further initiatives to address thin markets in rural and remote areas, including:
making more information available to the provider sector as to potential demand, including increasing the detail of this information to capture the location of participants and their needs; and
for 'really remote areas', working on a series of trials of aggregated service provision, where 'effectively, the agency steps in, aggregates demand among the number of participants, and sources the provider services required'.
Work of the National Rural Health Commissioner
8.74
The position of National Rural Health Commissioner (NRH Commissioner) is established as part of the Government's broader agenda to reform rural health in Australia, and provides policy advice to the Minister responsible for rural health. The current NRH Commissioner is Associate Professor Ruth Stewart.
8.75
From December 2018, the NRH Commissioner consulted with the allied health sector to develop recommendations to improve the quality and distribution of, and equitable access to, the regional, rural and remote allied health workforce. The recommendations are provided below.
Recommendation 1—Improving access
To improve access to allied health services, it is recommended the Commonwealth progressively establish, initially through a series of demonstration trial sites, Service and Learning Consortia across rural and remote Australia. With the support of new and existing program funding, Service and Learning Consortia will integrate rural and remote 'grow your own' health training systems with networked rural and remote health service systems. Service and Learning Consortia will consist of local private, public and not for profit service providers, training providers, and community representatives collaborating across
multi-town and multi-sector networks, according to community need. Once established, Service and Learning Consortia will improve recruitment and retention of allied health professionals by making rural and remote allied health practice and training more attractive and better supported.
Recommendation 2—Enhancing Quality
To enhance the quality of allied health services in rural and remote Australia, it is recommended that the Commonwealth invest in strategies to increase the participation of Aboriginal and Torres Strait Islander people in the allied health workforce. Two strategies recommended are: further expansion of the National Aboriginal and Torres Strait Islander Health Academy model to all Australian jurisdictions; and the creation of a Leaders in Indigenous Allied Health Training and Education Network. Once established, these strategies will increase pathways for Aboriginal and Torres Strait Islander people to enter the allied health workforce and will improve the cultural safety of rural and remote allied health services and training for all Australians.
Recommendation 3 – Expanding Distribution
To expand the distribution of the allied health workforce across rural and remote Australia, it is recommended that, building on current national and jurisdictional initiatives, the Commonwealth develops a National Allied Health Data Strategy. This Strategy will include building a geospatial Allied Health Minimum Dataset that incorporates comprehensive rural and remote allied health workforce data. Once established, this data strategy and minimum dataset will inform and improve the design and development of rural and remote allied health workforce planning and policy.
Recommendation 4 - National Leadership
It is recommended that the Commonwealth appoint a dedicated full-time Chief Allied Health Officer (CAHO) to work across sectors and departments including health, mental health, disability, aged care, early childhood, education and training, justice, and social services. The CAHO will work with relevant peak bodies and consumer advisory groups to ensure equity of access to high quality allied health services for all rural and remote communities. Once established, the CAHO will provide valuable allied health input and leadership into Commonwealth government policy.
8.76
The recommendations have been developed to work interdependently while supporting existing programs and plans, and are designed to catalyse the system-wide change necessary in allied health and rural health environments. By enhancing allied health leadership, they will enable cross-sector solutions essential to the success of the NDIS.
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Submitters encouraged the committee to consider the work of the NRH Commissioner as part of the present inquiry. For example, IAHA observed that further development of the NDIS workforce should be informed by, and progressed with reference to, complementary national agendas including the NRC Commissioner's work.
Committee view
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The committee heard a substantial amount of evidence regarding thin market issues that are affecting the NDIS workforce. Much of this evidence reflects the same concerns raised during previous inquiries of this committee, and during other review processes. The committee is concerned that this suggests limited progress has been made to address the identified issues.
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As noted in Chapter 9, the committee considers that thin market issues require targeted intervention by government, and should be a core focus of a national workforce plan for the NDIS. Preliminary views on how to address some of the identified issues are also set out below.
Maldistribution of allied health professionals
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The committee heard that a key workforce issue is the maldistribution of allied health professionals, favouring metropolitan and inner regional areas across Australia. It appears that there is an urgent need to address this issue, to ensure participants can access supports in a timely manner, and exercise an adequate level of choice and control. Moreover, the committee is concerned that maldistribution of allied health professionals makes it difficult to attract and retain staff, or to invest in training and professional development.
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The committee heard that issues associated with the maldistribution of allied health professionals predate the NDIS, and have been exacerbated by the challenges of moving to the new funding system.
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The committee also heard that the maldistribution of allied health services owes to several factors—including the proportion of Commonwealth funding allocated to workforce development, distribution and sustainability; a lack of stakeholder input and allied health expertise in workforce planning processes; and the allocation of funding between service sectors. Overlaid on these factors are a number of cross-jurisdictional issues, including coordination of priorities and actions across ministerial councils; and considerations of the benefits and risks of cost-shifting between governments.
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The committee appreciates that the NDIA has taken steps to address thin markets in regional rural and remote areas—including through the NDIS Thin Markets Project—and that the National Rural Health Commissioner recently made a series of recommendations for workforce development, including recommending the rollout of the Service and Learning Consortia program. However, the committee remains of the view that issues associated with the maldistribution of allied health services require a coordinated national response. The committee considers that these issues should be escalated to the National Cabinet or another inter-governmental forum as appropriate.
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The committee recommends that the Commonwealth, states and territories, through the appropriate inter-governmental forum, consider the matter of allied health workforce maldistribution and implications for service access for people in regional, rural and remote Australia, and develop strategies for enabling workforce distribution, sustainability and growth.
Supporting Aboriginal and Torres Strait Islander communities
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The committee heard that Aboriginal and Torres Strait Islander communities are significantly underserved by the NDIS. According to submitters and witnesses, this is due to the acute shortage of affordable, culturally safe and appropriate services in regional and remote Australia, compounded by the lack of a targeted workforce development strategy and limited investment in capacity-building for local communities.
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The committee heard that there have been several successful initiatives aimed at growing the Aboriginal and Torres Strait Islander workforce. Relevantly, these have been designed and led by Aboriginal and Torres Strait Islander peoples. In particular, the committee was pleased to hear about the success of the National Aboriginal and Torres Strait Islander Health Academy (NATIHA), which has provided allied health training and career pathways for Aboriginal and Torres Strait Islander peoples. However, the committee was concerned to hear that there is not currently sufficient investment in the NATIHA to enable expansion of the initiative to all Australian jurisdictions.
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The committee notes that in June 2020, the NRH Commissioner recommended that the Commonwealth invest in increasing the participation of Aboriginal and Torres Strait Islander peoples in the allied health workforce, including expansion of the NATIHA. The Commissioner also recommended the creation of a Leaders in Indigenous Allied Health Training and Education Network to:
comprehensively implement the National Aboriginal and Torres Strait Islander Health Curriculum Framework in allied health training;
enable the extension of student placements in Aboriginal Community Controlled Health Services in Modified Monash Model (MMM) 4–7 areas to a minimum of eight weeks, and the introduction of mandatory course competencies in Indigenous health;
undertake a systemic national review of the current quotas for Aboriginal and Torres Strait Islander student enrolments in allied health courses;
increase pathways into allied health courses for Indigenous Australians through the VET sector, Aboriginal Registered Training Organisations and through the NATIHA; and
increase the leadership pathways and recruitment of Aboriginal and Torres Strait Islander allied health professionals to academic roles.
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The committee strongly supports the NHR Commissioner's recommendations, and encourages the Australian Government to consider them in developing and implementing the National Workforce Plan for the NDIS. The committee also considers that there would be value in broadening some of the measures recommended by the Commissioner to capture the recruitment, training and retention of Aboriginal and Torres Strait Islander peoples in the broader NDIS workforce—particularly disability support workers.
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In addition, the committee has heard that workforce development in rural and remote areas may require embedding a team within communities to support workforce growth—potentially via a block funding approach. The committee encourages the government to consider this matter as part of a broader review of funding arrangements, discussed in Chapter 5, as well as under a targeted strategy for Aboriginal and Torres Strait Islander peoples.
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Ultimately, a targeted strategy is needed to develop the Aboriginal and Torres Strait Islander workforce for the NDIS, recognising the need for access to supports on country and the paramount importance of cultural competency. Such a strategy should focus on growing the workforce from within communities, and on increasing investment in community-led initiatives such as the NATIHA, which have a proven record of success. The committee considers that the strategy should also include measures to recruit and retain planners and LACs from Aboriginal and Torres Strait Islander communities.
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The committee recommends that the Australian Government develop, publish and implement a national strategy for the Aboriginal and Torres Strait Islander workforce, co-designed with Aboriginal and Torres Strait Islander peoples and community leaders, Aboriginal Community Controlled Organisations and other key stakeholders.