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Joint Standing Committee on the National Disability Insurance Scheme
Independent assessments

McCALLUM, Mrs Tabetha, Project Manager, NDIS Quality and Safeguards Sector Readiness Project, Western Australian Association for Mental Health [by video link]

McKINNEY, Ms Chelsea, Manager, Advocacy and Sector Development, Western Australian Association for Mental Health [by video link]


CHAIR: I welcome you both to this teleconference. Would one or both of you like to make some opening comments?

Ms McKinney : I did want to make a few opening comments, but I'm conscious of your time. Would a couple of minutes be appropriate?

CHAIR: Certainly; please go ahead.

Ms McKinney : Thank you. I'll try and be quick. As you would know from our submission, WAAMH, the WA Association for Mental Health, is the peak body for the community mental health sector in Western Australia. We also have an individual membership of people who identify as having a lived experience of mental health issues as a consumer, carer or family member. So our submission and the evidence that we give today will be informed both by those individuals and community members as well as our member organisations.

We have focused on our submission to the IA inquiry on issues affecting people with psychosocial disability who are participants of the NDIS or potential participants of the NDIS. We are deeply concerned about the IA process as it currently stands. Our concerns relate mainly to this likely being an additional barrier for people with psychosocial disability. As the committee would already be very well aware, the rates of people with psychosocial accessing the NDIS are well under what was estimated by the Productivity Commission, and this is particularly the case in some jurisdictions, including Western Australia.

We also note that in the IA pilots the numbers of people with psychosocial disability who participated in that pilot were very low at seven per cent and nine per cent for each pilot. Given the complexity of psychosocial disability and the extensive range of challenges that the scheme is already facing with regard to access to the NDIS and meeting the needs of people with psychosocial disability, we think that the introduction of an independent assessment process without a robust pilot, including extensive numbers of people with psychosocial, is particularly problematic.

In terms of the barriers, I won't list them all, but we're concerned that this will create a barrier. People with psychosocial disability often have mistrust of government systems, very often have negative experience of government systems and often experience trauma in government systems. So it has been somewhat challenging for some service providers to convince people that applying for the NDIS is a positive and good thing to do.

People with psychosocial disability frequently tell us that they are exhausted by having to tell their story over and again, and we're concerned that the IA process and the annual IA assessment will only contribute to that. The process isn't recovery oriented or trauma informed. The tools are considered inadequate for assessing psychosocial. It is a snapshot approach and we cannot see how a three-hour assessment can account for the fluctuating nature of psychosocial disability, particularly where people need to have trust in a service provider and a relationship with the service provider in order to really be able to describe their true experiences.

We have other concerns. The assessor won't be known to the individual. We think the three-hour one-off assessment is inadequate. The person's treating professional will have a much more comprehensive understanding of the person and their fluctuating needs over time. We are well aware that the current process does not always result in good functional assessments for people. However, we are not convinced in any way that this current proposed process will address those concerns. Rather, we think it is more likely to amplify them.

As mentioned by the previous speakers in relation to the Aboriginal community, we are also concerned about the impacts in remote areas and, similarly, we are concerned that the tools proposed do not adequately take into account the person's familial and community context. Psychosocial disability and the ability to live a good life is relational by nature. A strength-based approach to the NDIS would better take account of the person's ability and connections in place and with family and community to live a good life.

In terms of addressing psychosocial competency, we remain unconvinced that the tender process will result in an adequate supply of independent assessors who are deeply experienced in psychosocial assessment, particularly outside metropolitan areas in vast states like ours—the Northern Territory, Queensland and South Australia.

We are unconvinced about how the independent assessment will be able to overcome those things. We are concerned that it will result in people either not going through with their whole NDIS process and getting a plan or that it will result in inadequate plans. This will compromise the ability of the scheme to meet the needs of the individual participants and may compromise the ability of the scheme to meet its objectives of supporting people with a disability to live a good life in the community. If this process does not work well for particular cohorts of people, then the whole objectives of the scheme for those cohorts of people will be compromised. We recommend that people should have the option of using their treating professional to complete the independent assessments instead of this sort of tender-based assessment process. We recommend that there needs to be a much more robust pilot process that has a strong focus on psychosocial disability and greater transparency for the numbers of people with psychosocial disability and the impact of the pilot on them before this is rolled out at all.

Finally, we are concerned about the NDIA's consultation processes. This is the latest in a series of examples where the NDIA's consultation processes do not feel genuine or adequate to understand or address the concerns of people with disability, their families and the service providers who support them. Our experience of the IA consultation process was that it was more like an information session focused on NDIA delivering information with very limited time for questions. Our concerns were only amplified when the tender results were released just a few days after the consultation closed. A genuine consultation should take into account the information received in that consultation in order to determine whether any changes are needed. For example, the qualifications of assessors and the pricing of IAs could have been impacted by the consultation outcomes. This poor consultation process has contributed to a continuing decline in confidence in the NDIS by NDIS providers as well as many participants and family members. So we recommend that the joint committee consider how to support the NDIA to improve its consultation processes.

CHAIR: Thank you. I'll go to Mr Wallace first.

Mr WALLACE: Can you help me with a specific issue around conflict of interest? The independent assessors are not directly employed by the NDIA. On 26 February 2021, the NDIA appointed eight organisations to undertake these assessments. Firstly, based on what we have heard so far, I am questioning whether eight organisations are enough. Secondly, going more to the point of conflict of interest, where those independent assessors are operating on a panel basis, does a conflict of interest perhaps arise? I know that the participant can choose the company or the organisation that will do the independent assessment, and I am not saying this is going on, but you always have to look at the worst things that can happen in government. This is where the conflict arises: in order for the organisations that do these assessments to get continuing work for them to be rolled over into the next panel, is there a perverse attraction for them to be difficult when they do their assessments, and assess low rather than actual? Does that make sense? Am I explaining myself properly?

Ms McKinney : Could I clarify? There is a potential risk there. Are you concerned, because of the reported focus on the scheme's sustainability and the various media leaks and so on, that the assessors might have an interest in assessing a lower level of needs because of scheme sustainability or something like that?

Mr WALLACE: It is a theoretical concern; I don't have any evidence to suggest that that is happening. But where a system is designed so that independent organisations are remunerated based on their ongoing work, there's an attraction for them to assess someone's disability as low and with a low budgetary plan rather than as actual or as more than that person would be entitled to, which might be good for the participant but bad for the overall system. Does that make sense?

Ms McKinney : It does. I don't have a view on the matter. One of the purported benefits of the independent assessors is that they are allied health professionals who have ethical standards that they need to adhere to. I don't have a comment.

Mr WALLACE: This is not a loaded question; I am trying to elicit some evidence from you, and your evidence is that you think a medical professional or health professional's ethics would be sufficient to circumvent a conflict of interest that could potentially arise. Is that what you are saying?

Ms McKinney : Theoretically, the ethical requirements of health professionals should do that. I think that with the market-based approach to the NDIS there is a risk that a service provider of any kind would potentially be influenced by market forces that may impact on their ability to win future tenders. However, as you suggest, Mr Wallace, this is only a theoretical view, and I don't have any information or evidence to suggest that that would occur.

Mr WALLACE: Thank you. My second question is around accessibility to assessors who have particular skills around mental health care. Obviously, it is a specific skill set. We are talking about people with sometimes severe psychosocial disabilities. Are there enough independent assessors in the marketplace to do this sort of work? Can you break that down even further? Are there enough of those people to do that work in the cities, let alone in regions and in rural and remote Australia?

Ms McKinney : We very much doubt that there will be adequate coverage in rural, let alone remote. There are well-documented challenges in access to allied health professionals of many kinds in rural Australia, particularly remote Western Australia. We cannot see how it would be possible to offer sufficiently qualified face-to-face independent assessments to people in the regions. I think that was brought up by the participants in the inquiry this morning.

As to whether there are currently adequate independent assessors with the skills to assess people with severe and complex mental health issues and psychosocial disabilities, we have not done that market assessment, so we don't know whether those skills are there. However, we have been informed through other processes that there is currently an allied health and mental health clinical workforce shortage in Western Australia and that it is very difficult to recruit clinicians into other processes. So I would imagine, without any evidence, that will also translate into a challenge in being able to recruit or appoint sufficiently skilled independent assessors for people with psychosocial disability.

We are very concerned that the independent assessors may not have the skills required to have the deep experience that is needed to adequately assess psychosocial functional capacity, particularly with the process as it currently stands. It is a three-hour process, and most psychosocial disabilities are episodic and fluctuating. In a snapshot independent assessment the assessor would need to be extremely skilled in assessment, have deep knowledge around mental health and functional impact and have very advanced skills in developing rapport in order for a quality independent assessment to occur. We are concerned that that would not be met.

Part of our concern stems from historical issues around the NDIS. With current planners, LACs and assessors, we are continually receiving significant concerns from stakeholders that psychosocial plans are not quite right, are inadequate. Things like support coordination took years to get right in terms of the number of people with psychosocial disability having it or having a sufficient amount of it. We are seeing the same problem roll out now with recovery coaches, with very few people in psychosocial disability having it in their plans. Very few planners seem to understand what a recovery coach is. We have had reports from providers that a recovery coach will even pick up UberEats. That is not the role of a recovery coach. So we are concerned that the same problems we have seen in terms of sufficiently training planners and assessors and LACs and psychosocial disability will apply to this next process. I hope that makes sense.

Mr WALLACE: It does, thank you.

CHAIR: Senator Brown.

Senator CAROL BROWN: To follow up a question Mr Wallace was asking around the impartiality of assessors, and hearing your answer: do you believe that concerns around the impartiality of assessors have been adequately assessed by the NDIA? Putting aside professional standards, has the NDIA looked at this question and adequately addressed it?

Ms McKinney : I am not aware of the NDIA's responses to that concern, so I don't feel able to answer that question.

Senator CAROL BROWN: Right. How do you think the application of the tools selected to be used in independent assessments will work for people with psychosocial disability?

Ms McKinney : I'm not an expert on the tools, so I can only provide comments based on other stakeholders who have a closer knowledge of the tools than I do. Our feedback from some of the NDIS providers who are part of the WAAMH NDI Mental Health Reference Group have advised that they believe the tools are inadequate for assessing psychosocial disability. As I mentioned in my introductory statement, they report that they are not strength-based or recovery-focused. While there is a need to understand what people cannot do, the role of the NDIS is also to focus on what people could do in their lives with support.

So the recovery orientation of the NDIS is not evident in the tools. The application of the tool does not appear to be trauma-informed. So the participant who might have a deep experience of trauma that has contributed to their mental health condition and psychosocial disability is being asked to meet with someone they have never met before and with whom they don't have a relationship, and disclose personal details. That is not a trauma-informed approach, which is very important in psychosocial disability. Stakeholders are also concerned that the tools do not adequately account for the context of the person's life. What level of community inclusion do they experience? How do their relationships with their family enable their goals and objectives? What are their relationships like? How is their ability to get a job influenced by that contextual factor? While there are questions that would go to some of those details, the richness of the person's community context is not captured by the tool. Service providers are concerned that is inadequate because it is such an important component for psychosocial disability improvement or recovery.

Senator CAROL BROWN: Thank you for that. My last question is: do you believe, or has this concern been raised with you through the NDIS reference group, that it's possible that people with psychosocial disabilities will be targeted, intentionally or not, by independent assessments due to the conflict of the recovery model used in mental health care and the NDIS eligibility requirements?

Ms McKinney : I'm sorry, could you please clarify what you mean by 'targeted'?

Senator CAROL BROWN: Intentionally or not, I suppose, will they be at a disadvantage?

Ms McKinney : We believe that people with psychosocial disability are very often at a disadvantage in accessing the NDIS already. It's been quite well documented we need to retrofit to make psychosocial disability under the NDIS work. For example, we're seeing a recovery framework being drafted only now despite that being a primary focus for mental health work, including where people have a psychosocial disability. I think that we are particularly concerned that this new process will not sufficiently account for the nuances or difference of psychosocial disability and how those participants or potential participants are able to access the scheme and receive supports under the scheme. Does that answer your question?

Senator CAROL BROWN: Yes, thank you.

CHAIR: Senator Steele-John.

Senator STEELE-JOHN: Ms McKinney, I'm just going to ask you a series of quick-fire, yes/no questions just to establish a shared understanding of the context in which WAAMH is currently working because there's a key point here. It's the case, isn't it, in WA, particularly exacerbated in regional or rural contexts, there is an absence of allied health professionals of the types that are slated to become independent assessors? There's already a situation where it is very hard to get a physio, a social worker et cetera in these types of contexts; that's right, isn't it?

Ms McKinney : Yes, that's right—social workers, OTs, and psychologists as well.

Senator STEELE-JOHN: So it's not like it's very easy to get them, particularly in rural and regional contexts. And that's the same in Queensland and other states as well. Since there is no current qualified, separate role of an independent assessor and we are drawing independent assessors from that existing pool of allied health professionals, it stands to reason that the implementation of independent assessors will either require people to exit current work to focus on becoming an independent assessor or in some way break up the work they are doing between independent assessment and other roles?

Ms McKinney : Yes, I think that's likely. If I can just add that the COVID pandemic has exacerbated the challenges in recruiting clinical or allied health workforce because many of the people in that workforce, new entrants to that workforce, would very often come from overseas locations and that's been hampered. We recently received information from a clinical mental health service provider that they were anticipating it could take 12 months to recruit new allied health mental health roles.

Senator STEELE-JOHN: So the impact of this change could be either a diversion of these allied health professionals from the roles they are already playing in the community to independent assessment roles in rural or regional communities particularly or a prolonged period in which those allied health professionals are not found to play those roles as independent assessors particularly in rural or regional contexts, thereby drastically increasing the time it would take a participant to be assessed or reassessed independently to access the NDIS?

Ms McKinney : Yes, I would agree with that. And we are very concerned about the potential delays.

Senator STEELE-JOHN: Can I also just ask you: in your experience, and also in my experience too, one of the hallmarks of psychosocial disability of mental illness is that it can be episodic or can fluctuate up and down across different patterns of time or due to certain contexts; that's right, isn't it?

Ms McKinney : Yes, that's right.

Senator STEELE-JOHN: So it stands to reason then that an independent assessment conducted within a three to four-hour time period may not, in fact, capture the full picture of somebody's experience of psychosocial disability or their impairment that they experience as a result of that?

Ms McKinney : Yes, that's right. We're deeply concerned about that, and we would suggest that at the very least the assessment should be conducted over several time periods. It is also commonly very challenging for people with psychosocial disability to concentrate for three hours because of the cognitive impacts of medication or the mental health condition itself. We think it's very unlikely that a snapshot assessment is likely to capture, for the majority of psychosocial participants being assessed, an accurate picture of their functional capacity.

Senator STEELE-JOHN: And it's also true, isn't it, that when you are working alongside somebody with a psychosocial disability, particularly when discussing some of the questions that are asked of a person during an independent assessment as outlined in various tool based questions, the existence of a prior relationship and/or trust between the individual and the person that is assessing them is very important to be able to capture that full picture; that's right, isn't it?

Ms McKinney : Yes, that would be the dominant view of clinical, non-clinical workers, people with psychosocial disability themselves and their family members, yes.

Senator STEELE-JOHN: And it's very unlikely for that trust to be built with a stranger within a three-hour period?

Ms McKinney : Yes, I would agree that's very unlikely, and it has been a key concern raised by our stakeholders.

Senator STEELE-JOHN: Do you have further concerns that the presence of a person in this person's house or in any other location where the assessment may take place, and the nature of the questions asked by a stranger, with whom they don't have a pre-existing relationship and, indeed, who may have no former experience with somebody with a psychosocial disability—qualified as a physiotherapist but not qualified in this particular field—might, in fact, cause the participant harm?

Ms McKinney : For some participants, that may be experienced as traumatising or intrusive or triggering or unhelpful—for some, yes.

Senator STEELE-JOHN: You've referenced, I think, in your submission that, particularly with the WHODAS 3.0 centres very much on the 30-day period time frames, a lot of its questions are 'Over the last 30 days, have you X, Y Z?' If we're looking at somebody with a psychosocial impairment who is currently a scheme participant and has, say, a good plan that is providing them with the support they need, the question may well come back positive—that is, 'I have been good over this period of time'—precisely because they are currently receiving the supports that they need. However, this this can have the impact of lowering their score against WHODAS 3.0. That's right, isn't it?

Ms McKinney : That is a concern of participants, families and stakeholders, yes. It's also because 30 days may not be a long enough period in which the fluctuating or intermittent nature of the impact of psychosocial disability is felt. People may be well for 30 days with or without supports and then experience periods of extreme unwellness, and it is also the case that the presence of good supports is likely to keep people well. Yes, there are concerns that the independent assessment will not take into account the positive scores because of the presence of those quality supports.

Senator STEELE-JOHN: Finally, to Mrs McCallum, you are currently involved in the readiness project with the Quality and Safeguards Commission. We as a committee have received varying views as to the relationship between the commission and independent assessors, primarily in relation to whether a participant is able to report complaints to and have them investigated by the Quality and Safeguards Commission. Can you shed any light for us on what your understanding is of the current role of the Quality and Safeguards Commission in relation to independent assessors?

Mrs McCallum : We've had no information distributed by the Quality and Safeguards Commission in Western Australia with regard to independent assessments as yet. Our commission only rolled out on 1 December, the end of last year. While there's been a great deal of communication from them, it's all focused on preparing the sector to engage with the quality standards and nothing around independent assessments that I'm aware of.

Senator STEELE-JOHN: It seems to me, just finally, Ms McKinney, that if we think about rural and regional contexts particularly and the absence of existing allied health professionals in those contexts in WA and in other states, the proposal to have independent assessments performed by allied health professionals presents quite a significant risk of diversion of those allied health professionals into that assessment role, causing the flow-on effect that it is harder for people in rural and regional Australia to gain those allied health services for other purposes. Is that a valid concern, do you think?

Ms McKinney : Yes, there definitely needs to be much more attention to workforce planning for the NDIS across all its roles, including allied health roles. And I would encourage the exploration of that as part of the forthcoming national partnership agreement because it also impacts on the interrelationship between an NDIS workforce, including independent assessors, and also allied health workforces in mental health, in other service settings. It's all interconnected. There is only this pool at the moment and we haven't had sufficient focus on developing those workforces, including the non-clinical workforces that provide those full supports, which are pretty much absent in regional areas with any psychosocial capability anyway.

CHAIR: Ms McKinney and Mrs McCallum, thank you very much for your submission and thank you for coming online to discuss it with us today. We appreciate it very much. Thank you.

Ms McKinney : Thank you very much.

Mrs McCallum : Thank you.