Anybody with a reasonable understanding of the NDIS could not fail to see the similarities between the recommendations of the Aged Care Royal Commission and the existing NDIS. Both the aged care recommendations and the NDIS are built on the human rights principle of person centred care and choice and control, but many of those with lived experience of the NDIS – as a participant, carer or service provider – will know that some of the best principles have fallen in the scheme’s execution. So where are the parallels, where are opportunities for aged care to learn from the NDIS, and where are the key diversions? We’ve focused on some of the major issues below.
Person centred, choice and control, with rights-based access to a package of care based on need
The Royal Commissioners put significant emphasis on a shift in practice to person centred care, where older people are assessed based on their support needs, and then awarded a package of care, with discretion around the providers they select to provide them with services. So far, so NDIS. A key driver of the Commission’s approach is around entitlement to services, based on need, just as Australians access health care. In the early days of NDIS transition, we heard from providers about the significant (unfunded) time they were investing in supporting their clients to prepare for their NDIS assessment. This continues today. Participants who are not able to articulate all their support needs are at risk of getting an inadequate package, even with supporting medical evidence. Many are now concerned that the NDIS’ shift to independent assessments via an interview between assessor and participant will further undermine participants’ access to the supports they need to live ‘an ordinary life’.
Where assessment is the gateway to accessing services, older people who are unable to strongly advocate for themselves will need significant support from carers, advocates, or existing providers to ensure access to the services that they really need. The proposed network of care finders may support older people to access the system, but the NDIS experience with local area coordinators indicates that this may not be sufficient without significant additional advocacy.
Pricing structures, and quality standards
The Aged Care Royal Commission recommends independent price setting, and stricter quality standards. The NDIS price guide controls the maximum fee a provider can charge to NDIA and plan-managed participants. We have worked with numerous providers over recent years as they seek to ensure the financial sustainability of new or existing services. There are some areas of the price guide that allow providers to operate with fairly comfortable margins, but others are extremely tight. In particular, the disability support worker model expects high levels of utilisation and pretty low levels of supervision for the backbone workers of the disability sector. The Joint Standing Committee on the NDIS: NDIS Workforce Interim Report identifies the same problems in the disability sector as in aged care: frontline workers are underpaid and inadequately trained. Pricing for aged care needs to learn from the experience of the disability sector – workers need to be valued and effectively developed – and that includes supervision and training.
Pricing also needs to take account of quality requirements. NDIS providers already have compliance requirements around worker screening, codes of conduct and mandatory training. Then there’s the 80+ quality indicators (depending on your service offering). Providers are telling us about increasing questions and reporting requirements from the NDIS Quality and Safeguards Commission (for example, around a single worker supporting a participant who lives alone, following the death of Ann Marie Smith). All of this requires additional resources, but none of this attracts additional funding.
Pricing for aged care will need to reflect the true and full costs of service delivery.
The Royal Commissioners recommend a care management system, where each older Australian with an aged care plan is supported by a care manager to navigate the system and manage their package of services. One of the biggest flaws of the NDIS is that participants have to navigate the system themselves. Local area coordinators may provide a list of local service providers, and the NDIA or a plan manager may manage their plan (and budget) for them, but there is no case management to ensure it all fits together. For participants accessing services from multiple providers, there is no one person that has a clear view of all the supports that a participant is accessing and how effectively these are working in supporting the participant to achieve their goals. Participants may have support coordination included in their plan, to help with navigating the system and putting their services in place, but support coordination is capped at a maximum number of hours per year. And it’s not case management. There are some brilliant support coordinators in the market, many with lived experience, but there is no requirement for support coordinators to have lived experience, or any social work or case management training.
Services for Aboriginal and Torres Strait Islander people, and others living in regional, rural and remote Australia
The Aged Care Royal Commissioners do appear to have picked up on some of the issues from the NDIS with their recommendations for a dedicated pathway for Aboriginal and Torres Strait Islander people to access aged care services, and with some market management to ensure the supply of services in regional, rural and remote areas. Access to services for Aboriginal communities and those living in low density (thin) markets has been a persistent problem for the NDIS.
Recommended measures include accurate costing for service provision in regional, rural and remote areas; pooled, flexible funding, and some block funding to support sustainable service provision. In addition, the Commissioners propose an Aboriginal workforce plan, with services being provided by people from the community, or by people who are trained in culturally safe, trauma informed services. In addition, the Commissioners recommend that existing providers of community services to Aboriginal and Torres Strait Islander people receive priority support to extend their services into aged care. If these recommendations are implemented – and prove effective – they offer a rich opportunity to strengthen NDIS service provision.
In recent years we have worked with a number of organisations who bridge disability, aged care and – in some cases – other community services. The Royal Commission – and decisions on its recommendations – offer a great opportunity to share learning between disability and aged care service provision. Let’s hope this doesn’t get missed.