The National
Disability Insurance Scheme involving a major reconceptualisation of the
delivery of support to disabled citizens is currently being rolled out nationally.
The 2011 National
Disability Strategy noted that the proportion of Indigenous Australians 15
years or older reporting they lived with a disability or long term health
condition was 37 percent, twice the rate in the general population. The
proportion was similar in both remote and non-remote regions, and did not
include psychological disability.
The Minister
for Social Security Christian Porter recently noted that bilateral agreements with all
states and territories except WA and the NT had been finalised, and that in the
case of the two outstanding jurisdictions, discussions were progressing.
Reflecting an
appreciation that remote regions may have particular issues to address, the
Commonwealth and NT Governments agreed in 2013 to establish a trial site in the
Barkly region centred on the regional centre of Tennant Creek.
The NDIS released
a rather brief and uninformative progress report on the trial in the Barkly region in
October 2015.
The Australian
Parliament’s Joint Standing Committee on the National Disability Insurance
Scheme published a progress
report in November 2015, which included an assessment of progress in the
Barkly trial site: refer paragraphs 2.74 – 2.86 for progress on the Barkly
Trial site and paragraphs 4.56 – 4.80 for a discussion of various issues
relating to Indigenous clients and the challenges of implementing the scheme in
remote areas.
On the challenges
of delivering services in remote locations, the Joint Standing Committee made the
following comments:
Challenges in the
Barkly trial site
2.84 As outlined
earlier, it is anticipated that the Barkly trial will provide valuable
experience and understanding in delivering the NDIS in remote areas, which will
inform the roll-out across the rest of the NT and other remote parts of
Australia. Apart from dealing with the direct challenge of the high rate of
disability among Indigenous Australians compared to the general Australian
population, the implementation of the Barkly trial presents a number of
specific challenges:
• low numbers of
Indigenous Australians with disability accessing the disability service
system—a contributing factor is the reluctance of Indigenous people with
disability to identify as a person with disability. This presents a significant
barrier to the successful implementation of the NDIS in this region;
• experience of
Indigenous Australians when using services—a lack of confidence in dealing
with, and a mistrust of, government agencies and service providers;
• differences in cultural backgrounds and
understanding between service providers and Indigenous Australians—this can
form an impediment to effective delivery of support services; and
• access to
services—lack of available and appropriate services due to the remote location.
2.85 The fundamental
principle of the NDIS is individual choice and control. Enabling Indigenous
Australians to exercise such choice and control may be difficult where the
absence of service providers in remote areas precludes meaningful choice.
2.86 The evidence that
the committee heard in Darwin regarding the Barkly trial confirms the
incredible difficultly in delivering high quality services to regional and
remote areas of Australia and as such represents one of the biggest challenges
to the Scheme.
Later in the
Report, the Committee reported and assessed some of the structural issues
underlying these challenges:
4.78 The NT
Government's Minister for Disability argued that for some types of allied
health services, and in some areas, there is no other option but to restrict
the service delivery to only the NT Government:
The experience to date
has highlighted gaps in the NDIA service delivery model in particular and around
the coordination of disability supports and allied health services. There is no
provision in a participant support plan for coordination of allied health
supports. The Office of Disability has provided this coordination of allied
health services for the trial due to the small numbers; however, it is not
feasible on a larger scale. Under the NDIA model, a client may receive allied
health services from three different providers, further exacerbating the
fragmentation of services and required coordination. In addition to the
implementation of a participant's plan is the reliance on a service provider to
coordinate the disability supports for an individual. In the Barkly it has been
difficult to identify service providers to provide this service.
4.79 According to the
NT Government's Office of Disability, service providers 'are inconsistent in
their availability to provide services', which leaves the responsibility of
coordinating services with the NT Government.
The Minister continued with the conclusion that the unfortunate
consequence of thin markets in remote areas is that the principle of choice and
control that may be evident elsewhere will have to be sacrificed to ensure
access and equity of services:
Whilst the principle of
choice and control is supported by the Northern Territory it is not going to be
feasible in thin and non-existent markets. In many instances the focus in
remote areas needs to be on access and equity as a first step.
The Committee
recommended that the Government ‘through the Disability Reform Council, make
all haste with the finalisation [of] all the bilateral agreements for the
transition phase of the National Disability Insurance Scheme’ (para 5.13).
In an as yet
unpublished submission to the Joint Committee, the MJD Foundation (a small organisation
based in North East Arnhem Land servicing around 500 people either suffering from
or at risk of MJD, a neuro-degenerative disease similar to Huntington’s
Disease) pointed to a series of deficiencies in current service provision for
disabled citizens in the Northern Territory:
In the experience of the MJDF the following
evidence provided at the [previous Committee] hearing reflects the current
practice in non-trial sites areas where the MJDF operates (and in the Barkly
prior to the trial commencing):
·
Wait times for mobility and other specialist
disability equipment are frequently in excess of 6 months.
·
Disability specific transport is a significant an
issue in every community and this is compounded by the unavailability of public
transport or private transport/taxi options.
·
Services are provider driven, where cost restrictions,
maintaining personnel and remote infrastructure challenges heavily impact on
the scope of services available. There
is exceptionally limited access to therapeutic intervention and a high reliance
on home based programs and family support (where programs are developed), and
inadequate support for families to implement them.
·
FIFO/DIDO models are problematic because there are
difficulties with getting and maintaining accurate personal information in real
time and establishing appropriate relationships conducive to providing
specialist disability support services. This is compounded, and demonstrated,
by the very high turnover experienced in government provided services.
·
In the compilation of the Disability Audit, MJDF
staff identified several people with disabilities in NE Arnhem Land who had
previously not been identified or were not receiving services.
·
There are very high levels of disability creating
chronic disease and these comorbidities create a complex interface between
primary health care and disability services that is not comprehensively
addressed. There is a siloed approach to
the provision of disability care and primary health care, complicated by a
delivery model that includes both Aboriginal Medical Service (AMS) and NT
Department of Health provision. See
appendix A.
·
Current government provision has not enhanced
local capital and capacity, for example there are no partnerships with local
communities and other services for repairs and maintenance and equipment
provision which would benefit consumers and communities alike.
There are accessibility modification needs
across the NT, for infrastructure and public facility access, which will not be
addressed through individualised packages.
COAG had
originally scheduled the finalisation of the bilateral agreements for July-August
2015. Yet progress in finalising all the bilaterals has been slow, and as mentioned
above two remain outstanding, including the agreement to establish the scheme
in the NT.
The Commonwealth
has made much of the alleged funding gap in supporting the full roll out of the
scheme, recently announcing the establishment of a
special fund to assist in financing the scheme. While not my main focus
here, the rationale for such an account appears rather thin, but it does serve
as a useful prop in making the political argument for the existence of a
financing gap. What is relevant however is that the scheme involves joint commonwealth/state
financial support, and the NT Government is chronically reluctant to commit to
a demand driven funding model which it will not control and which will inevitably
flow in large measure to the bush.
It is worth
making the point that while there is a bipartisan commitment at the Commonwealth
level to funding the full costs of the NDIS, the States, and for present
purposes, particularly the NT have failed to make similar commitments, and have
taken no action to transparently identify the funding to be allocated to the
NDIS.
Unsurprisingly
then, the Territory Government appears to be delaying signing up to the NDIS. It
will be holding out for a greater share of Commonwealth funding (leveraging off
its comparatively small scale) and is also arguing that it should control
service provision rather than independent service providers. The irony of a
political party normally associated with advocating market based policy
frameworks which are underpinned by consumer choice and autonomy emerging as a
proponent of increased government control and consequential reductions in
opportunities for private sector development is remarkable.
If agreed by
the Commonwealth, the risk will be that government controlled provider arrangements
will increase the likelihood of ‘nickel and diming’ in the provision of
individual services, particularly in remote regions. Moreover, the near-absence
of advocacy organisations for disabled citizens in remote will minimise the opportunities
for holding a government controlled provider arrangement to account.
A recent (unpublished)
newsletter from an advocacy group on disability in the NT noted:
1 JULY FAST APPROACHING
Last week on Daryl
Manzie’s morning program Minister Elferink was talking about the various
“sticking points” there are in relation to the NDIS. Pleasingly he did say it was not a case of if
but when the NT Government will sign the Bilateral Agreement. However according to the Minister, it will not
be on the 1 July like most other States and the ACT. Unfortunately in trying to justify the delay
he firstly said the rollout was due to commence in 2017 not 2016, he failed to
use the most recent stats available from the Barkly Trial, in relation to the
number of participants, which stood at 127 not 109 and amongst other things he
talked about equity and the fact that many people would now not be eligible for
the scheme. Minister it was never
envisaged that everyone would be eligible, either because of age or not meeting
certain criteria. It was always going to
be the case that State and Territory Governments’ will still have a
responsibility to continue to provide services to those people. Yes we know the Territory is both unique and
remote, which does pose some very special challenges when it comes to service
delivery, but surely we know enough now as a result of the Barkly Trial to sign
the Agreement. Two things we know for certain, 1. There will always be issues
regardless of how long we wait and 2. The trial has already been very
successful and a real boost to business in Tennant Creek. Planes are once again flying in and out, the
town is very much alive and well and the Territory economy overall is set to
continue to improve….
In contrast
to the reported comments of the NT Minister, the NT Health Department web site indicates that the NDIS will commence in the
NT in July 2016.
The NT
Government’s approach to disability support has been opaque to say the least.
The delay in signing up to the NDIS displays all the hallmarks of a strategy
aimed at persuading the Commonwealth to just hand control of NDIS funding to
the NT Government.
The argument
outlined above that the provider market is thin in remote regions is accurate. The
solution however is to build that market. The experience of the Aboriginal Controlled
Medical Services is instructive in this respect. They were originally introduced
to address exactly the same type of market failure: GPs were virtually non-existent
in remote regions. Government action over a sustained period has essentially
filled that gap, and built a network of medical services that while focussed
primarily on treating Indigenous patients, increasingly provide services across
the whole community in the areas where they operate. Moreover, the economic
benefits of building a service provider capability in remote regions will be
considerable.
Indeed,
there would appear to be a potential social and economic opportunity here for
Aboriginal Medical Services to expand their service delivery footprint into
disability services as a contribution to building a market in these services in
remote regions.
In the event
that the Commonwealth caves in to the Territory Government’s hard ball
bargaining, the outcomes for Indigenous Territorians living with a disability
would be placed at risk given the Territory Government’s structural imperative
to over-service (across the breadth of government services) its small and
highly demanding urban electorates and the consequential poor record of service
delivery to bush communities and in particular to the largely invisible (in
political terms at least) disabled people in the bush.
It is time
that the both the Territory and Commonwealth Governments got serious about
remote Indigenous disability. There is a need for much greater transparency at
the state and territory levels on the funding allocations for the NDIS. The
Commonwealth should be insisting on a fully transparent model both to ensure
accountability and to facilitate future adjustments to the model aimed at
improving its effectiveness and efficiency.
The Commonwealth
should also be supporting the development of provider capacity in remote
regions, primarily because
there are strong policy arguments against the establishment of a government
monopoly in this service, but also because of the economic development
potential in such a strategy.
Finally, consistent
with the recommendation of the Joint Committee, the Commonwealth needs to
stand up to the Territory, and ensure that an agreement to implement the NDIS
across the whole of the NT is reached quickly. The terms of that agreement
should ensure that the Territory Government delivers on its responsibilities to
its remote citizens, and should provide for the transparency and provider capacity
development which will ensure that the NDIS fulfils its potential in remote Australia.
The numbers
of remote citizens living with disability may not be large in an absolute
sense, however they and their families and carers face enormous challenges and
yet they end up being doubly penalised: first as victims of disability itself
and second as victims of government neglect and carelessness, in the sense that
governments do not appear to care less about ‘invisible’ interests in the bush.
After all, it
can hardly just be a matter of chance that the jurisdiction with the largest
proportion of the most disadvantaged disabled citizenry is the jurisdiction
which is slowest off the blocks in implementing the changes which offer the
promise of transformative change.
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