The NDIS: ethics, dignity and choice: some dilemmas for social workers

smaller finger painting

Let me frame this piece by stating unequivocally that the NDIS is a genuine capacity building initiative and a great social good. Its current target is to improve the lives of 460,000 Australians with individual funding packages, to help them to participate more fully in their communities. It enshrines in legislation the assertion that,

people with disability have the right to determine their own best interests, including the right to exercise choice and control, and to engage as equal partners in decisions that will affect their lives (National Disability Insurance Scheme Act 2013, Section 4 (8))

and that people with disabilities should be supported so that,

in all their dealings with the NDIA..their capacity to exercise choice and control is maximised in a way that is appropriate to their circumstances and cultural needs (Section 4 (9))

 Our taxes (via the Medicare levy) have been increased to help cover the costs, and no sensible person would begrudge paying a bit more to help their fellow citizens to participate more fully in their communities.

The design of the scheme and the manner of implementation does however create risks which will inevitably continue to cause harm if not dealt with quickly.

Firstly a few words about outsourcing. This is the ‘go to’ methodology of governments captured by free market thinking. Outsourcing ensures that labor markets are fluid and flexible. But as we know the ‘flexibility’ is one way. Workers are paid less, career prospects diminish, 12 month contracts are standard, and professional development is less likely to be employer subsidised.

Governments are also striving to outsource risk and responsibility; not always successfully. And when things go wrong, the fallout can degenerate into enquiries, commissions, and a farrago of fingerpointing.

The NDIA has outsourced to varying degrees the assessment for eligibility, service planning and delivery of the scheme. In NSW for example, the NDIA has “commissioned” three “Partners in the Community”, for what is described as “local area co-ordination”. These partners are Uniting, the St Vincent de Paul Society, and Social Futures.

To use the word ‘partner’ in this context is to stretch the word completely outside its ordinary meaning of – a joint venture with shared risks. The NDIS has designed and funded the rollout to its smallest detail. In this context, comparing even the largest NGO to the NDIA is to compare a mosquito to a 160 kilo gorilla. It is a franchise, not a partnership; and the NDIS has done its best to outsource all risk to its franchisees.  Every NGO, every relevant NGO employee and every sole provider or small business must sign a Declaration of Suitability to be registered as a service provider with the NDIS. Providers declare that they are compliant with all employment and workplace health and safety laws, and that they have mechanisms in place to ensure that any contractors engaged also comply.

The Royal Commission into the Home Insulation Program (HIP) had some relevant points to make about the attempts of the Australian Government to outsource risk. Why, do you ask, am I bringing the ‘pink batts’ disaster into this discussion? We are all familiar with mess and chaos around outsourcing refugee processing and the operation of detention centres, but the example closest to the NDIS is probably the HIP rollout; A huge scaling up of existing services, a significant social good, and the apparent necessity that it be done in a hurry. In its wake, there were four tragic, avoidable deaths, as well as number of enquiries and a royal commission. Most readers will recall that the aim for the HIP was to install insulation into the ceilings of some 2.2 million Australian houses in a period of two and a half years. This was a stimulus package in response to the global financial crisis, that was also designed to bring significant environmental benefits.

In relation to outsourcing, there are some comments of the Royal Commissioner, Ian Hanger, that are worth quoting at length,

Government must recognise that as much as it might seek to do so, risk cannot be abrogated. The responsibility of Government is to care for its citizens and to exercise care and diligence to do everything reasonable to ensure citizens are not placed in danger by its actions…

It was said, by a number of federal public servants, that the Australian Government had no regulatory power in the field of workplace health and safety, and therefore that it was not a risk that the Australian Government could control. In my view, this attitude was deplorable. I discuss..the purported reliance of the Australian Government on the States and Territories and conclude that such reliance was both unjustified and unreasonable

Pretty blunt!

In my view, the most serious flaws in the NDIS occur at the very beginning of the assessment and planning process, and continue for those participants who need service coordination funded by the NDIS.

As things stand, at the beginning of the planning process, potential participants are asked a range of questions by “local area coordinators” to determine eligibility and formulate a plan. All the information needed to generate goals, support and a 12-month budget are gathered; usually in one meeting. Participants may have some verbal confirmation of the answers they give. This data is uploaded for a centralised desktop assessment and a plan is sent back to the participant as a fait accompli. The legislation makes it quite clear that as soon as a plan is approved, it comes into effect. But there is in fact no reason why a paper copy of the participant’s answers could not be left with them for a week, in order to double check completeness, accuracy, and to fully digest the implications for the participant; and further, that the plan be considered a draft, subject to discussion. Remember that the Act states,

people with disability have the right to determine their own best interests, including the right to exercise choice and control, and to engage as equal partners in decisions that will affect their lives. (my emphasis)

This a lopsided transaction; it is not a partnership. It is an insurance assessment that gives the most vulnerable participants no time to review or reflect. (Sixty percent of approved plans in the third quarter of 2016/17 were for participants with an intellectual disability or autism.) I have heard anecdotal evidence of 12 month reviews of plans that revealed unreasonable anomalies between what was needed and granted to assist participants in achieving their goals. But this is not just a question of efficiency and accuracy; it is one of fundamental dignity.

I don’t know what has been happening behind the scenes, but I find it puzzling that disability advocacy groups have not made more of a public fuss about this? I do know however, that governments of all persuasions have lately paid lip service to human rights, whilst simultaneously de-funding robust advocacy. Any consumer group funded by government has difficult choices to make, if it involves biting the hand that feeds it.

These ‘take it or leave it’ plans also present ethical dilemmas for local area coordinators. Some of these frontline workers might make an ethical choice to defy NDIA driven KPI’s and routinely give participants time to reflect in a genuine partnership. But this could be a hard choice for anyone to make, working on low paid 12 month contract.

Ironically, in the Royal Commission into the HIP, Commissioner Hanger had plenty to say about ethical pressures faced by public servants fearful of their tenure.

It has been a long-standing principle that public servants had security of tenure giving them both longstanding experience in the field of public administration, a great depth of knowledge about that art and the workings of various portfolios. Security of tenure has another important consequence: public servants could, if warranted, advise their Minister against certain courses of action, and in trenchant terms if necessary.

 I found the APS Values and Code of Conduct .. a valuable resource..(in particular) the concept of frank, honest, comprehensive, accurate and timely advice, referred to in ..the Public Service Act. After having read all of the documents provided to the Commission, and having heard all of the evidence given particularly by public servants, I have little doubt that had such advice been given at key junctures of the HIP, the tragedies that occurred would have been avoided..

Commissioner Hanger couldn’t however bring himself to recommending security of tenure. Instead he advised these senior civil servants to include a “devil’s advocate” section in their briefing templates! Astonishing advice to some of the smartest and most skilful people in the country.

This underlines just how unreasonable it is to expect individual workers, either in management or the frontline, to defy the powerful, when dignity and human rights ought to be built into the system. Only a concerted, combined effort by the relevant trade unions, disability advocacy groups, and the range of professional associations that cover these frontline workers, will ensure that justice prevails.

And, as can be seen from the pink batts disaster, should some scandal or tragedy occur, there is no guarantee that the senior public servants will be able to successfully argue that they washed their hands of all risk.

Turning our focus to ‘support coordination’, it is important to note that this is the only funded service that gets a mention in the Declaration of Suitability. It will soon become apparent why this is the case. (The role of support coordinators is to work creatively and resourcefully with NDIS scheme participants in how they utilise their support budgets to achieve their goals.)

Social workers (along with other Allied Health professionals) can register to provide specialist support coordination; their tertiary qualification and relevant experience being routinely accepted as sufficient credentialing. But few participants need specialist support, and the more generic ‘line item’ of support coordination is open to a broader range of workers. Obtaining credentialing to provide generic service coordination requires the provision of extensive evidence to state based credentialing agencies. It is time consuming, and may cost thousands of dollars. Workers who already have specialist support coordination credentials, are given no recognition, or advanced standing in applying for generic support coordination; an illogical anomaly that also has important consequences for participants.

NGO’s have put themselves in the business of providing support coordination in the marketised environment of the NDIA. Importantly some of them seek to provide a ‘one stop shop’ that offers both coordination, as well as the services themselves. (Sometimes as a hangover from how they used to do business pre the NDIS era.) The inherent conflict of interest is so great that the Declaration of Suitability document seeks to outsource this risk. Paragragh 12 requires that individuals and agencies to declare that

If you are seeking approval in relation to both the provision of supports and managing the funding for supports under plans- the provider has mechanisms in place for dealing with conflicts of interest when performing both of those roles in relation to the same participant.

Because of social work’s robust code of ethics, it is reasonable to say that social workers (along with other health and disability professionals) have been at the forefront of embracing the disaggregation of service coordination from service provision. Let me remind you again of Section 4 (8) of the Act,

people with disability have the right to determine their own best interests, including the right to exercise choice and control, and to engage as equal partners in decisions that will affect their lives 

Hypothetically, if a sole practitioner social worker were providing support coordination, and a participant wanted to stay with agency XYZ for occupational therapy based services, but wanted to change their speech therapy from agency XYZ to another provider, the social worker would do their best to honour this choice. If, however agency XYZ is providing support coordination and a range of services (as it might have before the NDIS), it is a nonsense to think that the agency will be as scrupulous in honouring the wishes of the participant, no matter what “mechanisms” it has “in place”. The proper intent of the Act could easily be implemented, by simply stating that agencies cannot provide both coordination and services to the same participant. Problem solved; end of story.

Let us hope that it does not take a scandal or a tragedy for this problem to be fixed. And again, we ought not rely on individual whistle blowers to bring it to the public’s attention. The combined efforts of trade unions, consumer groups and professional associations is a better way to get the changes we need. To continue to allow agencies to provide a ‘one stop shop’ simply facilitates patronising attitudes that no longer have a place in a society that respects the worth and dignity of every human being.

Want to continue the conversation on Facebook? I have created a page connected to my blog for just that purpose.

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12 Responses to The NDIS: ethics, dignity and choice: some dilemmas for social workers

  1. jennie burrows says:

    thank you for this analysis…i am determined that we will take the time we need to consider options and decisons!

  2. Hilary says:

    hello vittorio, and thanx for your article, which raises many useful questions.
    i am a social worker with quadriplegia, and have some personal familiarity with the individualised funding model. here are some of my thoughts/responses:
    1. “Firstly a few words about outsourcing.”: the developing thinking is to give end users the option to employ carers and services directly, without an agency. while this would make carers etc contractors, who’d be responsible for their own PD, sick and holiday pay insurance, in theory it’d also mean the additional funds NDIA allocates to agencies would become available for the end user to allocate to carer fees etc. NDIA is able to ensure proper contracts are in place for service providers to end users to minimise the risks you refer to.
    regarding the requirement that agencies be registered in order to minimise risk – would that also be a means to protect end users by means of agency insurance and employment standards, as well as indemnity cover?

    every change entails risk, no matter how carefully one seeks to minimise it. i’d suggest that adding new elements to the assessment process at this stage would serve to delay yet again the roll out for many people who have been waiting for too long to benefit from a this opportunity to have agency in their own lives.

    your article highlights that good enough is hard enough to achieve, and perfection for one person can be disastrous of another.

  3. Joy Stevens says:

    Thanks again Vittorio for another interesting article.

    I think the roll out of the NDIS in NSW has been driven by idealogues, placing their pursuit of privatisation above the needs of NSW citizens with disabilities. In NSW they plan to completely closed down all government disabilities services. I understand this is not the case in other Labor States.

    The NSW Public Service Association has finally got itself on the front foot and is standing up for the many workers and communities around NSW who will lose out from this cold-hearted policy.
    Much of your argument can be applied to other human services sectors, notably out of home care services.

    There is a hidden agenda in these privatisation policies and it is to decrease worker’s opportunity to organise and thereby reduce the cost of the service – more money to the private sector, less to the workers and a poorer service to individuals and communities.

    I think the community will wise up and they won’t stand for this in the long run.

  4. Elizabeth McEntyre says:

    Thank you Vittorio for your important article.

    One of my family members who has mental and cognitive disability and complex support needs has an NDIS package that, at this stage, has no funding attached other than for support coordination to secure supported disability accommodation. However, they have been unable to secure any such accommodation from either of the local providers (Flourish or New Horizons) to meet their needs and remain institutionalised. Because they are institutionalised and therefore under the care of the Local Health District, they can not use the NDIS to access proper and meaningful cultural activities and the Local Health District provides no cultural activities. Their 82 year-old mother is however able to take them fishing every now and again. They have never accessed ADHC services and live in the Newcastle area which as we know was one of the first sites to commence the NDIS. I guess we should be grateful that they didn’t end up in prison.

  5. vittorio1 says:

    Mick Small asked me to post this comment for him
    The biggest problem with the NDIS is the greed of the so called service providers which are preying on NDIS customers for their percentage.

    Many organisations are not viewing the NDIS rollout as empowerment for the clients new independence but as an imposition on themselves due to the reduction in bulk funding.

    As soon as Social Workers enable more clients to self manage their NDIS packages, the better. Unfortunately many professionals sell their souls to Bureaucracy for the security of tenure and superannuation rather than supporting clients to the best of their ability.

    Mick Small OAM.

  6. Mary Drake's says:

    An early stage issue is the lack of transparency and accountability in decision making about who should or should not be a participant in the NDIS. Applicants receive rejection letters stating they have a health issue not a disability, even though they currently on the eligibility list for the DSP. No legislation, regulation or policy is properly cited, making appeals very difficult for the average person.

    All the issues raised above are further complicated by the inability of NDIS advisors on their 1300 number to give consistent information and advice. This is underlined by their refusal to give out last names and phone numbers so that they can be held accountable.

    I too think the NDIS has the potential to be the biggest positive social policy change change in Australia since Medicare. But surely we have learned how to run a government department well since then? Why are these basic procedural problems impeding equitable and timely delivery of services?

    And what are we, the members of the AASW, doing about it?

    • vittorio1 says:

      Heartily agree Mary! A coalition of unions, professional associations and consumer bodies is urgently needed.

  7. Tanya Denny says:

    Thanks Vittorio
    As you say
    Workers who already have specialist support coordination credentials, are given no recognition, or advanced standing in applying for generic support coordination; an illogical anomaly that also has important consequences for participants.

    I’m in the process obtaining 3rd Party verification. It costs around $5000 to be verified. If you’re a sole practitioner (As I am) or seeking verification as an NGO – no difference. I would like to the AASW working with NDIA to streamline the TVP process for Social Workers because you are right, we are already trained to do this work and verified by AASW.

    Maybe it’s time for AASW to take up the fight for advanced standing in the NDIS space.

  8. Gina says:

    Thank you for this my daughter had funding under ADAC and it was 100% brilliant full control and choice and NO pressure to spend. Her year long package lasted 3 years. Less $$$ but full choice. Now we have buckets of $$$ that can’t be used and can’t buy the smallest of items as no allocation. Clearly the NDIA planner didn’t read the file as even need to get a quote for something she patently can’t use. My experience is that the OT’s are now charging $1500 per item per OT report. I asked for a schedule of low cost items to be added to the report which I provided and was told that the service agreement would need to be re-written and $1500 added. Plus another visit. NDIA suggest getting someone else -well there is a huge shortage of OT’s with all the report writing and that is not possible. No OT report NO wheelchair.

  9. Gina says:

    The NDIA just wipe their hands of all problems and walk . In a slightly rural area PWD that need short amounts of help find that they can’t get carers because the carers prefer to look after clients that offer full days etc…. No fall back care. No responsibility. Personally I prefer larger org they ensure that someone comes and if I don’t like the person I can get them changed/

  10. Pathmaker says:

    As an independent support coordination business, our service item within the NDIA is being manually re-adjusted following the planning meeting by the Agency, resulting in less hours provided. Complex cases demand energy, experience, time and effectiveness to build self-determination and responsibility.

  11. Steve says:

    Massive concerns within the NDIS. Just focusing at this stage on SSC, as the lead actor for participants with with complex needs, most lack the requisite knowledge skills and experience. The barrier of qualification has been reduced with teachers, social scientists, exercise physiology graduates joining the fray as sole traders or contractors earning $193 per hour (or majority percentage as a contractor). Most SSC are contractors now even though the chief economist of the NDIS built the SSC model around employees working in an office supported within a team lead by a team manager with professional supervision, access to a senior practitioner, able to facts and perception check decisions made which potentially have significant impact on their participants. As a contractor they work in isolation wielding significant influence over participant plans and lives. They also lack understanding around the NDIS legislative best practice guidelines or even their role as SSC – registration processes are undertaken by their host organisation. As contractors they operate from a time based perspective, not needs based. This is usually a pragmatic approach to NDIA planners approving “just enough” funding. More SSC funding can be requested at review to try and achieve the values NDIS promises however outcomes are unknown with submission time usually unbillable. Easier just to take on another participant. Within this environment collaborative practice, self affective practice, robust consultation, case conferencing, and other professional standard practices rarely see the light of day. Conflict of interest also has suffered with most contractors referring therapy to the stable of contracted practitioners working with in the same organisation. Even if this wasn’t the case how is a SSC who does not understand the impact of complex developmental trauma on the life of an individual living with other compounding cognitive impairments meant to choose therapeutic interventions of best fit when they themselves do not understand the issues and cannot find the answers because they work in isolation? Finally given the outline of SSC practice standards within NDIS guidelines is very thin and they occupy the lead role position in a complex service delivery, SSC have limited accountability. The word responsibility is not used in the NDIS legislation. As I have asked myself on a number of occasions with regard to the Anne Marie Smith tragedy, where was the coordination services allocated to vulnerable people in all this? What should their responsibility have been given the vulnerabilities involved that checked the boxes for coordination eligibility (lack of insight into her own support needs, inability to establish services of need and lack of capability to advocate on her own behalf should service delivery fail). The coordinator, in particular specialised, is the lead agent. Best practice includes reporting protocols including having sighted your participant every 3 months. Simple really, and saves lives.

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