Patricia Scott, David Kalisch and John Walsh
Commissioners of the Disability Care and Support Inquiry
Productivity Commission
GPO Box 1428
CANBERRA  NSW  2601
 
Re:  Submission towards Productivity Commission’s Disability Care and Support Issues Paper, May 2010

29 June 2010

Dear Commissioner Scott, Commissioner Kalisch and Commissioner Walsh,
 
Thank you for this opportunity to make a submission (as attached) to the Inquiry into Disability care and support.  The Blue Mountains Interagency working party is a group of service workers representing services, staff, service users and carers in the Blue Mountains LGA (NSW), who have met specifically to look at some of the issues highlighted in the Disability Care and Support Productivity Commission Issues Paper, May 2010.

Our focus in the submission attached is on the importance of providing the following:
•	Consistency and continuity of service delivery and how the choice of funding models impacts on these issues. 
•	The importance of adequate service systems, workforce structure and skilling of the industry,
•	The impact of demographic and geographic factors on the determination of service delivery, and,
•	The needs of primary carers and those that they care for.
 
We are aware that a reshaping of the national health system is an enormous undertaking and one that will need much consultation and consideration.  We have selected four key sections of the issues paper to focus on in an effort to highlight some of the fundamental elements needed for efficient, effective and socially appropriate provision of services and supports to individuals with a disability and their carers.
 
We commend the Department for their review of the current systems, and for undertaking a commitment to planning for all members of the Australian society. We welcome your serious consideration of our recommendations and look forward to further consultation.

Yours faithfully,

BM Community Interagency Working Party
Leisa Davies, Judy Finch, Chris Muzzatti, Can Yasmut, Nadja Lawrence, Prue Hardgrove

 

Submission towards the Disability Care and Support Productivity Commission Issues Paper prepared by the Blue Mountains Community Interagency Working Party
June 2010

Key Issues

The Disability Care and Support Productivity Commission Issues Paper acknowledges that there is a strong rationale for government to improve care and support arrangements for people with disabilities and their families. The Issues Paper recognises that there are many weaknesses in the current system and that these flaws will be the focus for revising the current system and require change. These weaknesses are summarised in the Issus Paper as follows:
o	There are insufficient resources and gaps in certain kinds of services in some jurisdictions and location 
o	There can be inequity of treatment and the ‘hit and miss’ delivery of services 
o	There is an insufficient capacity for people with disabilities or their families to exercise choice about the services they use and have control over the financial resources directed to them. 
o	The system does not always give people with disability and their families a reasonable level of certainty about the future 
o	There can be insufficient opportunities for employment or participation in the community 
o	There is often a lack of coordination 
o	There are inappropriate models of support — such as care for young people with disabilities in aged care homes

The BM Community Interagency Working Party (the WP) agrees that these weaknesses do exist and are an adequate reason for the review of the current system. The WP recommends that the Productivity Commission in its review incorporates the importance and impact of 
•	consistency and continuity of service delivery and how the choice of funding models impacts on these issues. 
•	adequate service systems, workforce structure and skilling of the industry,
•	the impact of demographic and geographic factors on the determination of service delivery, and,
•	the needs of primary carers and those that they care for.

SECTION 5: Key design elements of a new scheme 

The WP recognises that there is a broad rationale for some form of mandated contributions to provide disability support. The Commission has identified that this can be achieved through taxation, compulsory contributions to insurance, or other means. This section is an attempt to demonstrate the core elements of a revised service system that addresses this broad goal.

The WP recommends that the decision making responsibility (power) should lie as much as possible with the people living with a disability and their families and carers. The WP the importance of prioritising the level of need and support required and that resources are allocated accordingly. However, there are other ways of empowering people living with a disability, which can be achieved through policy changes and changes in public opinion and awareness e.g. through education strategies around the need of carers or an initiative to improve employment and participation options.

“Are there are other design aspects of a scheme that are important? How are they important and how should be incorporated into a scheme?”

The WP notes that the Figure 2 in the issues Paper does not illustrate clearly how the new system is different from the current system. The WP recommends that the new scheme incorporates a ‘sustainability component’ incorporating processes to monitor and evaluate the new scheme.

SECTION 8:  The Nature of Services
 
People with a disability and their carers often have unique and complex care needs including and in addition to those of normal daily living. When developing a model for service funding and delivery, it is imperative that the Federal Government consider the following issues: 
-        consistency of service provision,
-        continuity of service delivery
-        funding models that are flexible but allow for ongoing service maintenance
-        adequate service systems, and,
-        Geographical considerations
 
Whilst it is critical that all funding models allow for individual choice and flexibility, reflecting the person’s individual needs. However, there are certain underlying components of a service system that need to be consistent and continuous across all models of service provision and geographical locations.  It is not adequate to just provide each individual with an amount of money to spend on acquiring services without allocating block money to services to maintain their basic operations and to allow for continuity in service provision.  Simply providing individualised packages and/or brokerage funding does not necessarily address the issue of consistency and availability of service provision.  

If there is no mechanism to ensure that a service has ongoing funding, then it becomes difficult to maintain the skill levels of staff, level of service provision, and motivation.  What seems like a simple and effective idea could potentially lead to increased stress levels for both families caring for a person with a disability and the services trying to assist them.  This scenario can lead to a further drain on carers and ultimately community resources when a crisis situation occurs.
 
What individuals and families need and the impact of these needs on a new disability care and support system:
 
The WP recommends that a new disability care and support system needs to be sustainable. That is, it needs to be:
•	Adequately funded and affordable

•	Accessible geographically. Lack of population numbers in any given area should not equate to a lack of choice and frequency and/or flexibility in service provision.  Current departmental funding models support a regionalised approach that is numbers based in any given area. So a densely populated area would have a larger proportion of funds allocated and therefore greater service provision.  Rural and geographically isolated communities with lower population numbers miss out on crucial service allocations.)

•	Accessible physically and in terms of the numbers of people able to use the system.  Due to the current regionalisation of service provision there is inefficient use of available funding options.  Often ‘middle-man’ services receive government funding and then allocate this as packages to individual clients.  These services are often out of the direct area of service provision and need to expend significant funds on staff travelling times and kilometre allowances.  The nature of this model means that they have to broker out the funds to smaller localised services anyway.  It would befar more effective and more streamlined to allocate this money directly to local services who have the area knowledge and direct client rapport.

•	Streamlined and transferrable to other services. Single point assessments need to be utilised to prevent duplication and stress. People should also not have to pay for the assessment process. This should be included as part of the overall service provision. Normal referral practices should be maintained and streamlined through a central intake process.  And,

•	Innovative, flexible and dynamic in its approach in order to ensure that the system continues to meet the changing needs of people accessing the service.  The complexity of issues and the care situation for people with a life-long disability is only likely to increase as they age and as their carers age also.

•	Audited on a three-yearly basis in line with a three yearly funding agreement model.  In addition the standards review processes already existing should be maintained.
 
The most important services needing consideration in a new system could include: 
•	A centralised intake service to reduce confusion and assist with a transferrable service system, case management and assessment services using qualified staff,
•	Transport components for all service provision. TRANSPORT is an essential part of all service types and SHOULD NOT only be designated to a sole transport service in any one area.  Also, funding needs to be available to adequately staff bus runs to ensure clients with higher support needs can access the service and to enable transporting of service users in a safe manner; and,
•	Most importantly, a significant increase in the number of places available across all levels of DIRECT CARE SERVICE. Examples of direct care services could include: greater availability of assisted living services – homecare, in-house support, home nursing, greater social and peer support-based respite care, flexible respite choices options (where the person can choose the type of respite care they require Such as, In-home support, community-based or other), and day program places (not everybody is able to work in a traditional job or workplace environment).
 
Again, it needs to be noted that the issues affecting people with a life-long disability are likely to become more complex over time as they live longer and move into old age. It should be acknowledged that having a person with a disability is a family issue and any new service system should encompass the family unit as the client and respite support should be tailored to meet the ‘family’s’ support needs. The definition of respite may need to be broadened to allow services the ability to provide support to siblings, to be able to undertake domestic assistance duties for carer support, and purchase equipment which will provide a respite effect. This should be flexible across funding streams.
 
A new system needs to respect that the situation for this group of people is not going to improve or disappear but require greater levels of service provision and intervention. Human service provision should not be operated on a big business model approach that requires a profit-based outcome.  Whilst the Expression of Interest process enables services to possibly be more accountable, a move towards a complete competitive tendering model may serve to undermine the collaborative approach that currently exists amongst many service providers.   The Competitive Tendering Model currently has its flaws with respect to this process and format but its use in the human services sector, that is a non commercial sector that relies on local service co-operation and co-ordination to maximise services to clients, has to be questioned.  Human services certainly need standardisation across jurisdictions. However, they need to maintain their focus on the individual, remaining flexible, allowing individual choice in meeting individual needs, and, remain LOCALISED to each area. 
 
It is an acknowledged reality that there are only a finite amount of financial resources available to government to provide the types of services needed.  Consideration needs to be given to a government-funded mechanism supported by a system of co-payments and  allocations or sponsorships from big business.  However, this consideration should not prevent or exclude people who are vulnerable and financially unable to contribute to a service in which they are in great need of.  It should also not negate the Governments responsibilities to all members of society.
 
Other Unmet Needs:
 
Older Parent Carers
The key support required for Older Parent carers is the planning and transition to long term supported accommodation. 

SECTION 10: Financing options

The WP is in agreement that carers do in fact shoulder much of the burden of care of children with disabilities. Their caring role now extends for many years as the child with the disability ages into adulthood.  This burden of care consists of a complex bundle of factors, including a financial factor.  We recommend that the issues for carers are placed high on the agenda of this review and recognised in funded service streams.

We are also in agreement that the community at large must take on the bulk of responsibility for supporting people with disabilities. Whether the disabling condition is from birth or resulting from a health condition or injury, the impact of the individual and their family is severe.  We suggest that care for people with disabilities should be treated in the same universal manner that the education of children is treated. This means that each person would have a base line entitlement to a good level of service provided through a public system and funded through public revenue.  It could be that there is a parallel private system of care set up but the public system would need to be comprehensive and freely accessible to enable universal access. 
In regard to how a new approach might be financed, we are recommending that there be a “mix of options”.  In terms of the principles that might be applied in determining the appropriate mix we suggest that efficiency and equity together with ensuring that there is not an impost or burden on people with low income should be considered. Sustainability into the future is clearly also a high priority in that this entire review is premised on the need to longer term planning and longer term certainty for people with disabilities and their carers.  We question the validity of “public acceptability of the funding method” as a priority principle though.  We suggest that the community at large ideally will respond to the needs of people with disabilities from equity and social justice perspectives. However, public response to specific funding and programming for people with high or special needs is not always consistent or constant. In our view, we should be planning for people with disabilities according to social justice principles then financing this policy from a mixture of options so that future funding will be assured (rather than altered according to political priorities or responses to pressure groups).

A financing method should take into account future demographic trends. Assumptions about changes in demographics should be conservative however. The mix or funding options should include insurance like options.  We agree that the introduction of risk incentives would be beneficial (including prevention and early intervention responses) to reduce the likelihood of disabling conditions occurring in the first place or resulting in longer term conditions. However, any financing approach must be aware that a whole spectrum of disabling conditions are not preventable and promoting a particular funding option as inclusive or prevention presents concerns for non-preventable conditions.

In relation to sources of funding, we recommend that this should be derived from the public purse.  Whether this be through regular taxation levies or Medicare levies, the impost should be shared across the community (with account taken for low income people).  Whilst parents might wish to contribute to their children’s futures via a trust scheme or some other system this should be entirely voluntary and not result in additional access to services – the principle that should be applied is that the funding of a service system for people with disabilities is a community responsibility. The general leveraging of community contributions is not supported as means of gaining the base income required for the scheme.

In regard to funding consolidation, we support the introduction of a single financing system under a national disability scheme.  This would facilitate the seamless coordination of program policy and service provision. We support a separation between the funds manager / collector and the body that will oversee the scheme. 

SECTION 11: Workforce issues 

The bulk of support for disability is informally provided by predominantly (female) family members. Formal disability services are delivered by a range of practitioners from the health and community sector. There is already a shortage of workers in this area. An ageing workforce and increasing competition for the same services by other sectors, such as aged care, will add to these shortfalls. Efforts are underway to attract new workers, including by improving wages, working conditions, training and career paths. However, increasing a workforce’s capacity is typically a slow process. 
In any event, the skills of the workforce will need to change over time to accommodate new and better ways of delivering services and supporting people with disabilities. 
How can workers be attracted to the industry? What role should government play in this process? 

•	Workers can be attracted to the industry by improving working conditions and wages. 

•	Government can play a role in this process by committing to improved funding and award rates for employees in the sector. Government can also look at establishing traineeships and apprenticeships in the disability sector, and positively promoting the disability sector, and promoting a careers drive for the disability industry.

What type of skills and workers are required? What role should government play in upgrading the skills and training opportunities available to workers? 

•	Tertiary skills such as Certificate 3 in Disabilities or Associate Diploma in Disabilities are a desirable requirement for disability service employers. Higher qualifications such as psychology are of course desirable, however the pay is not usually attractive for someone with this type of degree. A broad range of people of age and gender are required as workers. 

•	Again, Government can play a role in this process by committing to improved funding and award rates for employees in the sector, promoting the industry positively, allowing flexibility of study and work arrangements. 

How can a scheme be implemented so that extra funding results in more and/or better services rather than paying more for the same service? What transition arrangements if any, are required? How long would it take to build up the required workforce? Are there particular skill bottlenecks that need immediate attention? What role could volunteers and workers in mainstream services play? 

•	Accreditation by a tiered system for services.

•	Transition arrangements whereby services are allowed a timeframe to set up and upgrade, as this can be a problem for smaller services; a service may win a tender to provide a program or service, but the tender may not allow for transition/ set up. 

•	It could take several decades to build up the required workforce. 

•	“Bottlenecks” requiring immediate attention include training deficits; workers need to be regularly updated with training such as; first aid or “dignity of risk”. The responsibility of staff is very great (personal care, behavioural issues) and inconsistent with the wages offered.

•	Volunteers can play a role in assisting with staffing for services in a variety of ways; traditional volunteer support, supporting in more “mainstream” or community oriented ways eg; taking a neighbour who has a disability shopping or to church.

•	Mainstream services can assist by positively promoting people with disabilities and the disability industry. Larger services could assist by sharing resources such as Policies and Procedures or training.

Allied health professionals have specialist qualifications, whereas those providing direct care, such as personal care, are subject to lesser requirements — mainly aimed at ensuring minimum levels of service provision. 

What is the appropriate level of training required before commencing work in the industry? Should any existing certification requirements be altered to reduce obstacles to people working in the disability sector? What role is there for national accreditation? 

•	Tertiary skills such as Certificate 3 in Disabilities or Associate Diploma in Disabilities should be a minimum requirement for staff employed by disability services.

•	National accreditation would be onerous but desirable for the industry to be accountable for its services and clients; there should be a “baseline” standard for funded services to meet.

Given prospects for ongoing workforce shortages, realising unexploited productivity and efficiency gains will also be important. But there are diverse views on the extent and attainability of these unexploited gains. 

What scope is there for productivity and efficiency gains in the sector?
•	Professionalising the sector – Improving funding of services and promoting the sector as providing satisfying employment; moving away from the idea that the disability sector is the domain of underpaid and mainly female staff. This will give rise to more professional outlook from staff across the board and reduce staff burnout and exit.
•	Services working together to share resources and training