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Australian Rehabilitation Providers Association

Disability Care and Support Inquiry
Productivity Commission
Submission on behalf of the Australian Rehabilitation Providers Association (ARPA)
Introduction
The Australian Rehabilitation Providers’ Association (ARPA) is the peak body representing the workplace rehabilitation industry in Australia.  ARPA has a national membership of 150 member organisations of varying size, from small professional rehabilitation practices, to national organisations, in turn representing in the order of 1,400 FTE Workplace Rehabilitation Consultants across more than 500 sites. 
As a national peak body ARPA is leading in assisting with key industry reforms across the country that benefit the recovery, employment participation and social inclusion of people with disabilities. 
Our member organisations consist of multi-disciplinary allied health professional teams who assist persons with a disability, illness or injury to remain or return to the workplace or enter new employment, as well as achieve social outcomes such as independence in the community.
ARPA members deliver services within all jurisdictional workers’ compensation and motor vehicle accident insurance jurisdictions, veterans’ affairs and defence rehabilitation programs, and disability employment services on behalf of the Australian Government. ARPA members are recognised within the disability sector as providing services that lead to sustainable unsupported employment and independent living. The professional services provided by ARPA members include:
•	Early identification of need  
•	vocational, psychological and physical assessment 
•	 plan development, implementation and review
•	return to work support; and
•	service and systems review
These services are provided in environments that require short term assistance through to catastrophic injuries requiring long term care and support, such as those provided through the NSW Lifetime Care and Support Scheme. 

Formal Response to the Key Questions
Who should be eligible?
Who should be in the new scheme and how could they be practically and reliably identified?
A National Disability Insurance Scheme should assist persons with a disability, illness or injury that impacts on their ability to independently care for and support themselves as well as integrate, contribute and participate in the community and work.
ARPA members’ experience across jurisdictions indicates that there is a significant disparity in support available depending on the location and causation of disability in Australia. At the time of the Productivity Commission inquiry into National Workers’ Compensation and Occupational Health and Safety Frameworks ARPA identified a number of problems associated with different workers’ compensation jurisdictions. These problems related to both clients and service delivery and included:
•	Inconsistent approval processes and eligibility criteria
•	Inconsistent staff training and qualifications requirements
•	Inconsistent fee-setting arrangements
•	Inconsistent client compliance arrangements 
•	Inconsistent 'best practice' approaches
•	Inconsistent data collection processes

 A selective, narrow disability scheme is likely to lead to more disputes around eligibility and greater cost shifting between schemes or ‘scheme shopping’. In addition, a narrow approach may lead to increased administrative costs and a need for more complex assessment procedures, resulting in less financial resources available for service delivery. 
A national disability scheme with comprehensive coverage, which has potential to provide support and services for all people with a disability, and which is graduated based upon level of need, is considered the most appropriate.  This could be delivered in the form of a scheme which provides wide coverage, but which has a sound channelling process to deliver timely services that match the individual needs of clients.  The Queensland Government’ s Disability Services Growing Stronger Initiative, provides an example of a single entry approach that channels clients to a broad range of specialist services. 
Within a comprehensive scheme, clients could be practically and reliably identified through an assessment process which takes place independent to service delivery, and is delivered by people with knowledge and expertise relating specifically to type and stage of disability. For example, the biomechanical function and levels of independence in the home and community may be assessed by a Physiotherapist or Occupational Therapist; a client’s decision making capacity and intellectual functioning may be assessed by a Psychologist; social safety and social interface factors assessed by a Social Worker; and biomedical factors assessed by a Medical Practitioner.  An assessment process based on diagnosis, which takes into consideration, type, level and severity of disability, client needs, 
and also assesses carers and their needs, is considered an effective approach and is used broadly and successfully in workers’ compensation environments. A comparable assessment is the Job Capacity Assessment which is utilised in the Federal Government’s Employment Services sector. This assessment has received international acknowledgement. 

‘…the new comprehensive JCA is a promising step as an integrated assessment aimed at earlier intervention, and the last step in a shift from a medical to a functional view of disability. The dual assessment and referral role could develop into its key strength.’
OECD Report on Sickness, Disability and Work volume 2, December 2007:  Comments on Australia’s Job Capacity Assessment arrangements. 

The figure below represents the process for practically and reliably identifying those who should be served by the new scheme, and the steps for effective provision of services and system review. 
1.	Pre-referral Triage: This would generally take place at a Primary Care level, in the form of a medical assessment and diagnosis by a medical practitioner.
2.	Referral to the Disability Scheme: Following the assessment and diagnosis, a medical practitioner would refer the client to the disability scheme.
3.	Intake to a Disability Scheme: This provides a single entry point to a scheme that delivers a diverse range of services to meet the needs of people with disabilities, their carers, and other stakeholders. 
4.	Initial Assessment and Service Plan Development: This assessment includes determination of eligibility for the scheme and the development of a service plan in collaboration with clients and stakeholders. The development of the service plan is based on the determination of appropriate goals, and a set of “gold standard” templates, which includes multiple service options where available. If the individual is not considered eligible, signposting to an alternative, more appropriate service is considered valuable to ensure that clients don’t ‘fall through the cracks’ of the system. 
5.	Case Officer allocated: A Case Officer that best suits the client’s specific needs and demographics is assigned.
6.	Third Party Services engaged: The engagement of services is based on availability, cost and outcome record and is informed by the service plan. 
7.	Implementation of Service Plan
8.	Reassessment of Services: The reassessment process takes place in collaboration with the client and stakeholders and incorporates rules based measurement of cost, goal attainment and service standards. 
9.	System Review: The system review includes (at its core) client and stakeholder feedback. 
Which groups are most in need of additional support and help?
It is recognised that a large number of people with disabilities in Australia are not currently receiving adequate services. Groups which are most in need of additional support and help are those that are most restricted by their disability and environment. Need should be environmentally contextualised; for example, someone who uses a wheelchair and resides in a country town with no disability-friendly taxi or public transport services may have a greater need for support than someone in a wheelchair who lives close to a disabled access bus service and lots of disabled access facilities. 
Assessment of needs (including financial, health, education, social, accommodation, employment, safety and nutrition), should be holistic, driven by client strengths, goals and circumstances, and incorporating family and carer resources. 
What could be done about reducing unfairness, so that people with similar levels of need get similar levels of support?
To ensure that people with similar levels of need get similar levels of support, it is important to have a set of accepted ‘best practice’ guidelines and services that are based around particular types of disability and disability environments. In addition, a comprehensive, national training programme, which encourages service provision within a consistent framework, but that supports flexibility and knowledge growth and innovation, allows for greater consistency and fairness. 
ARPA has recently worked with the Heads of Workers’ Compensation Australia (HWCA) to develop a set of principles that ensure consistent service quality within workplace rehabilitation across a range of schemes, with a broad variety of legislative and regulatory frameworks. A principle-based approach is likely to deliver the flexibility required for the diversity of needs and life events that a fair and equitable national disability insurance scheme would demand.  
One of the emerging issues for disability service provision is the shortage in Australia of allied health professionals. This is impacting already in regional areas particularly, and the disability sector’s ability to recruit a range of professionals including occupational therapists, physiotherapists and psychologists in ACT and Northern Territory is at a critical level. Any funding model needs to take this into account. Insurance funded services as well as funding through the Australian Government’s Job Capacity Assessment and Employment Services Programs are working well. In this sector loading in funding is applied to remote locations across Australia.

Who gets the power?
How could people with disabilities or their carer’s have more power to make their own decisions (and how could they appeal against decisions by others that they think are wrong)?
Empowerment for people with disabilities and their carers comes with involvement in the decision making process. The development of a service plan and ongoing re-assessment of services should take place in collaboration with the client, their family, carers and stakeholders. Although the service plan would be based on a set of best practice templates (taking into account the client’s individual needs and what is realistic, cost-effective and supported by evidence) the plan could include multiple service options where available. The greater the range of best practice options for service plans, the more flexibility and choice can be offered to people with disabilities, and therefore the more power they have to make their own decisions.   In addition, clear goals should be determined in collaboration with the client and/or their carer’s. A principle-based assessment process and the use of flexible rather than black-and-white goal attainment strategies also ensure that people with disabilities and/or their carers guide the direction of the service. Involvement of clients in service plan development will support a shift from program-driven services towards a more client centred approach, without compromising the effectiveness of services. 
People with disabilities and/or their carers could make appeals against decisions by others or express concerns about the service that they are receiving using a service such as the Patient Advice and Liaison Service (PALS) offered by the National Health Service in the United Kingdom. This service is identifiable and accessible to patients, their carer’s, friends and families, and provides on the spot help, with the power to negotiate immediate solutions or speedy resolution of problems. In addition, the PALS service acts as a gateway to appropriate independent advice and advocacy support from local and national sources, and provides accurate information to patients, carers and families about services, and about other health related issues. This service also takes a systems improvement approach where complaints are systemic, and acts as a catalyst for change and improvement by providing valuable information and feedback on problems arising and gaps in services.
How should the amount of financial support and service entitlements of people be decided (and by whom)?
The amount of financial support and service entitlements of people would be determined by the recommendations in assessments and service plans. The allocated Case Officer would use the service plan to allocate third party services to cases, and these would be selected based on available providers and pre-agreed, capped service costs. Any financial support and service entitlements for clients would be informed by best practice recognised in current research and practice guidelines for a particular client’s strengths, needs and circumstances. 
What services are needed and how should they be delivered?
What kinds of services particularly need to be increased or created?
In order to increase and create appropriate and effective services, the development of a legislative framework that supports universal access, maximises participation and assists independence for people with disabilities is required. 
For a national disability scheme to function effectively the service administration should incorporate a national database, with a software system that offers rules-based options for service plans. From the perspective of clients and carers this means that they only need to tell their story once, because information can be shared horizontally and vertically within privacy protocols. The system could incorporate a buildable knowledge database to support timely improvements to disability services as evidence supports new practices.  
In addition, a national training package may be developed for staff working within the scheme ensures consistency and quality in service provision. This training package should be developed in collaboration with a central research body, which determines “best practice” for disability services. 
How could the ways in which services are delivered – including their coordination, costs, timeliness and innovation – be improved?
Services could be improved through the implementation of a national integrated disability approach which is managed locally with goals developed in collaboration with clients and stakeholders.  
As previously noted, a system that informs and guides service plans is valuable for improving speed and quality of service, and systems improvements such as this could reduce time frames from months to within a week from intake to service plan implementation. A robust system will drive performance by incorporating clear principles, key performance indicators and benchmarks that take into consideration geographical location and economic conditions. An example of this is the Australian Government’s Employment Services approach which delivers clarity of expectations and a competitive framework for third party providers around service and outcomes.
In addition, the involvement of a central research body, which ensures innovation and best practice, and the use of an advice and liaison service to enable ongoing system review and improve client satisfaction will assist in maintaining effective service delivery. 
A disability scheme with long term case management, which spans the lifetime of the client, also improves continuity in service particularly at key transition points (eg. Adolescence, illness, accommodation changes, education, work, ageing and relationships) and facilitates ongoing reviews to re-evaluate client needs over time. By having a single entry point and case officer, the cost and complexity of multiple siloed services would be greatly reduced, while improving access and service options. 
Are there ways of intervening early to get improved outcomes over people’s lifetimes? How could this be done? 
Over the last twenty years in Australia, the value of early intervention has been measured in the workers’ compensation environment particularly in relation to employment outcomes. This data invariably supports the earliest possible assessment and intervention. The table below illustrates return to work rates based on duration between injury and referral for rehabilitation services. 
ARPA believes this early intervention data has similar applications across a range of clients needs and is not limited to return to work outcomes. 
The use of a rapid referral and assessment process managed at a local level and facilitated by the use of a national database that informs and guides service plans, allows for early intervention. 
In addition, an effective case management model, which takes a collaborative approach to goal development, increases the likelihood that the service plan takes the right direction to get improved outcomes at the earliest possible stage. 
How could a new scheme encourage the full participation by people with disability and their carers in the community and work?
A new disability scheme should maintain focus on full participation, and should provide education to clients and carers about the benefits of participation in the community and work. Realistic participation options, covering the full spectrum from supported to independent employment opportunities should be afforded to people with a disability.
 In addition, collaboration with a broad range of stakeholders, including educators, employers, community agencies, clients and carers, can ensure appropriate and sustained participation in the community and work. 
Changing the perception of employers about disability and work, improving knowledge of the physical demands of specific jobs, and developing a legislative framework which aids participation in the community, are all important for encouraging participation. 
The utilisation of a specialist employment advisor within the disability scheme could assist people with disabilities to retain or obtain employment, complete further training, and engage more fully with the community. This would have the flow-on effect of freeing up carers to participate in the community and workplace. 
How can a new scheme ensure that any good aspects of current approaches are preserved?
A new scheme needs to draw on the best of all current approaches, and this could be achieved through a systematic review of existing approaches to develop best practice guidelines.  HWCA’s recent development of a national framework, which involves ten different schemes and hundreds of service providers, is an example of how this can lead to improvements on existing systems whilst retaining good aspects of current approaches. 
ARPA members that have diversified from workers’ compensation into other disability services have been able to deliver improvements in services and outcomes across programs through transferrable knowledge and understanding of the range of services in each sector. A cross-program service approach will support retention of the diversity of services currently available in each, and improve options for people with disability and their carers throughout Australia. 
As well as the good aspects of service delivery that a broad range of providers support, there are financial benefits through greater choice and competition within a rules based framework.
What should be done in rural and remote areas where it is harder to get services?
Under a national scheme, a critical mass of services will be accessible in many more areas, which will improve the availability of services to regional areas. The current siloed programs for people with disability provide effective specific support but do not promote collaboration across programs and are often difficult to access. 
A single National Disability Scheme would better identify and create access to the range of available resources across traditional scheme boundaries including:
•	Social Security 
•	Pensions, benefits and allowances
•	Carer Payments
•	Building Regulations
•	Disability Legislation
•	Health Care
•	Family Services  
•	Carer schemes
•	Housing Assistance
•	Advocacy and legal aid
•	Community Care programs
•	Workers Compensation schemes
•	Motor Vehicle Accident Schemes
•	Private Insurance
•	Veteran’s Programs
•	Charities Community
•	 Groups

Disability third party providers will be better able to provide services in rural and remote areas, as they will be covering the broad range of disability rather than siloed sectors making service delivery more financially viable. 
In the remote regions where financial viability is not possible and local services unavailable, sponsored remote service teams could be used to meet needs. Again the critical mass created by a single scheme improves viability.
How could a new system get rid of wasteful paper burdens, overlapping assessments (the ‘run around’) and duplication in the system?
A shift from a service centred approach to a client centred approach will support client access to multiple programs with a single service entry point and a single application. Privacy protocols across agencies as well as third party service providers can be built into the single national database. 
Funding
How should a new scheme be financed?
ARPA members provide services across a range of disability sectors with a variety of funding approaches. There are also different funding models to those used in each sector that apply in overseas jurisdictions. 
In the mid 1980’s in Australia when workers’ compensation schemes introduced workplace based rehabilitation, many thought the services provided to people with disabilities would be cost prohibitive in the long term for schemes. The opposite has been the case. Disability services in workers’ compensation have had a positive net effect reducing premium/levy rates dramatically (in most cases halving the scheme net costs). 
In terms of overall funding of the proposed scheme, it would seem that a consolidation of all existing streams of funding for Disability Care and Support would be the appropriate to provide a national pool of funds. This would encompass funding from all existing Commonwealth and State and Territory services for the client group including national disability support programmes and jurisdictional based compensation schemes. This national pool could then be distributed to the individual jurisdictions by utilising a weighted population formula that could incorporate factors such as the age of the population, rural and remote service loadings etc. Individual jurisdictions would then be responsible for managing service delivery, by assessing clients and planning and organising services for them in line with national guidelines and the “best practice” model described above.
How can it be ensured that there is enough money to deliver the services that are needed and provide greater certainty about adequate care in the future?
ARPA notes that schemes with actuarial requirements such as the insurance schemes are better placed to keep track of current and future needs. In many Canadian workers’ compensation jurisdictions there are requirements to guarantee full funding through annual adjustment of levies. Another model that has been raised from time to time is the purchase of annuities to ensure future funding of lifetime care and catastrophic disability. 

Organising and implementing a new disability policy
What are your views about the ‘nitty gritty’ aspects of a scheme that will make it work practically?
There are many factors that need to be considered in a wide reaching national disability insurance scheme. ARPA members, while providing services across many programs, do not believe they are qualified to comment across all programs available within the disability sector. 
ARPA is of the view that service delivery will be cost effective and practical through improving service access, incorporating service providers that exist across disability sectors currently, using an evidenced based national database to inform services that are planned collaboratively with people with disabilities, carers and other relevant stakeholders. Current problems related to scheme access, identification and referral to services, availability of services, flexibility for clients and siloed programs will be mitigated.
How long would be needed to start a new scheme, and what should happen in the interim?
Again ARPA is not in a position to determine the time required to implement a scheme of this scale. What needs to happen for such a scheme to begin is:
•	Developing a legislative framework
•	Developing a funding framework
•	Budgeting and financing for the new service
•	Consultation and negotiation with stakeholders around how the scheme can be structured
•	Tender processes for the national database
•	Expressions of interest for third party providers
•	Development of best practice guidelines
•	Development of service principles
•	Training packages for all stakeholders in access to services, the delivery of services, the range of services available
•	Promotion and implementation of the program
This is obviously not an exhaustive list though it is enough to indicate that several years would be required to fully implement such a scheme.   
There are a number of disability needs that would benefit from support prior to the introduction of the scheme. Legislative changes may immediately improve access, for example consistent and effective building codes that improve access for all. Many of these needs and their solutions have been indicated through the process of this Inquiry. Investigation of support options through the setting up of central research body to determine what legislative changes would enhance services for people with disabilities in Australia and to prepare best practice standards that could be built in to the national database prior to implementation of the scheme.
Yours Faithfully

Annette Williams
ARPA National President