Vision Australia’s submission to the Draft Report of the Disability Care & Support Scheme

Introduction

As stated in Vision Australia’s original submission to this inquiry, any reform to the disability sector should be guided by the principles set out in the United Nations Convention on the Rights of Persons with Disabilities (UNCPRD) and Australia’s National Disability Strategy.

The UNCPRD provides the most comprehensive articulation of human rights principles as they relate to disability.  Among other things, the Convention emphasises a non-medical understanding of disability that focuses on environmental, attitudinal, and social barriers that create exclusion.  Vision Australia believes that these same principles ought to be reflected in the eligibility requirements, service landscape, and governance of a National Disability Care and Support Scheme.

Australia’s National Disability Strategy represents a dramatic shift in attitudes to disability in Australia with every state and territory recognising the importance of people with disability being able to maximise their potential and participate as equal citizens in Australian society.  An effective Disability Care and Support Scheme will be essential to achieving the goals outlined in this strategy.

People who are blind or who have low vision are diverse with a range of needs.  A scheme that can provide the proper support to these individuals will unlock their potential for social and workforce participation and all the social and economic benefits that flow from this.

Executive Summary

This submission outlines key areas in which Vision Australia believes that the Commission should give further consideration when finalising its report to Government.

Eligibility

Vision Australia acknowledges that the Commission’s Terms of Reference are a limiting factor in relation to disability that occurs as part of the natural ageing process in deliberations on a proposed national disability long-term care and support scheme.   This requirement reflects a need for Government to manage costs and ensure effective delineation between the disability and aged care sectors.

While global programs such as Vision 2020 are making good progress on reducing the incidence of avoidable eye disease, it is still a harsh fact that the ageing process, and lifestyle factors, cause disease that leads to blindness in our ageing population. Global statistics support Vision Australia’s own data that confirms that the majority of clients seeking support are over 66 years of age.

There has been much commentary and debate about the capacity of the Australian Aged Care sector to support citizens as they age, particularly those who acquire disability as a consequence of ageing and living longer.

This issue is yet to be comprehensively addressed by our political and policy decision-makers.

Notwithstanding this, Vision Australia urges the Commission to highlight in its final report the need for Government to ensure that the review of the aged care system properly addresses the needs of those Australians who acquire a disability over age pension age.

It is also critical that any minimum medical threshold of vision loss be set at a level that recognises that the disruption to a person’s core function can occur much lower than the level of legal blindness in Australia.

Further, the Commission should ensure that full eligibility to access the early intervention services under the scheme is extended to those who are blind or who have low vision.

Services

Australians who are blind or who have low vision require a range of specialist services in order to live independently and have the opportunity to fully participate in society.  These include adaptive technology training, early childhood development, employment services, peer and emotional support, orientation and mobility training, occupational therapy, low vision clinics, and specialist equipment.

People who are blind or who have low vision will sometimes require daily support such as adaptive technologies for reading and writing and assistance with mobility.  However, some will not require long term daily intensive attendant care or therapy such as other disability groups may need under the scheme.

It needs to be recognised, however, that episodic services such as the initial and refresher training to use adaptive technology or orientation and mobility training when a person moves house or to a new location, are essential for people who are blind or who have low vision to be able to live dignified and fulfilling lives.  The final report needs to be clear on the new scheme providing support for such services.

Sustainability of community services

Not-for-profits should continue to play a part in providing services to people with a disability in the new market driven environment.  It is important that these providers remain because they will underpin the referrals under the second tier of the scheme and help service clients who may fall outside market mechanisms. The final report should therefore address the viability of existing not-for-profit providers under the new scheme.
 
The Commission should also recognise that the proposed scheme could create enormous cost pressure on existing programs servicing and supporting people with disability, such as disability employment services, taxi subsidy schemes, public transport travel passes, and aids and equipment programs.  The final report must include strong guidance to Government on how to find new money without sacrificing these programs.

Review

Recourse to review following assessment that prevents entry to the scheme should be addressed in the Final Report. Individuals who are denied entry should have access to a robust and transparent review process. 

Vision Australia supports the view of the creation of a specialist arm of the Administrative Appeals Tribunal, as in Draft Recommendation 7.13, rather than an independent statutory officer holder within the NDIS which does not create the perception of real independence.

The need for careful consideration should also be emphasised with regard to the implications of limiting an individual’s common law rights in the future. 

Recommendations

Eligibility

1.	That the final report specifies the World Health Organisation’s International Statistical Classification of Diseases, Injuries and Causes of Death designation of low vision, visual acuity 6/18 or less, as the minimum medical condition threshold.
2.	That the final report recognises that people who are blind or who have low vision, but who do not have a daily need for assistance, will benefit from early intervention support under the scheme.
Services

3.	That the final scheme be flexible enough to recognise that factors such as differing degrees of severity of vision loss, or different personal circumstances or preferences, will mean different services will better suit different people.
4.	That the final report emphasises that episodic services are a critical part of the services mix required by people with disability under the final scheme.
5.	That the final report includes guidelines to the NDIA to facilitate fast movement in and out of service provision and support.

Sustainability of community services

6.	That the final report includes adequate safeguards to ensure that not-for-profit service providers remain viable to support tier two referrals.
7.	That the final report details areas where block funding will need to remain to ensure that support continues to be provided for the most vulnerable in the community.
8.	That the final report emphasises the importance of continued funding for community programs that support those who require disability services but will not be eligible under tier three of the scheme.
Rights

9.	That the final report adopts the approach of having decisions reviewed by the AAT as described under Recommendation 7.13.
10.	That the final report takes into account any potential unintended consequences of removing common law rights in the proposed scheme and ensures that existing rights are protected under appropriate circumstances.

Eligibility
Persons over age pension age

Vision Australia recognises that the Commission’s terms of reference put the needs of Australians who acquire a disability as a result of ageing outside the scope of this inquiry.  The Commission states in recommendation 3.3 of the draft report that ‘support should be provided outside the NDIS for those people whose support needs would be more appropriately met by the aged care system.’

It is clear that any proposal to create a system that would merge the disability and aged care sectors would create a large, administratively costly and unwieldy system.
However, the median age of individuals who access Vision Australia’s services is 79, and 73 per cent of clients are aged 66 or over.  The Government should recognise that age precipitates a range of conditions that result in vision loss, including age related macular degeneration, glaucoma, cataracts, and diabetic related retinal disease. 
The inquiry into the aged care sector does not adequately address the needs of these Australians, particularly with regard to aids and equipment and support for people to remain in their own homes after acquiring a disability.
Vision Australia therefore believes the Commission should take steps in its final report to emphasise the need to properly address disability in the aged care system.  Further details have been provided on this in Vision Australia’s submission to the Commission as part of the Caring for Older Australians inquiry.

Health condition threshold

The Commission sets out a framework in the draft report that creates three tiers of access to the proposed scheme.  Some 360,000 Australians are estimated to be eligible to access the third tier of the scheme that provides access to individualised support packages.  The draft report states that this number has been arrived at using modelling from the Australian Bureau of Statistics against four broad eligibility criteria.
Currently under the social security system, a cut-off based on visual acuity is used to determine access to the Disability Support Pension (Blind).  It is not fully explained in the draft report how much of a role a minimum medical benchmark might play in the eligibility process.  
Vision Australia supports and reinforces the Commission’s idea that a person’s functional support needs are the primary factor in eligibility.  It is reasonable, however, that the scheme may need to mandate a minimum level of vision loss in order to be eligible for support.  Vision Australia strongly believes that the World Health Organisation’s definition of low vision at 6/18 should be the minimum health condition threshold at which a cut-off is drawn.  Conversely, setting legal blindness as a cut-off fundamentally underestimates the impact of low vision on a person’s ability to function in the community.
To illustrate this, Vision Australia’s open employment services provided assistance to 936 individuals in the 2010 calendar year.  Of these, 332 were legally blind and 604 had low vision, but better vision than legal blindness.  All of these people accessed services for different reasons. However, the uniting factor was that they all required services that the mainstream employment system could not provide.  The analogy can be drawn that if those individuals who had low vision but were not legally blind were excluded from the proposed scheme, the great majority of people in need would not receive crucial services.
Recommendation 1
That the final report specifies the World Health Organisation’s International Statistical Classification of Diseases, Injuries and Causes of Death designation of low vision, visual acuity 6/18 or less, as the minimum medical condition threshold.

The importance of early intervention

The Commission recognises that early intervention is important as it can prevent a person from having an escalating need for assistance.  This reduces cost on the scheme and ensures that a person’s quality of life does not have to deteriorate to the point of having a daily need for assistance before they can receive support under the scheme.

Under table 14.1 in the draft report, the criteria for qualifying for early intervention exclude all people with health conditions that are eligible under ‘significant limitations with a core activity’.  Sensory disability is a health condition included under ‘significant limitations with a core activity’.

This could, therefore, be read to mean that a person who has low vision, who does not have a daily need for assistance, but who would benefit from episodic early intervention services such as those described earlier, would not be able to qualify as eligible for early intervention support.

Recommendation 2
That the final report recognises that people who are blind or who have low vision, but who do not have a daily need for assistance, will benefit from early intervention support under the scheme.

Services

In its initial submission to this inquiry, Vision Australia provided a snapshot of the landscape in which services are provided to people who are blind, deafblind, have low vision, or have a print disability.  In short, these services are:
•	Library – audio books, braille books
•	Services to children and families – therapy services, early braille literacy, paediatric counselling, group programs
•	Training – adaptive technology training, adult Braille training
•	Open employment services, including worksite assessments
•	Emotional support – facilitated emotional support groups, peer support groups
•	Independence in the community – orientation and mobility training, Seeing Eye Dogs, equipment
•	Independence in the home – occupational therapy, equipment
•	Low vision clinics – assessment and prescription of aids and equipment by orthoptists and optometrists, low vision advisors
•	Recreation – facilitating access to mainstream service providers.

Typically, the profile of a person who accesses Vision Australia’s services is someone who receives services episodically at different times and for different reasons.

Daily support need

Those who are blind or who have low vision will, generally fall into the proposed scheme under the first part of recommendation 3.2, which defines part of the eligibility criteria to access tier three of the scheme as a daily need support with a ‘core activity limitation in communication, mobility or self care.’
One example of how a person who is blind or who has low vision would meet the requirement for daily support is the need to communicate by reading and writing.  Services to support this could include providing screen reading software, screen magnification software, closed circuit television systems which magnify print, electronic braille displays, and portable synthetic speech readers.
Another example of how a person who is blind or who has low vision would meet the requirement for daily support is the need for daily assistance with mobility.  Services to support this could include providing a dog guide or a long cane.

One size does not fit all

A dog guide may provide a person with greater confidence in an unfamiliar area as opposed to a long cane.  However, others may not be able or willing to meet the demanding care needs and upkeep cost of a dog guide.  Similarly, one person may have enough vision to be able to overcome barriers to communication with a magnifying device.  Others may require software to read text on a screen aloud in order to communicate using a computer.
People who are blind or who have low vision will have different circumstances and need different technologies at different stages of their lives.  People should be free to access the best services to cater for their individual needs.
Recommendation 3
That the final scheme be flexible enough to recognise that factors such as differing degrees of severity of vision loss, or different personal circumstances or preferences, will mean different services will better suit different people.

Importance of episodic services

Vision Australia is concerned that the focus on a daily care need for eligibility for assistance under the scheme may result in a focus on only providing services to support that daily care need.  This fails to recognise the nature of service provision in the blindness and low vision sector.

The draft report seems to be contradictory on the point of recognition of episodic services.  On the one hand, figure 3.1 emphasises the requirement for a daily care need.  On the other hand, recommendation 5.2 states that assessments should, ‘assess the frequency, nature and intensity of a person’s support needs’. 

The daily needs of a person who is blind may include the need to have adaptive technology to help them communicate or to have a dog guide or long cane to aid their mobility.  The daily need for a person with a physical disability might be an attendant carer.

Episodic services can be just as critical to a person’s ability to fully participate in society as the aforementioned services which support a person’s daily needs.

Examples of this include updated adaptive technology training and support when a new version of screen reading software is released or orientation and mobility training when a person moves to a new city.  These services will not be required every day, but they are essential for a person who is blind or has low vision to achieve their maximum potential.

Recommendation 4
That the final report emphasises that episodic services are a critical part of the services mix required by people with disability under the final scheme.

The importance of timely service provision

If, today a Vision Australia client wants orientation and mobility training to use a new shopping centre in their local area, they would only need to make a phone call to quickly receive that service.

The Commission should ensure that the National Disability Insurance Agency (NDIA) establishes minimal administrative requirements under any new scheme, avoiding excessive bureaucracy that could cause delays to access to timely services.

Recommendation 5
That the final report includes guidelines to the NDIA to facilitate fast movement in and out of service provision and support.

Sustainability of community services
The not-for-profit sector

Not-for-profit providers make up the vast majority of today’s disability services.  There is no doubt that not-for-profit organisations provide added value that few commercial services will be able to offer.  These include:
a)	Providing services where markets are thin and for-profit services would not be viable; and
b)	Providing services that do not just meet clinical needs but also create community and hubs of connectivity for people who often feel marginalised and isolated.

The Commission intends that, under the second tier of the new scheme, individuals will receive information and referral to a range of services that are unfunded by the scheme.  It can only be assumed that these are largely services currently provided by the not-for-profit sector.  If this assumption is correct, the Commission needs to consider that the rich landscape of services which currently exists today will not exist in an environment where the majority of funding is directed into competitive service delivery that is funded by individualised support packages.
Vision Australia strongly supports the greater choice that will be afforded to people with disability under the proposed new scheme.  Introduction of individualised funding and an open market of service providers will mean transformational change in the lives of many who have no choice but to receive poor quality service from existing providers.  There is consensus across the sector that a move towards this model is the correct direction. The sector, including Vision Australia will have to adapt to this new model.
In the draft report, the Commission states that ‘block funding may persist in exceptional circumstances.’  Vision Australia encourages the Commission to acknowledge in the final report the areas where block funding should remain ensuring that support continues to be provided for the most vulnerable in the community.
Further, effective transition will be critical to the survival of today’s service providers and Vision Australia would like to be part of the transitional working parties that are proposed in the draft report.

Recommendation 6
That the final report includes adequate safeguards to ensure that not-for-profit service providers remain viable to support tier two referrals.

Recommendation 7
That the final report details areas where block funding will need to remain to ensure that support continues to be provided for the most vulnerable in the community.

Existing community programs

The new scheme will cost some $6 billion in new funding to be found from budgets of all Australian governments.  Vision Australia applauds the Commission for recognising the magnitude of additional support required to properly fund the disability sector.
Vision Australia is concerned, however, that if the savings that the Commission has identified to fund the scheme are not realised, governments may look to reduce or discontinue support for existing community programs such as disability employment services, print disability library funding, taxi subsidy schemes, public transport travel passes, and aids and equipment programs in order to fund the scheme.
It is therefore critical that the Commission provides advice to Government on how it will fund the new scheme to ensure that there is no unintended financial pressure created on existing programs in the disability sector.

Recommendation 8
That the final report emphasises the importance of continued funding for community programs that support those who require disability services but will not be eligible under tier three of the scheme.

Rights
Right of review
In Recommendation 7.12, the Commission proposes that an internal office within the NDIA, headed by an independent statutory officer, would reassess contested decisions on a merit basis.
Vision Australia is concerned that any internal process could not provide the necessary objectivity and transparency required for people with disability or their representatives to have a proper hearing and an unbiased reconsideration.
In the draft report, the Commission sets out a more costly alternative option to the internal office which would set up a new arm of the Administrative Appeals Tribunal (AAT).  Vision Australia believes that this model, which mirrors provisions currently in place for appeals in the welfare system, would provide a greater level of accountability and higher standards of due process.
Recommendation 9
That the final report adopts the approach of having decisions reviewed by the AAT as described under Recommendation 7.13.

Common law rights

The establishment of a no-fault scheme is underpinned by a extinguishing some common law rights.  In the draft report, the Commission proposes removing the right to sue under the common law for long term care costs in place of the safety net provided by the new scheme.

The Commission suggests to Government that it may consider extinguishing other heads of damage, including negligence, in the future.  Vision Australia is concerned that removing the right to sue for negligence may interfere with a person’s right to justice and have other unintended consequences.

Vision Australia believes that any proposal must ensure that a person be able to participate in the scheme and, if appropriate, bring an action in negligence against a party who has caused the injury.

Recommendation 10
That the final report takes into account any potential unintended consequences of removing common law rights in the proposed scheme and ensures that existing rights are protected under appropriate circumstances.

ENDS