OTAUS2019 Conference: Advocacy & Policy Address
*The following address was delivered at Occupational Therapy Australia’s 28th National Conference
OTA’s 28th National Conference occurs at a time of considerable turbulence in the world of lobbying and advocacy.
While I am pleased to report some key wins for the profession, those of us charged with advancing the cause of occupational therapy are acutely aware that some problems remain unresolved; please be assured that these frustrate us every bit as much as they frustrate you, and we daily redouble our efforts to achieve an advantageous outcome.
Two years ago, when I spoke to a plenary session of OTA’s 27th National Conference, the NDIS was a massive problem. Two Ministers and effectively three CEOs later, the NDIS … remains a massive problem.
Telephone calls and emails continue to go unacknowledged for weeks, even months.
Wait times for eligibility to be determined are too long. Wait times for initial Plan meetings are too long. Wait times for Plan reviews are too long. And of course, these wait times leave highly vulnerable people without necessary supports, exposing them to unacceptable risks.
Even with Plans in place, too often the wait for assistive technology is too long, denying participants the support they need to achieve their goals.
Not a single piece of correspondence from OTA to the recently resigned CEO of the NDIA was ever acknowledged. For that reason alone, I do not mourn Mr De Luca’s departure. It is to be hoped that his replacement as CEO is someone with a background in disability services – there are enough bankers and insurance experts on the Board already.
Amidst the ongoing exasperation, however, there was one significant victory.
On March 28th the federal government announced that allied health professionals working with NDIS clients would receive an increase in the hourly fee they are paid, a gratifying outcome for all who lobbied hard to achieve it.
An increase in the hourly rate paid by the National Disability Insurance Agency (NDIA), from $179 to $190 per hour, was great news for those OTs who had experienced so much frustration during the early years of the NDIS. On July 1st we learnt that the fee paid is actually $193.99 per hour.
And things could have been so much worse.
Just 12 months ago, the Independent Pricing Review commissioned by the NDIA recommended significant cuts in the fees paid for most NDIS services. A tiered pricing structure, based around the highly problematic concept of the client’s “complexity”, would have seen some services attract payments of as little as $110 per hour.
OTA played a leading role in vociferous and protracted efforts to overturn a proposal which was bad for providers and potentially disastrous for their clients. We warned the NDIA and the federal government that hundreds, and possibly thousands, of OTs would have been forced to walk away from NDIS work because their businesses would have been rendered unviable by the lower rates of pay.
As a result of these efforts, the NDIA and the federal government saw sense, and a mass exodus of allied health professionals has been averted.
However, OTA was concerned to note that psychologists continue to command a higher hourly rate than other allied health professionals and, intriguingly, so too do physiotherapists working in some parts of the country, with only the vaguest explanation as to why.
Accordingly, we raised this matter as one of the highest importance in our recent submission to the NDIS Annual Price Review, and in another recent submission to the Department of Social Service’s inquiry into NDIS Thin Markets. Both these submissions can be read on the advocacy page of the OTA website.
If the response from the NDIS is unconvincing, we will renew our request to see the data on which this decision was purportedly based.
In short, our submissions are the opening salvo in what will probably be an ongoing lobbying effort.
Another threat to the sustainability of OT practices working within the NDIS is the requirement for some OTs to be certified by the new NDIS Quality and Safeguards Commission. Not only is this another layer of bureaucracy with which to contend, the associated audit process is prohibitively expensive. Some OTs have been quoted audit fees in excess of $15,000. Those based in rural and remote locations are expected to cover the travel and accommodation costs of the visiting auditors.
And the fact that this cost will have to be met every three years renders NDIS work for many practices unsustainable.
Making matters worse is the requirement that only auditors from a small list approved by the Commission can tender for the work. While we have been assured that the number on this list is to increase, that growth to date has been slow.
As OTA wrote in a submission to the Australian Parliament’s Joint Standing Committee on the NDIS in February:
Certification by the NDIS Quality and Safeguards Commission is a disincentive to continued registration with the NDIS, in particular the prohibitive cost of the required audit. OTA asks again why one arm of government, the Australian Health Practitioner Regulation Agency (AHPRA), deems our members fit to practice while another, the Commission, questions that fitness. In discussions with the Commission and the NDIA, it has become evident that there is a difference in understanding between the two organisations with respect to members providing support to children under the age of 7 years. The Commission advises that it is of the view that members providing therapeutic supports to these children in a single practice, often sole provider, capacity should not need to undergo certification. In practice, however, the NDIA are placing funds within the Early Childhood supports line item, thereby necessitating our members to undergo certification to support these participants. OTA is aware that a large number of providers are choosing not to re-register and that this has led to a significant increase in the number of families requesting plan reviews to change their funding to self or plan managed, thereby enabling them to see unregistered providers.
Since then, the problem has become even more acute, as the Commission’s requirement for certification is rolled out across the country.
I recently took a call from the CEO of Assistive Technology Suppliers Australia (or ATSA), warning that the entire AT sector within Australia was on the verge of collapse. This was because the Commission’s certification requirement was rendering smaller, often family-run businesses unsustainable. Moreover, those businesses that might be able to survive were running out of customers because of the diminishing number of OTs prescribing assistive technology. And why are there fewer prescribing OTs? Because of the NDIS Commission’s audit requirement.
So, small OT practices, small businesses and an entire industry sector – with its generations of accumulated expertise – is threatened by what we would contend is an entirely unwarranted bureaucratic requirement. Despite assurances from the Commission, the cost of certification is not proportionate to the size of the practice or the business. In the words of the NDIS itself: Is this reasonable and necessary?
However, as the problem has become more acute so has governments’ awareness that there needs to be an urgent solution to it. Thanks to the efforts of the ATSA CEO, our team at OTA, and Allied Health Professions Australia, we have alerted the nine ministers across Australia with responsibility for the NDIS to this looming crisis, and we have been reliably advised that urgent consideration is being given to the matter.
About twelve months ago, OTA made a submission to the Productivity Commission’s Inquiry into Compensation and Rehabilitation for Veterans. Again, this can be found on the OTA website. In that submission we noted that the OT profession had its roots in the horror of the First World War, when grievously wounded veterans returning home from war had to be assisted to relearn and perform the functions of everyday living.
Given the demands of military service, both physical and mental, a sizeable proportion of Australian veterans require the services of an occupational therapist, and this number grows as our veterans age.
While occupational therapists derive enormous professional satisfaction from working with veterans and war widows, it has become increasingly difficult work to sustain. This is because remuneration for such work has, in effect, been frozen for nearly twenty years.
This is leading to a significant change in the nature of the workforce treating our veterans. Experienced clinicians are having to walk away from veterans’ work, a development of particular concern given the very complex conditions with which many veterans present. A veteran experiencing functional impairment as the result of mental illness needs and deserves a highly experienced occupational therapist or, at the very least, an occupational therapist with recourse to highly experienced colleagues.
OTA welcomed the removal of the freeze on the indexation of fees paid for allied health services by the Department of Veterans’ Affairs from 1 July 2018. It is important to note, however, that during the five year period in which indexation was paused there was no attendant pause in the costs of doing business. Those of our members working in MBS funded service delivery roles experienced a prolonged period in which, as a result of deliberate government policy, their outgoings rose while their income stagnated.
Those occupational therapists still doing veterans work, do so at a loss; they only keep doing it out of loyalty to longstanding clients and by cross subsidies from more profitable work.
And it must be noted that occupational therapists are different from other allied health professionals. They usually travel to and from the place in which the client is trying to function (their home or residential facility). Despite recent changes, this travel remains inadequately subsidised.
Similarly, occupational therapists are required to complete much more written reporting than other allied health professionals. Initial clinical assessments, the design of home modifications and the prescription of assistive technology all involve extensive written reporting. Significantly, the DVA’s audit requirements necessitate careful written reporting but the time spent completing necessary documentation is not, or is inadequately, subsidised.
Inexplicably, a single flat rate is paid for all consultations, irrespective of how long a consultation takes. As a thorough initial assessment can take up to two hours, only part of this time is effectively remunerated.
The fee schedule is outdated, no longer reflecting the increased complexity of the work done by occupational therapists and the assistive technology they prescribe. Our members often identify mental health issues while doing assessments and are subsequently expected to perform a case management role which is not remunerated. An updated fee schedule should reflect the changing landscape in which occupational therapists work. It should remunerate them for the time it actually takes to perform increasingly complex consultations.
Despite OTA raising these issues in a letter to the Minister for Veterans’ Affairs, the Hon. Darren Chester MP, dated 2 March 2018, and in our 2018-19 pre-Budget submission to Treasury, that Budget was potentially a hammer blow for our members.
It decreed that more than $40 million was to be cut from funding for allied health services over the following four years as part of what is termed a “new treatment cycle” model of care. While the Federal Government refers to this measure as a means of “achieving efficiencies”, occupational therapists have every right to be sceptical. Unless the money saved is reinvested in allied health care for veterans, ideally by paying allied health providers a living wage, this amounts to a cut in funding.
We have since been advised by the Department of Veterans’ Affairs that these efficiencies are aimed at freeing up funds for future health needs and that this will include ensuring DVA’s fees schedules are up to date.
This assurance notwithstanding, occupational therapists can be forgiven for concluding that the cuts are yet another fiscal assault on soft targets – namely veterans and the allied health practitioners who care for them.
But amidst this angst, we have won a small victory, and we have launched a new offensive.
On Friday 28 June the Minister for Veterans’ Affairs announced a deferral of the new Treatment Cycle Initiative (TCI). This was our small victory.
Originally to take effect on Monday, July 1st, the TCI was postponed until the 1st of October.
As members working with veterans would be aware, the new treatment cycle is to run for 12 months or 12 sessions, whichever comes first. It also involves new reporting requirements.
OTA and other member associations of Allied Health Professions Australia (AHPA) wrote to the Minister in the week before his announcement, expressing grave concerns about the rushed nature of the TCI’s implementation. OTA CEO, Samantha Hunter, wrote:
Occupational Therapy Australia (OTA) is extremely concerned by the absence of preparation and guidance provided to the allied health sector to facilitate a successful transition to the TCI for both clients and providers.
To date, providers have not received any guidance from the Department to support implementation of this significant initiative, despite the introduction being only two weeks from now.
We are urgently requesting a delay in the introduction of the TCI, with a revised implementation date of 1 October 2019.
We anticipate this short postponement will allow sufficient time for DVA to work with the peak bodies to develop and disseminate the appropriate guidance for providers to ensure a smooth transition for veterans.
As a result of this correspondence, the Minister met with representatives of AHPA and subsequently agreed to the proposed postponement.
At this meeting another, crucially important matter – namely, the unsustainably low rates paid by DVA for services delivered by allied health professionals – was also raised with the Minister.
The postponement of the TCI is an important advocacy win, and OTA wishes to thank those members who supported and informed the representations we made to the Department and the Minister.
The new offensive to which I referred takes the form of a standalone website dedicated to the issue of DVA rebates.
www.otsforveterans.com.au acquaints visitors with the history and facts of the issue and invites them to sign a prepared letter and send it to either of, or both, the Minister for Veterans’ Affairs and the Shadow Minister. Significantly, the website was launched on the eve of ANZAC Day and prominently proclaims: “This is not the way a grateful nation treats the people who treat its veterans”.
As reported in the June issue of Connections, within just a few weeks of its launch the website had attracted more than 2,000 views, and generated more than 250 letters to the Minister and the Shadow Minister. Associated Facebook posts had reached more than 15,000 people, generating more than 180 likes and more than 100 shares.
But the battle goes on. Now that the federal election is over and we know who is the member in each of Australia’s 151 lower house electorates, we will soon invite interested OTs, their clients and their carers to write to their local federal MP, asking that they raise this injustice in their party room and on the floor of the parliament. If we can’t win this one from the top down, then we’ll win it from the bottom up.
Those of you affected by or concerned about DVA’s, or more correctly Treasury’s, unwillingness to pay OTs a living wage, should be relieved that Jacqui Lambie fell over the line on May 18 and is again an Australian senator. She has two great qualities: first, a genuine and demonstrated concern for Australian veterans and; second, the balance of power in the upper house. For the next six years she and a handful of other crossbenchers will decide what does and what doesn’t become law in Australia.
Now that her position in the Senate has been confirmed, our CEO will soon be writing to Senator Lambie, outlining the facts of this issue and requesting a meeting.
I would like to touch briefly on the subject of the Federal Government’s ongoing review of Medicare Benefits Schedule, or MBS, items. The reason I shall only mention it in passing is because of time restraints and the fact that I will be devoting a presentation to this issue exclusively, as part of the conference’s scientific program. For those of you interested, that presentation will be at 2:00pm today in room C2.5 on level two.
There were, in fact, several reviews undertaken as part of the review of MBS items, three of which are of direct relevance to occupational therapists: the review of allied health items, the review of mental health items, and the review of items pertaining to eating disorders.
In the case of the Review of MBS Allied Health Items, OTA opted not to prepare a submission to this review, choosing instead to contribute to the submission being developed by Allied Health Professions Australia. While we have had input into all aspects of the AHPA submission, that is to say all item numbers under review, OTA was the lead association in the development of arguments around the issue of case conferencing. This is because OTs so frequently find themselves de facto case managers, convening and driving meetings aimed at the coordination of multi-disciplinary care.
In the case of the Review of MBS Eating Disorder Items, the results are effectively in. From November 2019, people diagnosed with severe eating disorders will be able to access up to 40 subsidised psychological services and 20 dietetic services each year. OTA joins with other peak bodies in welcoming the introduction of a separate program for eating disorders. OTA has sought clarification on whether the new program is inclusive of occupational therapy services, and has been advised that the initiative will be consistent with Better Access.
In the case of the Review of MBS Mental Health Items, the process has been significantly delayed by one profession in particular, which, while riven by internal brawling and utterly incapable of speaking as a unified profession, still presumes to tell government that other professions are not mature enough to work in mental health. Well, you can read our views on that particular presumption in our submissions to the Review – again, available on our website. Submissions, I might add, thoroughly evidence-based.
We also wrote to the Health Minister recently, drawing his attention to the great work done by OTs in mental health care and repudiating the abuse of due process exhibited by others.
Before I run out of time I would like to talk briefly about aged care – a field in which so many of you work and in which more and more of you will work as our population ages.
Please be assured that our submission to the Royal Commission into Aged Care is well advanced and will be submitted in early August – well before the September deadline.
Despite the horror stories emerging from some residential aged care facilities, our submission is deliberately positive, highlighting ways in which these facilities can be improved, not least by allowing OTs to exercise the full range of their skills. The existing system, in which OTs are effectively prevented by the Aged Care Funding Instrument from bringing their expertise to bear, is professionally frustrating for you and a tragedy for your clients.
And our submission will highlight the importance of home care – increasingly the preferred way to age for millions of Australians. We will remind the Commissioners, as we constantly remind government and the private health funds, that every dollar invested in falls prevention returns multiple dollars to the health system in savings. But for a $100 grabrail in a shower recess, an elderly person would not be occupying a public hospital bed at a cost of thousands of dollars a day.
In the field of primary care, something about which government says so much but achieves so little, OTA is on the front foot. This week, in Adelaide, we have a poster presentation at the Australasian Association for Academic Primary Care Annual Research Conference. In October we will have an exhibition booth at the Royal Australian College of General Practitioners’ National Conference in Adelaide. On both occasions we are telling those at the very frontline of health care “This is what we do. This is how we can help your patients”.
As I hope I have made clear, OTs live and work in an issues-rich environment. Everything I have addressed today is federal in nature – but in each and every state and territory there are issues unique to that jurisdiction, and different governments, oppositions, and bureaucrats to lobby. Be it OTs in schools, driving assessments or the compensable schemes, there is more work to be done at the state and territory level.
I want to conclude by thanking the hundreds of you who make our lobbying possible. It is you – the clinicians – who provide the content for well-reasoned, persuasive and evidence-based submissions to government. It is you who appear before the parliamentary committee inquiries. It is you who sit on the National Reference Groups.
Without you, I would literally have nothing to say today. Thank you.
About The Author
Michael Barrett is OTA's National Manager, Government and Stakeholder Relations.