In the first article in the series ‘Defending the NDIS’ – Complexity – I pointed to the actuarial fiction of ‘primary disability’ as the root cause of NDIS complexity. Algorithms have not and cannot fix this.
In this second article, I zero in on the unholy mess of Assistive Technology. All Australians should be shocked as to how this massive and growing market is being squandered.
Over the years, the NDIA’s approach to Assistive Technology has descended into a word salad of red tape, confusion, tricky processes, and incompetence. All while desperate people wait, often in the most desperate circumstances.
Assistive technology (AT) is broadly described as any tool, product, software, or device that helps people do things they would otherwise have difficulty doing or would not be able to do. Examples include sensors, immersive environments, tablets, exoskeletons, wheelchairs, speech synthesisers and robots.
According to the World Health Organisation, ‘Assistive technology enables people to live healthy, productive, independent, and dignified lives, and to participate in education, the labour market and civic life. Assistive technology reduces the need for formal health and support services, long-term care, and the work of caregivers.’
Clearly, the WHO considers that AT drives a return-on-investment (ROI) for the individual as well as ‘…broader socioeconomic benefits.’
This was also recognised by the Australian Human Rights Commission landmark statement on technology as an enabling human right, which called for changes to the way in which the NDIA considers and funds assistive technology.
But don’t expect any action from that given the AHRC recently lost its international accreditation due to serious matters of compliance regarding its independence to ensure the protection of human rights.
But there was a time when the NDIS did consider Assistive Technology a driver of system-wide benefits. From the 2015 NDIS AT Strategy:
‘Spending on AT is expected to reach $1.06 billion per annum when the scheme is fully rolled out in 2019-20…Efficiency gains are expected from the potential for new and emerging technologies to disrupt support and service delivery and increase participants’ independence and capacity for active social and economic participation.
…This could potentially have a significant impact on Agency expenditure… by reducing the cost of personal and community supports, which at 45 per cent of spend on average, is the biggest annual expenditure item in participants’ plans.‘
In defence speak, AT is a force multiplier which is relevant from a workforce perspective.
The 2015 $1.06 billion per annum figure has also been estimated at $4 billion per annum: a massive and growing market in Australia alone. And the WHO expects the global market to double by 2030.
Putting it another way, for Australia that’s $40 billion over 10 years. But what is the return on investment we as a caring community would expect? Well, we don’t know.
Because just as the culture of co-design disappeared from the NDIA (until forced to revert by the Joint Standing Committee on the NDIS), the culture of ROI on AT also disappeared. This is very strange for a political narrative so focussed on sustainability.
In a number of submissions to inquiries, the Australian Rehabilitation and Assistive Technology Association (ARATA) pointed to the systemic deficiencies and a culture against a return-on-investment approach by the NDIS for the funding of AT over time. Specially, ARATA emphasised the need for ’…methods to create a culture of selection of AT based on ROI.’
Indeed, there is no reference to return-on-investment in the most recent NDIS Annual Financial Sustainability Report, and nor is ROI included as a factor in the schematic of the modelling approach which is all cost based.
The omission of Assistive Technology from the forward analysis of scheme sustainability, should be of concern to everyone concerned about scheme sustainability.
Otherwise, how do we know if the reported $1.1 billion total annualised committed AT supports as at 31 Dec 2021 is optimal? Once again, we don’t know.
This brings us to the next topic on AT: the big announcement on 1 March by the minister on changes to Assistive Technology processes.
In an apparent response to the horrific stories of kids not getting wheelchairs, catatonic processing delays, excessive documentation, the government is ‘improving the participant’s experience’ by increasing the upper limit for automatic approval of AT purchases to $15,000. That is, ‘no quote required’ for mid-cost AT.
So, what does this automatic approval actually mean?
In an interview with Hireup, paediatric occupational therapist Prue Nix stated that she would “…never recommend that a client buy a wheelchair without trying it and having it prescribed to their needs.”
Ms Nix went on to describe the new processes as “unusual”. “From what I can tell, the process of applying for AT has been re-ordered, rather than improved.” Meaning that no time would be saved: the laborious processes have just been re-arranged.
But the automatic approval was not the only change to the management of Assistive Technology by the NDIA.
The announcement also established the new role of ‘AT Mentor’. This role would write support letters for participants for items of AT, a process that replaces the previous application process.
In an analysis of these changes, occupational therapist Ms Muriel Cummins, a member of the ‘allied’ group of OT’s/health professionals, highlights significant concerns from a systemic safeguard perspective.
“A decreased focus on clinical advice and allied health professional input to the process, combined with the introduction of a poorly defined and unregulated AT mentor role, escalates the risk of inappropriate AT purchases; AT being unsuited to the participants needs; AT that is out of tune with prognosis and expected changes to future functional capacity; or AT that elevates risk of preventable harm to both participants and carers.”
In this massively booming AT market – a market that the agency does not consider from an ROI and scheme sustainability perspective – there is a lot of risk riding on this new Cert IV AT Mentor role.
So, whilst there is not a culture or practice of ROI on AT, participants nevertheless are told that their choices must be ‘value for money’.
Think about this. ‘Value for money’ is a government procurement construct with all sorts of tests and frameworks to work this out. Bureaucrats get training to do this and get it wrong – a lot – as found through endless ANAO reports.
In this faux procurement word salad, there is no value for money ‘test’. Just how could anyone actually even understand the consequences of such a decision.
As Ms Cummins has stated, “…what is clear, is that participants will be held accountable for their choices. It has been indicated that the Agency will strive to recoup debt from the participant if they purchase the ‘wrong’ AT.”
Just imagine if ‘value for money’ was applied to Medicare: a patient held responsible for the ‘VFM’ decision for a medical device.
This leaves the participant entirely at risk, from a debt perspective as well as a safety perspective.
Through every bureaucratic layer there is an ethics minefield.
The ethics minefield of the actuarial fiction of ‘primary disability’ that forced people to ‘pick one’ of their conditions, compounded by the procurement fiction of VFM, forcing people to make a decision they are not equipped to make.
But it gets much worse as we’ll see in the following articles.
Rebuilding the NDIS must start with instituting the foundation of an ethics-based return-on-investment practice supported by safeguards co-designed with healthcare professionals and the community. This will wipe out the layers of destructive processing bureaucracy.
Even better, for the NDIS to be a world leader and establish a national assistive technology agenda.
The third article in this series will be on the coming Copernican moment for the highly contentious NDIS actuarial model.
Marie Johnson is the CEO of the Centre for Digital Business. She is a global award-winning digital authority and advocate for the humanitarian application of AI. Her experience encompasses the public and private sector experience in Australia and internationally, including leading Microsoft’s Worldwide Public Services and eGovernment industry based in Seattle.
Marie was Head of the Technology Authority for the National Disability Insurance Scheme responsible for the technology business case, co-design, and the creation of Nadia. For many years, Marie was the Department of Human Services Chief Technology Architect, with responsibilities including the architecture and technology business cases bringing together the massive systems of Centrelink, Medicare Australia, and the Child Support Agency.
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