Males and people with higher incomes are more likely to benefit from the National Disability Insurance Scheme (NDIS) than other demographic groups are, according to a new report.
The article by BMC Public Health, a journal which looks at the community impact of health policy and practice, studied how social determinants of health at the individual level can contribute to deep-seated health inequalities when combined with complex policy-delivery systems.
It found the ability to exercise choice is distributed unequally through personalisation schemes like the NDIS.
“This is concerning given the international push towards personalisation in various areas of social care, with widespread implications for efforts to address the social gradient in health,” authors Eleanor Malbon, Gemma Carey and Ariella Meltzer said.
The most vulnerable were those with intellectual disability or complex needs, substance abuse, mental health or forensic issues, socially isolated older carers and those from culturally and linguistically diverse backgrounds.
These groups were found to receive less funded support in their NDIS plans than others with similar needs, highlighting that individualised funding packages don’t automatically equate to more choice.
Malbon, Carey and Meltzer suggest more attention be given to the administrative structures and systems through which personalisation schemes are delivered to avoid increasing inequity.
Effective, fair service depends on market
Choice and control of services relies on a well-functioning market to make service providers available, according to the paper.
Market gaps in the NDIS are a growing problem. Remote and regional areas may be more vulnerable due to distance between participants and providers, and there may be a lack of services for more challenging conditions.
Money in NDIS plans that isn’t spent by participants could be reclaimed by the NDIS, even if they’ve been sitting on a waiting list. Women, non-men and people with lower education levels are least likely to find providers for their care, putting them at risk of having their money reclaimed.
Service providers are now less able to respond to general crisis events, as the personalisation structure means that they cannot be paid to help someone unless that person has money in their plan for that specific service, the paper said. This means some people could miss out on crisis support, tailored services, or the NDIS as a whole.
Budget management reveals inequality
Those who manage their own individualised budgets make up 7% of NDIS participants but carry a higher administrative burden, the report found. They pay service providers without dealing with the NDIA, allowing the providers to negotiate their own prices. This means self-managed participants have the opportunity for more tailored, boutique services and innovations. Self-managers are more likely to be upper- or middle-class users.
Advocacy is not covered by the NDIS, meaning that those with stronger supports may have larger plan budgets than others who are less enabled or experienced. Families often rely on their own skills or resources, and those who had experience with meetings, preparing funding requests and liaising with professionals appeared more confident in their planning processes, the report found.
Up to 40% of NDIS participants said they need more training to complete certain tasks, like looking after money, using computers, finding the right service for the right price, talking and writing, planning time, making choices and being heard.
Knowledge of how to navigate the NDIS influences individuals’ choice, according to the paper. Participants need to understand certain scheme resources, such as an online NDIS payment portal. This demands a need for skills and time to understand structural and operational details of the scheme.
Having such skills can be hindered by a range of social factors, including cultural and language background, literacy level and level of complexity of need. Accessible, available information is a “key component of consumer rights”, the report said.
Information availability and frequent changes to bureaucratic processes present challenges which sector staff may not even understand, the paper argued. Implementation issues affect bureaucratic accessibility of the NDIS and capacity of participants to exercise choice.
The NDIS online portal has been a central accessibility issue, particularly for those who find digital access challenging. During instances where the portal crashed, NDIS participants who were confused and frustrated struggled to receive assistance from the NDIA, according to the paper.
The bureaucratic nature of the scheme and accessibility issues – including the dependence on personal networks – means that choice and control may be limited for those who are socially isolated or lack skills and resources to navigate complex service systems.
Changes to how service provider staff work, are paid and managed within the NDIS can have negative implications. For example, low NDIS prices results in low-paid staff, making it difficult to attract and retain quality staff and quality services. Having enough funded hours to give high-quality and coordinated service is another challenge of individualised funding packages, which could leave those with more complex needs vulnerable.
While the NDIS is supposed to give its participants more choice, some service providers are choosing to work with only self-managed participants or people with less complex needs, disadvantaging those who are most vulnerable.
“Where there are more coordination costs and where service providers and workers may choose not to work with them, people with disability and complex needs may not have the same choices for services as their middle-class peers,” Malbon, Carey and Meltzer said.