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What are the NDIS funding responsibilities versus other mainstream service systems?

What are the NDIS funding responsibilities versus other mainstream service systems?

The Council of Australian Governments (COAG) has agreed that the NDIS will fund personalised supports related to people’s disability support needs, unless those supports form part of another service system’s universal service obligation and in accordance with reasonable adjustments required under a law dealing with discrimination on the basis of disability.

Whilst participant plans will take into account areas such as health, housing and education in order to provide a holistic overview of participants’ needs, the NDIS should only fund supports that are not provided (or supposed to be provided) via existing service systems. The Productivity Commission highlighted the importance of this principle in its 2011 Inquiry Report, Disability Care and Support stating:

'It will be important for the NDIS not to respond to problems or shortfalls in mainstream services by providing its own substitute services. To do so would weaken the incentives of government to properly fund mainstream services for people with a disability, shifting the cost to another part of government. This ‘pass the parcel' approach would undermine the sustainability of the NDIS and the capacity of people with a disability to access mainstream services.'

What are the funding responsibilities of the NDIS versus other mainstream service systems?

In November 2015 a set of general principles (PDF) were developed and outline the responsibilities of the NDIS and other mainstream service systems. These principles are being used to assist in understanding and developing the interface between the NDIS and other service systems including:

Health
Mental Health
Early childhood development
Child protection and family support
School education
Higher education and Vocational Education and Training (VET)
Employment
Housing and community infrastructure
Transport
Justice
Aged care

What are the general principles that determine funding responsibilities between the NDIS and mainstream services?

There are six general principles which include^[1]

People with disability have the same right of access to services as all Australians, consistent with the goals of the National Disability Strategy which aims to maximise the potential and participation of people with disability.
The NDIS will fund personalised supports related to people's disability support needs, unless those supports are part of another service system's universal service obligation (for example, meeting the health, education, housing, or safety needs of all Australians) or covered by reasonable adjustment (as required under the Commonwealth Disability Discrimination Act or similar legislation in jurisdictions).
Clear funding and delivery responsibilities should provide for the transparency and integrity of government appropriations consistent with their agreed policy goals.
There should be a nationally consistent approach to the supports funded by the NDIS and the basis on which the NDIS engages with other systems, noting that because there will be variation in non-NDIS supports funded within jurisdictions there will need to be flexibility and innovation in the way the NDIS funds and/or delivers these activities.
In determining the approach to the supports funded by the NDIS and other service systems governments will have regard to efficiency, the existing statutory responsibilities and policy objectives of other service systems and operational implications.
The interactions of people with disability with the NDIS and other service systems should be as seamless as possible, where integrated planning and coordinated supports, referrals and transitions are promoted, supported by a no wrong door approach.

^[1] Source - NDIS Principles to Determine Responsibilities of the NDIS and Other Service Systems (PDF)

What are the applied principles that determine the delineation of funding responsibilities between the NDIS and mainstream services?

In addition to the six general principles a set of applied principles (PDF) have been developed to assist governments to understand which service systems are responsible to fund particular services. This guide has been developed with the launch and early implementation of the NDIS and will be reviewed as required.

It is essential to understand that the NDIS is not designed to fund or replace the responsibilities of other service systems. However, bringing attention to the delineation of responsibilities between service systems is likely to highlight gaps in service systems.

What are the applied principles that relate to the health service system?

There are five applied principles that relate to the responsibilities of the health service system and the NDIS and these are articulated below^[1]:

Commonwealth and State and Territory health systems have a commitment to improve health outcomes for all Australians by providing access to quality health services based on their needs consistent with the requirements of the National Healthcare Agreement and other national agreements and in line with reasonable adjustment requirements (as required under the Commonwealth Disability Discrimination Act or similar legislation in jurisdictions).
The above health system will remain responsible for the diagnosis, early intervention and treatment of health conditions, including ongoing or chronic health conditions. This may involve general practitioner services, medical specialist services, dental care, nursing, allied health services, preventive health care, care in public and private hospitals, and pharmaceuticals (available through the PBS).
Health systems are responsible for funding time-limited, recovery-oriented services and therapies (rehabilitation) aimed primarily at restoring the person's health and improving the person's functioning after a recent medical or surgical treatment intervention. This includes where treatment and rehabilitation is required episodically.
The NDIS will be responsible for supports required due to the impact of a person's impairment/s on their functional capacity and their ability to undertake activities of daily living. This includes "maintenance" supports delivered or supervised by clinically trained or qualified health professionals (where the person has reached a point of stability in regard to functional capacity, prior to hospital discharge or equivalent for other healthcare settings) and integrally linked to the care and support a person requires to live in the community and participate in education and employment.
The NDIS and the health system will work together at the local level to plan and coordinate streamlined care for individuals requiring both health and disability services recognising that both inputs may be required at the same time or that there is a need to ensure a smooth transition from one to the other.

^[1] Source - NDIS Principles to Determine Responsibilities of the NDIS and Other Service Systems (PDF)

How are these principles translated into practice at the health/disability interface?

The following table provides an overview of indicative funding responsibilities of the NDIS and the health service system^[1].

Overview of indicative funding responsibilities of the NDIS and the health service system

Indicative Role of the NDIS And Other Parties - Health
Reasonable and Necessary NDIS Supports for Eligible People	Other Parties
Elements of community re-integration which enable the person to live in the community such as assistance with activities of daily living and home modifications. Active involvement in planning and transition support, on the basis of the person having reached a point of stability in regard to functional capacity, prior to hospital discharge (or equivalent for other healthcare settings) wherever there is a need for ongoing maintenance support. Prosthetics, orthoses and specialist hearing and vision supports (excluding surgical services) where these supports directly relate to a person’s permanent impairment. Allied health and other therapy directly related to maintaining or managing a person’s functional capacity including occupational therapy, speech pathology, physiotherapy, podiatry, and specialist behaviour interventions. This includes long term therapy/support directly related to the impact of a person’s impairment/s on their functional capacity required to achieve incremental gains or to prevent functional decline. Also includes allied health therapies through early intervention for children aimed at enhancing functioning. The delivery of nursing or delegated care by clinically trained staff (directly or through supervision), where the care is required due to the impact of a person’s impairment/s on their functional capacity and integral to a person’s ongoing care and support to live in the community and participate in education and employment (including, but not limited to, PEG feeding, catheter care, skin integrity checks or tracheostomy care (including suctioning). The delivery of routine personal care required due to the impact of a person’s impairment/s on their functional capacity to enable activities of daily living (e.g. routine bowel care and oral suctioning) including development of skills to support self-care, where possible. Any funding in a person’s package would continue for supports for people with complex communication needs or challenging behaviours while accessing health services, including hospitals and in-patient facilities. Training of NDIS funded workers by nurses, allied health or other relevant health professionals to address the impact of a person’s impairment/s on their functional capacity and retraining as the participant’s needs change. Aids and equipment to enhance increased or independent functioning in the home and community. In relation to palliative care, functional supports as part of an NDIS participant’s plan may continue to be provided at the same time as palliative care services, recognising that supports may need to be adjusted in scope or frequency as a result of the need to align with the core palliative care being delivered through sub-acute health services. Funding further assessment by health professionals for support planning and review as required. The coordination of NDIS supports with supports offered by the health system and other relevant service systems.	[Jointly with NDIS] Provision of specialist allied health, rehabilitation and other therapy, to facilitate enhanced functioning and community re-integration of people with recently acquired severe conditions such as newly acquired spinal cord and severe acquired brain injury. Acute and emergency services delivered through Local Hospital Networks including, but not limited to, medical and pharmaceutical products (available through PBS), medical transport, allied health and nursing services (where related to treatment of a health event), dental services and medical services covered under the Medicare Benefits Schedule, or otherwise government funded (including surgical procedures related to aids and equipment). Sub-acute services (palliative care, geriatric evaluation and management and psychogeriatric care) including in-patient and out-patient services delivered in the person’s home or clinical settings.Rehabilitative health services where the purpose is to restore or increase functioning through time limited, recovery oriented episodes of care, evidence based supports and interim prosthetics, following either medical treatment or the acquisition of a disability (excluding early interventions). When a participant is receiving time limited rehabilitation services through the health system, the NDIS will continue to fund any ongoing ‘maintenance’ allied health or other therapies the person requires and that are unrelated to the health system’s program of rehabilitation. Preliminary assessment and disability diagnosis as required for the determination of an individual’s eligibility for the NDIS (e.g. developmental delay). General hearing and vision services unrelated to the impact of a person’s impairment on their functional capacity as determined in the NDIS eligibility criteria (e.g. prescription glasses). Inclusion of people with disability in preventative health and primary health care delivered through General Practice and community health services, including dental and medical services covered under the Medicare Benefits Schedule. Intensive case coordination operated by the health system where a significant component of case coordination is related to the health support.

^[1] Source - The table has been reformatted and the information is sourced directly from the document: NDIS Principles to Determine Responsibilities of the NDIS and Other Service Systems (PDF)

What healthcare related supports will the NDIS fund?

The NDIS will fund supports that assist a participant to undertake activities of daily living where the impairment relates to the person's disability. These supports includes^[1]

aids and equipment such as wheelchairs, hearing aids and adjustable beds
items such as prosthetics and artificial limbs (surgery remains the responsibility of the health system)
home modifications, personal care and domestic assistance. This will assist participants exiting the health system to live independently in the community or move back into their own home
allied health and other therapy where this is required as a result of the participant’s impairment, including physiotherapy, speech therapy or occupational therapy. The health system is responsible for these supports if they are required as part of rehabilitation from an accident or injury or as part of treatment for medical conditions (see below).

^[1] Source - 10.8 of NDIA Operational Guideline for Planning

What healthcare related supports will the NDIS not be responsible to fund?

The NDIS is not responsible to provide funding for the following services^[1]:

the diagnosis and clinical treatment of health conditions, including ongoing or chronic health conditions;
other activities that aim to improve the health status of Australians, including general practitioner services, medical specialist services, dental care, nursing, allied health services (including acute and post-acute services), preventive health, care in public and private hospitals and pharmaceuticals or other universal entitlements;
funding time-limited, goal-oriented services and therapies:
1. where the predominant purpose is treatment directly related to the person's health status;
2. provided after a recent medical or surgical event, with the aim of improving the person's functional status, including rehabilitation or post-acute care; or
3. palliative care.

^[1] Source - 10.8 of NDIA Operational Guideline for Planning

What supports are funded by the health system?

The health system has responsibility for assisting participants with clinical and medical treatment. This includes:

the diagnosis and assessment of health conditions
clinical services and treatment of health conditions –including all medical services such as general practitioners, care while admitted in hospital, surgery, the cost of medical specialists and so on
medications and pharmaceuticals
sub-acute care such as palliative care, geriatric and psychogeriatric care
post-acute care, including nursing care for treating health conditions and wound management
dental care and all dental treatments
supports related to maintenance of life, e.g. oxygen therapy.

Individuals and families sometimes also have a role in funding the medical and clinical services, such as out of pocket expenses, gap payments and private health insurance fees. The NDIS will not cover these costs.

How do I work out if the support is most appropriately funded or provided through the NDIS?

The NDIA provide further information and guidance on whether health related supports are funded by the NDIA or other service systems including health. A table of Working Arrangements is available on the NDIA website that provides detailed information, guidance and examples relating to the following three areas:

Supports typically funded by the NDIS;
Supports which, dependent on their purpose, may be funded by the NDIS or other parties;
Supports generally funded by other parties.

The interface between health and disability in terms of who is responsible to fund particular services is complex and may require engagement with the NDIA to reach definitive answers in relation to particular cases. As the NDIS progresses more real life cases will assist with understanding the demarcations of this interface.

Which system assists with rehabilitation?

The NDIS and the health system will work closely together where a person needs rehabilitation following an accident or injury. Where the initial rehabilitation is needed following injury, accident or other medical event, the support is the responsibility of the health system. This means that any surgery or treatment following an injury, accident or other medical event is not funded by the NDIS.

The health system would provide supports that enable a person to regain their maximum achievable level of functioning. This could include, for example, care in a rehabilitation unit, or home based rehabilitation services, after a spinal cord injury.

The NDIS assists the participant once the health system has provided these rehabilitation services. The supports offered by the Scheme may include:

home modifications, aids and equipment personal care and
domestic assistance to enable the participant to live independently in the community
on-going allied health or other therapies to enable the participant to maintain their level of functioning.

What assistance is there in the healthcare area under ILC?

Under the Information, Linkages and Capacity Building (ILC) framework the NDIA will only fund activities that fall within five key ILC activity areas. One of those activities is about building the capacity of mainstream services to ensure they have the appropriate knowledge and skills to meet the needs of people with disability.

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