Sooner or later, the National Disability Insurance Scheme will take over some of the services for your permanently disabled patients, and you, as their GP, will have a pivotal role as the gatekeeper to the system.
But if you don’t quite know what will be expected from you, you’re not alone. Information on the specific role of GPs has been patchy and incomplete, but thanks to a number of recently published guides, the pathway is becoming clearer.
WHAT IS THE NDIS?
The NDIS, run by the National Disability Insurance Agency, will supplant a large number of disability services nationally, and has been billed as the biggest social reform since the introduction of Medicare in the 1980s.
Disability services have previously been considered so poor in Australia that the 2011 Productivity Commission report described it as “inequitable, underfunded, fragmented and inefficient” and giving recipients little choice.
So the key philosophy of the NDIS is to give participants choice and control to suit their personal needs and objectives, with the opportunity to review their management plans yearly or as-needed.
By the time all is said and done, almost half a million Australians will be supported by the NDIS, for anything from help with daily activities to vehicle modifications and prosthetics.
Instead of setting a specific amount of funding, the federal and state governments have agreed to make this a demand-driven scheme that looks set to grow as more people join.
To date, more than $5.1 billion has been spent on the 61,000 participants who have at least one plan, but the Productivity Commission estimates the yearly running costs will be $22 billion from 2019 onwards. This figure appears on par with how much the government is expected to spend on Aged Care and Disability Support Pension over the 2019-2020 year, trailing slightly behind the estimated $25 billion cost of Medicare.
The federal government foots the bill for just over half the cost of the NDIS, the money for which it plans to find largely by redirecting existing funding for disability services.
A three-year trial period has now wound up, and the NDIS is set to be rolled out progressively across the country over the next two years.
A visit to the NDIS website will be able to shed light on when exactly the scheme will become available in your area, but be prepared for patients to come in with documentation to get the ball rolling with their application in the six months prior to the formal introduction date.
HOW IT WORKS
The first step for Australian patients under the age of 65 with a permanent or significant disability will be to see whether they are eligible by going onto the NDIS website and going through their Access Checklist.
It’s likely that around half of the estimated 460,000 patients to be eligible for the NDIS already have some form of disability funding. For these patients, a representative from the NDIS is supposed to call and send a letter when the time comes for them to transition to the new scheme. In these cases, the GP’s role may be limited to bringing the patient up to speed on what the new system means for them.
But for the other half, this new NDIS represents the first opportunity for them to get funding support, says social services researcher Professor Karen Fisher from the University of NSW.
What is especially valuable is the non-stigmatising way that for many people who may not even identify as having a “disability” can have the discussion about the NDIS in general practice, she says.
Of the approximately 200,000 people who will be encountering disability services, possibly for the first time, an estimated one in 10 will have a disability.
“However, the other 90% are the ones that also benefit from NDIS in terms of information and referral into mainstream and community services,” Professor Fisher says.
“I think this is probably the greatest role for GPs, because these are the people who are less likely to receive a funded plan from NDIS, but the structure of NDIS means that the 90% need to be supported by other parts of the system.”
The mainstream and community services eligible patients will be able to access include education, employment and housing services, she says.
The GP can let people know whether they might be eligible for services and put them into contact with Local Area Coordinators, whose role is to act as one conduit between individuals and the NDIS.
Local Area Coordinators, designed to be familiar with the local services and community, might run NDIS workshops in the community or have one-on-one conversations with individuals to help them understand the NDIS.
They will also provide support for people already on some disability service, or those hoping to access this for the first time, by taking them through the signup process and linking them to services in the community that will help them achieve their goals.
At the moment, however, many Local Area Coordinators were new or did not yet exist in many parts of the country, leaving clinicians and patients understandably confused, Professor Fisher added.
When resources become more widely available, the key role for GPs will either be one of referral onwards and to provide evidence in support of patients who are making an application. This includes information about the diagnosis, current and proposed treatments, severity of impairment on everyday tasks and the estimated duration of the condition.
The Royal Australasian College of Physicians recently released a handy guide to help understand what the role of the clinician is in determining somebody’s eligibility.
WHAT ARE THE DISABILITY REQUIREMENTS?
Patients are eligible for assistance under the NDIS under two streams, the disability stream and the early intervention stream. Under the disability stream, people need to have an impairment or a disability that is likely to be permanent, and affects their ability to do everyday things. This might include difficulties communicating, socialising, regulating emotions, learning and remembering, doing daily activities such as cleaning, showering, handling money or moving around in and out of the house.
Permanent or lifelong disability is relatively straightforward if the individual is diagnosed with one of a set list of conditions or impairments, which include intellectual disability, autism, cerebral palsy, amputation, permanent blindness or deafness.
Some spinal cord and brain injuries also qualify, as well as a long list of genetic conditions that cause permanent and severe intellectual and physical impairment.
Under the early intervention stream, individuals are eligible if they require some help and support now in order to reduce their needs in the future or to prevent further deterioration of functional capacity.
Adults who have a condition that is likely to be permanent fall into this category, providing the NDIS believes they would not be better supported by another service or provider.
Children under six years with a developmental delay are also eligible under this pathway, providing they have some mental or physical impairments that substantially reduce their ability to function in: self-care, receptive and expressive language, cognitive development and/or motor development. These children also need individually planned and coordinated services or care over a long period of time to be considered eligible.
WHAT DO I HAVE TO DO?
To apply for NDIS support, some individuals will need to fill out an Access Request Form, and section F is for GPs and other health professionals to provide information backing up the individual’s claim.
Here, GPs will be asked to provide their name, qualifications, contact details and the length of time they have treated the patient. Clinicians will need to list the patient’s primary disability and any secondary disabilities, as well as current treatments and potential future treatments that could help improve the condition.
The form then requires the doctor to outline the ways in which the impairment affects the individual in six different domains: mobility and motor skills, communication, social interaction, learning, self-care and self-management.
As well as a lack of appreciation for the important role they play in helping patients access NDIS support services, market research by mental-health organisation Aftercare indicated many GPs also felt unprepared on how to assist their patients in outlining the extent of the impairment.
In response to demand for education and guidance from GPs, Aftercare mailed out a guide on how to approach the Access Request Form to all GP practices in towns within a 200km radius of their service locations.
Because psycho-social impairments run the risk of covering more of a grey area than physical conditions, it is important to emphasise the details about the specific functional impact the patient experiences as a result of their issue, they say. For example, if a patient has mobility and transport needs, the GP should give examples of how exactly they need help. This might include: moving around the house, volunteering, using cars or public transport, getting in and out of bed and difficulties as a result of side effects of treatment. Characteristics of the illness that create difficulties may be paranoia, anxiety, depression or obsession.
The functional implications could be that the patient is unable to use public transport without assistance, or they have difficulty leaving the house. Here you can give suggestions on the type of support needed, for this example the patient could be helped by having a person to accompany them while using public transport. The GP can then suggest the frequency a patient might need support, whether it be one hour a week to attend an activity a week and two hours to go grocery shopping or more.
They provided an example of an appropriate GP referral: “X is unable to leave the house or use public transport on a daily basis as a direct result of her severe anxiety and lack of motivation which are symptoms of her mental illness.”
The NDIS provides services to help patients improve their functioning in these realms, providing the information is listed as part of the initial assessment. As a result, Aftercare suggests including information outlining specific support that would help the patient, such as “one-on-one support on a weekly basis would assist her to cope with her anxiety and improve her motivation assisting her to be more mobile.”
It is critical to consider the less obvious impacts the patient’s medical diagnosis, “for many these impacts can trigger episodes or ongoing states of impairment, which in turn contribute to ill health”, they say.
Another example illustrates how a GP might describe the way that a mental illness impacts on social interaction: “X has become socially isolated since being diagnosed with depression. X rarely ventures into the community alone and prefers to spend time at home. X feels very anxious when meeting new people which further adds to his social isolation. X speaks very quickly due to mania, and at other times she is unable to speak due to feeling depressed. This means it is very difficult for X to interact socially and maintain friendships. X often has feelings and emotions she is unable to cope with due to her mental illness.”
These cases outline the specific ways the impairment may be exacerbated by psychosocial factors, and avenues for the NDIS to provide support through funded activities, training or help from a carer.
Despite the teething problems during the transition period, Professor Fisher says her research into the scheme at the trial locations has left her optimistic that this new system will be a great improvement.
“One of the really interesting things is that those early start areas went through the same transition difficulties,” she says, pointing to resistance and complaints from health professionals, patients and their families. But they very quickly came out the other side with an appreciation for the system, and a workable understanding of the gaps and ways to train people up under the new scheme.
Nevertheless, there are a lot of people who remain marginalised from access, particularly over the transition period, Professor Fisher says. People with mental-health issues, the homeless and those in jail are especially vulnerable of being overlooked, “so we really need a concerted effort to be able to hook those people into the system”.
NDIS Guide for Physicians and Paediatricians: racp.edu.au/ndis-guide-for-physicians