Exploring the NDIS Review's case for how people with disability should live, and why (Part 1)

For participants who rely on 24/7 living supports, the final report of the NDIS Review - "Working together to deliver the NDIS" - contentiously recommends that,

"In general, reasonable and necessary funding should be based on an average shared support ratio of one support worker to three participants (1:3), consistent with an assessment of need that determines the maximum support intensity and level of overnight support that a participant is eligible to receive." Page 141.?

This is in one of the NDIS Review Panel's vision statements, titled "Participants should receive housing and living support funding in a clear, fair and consistent way, in line with their needs and circumstances".? I suppose it is clear and consistent that a vision statement talking about a participant's needs and circumstances identifies a support ratio.? Whether it is fair is a more complex question.

The only other place this position is mentioned in the Final Report is on page 144, in recommendation 8, "Fund housing and living supports that are fair and consistent, and support participants to exercise genuine choice and control over their living arrangement".

The justification for this position is documented in the NDIS Review's 1,297 page Supporting Analysis document.? Within chapter 3 "Housing and living supports", section 3.1.2 "Living alone with no sharing of supports can be a key driver of scheme costs" holds the core logic - see pages 562 to 565. That is where I will focus my attention.

While section 3.1.3 acknowledges that "In limited circumstances, living alone with no sharing of supports may be appropriate", the writer presents an argument in four parts against 1:1 24/7 living supports:

1. It will cost too much,
2. We won’t be able to find enough support workers,
3. Living alone is not in line with community norms, and
4. Relying on 1:1 24/7 support fosters dependence, increases risks of exploitation, reduces focus on capacity building, and increasing social and economic (working) participation.

I intend to consider the first two parts of the argument here.

It costs too much

The NDIS Review first looks at the increased costs associated with 1:1 supports - see pages 562 to 563.? It is straight forward to acknowledge that 1:1 support will have a higher direct cost than 1:3 support - I'll lay the issue of indirect cost to one side for now.? I was interested to note that reference 1196 cited at the bottom of page 563 - NDIA's own work, "‘Having a go’: Exploring the use of supports to make individualised living a reality" - points out that NDIS participants who live alone are up to 9% more likely to achieve positive home and living-related outcomes.

At the top of page 564, a $0.5 B annual price-tag is presented as the cost of more 1:1 24/7 support.? It is my understanding the NDIS will cost about $42 B 2022/23, so more 1:1 24/7 support represents just over a 1% increase.? The overall increase in 2023/24 expenditure compared to 2022/23 is projected to be between 12% and 17%.? So I believe it is reasonable to suggest more 1:1 24/7 support would not be a major driver of scheme growth.

The NDIA seems constrained by the view that supported independent living (SIL) delivered by registered providers is the only solution for the NDIS cohort who need 24/7 support.? A family-governed service-for-one (or two!?) has lower overheads and delivers better outcomes.? Participant outcomes should be the primary focus.? How to achieve that efficiently and effectively is the right question to pose.

We won’t be able to find enough support workers

At the bottom of page 564 the argument is put forward that finding the additional support workers will be too difficult.?

"Both participants and providers report difficulty finding and keeping workers with the right skills, values and attitudes. An ageing population and growing demand for care and support services (disability, aged care and veterans’ care) suggests there will be a shortfall of 285,000 care and support sector workers by 2049-50. Even with greater funding, widespread adoption of 1:1 24/7 support could not be realised due to workforce constraints."

So how many extra workers would be needed to accommodate the additional 1:1 27/4 support modelled here?? Looking back to the top of page 564, a total 1,255 participants are mentioned.? If I take the straightforward view that the full time equivalent (FTE) of 2 workers is needed per participant, I arrive at a FTE total of an additional 2,510 support workers.

Section 7.1 "The needs of the future NDIS workforce" of the Supporting Analysis document - page 849 - tells us that on a full-time equivalent basis, the NDIS workforce grew to 202,000 in 2021-22.? So my estimated additional 2,510 support workers represents a bit over 1% of the support workforce.? So I believe it is reasonable to say the additional 1:1 24/7 support would not a substantial burden on the overall NDIS workforce.

My view is supported by the Minister for the NDIS himself.? At the NDIS Review Town Hall briefing I attended in Brisbane in January this year, the Hon Bill Shorten MP during his speech explicitly dismissed the argument that the sector cannot find enough workers.

Conclusions … thus far

The NDIS Review argues that it would too expensive to support people with high needs below an average 1:3 ratio.? The Review also argues that it would be too hard to find the additional support workers needed.? I am of the view neither of these issues is as insurmountable as they are portrayed, given the small number of high needs participants.

My follow-on article will look at the two final arguments put forward by the NDIS Review - that living alone is not in line with community norms, and relying on 1:1 24/7 support fosters dependence and unacceptable risks.