Critical lessons for NDIS, disability services in new market stewardship framework

UNSW researchers have recently developed and published an important new framework for supporting constructive market stewardship in disability markets.

Dr Ariella Meltzer, Professor Helen Dickinson, Ms Eleanor Malbon and Professor Gemma Carey collaborated on this framework, which demonstrates the importance of consulting with people who have lived experience of disability during development and improvement of disability service markets.

Market stewardship refers to efforts made to address market deficiencies, gaps, and failures. These often take the form of policy and market intervention strategies.

Typically, stewardship is approached using an inputs and outputs lens: what goes into a market, such as funds, resources, and time, measured against what comes out of it, such as profits, losses, and service or product availability.

In disability markets, this approach leads to an emphasis on number of services delivered, price points, and how much a program costs to deliver.

However, the new framework suggests that this typical inputs and outputs approach is insufficient for disability markets. It often fails to detect the outcomes that the market is failing to achieve such as specialised care outcomes, patient satisfaction, and service suitability.

Instead, a consultative and outcome-focused approach to improve disability markets is proposed, with three key recommendations put forth to promote more engaging, sustainable market stewardship.

Market stewardship: the missing piece in disability service conversations

Professor Dickinson, director of the Public Service Research Group at the UNSW Canberra School of Business, thinks that market stewardship is the missing puzzle piece in contemporary discourse around disability service provision, such as that funded by the National Disability Insurance Scheme (NDIS).

In the disability context, market stewardship refers to efforts to address ‘thin markets’ where there are either a low number of service providers, or where the providers in the market are not offering tailored services appropriate to the needs of the market.

Professor Dickinson explains that the lack of consideration for lived experience in market stewardship consultation has been a factor in service providers registering for and remaining under the NDIS which are not differentiated in the way desired and required by different disability user groups.

Without the inclusion of disability market users in stewardship and consultation efforts, providers in the market fail to respond to the market’s desired service outcomes due to lack of guidance from those with lived experience.

This creates gaps and thin markets in essential services such as disability-specific aged care services, services aimed towards children and young people with a focus on empowerment, disability-aware home care services, services for NDIS package recipients with personality disorders, and many more.

Up to a half of all registered providers have never supplied a service to package holders under the scheme – this could be explained by recipients identifying these providers as unsuitable and turning to those which are more closely tailored to their needs.

The current utilisation rate of packages – this refers to the average percentage of total assigned funding that is utilised by package recipients – is approaching 70% in some areas, though is as low at 35% in others.

Professor Dickinson suggests some NDIS recipients are spending their packages on services which are not necessarily purpose-designed to achieve their desired outcomes, eroding the degree of choice and control that participants have over their own care.

The risk of losing funding in subsequent years if it is not spent in the year that it is issued is also a threat to recipients – as such, the incentive to spend on unsuitable services proliferates throughout the community and solidifies the presence of providers that do not address thin market gaps.

The framework says that increasing the representation of people with disability in consultation efforts will make strides in improving both the structure of the NDIS as it stands, as well as the services that recipients are able to access under it.

However, it is crucial that consultation efforts are not tokenistic. Professor Dickinson encourages these decision makers to consider what they want this consultation to shape.

“If you’re doing a consultation and everyone tells you what you’re proposing is a bad idea, but you still intend to go ahead with your changes, is this consultation really valuable or authentic?”

Other duties as directed: under-staffing and lack of local level market management

The Abbott-era staffing cap on the National Disability Insurance Agency, the agency which oversees the NDIS, may also be responsible for some of the thin markets affecting funding recipients.

Professor Dickinson says that the cap, which restricted the staffing levels of the NDIA to approximately 3500 by 2021, is substantially under the proposed staffing requirements in the initial design of the scheme, which was closer to 15,000.

This under-resourcing has meant that local area coordinators (LACs), which were initially designed to function as liaisons with local funding recipients and registered providers, have been engaged in more operational tasks and package planning to ensure continued access for participants.

The Quality and Safeguards Commission also has a role to play in this regulation and market management, Professor Dickinson acknowledges, but like the NDIA it is small and arguably under-resourced to evaluate service provision at the granular, local level intended for LACs.

This has in part led to conversations around service appropriateness and program feedback slipping down the priority list.

In their place, higher level consultations have been arranged to take place often after decisions about program changes and updates have been made. The NDIA recently acknowledged that their consultation on the recently proposed changes to the program and the introduction of independent assessment for funding recipients had not been approached as effectively as it could have been and resulted in a high degree of anxiety and uncertainty.

Passing the microphone: improving stewardship and consultation efforts

The framework sets out three principles for the inclusion of lived experience as evidence in market stewardship and consultation, centred around co-design and co-production principles of planning.

Firstly, market regulating and influencing institutions are encouraged to “invite meaningful and flexible participation from people with disability”.

In practise, this requires consultation efforts to be responsive to how people with disability can and want to contribute.

For example, lengthy parliamentary inquiries with requirement for highly structured submissions with vast administrative requirements may not be suitable for the communities they are aiming to hear from.

Secondly, market stewardship information needs to be accessible and presented in formats that people with disability can consume. Using the language of disability communities is also crucial, and should avoid reducing those accessing the scheme to ‘service users’, and their rich day-to-day social lives to ‘community participation’.

For example, Auslan interpreted videos and the provision of transcripts, screen-reader accessible content with the appropriate visual and structural characteristics for people with low-vision, and following the Web Content Accessibility Guidelines are some of the many ways that information can be presented accessibly.

The provision of support around this content is also important: skilled and trusted support people who can assist in drawing attention to and interpreting important stewardship information also play a huge role in the availability of this knowledge base.

Professor Dickinson notes that this is not a case of needing to ‘dumb down’ information for people in this community; she says that this is a common rhetoric in conversations with people looking to advance their consultation efforts which ignores the extent to which lived experience equips consultation participants with more than enough knowledge to contribute valuably.

Finally, amplifying the voices of people with disability ensures that the market can respond to what people accessing and relying on its outputs and outcomes need, rather than what able-bodied advocates and policy makers think or say that they need.

Advocating with, rather than speaking for people with disability, is the answer to many problems currently experienced in the community, not just those caused by thin markets and a lack of market stewardship.

The implementation of the framework’s key recommendations will offer increased insight into the ways lived experience can revolutionise market stewardship in this space. In turn, improved outcomes and market efficiency will follow, improving outcomes for people with disability around Australia.