Empower. Enable. Entrust. Three words that have become the core of Australia’s new National Disability Insurance Scheme (NDIS), a reform programme which aims to transform the lives of people with disability.
It’s a daunting task but David Bowen, inaugural chief executive of the National Disability Insurance Agency (NDIA), is relishing the opportunity to deliver real, tangible improvement to the lives of some of Australia’s most vulnerable people.
Underpinning his approach is the belief that over reliance on disability-specific support removes the pathway towards true empowerment and fulfilment. “The more you wrap a person up in funded disability supports, the more you in fact disable the person from being able to take control and move towards greater independence,” he says.
Few countries have tried anything as radical or ambitious as the NDIS. With a price tag of more than A$22 billion a year when fully rolled out, it is an impressive commitment to reform at a time when the budget is in deficit. The increased levels of support means that more people with disability will be able to attend school, get jobs and participate more fully in society.
The programme, though, is not just about increased spending. Instead, it aims to deliver a national system of disability support focused on the individual needs and choices of people with disability. A tailored approach, rather than previous block-funded, grant-based systems that proved unable to deliver the flexibility and control that NDIS now offers. Under the new system, people with disability, their families and carers, will have greater control over choosing their own supports and service providers. “Now they have greater opportunity to live independently and exercise more choice and control in their own lives.”
Bowen identifies three pillars that underpin the new approach. “The first is putting the person with the disability at the centre of the scheme,” he says. “Evidence accumulated over 20 years has shown that when you individualise the funding and give control and choice to the person, they invariably make better decisions and achieve better outcomes. Over time, the scheme costs less because of those good life outcomes and we fundamentally support empowering and enabling individuals in their own life.”
The second pillar is the recognition that the scheme is insurance-based, rather than a more traditional welfare model. “We are not dealing with a static and passive system,” he says, “but one in which you invest in people to achieve good outcomes. The consequence of those outcomes is that in the long run the support and services required are reduced and cost less. It is a scheme in which the funding and supports that people receive change as their needs change.
“And the third is that the scheme can’t be seen in isolation of where people live and who they interact with. It is critically important that the scheme connects people to their communities and sustains and grows the family and community support so that people don’t become just reliant on disability-specific funded supports.”
Disabilities: metrics matter
The Australian parliament greenlighted the scheme in 2012 and there are now eight trial sites across the country. Although it is still early days, Bowen says that the first signs are hugely positive. “The scheme is on time and under budget and we have recorded high levels of satisfaction so far,” he says. “It is too early for outcomes trend data but we also have anecdotal evidence that shows how the scheme has helped people become more independent, move into employment, have more control in their lives and so on.” Bowen says that the impact of the reform should also be measured in social and economic terms.
“In social terms, it’s about improving the circumstances of people with a disability against three measures,” he explains. “Firstly, it is about independence – the ability to make choices and control what happens in your life. Secondly, it is about the person’s ability and opportunity to participate in broad economic activity and, thirdly, meaningful social participation. And in economic terms it is about the return on this expenditure from improving the circumstances of people with disability, and that involves benefits not only on the agency’s balance sheet but also on the broader economy. As more people move into work they will require less government funding support but the long-term aim of the scheme is that it becomes a net contributor to GDP of up to 1% growth.”
Bowen says the NDIA is in the process of creating an outcomes framework. “This will gather people’s own self-assessment of their capacity in a whole range of life situations,” he says. “Over the next three to five years we will get better and better at that measurement and understanding the correlation between what types of services and support lead to good outcomes. The benefit is that it becomes a strong evidence base that we can use to deliver more appropriate and more evidence-based services. And, over time, it can lead to outcome-based pricing, where service providers are not paid for an output but rather for the outcomes of their individual clients.”
The NDIA is now fully focused on embedding the focus on outcomes throughout the organisation – something that is not always the case in the public sector. “The outcomes framework is not just a data collection but also a source of information to help construct people’s individual plans,” he says “This requires hard work around organisational culture – values, performance and around continuous learning.”
Bowen is also keen to stress that the impact of the scheme has the potential to spill over into numerous other areas of government and society. A new job, for example, has a hugely positive effect – not only on the individual concerned, but also in other, less obvious ways. “There is a double benefit reduction in taxpayer-funded income support via DSP, and increases in tax revenue collected. These are quantifiable benefits,” he says. “In addition, we know that people with disability are heavily over-represented in healthcare systems, for example. They often end up as bed-blockers because of their need for emergency care on a last resort basis. Better and more appropriate community support can reduce the amount of time that people with disability are utilising acute care, as well as reduce readmission rates.”
The criminal justice system, too, stands to benefit. “A significant proportion of people in this system have a disability and the risk of incarceration is high,” Bowen points out. “People can fall back into criminal or risk-taking behaviour where they end up cycling through the system repeatedly. Good community support, and the potential for training and jobs, can alleviate some of those risks.”
And families – so crucial in any disabled person’s life – should also gain from the changes, and not before time. “For every dollar currently spent in formal disability support, there is probably an equivalent $3 of value provided by families,” says Bowen. “The scheme doesn’t want to displace this support but we do want to alleviate some of that burden where people are overwhelmed by their care responsibilities.”
He goes on to cite the increase in social wellbeing that will arise from more disabled people leading better, more fulfilled lives. It has been interesting to watch the debate over the past 10 years about whether wellbeing is economically measurable and if it is, then how to measure it,” he says. “Undoubtedly, societies that do value things like how well they provide support to disability and the wellbeing of people with disability often have stronger economies.”
Looking back, looking ahead
Reform is a messy business and inevitably encounters some unexpected bumps on the road and Bowen readily admits that the trial sites have generated valuable insights. “The scheme was set up too isolated from the social context and environment in which it was operating,” he concedes. “In the trial period we didn’t get the opportunity to build the community connection and sustain the family supports to the extent that we would want in full scheme. This meant that the focus has been on the funded package of supports, which is not good for the person or the costs of the scheme longer term.”
Bowen is no fan of a piecemeal approach. “The lesson for me is that if you’re implementing something like this it should be implemented in its entirety, or be very aware of the potential impact of not doing so,” he says. “We had the luxury of running this as a trial, and learning that lesson in the trial, so we realised in time that it is important to have that community connection occur before discussions about funded supports.”
The design of the NDIS embodies much of what has been fashionable in social and human services in recent years – investment-based, early intervention, outcomes-focused, contestability, outsourcing and market stewardship. But rather than just talking about it, Bowen and his team at the NDIA have been getting on with it and, in the process, creating a world-class disability insurance scheme which is already delivering real public impact and value.
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