Blood from a stone: What allied health NDIS providers can do to improve their lot

Allied health providers in the NDIS space are struggling. Some are reducing or ceasing work with NDIS participants; and others are shutting down. Stress across the sector is palpable.

Costs increase, but NDIS price limits remain frozen. Governments tell us to do more with less, but the head of our Productivity Commission appears to think that it will always be difficult to increase our productivity because we are labour intensive, and that we’re a drag on Australia’s overall economic growth. In the press, and on social media, ethical providers continue to be lumped together with providers alleged to have ripped off participants and/or underpaid workers. 

It’s grim. 

I’m a realist. Like Joseph Tussman, I think that everything in life is easier to navigate if you identify how the world really works and then align with those realities. Fair or not, the pricing decision is a reality. Inflation is a reality. Anti-provider sentiment from influential voices in government and the media is a reality. Ongoing uncertainties about NDIS sustainability, regulation, and reforms are realities, and will remain that way for some time yet.   

So what can we do to keep going? 

There is no magic bullet. But, to get some perspective and ideas from outside the industry, I’ve been reading research and white papers. This week, Working Future: The Australian Government’s White Paper on Jobs and Opportunities, caught my eye. 

I learned some useful things:

• Economy-wide productivity growth is slowing: Since the mid-2000s, productivity growth has slowed in Australia. Australian businesses – especially in the services sector – have been slower to adopt new technologies and processes than businesses overseas. This is a big challenge if we want to maintain wages and living standards. 

• Our sector is growing: Our sector – the care and support economy – is expected to grow by 22% by 2033. The sector includes the work of child carers, child care centre managers, early childhood educators, education aides, welfare support workers, personal care workers, nursing support, diversional therapists, enrolled and mothercraft nurses, Indigenous health workers, social professionals, registered nurses, nutritional professionals, occupational therapists, physiotherapists, podiatrists, audiologists, speech pathologists, nurse managers, and health and welfare service managers.

• We employ a lot of people: The healthcare and social assistance economy is the fastest growing part of the labour market. We represent about 10% of Australia’s workforce, and this growth is expected to continue.  

• Our sector needs to improve its employment practices: Across the care sector, staff turnover is too high, probably due to a range of factors including uneven service quality, pay (including gendered undervaluation of work in female-dominated industries where women make up 76.5% of the workforce), work conditions in some settings, relatively high rates of casual employees (28%), too many workers working multiple jobs, and unclear career progression opportunities. 

• Our sector needs to improve its training practices: Healthcare and social assistance have the highest prevalence of workplace training in the economy, probably because ongoing training is required as part of occupational accreditation. However, time and financial constraints are barriers to quality training for both providers and workers. Some providers are ambivalent about investing in staff skills and training because of high worker turnover. (This is short-sighted, to say the least.)

• Our workers have other options: Within the sector, different providers demand similar skills and compete for the same workers. But different sub-sectors (e.g, childcare, health, the NDIS, aged care, veterans’ care) are accessed, funded and regulated differently. If one sub-sector becomes dysfunctional or uneconomic, many of our workers have other options – in and outside the sector. So, too, do many providers.

Clear-eyed choices 

If we accept these realities – and we must – providers have three main options:

1. Shut down NDIS activities altogether and do something more (economically) productive – whether in the sector or elsewhere. (This would not be a good outcome for NDIS participants, especially in rural and remote areas.) 
2. Reduce NDIS work and work more with other client groups not subject to price controls to offset the losses made on NDIS-funded work.
3. Stay focused on NDIS-funded work and become more productive to re-establish margins and stay in business. 

If we choose options 2 or 3, we need to raise our productivity. But, given all the constraints, how?

Ideas

In the White Paper, the Government makes a number of suggestions for employers to ‘reignite’ productivity, including that we:

• increase our management capabilities (currently relatively limited on average, compared to US firms, for example);
• adopt “innovative work practices…better models of care and support and best practice processes and techniques”;
• invest more in people and technology to change our models of care and to increase our clients’ choice and control and access to support, including in regional areas with thin markets (e.g. through telehealth);
• improve our mixes of staff, qualifications and skills;
• make more efficient use of existing resources by allowing staff to deliver multidisciplinary care;
• train workers to use robots, automation tech and/or AI to allow workers to focus on higher value activities (e.g., problem-solving, interpersonal and non-routine tasks), and to access and process information, complete mod-level professional writing tasks, make decisions, and undertake admin tasks more efficiently; and
• accept that ‘firm exits’ (i.e. businesses shutting down) are something that is necessary and perhaps (from the Government’s perspective) desirable to free up workers and capital to move to more productive businesses. 

Many of these suggestions lack specificity. Almost all require investment and additional risk-taking, which is hard to stomach in the current economic environment.

It’s clear from the White Paper that the Federal Government knows that it’s always been difficult to achieve productivity gains in our sector. If we want to improve provider productivity across the system, we need the Government to step up, too, to revisit policy settings on training, occupational licensing, skilled migration, and ‘knowledge translation’ collaborations between businesses, universities and government institutions. We need regulatory certainty (something sorely lacking at present) and harmonisation across sectors and States to resolve inconsistent rules, reduce red tape and admin busy work, and remove barriers to worker mobility (e.g. by consolidating worker screening regimes). 

The NDIS and the care and support sector as a whole are complex adaptive systems. They are made up of individuals who have freedom to act in ways that are not always totally predictable. The actions of governments, regulators, providers, workers and NDIS participants are interconnected: one group’s actions can change the system for everyone else, potentially in unexpected ways.

Bottom line

Ethical providers need to do something if we want to continue to provide high level care to NDIS participants while investing in our workers and staying in business. 

We need all the good ideas we can get.

Further reading:

Working Future: The Australian Government’s White Paper on Jobs and Opportunities | Treasury.gov.au

How will allied health NDIS providers survive? Some difficult choices ahead

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