Next year marks a decade since the start of the National Disability Insurance Scheme, one of Australia’s biggest social policy reforms. The NDIS represented a fundamental shift in the way Australia supports people with disability to live full lives.
To understand why this was the biggest social policy shift since the introduction of Medicare, it is helpful to remember the NDIS radically reformed the disability service system in five key ways: it significantly increased the funding for services; adopted national consistency; empowered people with disability with ‘choice and control’; developed a market-based structure; and introduced social insurance techniques.
Given its scale, we think the experience of the NDIS offers valuable lessons for other policymakers undertaking complex social policy reform. Now is a good time to reflect on what we know from the NDIS and what lessons we can learn to inform future attempts at reform – not only in disability services, but in other human services systems.
Recently we edited a book on this topic, “The National Disability Insurance Scheme: An Australian Public Policy Experiment”, in which we collaborated with other authors to explore the NDIS in detail.
From that work, we are pleased to share seven key lessons from the NDIS for policymakers.
Policy change and implementing reform takes time. It is hard to achieve and won’t happen overnight. This is because implementation is path dependent – that is, your starting place will heavily influence the route to your intended outcome, and the chances of success.
In their chapter of our book, Professor Gemma Carey and Eleanor Malbon show that path dependency explains how the NDIS got to where it is now. States and territories did not start implementation from a blank page; they each had existing disability services system that worked in different ways. This has influenced the way the scheme was implemented.
This tells us that mapping the transition of a service system should be front and centre when considering if a policy is right. Considering how to get there is just as important as where you want to end up.
The NDIS was a complex system to design, let alone implement. There were nine jurisdictions involved, challenging questions about reach and eligibility, new regulatory frameworks to put in place and new market-based arrangements. So it is unsurprising the implementation planning came later.
There were pilots of the scheme in several parts of the country, but these did not surface all the issues that needed to be dealt in the transition to the scheme. There was also a strong focus in the early days of the scheme of transferring people in, as opposed to thinking about how people (including those not yet born) might need to receive NDIS-related assessments and supports in future.
The NDIS experience shows that investing in working out how you will get there during policy design is just as important as defining where you want to go. Mapping how you will get there and going deep into how things work now will inform the design of the future reform state.
Nous Principal Simon Guttmann has thought a lot about successful implementation. As Simon argues, “implementing significant change is challenging in the public sector due to complex government and stakeholder agendas, increased customer expectations and the likelihood that significant change will generate public attention”.
Personalisation holds great potential for health and social policy areas, including child protection and aged care. Personalisation gives people choice and control over how their care is planned and delivered.
The NDIS has shown us the benefits of one aspect of personalisation: individualised budgets. These have proven especially beneficial for people who have a clear idea of how they want their life to be and can navigate their care systems well.
But adopting personalisation is about more than this. For some people in the scheme, individualised budgets alone has not been enough to enable choice. Those who have multiple and complex issues, lack strong support networks or need support to express what they want can find it challenging to make informed choices about their future supports.
The NDIS shows that personalisation of services needs to go beyond individual budgets; this approach must be complemented by supported decision-making for those who need it, and communication and planning approaches tailored to individual needs.
Personalisation need to be adapted for different cohorts of people (say, people in regional areas, with complex mental health needs, or Aboriginal and Torres Strait Islander people). For these groups, more intensive assistance or scaffolding will be required.
Delivering personalised services – working in a truly person-centred way with people – involves a specific skill set based on building relationships of trust. You can see this in action in support Nous provided to identify the key attributes that hospitals and health services need to embed person-centred care. This is a very different skillset from policy, or administration of funding or compliance systems. (We explore this issue more in lesson 7.)
Moving toward a more market-based service system is key feature of the NDIS. This model requires active market-shaping, including addressing ‘thin markets’ through market stewardship.
Disability market stewardship was previously a state government responsibility. Now the role is split and continues to evolve; some of it sits with the NDIS Quality and Safeguards Commission, some with the National Disability Insurance Agency and some with state government disability areas.
For any service system to transfer to a market-based system, clear and active market stewardship is essential. Only then can you prevent thin markets and market failure. For the NDIS, this has been especially true in remote areas and for complex services that require highly specialised staff.
Key questions for any wholesale system reform are: Who is responsible for market stewardship and how should it be done?
As the NDIS is showing us, there may be parts of the service system that a market model may never be able to fill. In some thin markets, you may need to think about an agreed provider of last resort or there may need to a preferred provider arrangement to help specialist services who serve a small but high-needs cohort to stay afloat.
In the NDIS, Local Area Coordinators (LAC) were intended to help people with disability to navigate the system and to link the NDIS and other service systems. But early in the life of the NDIS, LACs were instead drawn on to design people’s support plans and get people into the scheme.
Coordination reduces system-wide costs and leads to better outcomes for people accessing the scheme. For example, under the old WA disability system, LACs were used to ensure better outcomes and to reduce costs by ensuring people made best use of existing services. LACs could help people with disability, their families and carers to navigate existing systems such as housing, allied health, or community-based programs, which in turn prevented presentation in more expensive acute services. This is a central part of a social insurance scheme – the reduction of the lifetime cost of support.
The lesson here is that policymakers should invest seriously in service and system coordination. This will not only improve outcomes; it will also reduce system costs by better connecting people with available services.
Under the previous system the true prevalence of disability in Australia was masked by the constrained service environment. The actuarial approach to the NDIS has delivered extensive data on people with disability. Now we have a better idea of need. This is due to the upfront investment in data capture and actuarial approaches.
There is a lot of discussion about the sustainability of the NDIS and the cost of individual packages. Part of the reason we can have this debate is because we have data that reveals the true cost of supporting people with disability in Australia and allows us to engage in meaningful work to improve our approach.
Other service system reforms should consider investing in data, including using actuarial approaches to capturing data to inform decisions. The actuarial element of the NDIS has been criticised, but the idea of capturing and understanding data should be separated from the policy and political decisions taken once the data is available.
A new service system does not sit in isolation from the services around it and people do not neatly access services from one discrete area. People and their lives are complex.
Breaking down siloes between services sectors has proven challenging work for the NDIS. The interface of the scheme and other services – aged care, mental health, justice and education, to name a few – has been difficult to define and tough to navigate.
Just like Medicare changed the landscape of healthcare and everyone interacting with it needed to adjust, the NDIS has changed the social services landscape. People, systems, and policymakers are still adjusting.
When designing new service systems, policymakers should be alive to the impacts this will have on other service systems. This is often hard to achieve because other policy areas are often consulted late, if at all.
Thinking through a person’s journey and their multiple touch points with different service systems can help in understanding pathways and frustrations. You can see this in action in the award-winning design work Nous undertook for Child Link, where we mapped the current state and future state journey of stakeholders in Victoria’s child protection system.
When the NDIA was first established it was staffed by people seconded from other Commonwealth agencies. While skilled in some areas, many did not have direct experience in the disability system or service delivery. Specialist skills needed to either be developed in-house among or brought in from outside.
The lesson for other systems is that staff with the right skillsets will rarely be immediately available. In some cases, like the NDIS, a whole new workforce needs to be developed, with a combination of technical and subject matter skills that did not exist at the necessary scale.
Recently a state government agency shifted toward operating as a principles-based regulator, which required a new and different capability from its workforce. Nous worked with the agency, using design sprints, to develop a Workforce Capability Strategy and then supported the agency to implement it, ensuring the workforce had the skills they needed for the new organisational approach.
These seven lessons are most useful if they are incorporated into major policy reforms from the outset. Just as an ounce of prevention is worth a pound of cure, keeping these things in mind early can avoid entangling complex reforms in foreseeable problems.
While the NDIS continues to learn from its own experience, so too can others benefit.
Get in touch to explore how we can support you on major policy reforms.
“The National Disability Insurance Scheme: An Australian Public Policy Experiment”, edited by Mhairi Cowden and Claire McCullagh, is available online.
Article prepared with input from Tanya Smith.