Care and support for people with disability

2.1 The role of GPs in caring for people with disability

GPs are most often a patient’s first point of contact in the healthcare system. They provide continuity of care and have extensive knowledge of their patients’ medical history and social context. Continuity of care with a regular GP results in improved patient satisfaction and health outcomes.^{2 3 4}

GPs provide patient-centred, comprehensive, and ongoing care to people with disability through all life stages. Even when other health professionals are providing support to a person with disability, many people with disability have other health issues which require care from GPs and their teams. GPs are therefore intrinsically involved in disability care and support. The Australian Bureau of Statistics’ (ABS) 2018 Survey of Disability, Ageing and Carers (SDAC) revealed that 92% of people with disability see a GP, and one in five (20%) saw a GP for urgent medical care in the last 12 months.^{5 6}

GPs also help patients to improve their health literacy.⁷ This is particularly important for people with disability, as data shows this cohort finds it more difficult to engage with healthcare providers.⁸

2.2 National Disability Insurance Scheme

The NDIS was introduced in 2013 and is now the primary funding source for disability care and support in Australia.

The NDIS funds a range of services including therapeutic supports, assistance with household tasks, home and vehicle modifications, mobility equipment and transport to enable participation in daily activities.⁹ The NDIS provides people with disability information and connections to services in their communities such as doctors, sporting clubs, support groups, libraries and schools, as well as information about what support is provided by each state and territory government.⁹

2.3 The role of GPs in supporting NDIS applicants and participants

GPs play an important role in assisting their patients to access the NDIS. When a person is applying to become an NDIS participant, they will often ask a GP to provide evidence of disability and functional impact. The GP may provide this evidence by completing the relevant section of the NDIS Access Request Form, as well as providing assessments or reports outlining the applicant’s functional capacity. This helps patients and families who do not feel confident articulating the impact of a disability themselves. In some cases, there is a practice team approach to helping patients navigate the NDIS, with practice nurses and Aboriginal and Torres Strait Islander Health Workers and Practitioners involved in this process.

If a patient’s NDIS request is denied, they have the right to appeal the decision.¹⁰ Their GP will often play a role in supporting them to do so, including alerting them to the possibility of appeal and what this process entails. If the original decision is upheld, the GP will often try to provide or find appropriate support services for them. This can be especially difficult in rural and remote areas.

Other ways in which GPs support patients as part of the NDIS include:

• helping them to understand NDIS fact sheets, letters and emails, as well as their NDIS plan once this has been developed
• going through the NDIS process ahead of a planning meeting and preparing a list of services and items of equipment they think would be beneficial for the patient’s needs
• helping patients and families to interpret the recommendations of assessments performed by other health professionals as part of the access process
• coordinating care, as non-GP specialist and allied health reports are often required to support a patient’s NDIS application
• supporting established participants experiencing issues with their NDIS plan, including advocating on their behalf to support coordinators and the NDIA
• advocating for changes in support needs associated with a deterioration in the patient’s condition.

3.1 Provide clear information on NDIS processes

People with disability frequently seek help from their GP to understand NDIS processes and communications, as well as the funding included in their plan. This is especially true of people who:

• have English as a second language
• have a cognitive disability affecting their language comprehension level
• are overwhelmed with a new diagnosis of a disabling condition.

Patients and families/carers may also seek the help of GPs to interpret the recommendations of multidisciplinary diagnostic assessments and functional capacity assessments performed by other health professionals as part of the NDIS access process.

The NDIA should support GPs to assist their patients to access NDIS funding by providing clear, up-to-date information on the NDIS and available supports. Current Medicare rebates do not allow for GPs to complete NDIS forms without the patient present. GPs must be remunerated for completion of NDIS forms with or without the patient present, and these forms should be accessible and integrate with general practice clinical information systems.

Targeted outreach by the NDIA is needed to increase uptake of NDIS supports in areas with limited access to primary healthcare services. There are fewer GPs in remote locations than in Australia’s major cities, while patients in outer- regional, remote and very remote areas report longer wait times to see a GP.¹¹ Barriers to healthcare access for Aboriginal and Torres Strait Islander people, including a lack of culturally appropriate services, have also been well documented.¹²

3.2 Ensure GPs have input into the NDIS planning process and are kept informed of changes to NDIS plans

GPs should have input into the NDIS planning process at an individual participant level and be able to communicate with NDIS planners. Input from a patient’s GP can improve the efficiency of the planning process, better target supports and empower patients to recognise and achieve their goals.

Greater involvement of GPs would better integrate health and disability services with tangible benefits for patients, more efficient use of resources, reduced fragmentation, and stronger accountability. GPs play a central role in the coordination of care, liaising with non-GP specialists and allied health professionals as part of multidisciplinary teams, and directing patients to relevant services and supports in the community. They often have in-depth knowledge of supports that have been unhelpful for their patient in the past or where current contraindications exist.

Although GPs are not NDIS service providers, their accessibility and role as healthcare stewards and patient advocates means they are ideally placed to contribute to the NDIS planning process. GPs’ involvement will help ensure patients continue to have access to appropriate NDIS funding throughout their lifetime as their support needs evolve.

The RACGP recommends that:

• GPs have the opportunity to view and discuss a draft of a patient’s NDIS plan with the patient, and provide feedback and advice to NDIS planners for consideration when finalising the plan
• GPs automatically receive a copy of a patient’s NDIS plan (with patient consent) to allow them to keep a complete record of their patients’ health and social journey and thus supporting continuity of care
• notifications be sent to a patient’s usual GP to update them on the patient’s NDIS status and provide information relevant for the provision of ongoing, holistic care by the GP
• GPs be able to make direct contact with NDIS planners (with patient consent) to advise of issues being experienced by a patient or the need to amend their plan. 

3.3 Ensure NDIS funding is allocated appropriately and fairly

The NDIS is centred around the principles of reasonable and necessary supports and individual choice and control.¹³ Judging what supports are needed for an individual will often take time and will include the person themselves, their family and carers and a range of health professionals.

The following principles should be applied to individual plan approval and funding:

• NDIS legislation be applied consistently by staff with knowledge of evidence-based supports in disability care. Treating medical and other health professionals should have input into this process.
• Functional capacity assessments factor in other determinants of health such as income or education, which are key to determining a person’s support needs.
• People with disability be able to review assessment reports before being submitted to the NDIA to ensure their needs and concerns have been correctly represented.
• NDIS funds be consistently allocated to evidence-based therapies best suited to an individual patient’s level of disability.
• A fraud reporting mechanism be established to promote better oversight and scrutiny of service providers.
• A reporting mechanism be established to enable feedback on the quality of supports provided to NDIS participants.
• Consideration be given to the efficacy of past supports provided to NDIS participants prior to any plan changes.
• Step-by-step information with clear service timeframes be provided to participants and their families.
• An independent mechanism for individuals and families to allow for collaborative review of cases where necessary. Treating medical and other health professionals should have input into this process.

3.4 Provide access to culturally safe services

Aboriginal and Torres Strait Islander people with disability face unique barriers to accessing support services. Under- utilisation of disability services is a result of historical and cultural constructions of disability. These have historically been used to control and separate people from their culture and communities, with disability service providers failing to understand this context and provide culturally appropriate and trauma informed services.

Twenty-four per cent of Aboriginal and Torres Strait Islander people had a disability in 2018. Indigenous Australians were 1.9 times as likely to have a disability as non-Indigenous Australians.¹⁴

Aboriginal and Torres Strait Islander people with disability require access to culturally safe disability services, including supports available through the NDIS.¹⁵ Community and culture are central to the health and wellbeing of Aboriginal and Torres Strait Islander people.¹⁶ The NDIA acknowledges that relationship building with Aboriginal and Torres Strait Islander people with disability extends beyond the individual to a person’s community, and it takes time to build confidence and rapport.¹⁵

Displaying awareness of cultural sensitivities can be achieved through measures such as cultural competency training for disability service providers¹⁶ and providing access to appropriate interpreters.¹⁵ However, ensuring service providers are able to provide culturally safe, trauma informed care to Aboriginal and Torres Strait Islander people requires a broader assessment of engagement with Aboriginal and Torres Strait Islander communities. Measures of success may include employment of Aboriginal and Torres Strait Islander people by the service provider, implementation of a Reconciliation Action Plan (RAP), and efforts to ensure people in their care are connected to their community and culture.

3.5 Increase collaboration between GPs, other healthcare professionals and the disability sector

Collaboration and dialogue between GPs, other healthcare professionals and the disability sector is key to preventing fragmentation of care, inappropriate supports, or duplication of services.

Effective and comprehensive healthcare, delivered through collaborative and multidisciplinary teams in general practice, has the potential to not only improve quality of life for people with disability, but also lead to greater financial efficiencies and better use of limited resources.
New lines of communication need to be developed to prioritise capacity for ongoing cooperation between the health and disability sectors. Prior to the introduction of the NDIS, people without family support were assisted when accessing GP or other specialist health services by case managers who knew them well. This improved their attendance at appointments and helped with communication between the doctor and patient, as well as treatment and management of their disability.

GPs should be supported and appropriately funded to liaise with NDIS service providers to advise of issues being experienced by their patients (with patient consent).

3.6 Ensure GPs are appropriately remunerated to support the healthcare needs of patients with disability and help them apply for the NDIS

People with disability face several cost constraints when attempting to access healthcare. These can delay people with disability seeing a health professional, particularly if they rely on the Disability Support Pension or other forms of welfare.

There is a financial disincentive under the current Medicare system to provide long or prolonged consultations.¹¹ It may therefore be financially unsustainable for many GPs to take on large numbers of patients with disability.

Medicare Benefits Schedule (MBS) items for GP consultations can only be billed if the patient attends a face-to-face or telehealth appointment. Despite the fact that attending a consultation is an additional financial, access and time burden on a person living with a disability, MBS rebates are not available for paperwork completed in the patient’s absence. There is no other avenue for GPs to be remunerated for their time and expertise unless they charge the patient a fee.

For GPs working in the Aboriginal and Torres Strait Islander health sector, there is an added financial impost as these patients may require more paperwork to be completed to support their NDIS application.

GPs should be remunerated for time spent preparing reports and other relevant documentation to support NDIS applications when patients are not present. One option is to fund this through MyMedicare, the federal government’s voluntary patient registration (VPR) scheme, however an increased allocation of funding would likely be needed to support this.

Under a properly funded VPR model, GPs and practices would receive multiple targeted payments to support the delivery of additional and more comprehensive services, including care coordination activities between consultations, beyond the relevant fee-for-service MBS items. This has the potential to improve timeliness of care, reduce the financial and access burden on the patient, and improve capacity for GPs and practices to undertake population and preventive health activities.

The RACGP is open to engaging in discussions with the Department of Health and Aged Care around alternative remuneration options for GPs completing application forms for their patients.
Other ways to improve the healthcare of people with disability include:

• increasing Medicare rebates for standard GP consultations to reflect the real cost of providing ongoing comprehensive, patient-centred care to people with disability
• better promotion of MBS health assessment items by both the Department of Health and Aged Care and the NDIA to encourage greater uptake. People with intellectual disability are currently one of the target groups eligible for an annual health assessment.

3.7 Improve access to NDIS supports in rural and remote areas

Targeted outreach by the NDIA is needed to increase availability and uptake of NDIS supports in areas with limited access to primary healthcare services.

Additionally, patients who live in rural and remote areas with poor access to healthcare and who are often socio- economically disadvantaged encounter significant barriers to meeting the onerous evidence demands (occupational therapy, psychiatry, intellectual capacity testing) required to apply for NDIS supports. Consideration of the impact of barriers to access for rural and remote patients should inform the design and implementation of application processes.

Where NDIS applicants reside in rural and remote areas, increased weight should be given to the opinion of their regular GP to reduce the burden of gaining new supporting evidence from non-GP specialists and allied health professionals.

GPs with prior knowledge of a patient’s medical history have the expertise needed to determine that a patient’s impairment is permanent and treatment options have been exhausted. It is unnecessary that the patient be referred to a non-GP specialist who they have never seen to provide the same assessment.