Care and care-work in a marketised disability sector

In the midst of the precarity produced by our political and economic system, we too often forget who our real enemies are. Without a clear identification of who makes the decisions that produce suffering (and why), the blame can easily shift onto another marginalised group. During the rollout of the National Disability Insurance Scheme (NDIS), we have seen the disability services sector- largely made up of an underpaid, precarious workforce - too often positioned as the enemy of people with disabilities and their families.

This article is the second in a series of Flood Media pieces on the NDIS. (Read the first article here.) This piece explores some impacts of the NDIS on the disability services workforce, and how the scheme may impact the quality of care for people with a disability.

Most of us are now becoming familiar with the general concept of the NDIS, but what does it mean in practice? The National Disability Insurance Scheme is the new Australia-wide approach to funding disability services. It is founded on market-based principles where people with disabilities are viewed as consumers, who gain choice and control through being given purchasing power in a quasi-market of social services. It has all but replaced all existing disability services funding in Australia’s states and territories. 

Previously, not-for-profit disability service providers received block funding from state and federal governments. Under the NDIS, an organisation’s funding is largely reliant on a fee-for-service model where people with NDIS plans (if you’re lucky enough to get a plan - you can read more about the challenges of getting a plan here) purchase support from a service provider. If the person no longer wants to receive support from this service, a portion of funding can be withdrawn from the service provider at two weeks to a month’s notice. While this model can provide some people with disabilities a certain degree of ‘purchasing power’ and control over the services they receive, this has broader reaching implications for the not-for-profit sector, its workforce and its ability to provide high quality support. 

Not-for-profit service providers struggle to hire permanent part-time or full-time workers under these funding arrangements. A careful reading of the Productivity Commission’s proposed design of the NDIS shows that the scheme is underpinned by a mass-casualised workforce, and posits shorter shifts and more flexibility as attractive working conditions for disability support workers. This may hold true for a section of the workforce. But for others, who have families to care for, mortgages to pay and no other sources of income, a move to more insecure work is deeply concerning. 

It is also worth considering what kind of workforce will accept these casualised conditions long-term. It is hard to imagine that experienced, qualified workers will remain if they are offered a permanent job outside the sector. If the disability sector is primarily left with an inexperienced, untrained workforce, it is likely we will see a drop in the quality of support. 

Once again, the Productivity Commission’s proposed design of the NDIS makes it clear that an untrained workforce is pivotal to the scheme. They justify this with not only economic argument, but go as far to suggest that:

...governments should not require that all disability workers have minimum training...It should also be emphasised that the overwhelming current source of care is unpaid and usually untrained family carers, who are usually preferred by people with a disability.

Aside from the strange logic that underpins this statement-  that an untrained paid support worker is similar to an ‘untrained’ family member - this directly contradicts the wishes and statements of people with disabilities and their families. In the 2009 Shut Out report, people with disabilities and their families explicitly identified poorly trained staff and the resulting poor quality of care as an ongoing issue. 

The current mechanisms of the NDIS are fundamentally unable to provide well-trained staff and high-quality care. Not only are the working conditions produced by the NDIS antithetical to attracting and retaining an experienced and highly-trained workforce, the NDIS funding mechanisms do not really cover on-the-job training and supervision.  

The National Disability Insurance Agency (NDIA) price guide sets the maximum hourly rate for support. It varies slightly depending on activity, but for most one-on-one support during ‘business hours’, the maximum rate an organisation can charge is around $48 an hour

To put this into context, the lowest award rate for a casual support worker is around $26 an hour, leaving an organisation with at most $22 an hour for all their overheads. With this remaining $22 an hour, an organisation will need to pay the rent on their office space, pay employee superannuation and insurance, pay someone to do rosters, payroll, reception, pay someone to ensure they are complying with all government regulations and current legislation, to manage critical incidents, to meet audit requirements and if they are lucky, maybe pay some supervisors and managers. It is simply not enough to cover regular training or supervision to frontline support workers. 

This is an issue for people with a disability and their families and workers alike. For people with a disability, this may mean that they receive lower-quality support. The lack of supervision for disability support workers raises questions around safety and an organisation’s ability to monitor and quickly respond to any possible exploitative or abusive behaviour. In turn, frontline disability support workers may find themselves ill-equipped to respond to complex behaviours and find themselves in unsafe or, at worst, traumatising situations. This funding mechanism also limits their pay rate, and for many existing disability support workers this represents a pay cut from their pre-NDIS wage.

The Productivity Commission, and more recently the NDIA, are seemingly wedded to the idea that with enough efficiency and agility the market will be able to provide both cheaper and higher-quality care for people with a disability. Unfortunately, as Fiona Macdonald points out in her fantastic piece ‘Marketising Social Care’, disability support is fundamentally a labour-intensive exercise and consequently, the only significant costs that can be cut are labour costs. The only way to provide substantially more hours of care for less is to cut wages.

So what does that leave us with? Support workers who find themselves in worsening conditions with lower wages. People with a disability who do not receive the highest quality of support. Under this new funding system many organisations are at best struggling to deliver quality support, at worst going bust. 

In all of this, it cannot go unsaid that people with a disability in Australia continue to experience coercion, abuse and neglect at the hands of some support workers. And perhaps if the NDIS lived up to its glossy booklets, and truly ensured that all Australians with a disability had choice and control over their lives, we could see a reduction in these horrific instances. More to the point - can a mass scale marketisation and privatisation of disability services, that systematically devalues and deregulates disability support work, deliver higher quality support that reduces abuse and neglect? 

I truly wish I had a more positive answer to that question. But if we are honest with ourselves, it is far more likely that the NDIS will produce both lower-quality, higher-risk support for many people with a disability and more precarious working conditions for disability support workers. 

Nicole Laffoley is a Greens organiser and agitator living in Brisbane. She has worked in the community services sector and spent a lot of time exploring the impact of the NDIS on community mental health support services.

Photo by Josh Appel on Unsplash