Government Response to the Social Services Select Committee Inquiry into the Quality of Care and Services Provision for People with Disabilities

Introduction

1. The Government welcomes the Social Services Select Committee's report on its "Inquiry into the Quality of Care and Services Provision for People with Disabilities".  The report is the result of a considerable amount of work by the Select Committee over a long period of time, and represents a major contribution to the development of policy in this important but challenging area.  The Government responds to the report in accordance with Standing Order 248.
2. The Government supports the underlying intention of the Select Committee's recommendations of adopting a citizenship-based model for disability supports that is based on improving disabled people's ability to live everyday lives through giving them increased choice and control over the supports they receive and the lives they lead.
3. There are two broad approaches to the Government's response.  For the majority of recommendations the response indicates that further work is required before the Government can make decisions on the particular steps it will take, as the recommendations are wide ranging and have significant implications for a range of government agencies and disabled people.  The Government's ability to respond to some of these recommendations is also affected by the need to consider the results of consultation processes before taking decisions.  This particularly affects the recommendations relating to the Health and Disability Commissioner and the Health and Disability Services (Safety) Act 2001.  In other cases, however, the Government has already implemented several responses that are consistent with the Select Committee's recommendations, or is expanding and modifying its existing work programmes so that they are consistent with the Select Committee's recommendations.
4. The Government expects to progress the substantial work programme outlined in this response during 2009.  The scope of issues to be considered, however, means that the Government will need to prioritise the order in which it considers issues.  In doing so, the focus will be on steps that make the biggest difference to disabled people through enabling them to live an everyday life and to have increased control and choice over what they do.  The current fiscal climate means that the immediate focus must be on using existing resources in more cost-effective ways rather than on major structural change or increased levels of funding.
5. The Government acknowledges that the Select Committee considers that there should be ongoing monitoring of the Government's progress in implementing some of the Select Committee's recommendations.  The Government suggests that this ongoing monitoring take place as part of a regular, annual examination - such as through reviewing the annual report on the implementation of the New Zealand Disability Strategy - rather than as part of an ad hoc process.  This would avoid the additional and resource intensive work that can result from ad hoc monitoring arrangements.  Options for doing this will be examined in the further work outlined under Theme One below.
6. The response below is presented under seven themes, with each theme covering one or more recommendations.  These themes largely reflect the way in which the issues are presented in the Select Committee's report.  The responses should be treated as relating to all the recommendations in a particular theme unless it is clearly indicated that it relates to particular recommendations.

Recommendations and government response

1. Enhancing leadership and accountability structures (this section covers recommendations 1, 2, 3 and 4)

Response

7. The Government acknowledges that improvements can be made to the leadership of, and accountability structures for, disability services.  As an initial step, the Government has decided that it will improve Ministerial-level collaboration on disability issues through establishing a Ministerial Committee on Disability Issues, chaired by the Minister for Disability Issues. The Government has also directed officials to further examine the two broad issues raised by these recommendations:
   1. What practical changes should be implemented that will improve government agency responsiveness to disabled people as envisaged by the 2001 New Zealand Disability Strategy? We note that the recent Review of the Implementation of the Disability Strategy found that central government agencies have undertaken a significant level of activity to implement the Disability Strategy, but that in all areas more work is needed to meet disabled people's needs and aspirations. 
   2. What practical changes should be implemented that will improve the way in which government agencies that fund disability supports operate together? This would allow them to be more cost effective and reduce the burden on disabled people and their families of dealing with multiple agencies. This could result from, for example, better coordinating mechanisms, improved information sharing, and improved incentives to collaborate. 
8. The Government does not, however, favour establishing new agencies, such as establishing a Disability Commission.  Such significant structural changes are likely to be costly and distract officials from carrying out the substantial work programme that is outlined in this response.
9. The Government has also asked officials to consider, as part of the work they already have underway to improve the monitoring of the New Zealand Disability Strategy and to monitor the United Nations Convention on the Rights of Persons with Disabilities, how progress on the work programme outlined in this response might also be monitored (recommendation 4). 

2. Changing the way that people access the disability support system (this section covers recommendations 5, 6 and 12)

Response

10. The Government is committed to an approach to accessing the disability support system that gives disabled people greater control over their lives and supports participation in the community.  Consistent with this, the Government acknowledges that evidence from some other jurisdictions suggests that Local Area Coordination is valued by many disabled people and is more cost-effective than some alternative approaches.  Accordingly, it has directed officials to investigate how Local Area Coordination-type processes might be implemented in New Zealand, and the desirability and feasibility of doing so (recommendations 5 and 6).  That investigation will include the following types of issues:
    1. the impact that Local Area Coordination-type processes would be expected to have on the ability of disabled people and their families to live everyday lives, the costs of introducing it, and whether it is expected to lead to a more cost-effective use of resources;  
    2. the particular form that Local Area Coordination-type processes could take in New Zealand, and the resulting changes that would be required to the roles of existing Disability Information and Advisory Services, Needs Assessment and Service Coordination organisations and providers;
    3. what changes to the overall approach to funding, assessing for, and delivering disability supports could support the introduction of Local Area Coordination-type processes; and
    4. the potential to extend Local Area Coordination-type processes to Government agencies, other than the Ministry of Health, that fund disability supports.
11. The Government agrees that improvements can be made to processes for accessing basic, low cost equipment and modifications (recommendation 12). Consistent with this, the Ministry of Health is working with its contracted Equipment Management Service providers to improve the speed with which people can get basic equipment through, for example, expanding the range of people and providers who can assess people's need for basic equipment, and improving the distribution arrangements for equipment.  The investigation of Local Area Coordination-type processes will also consider whether it is possible to streamline the delivery of other low-cost supports. 

3. Increasing choice and flexibility in disability supports (this section covers recommendations 7 and 8)

Response

12. The Government supports an approach that empowers disabled people to manage their own personal support services and gives them greater choice and control over their lives, including through providing better access to supported independent living [in which services are wrapped around a person to enable them to meet their goals] and individualised funding [also known as direct funding, in which people directly manage the support services they receive] (recommendation 7).  Consistent with the Government's direction to officials to implement such an approach the Ministry of Health, in consultation with other government agencies and within available resources, is:
    1. Expanding the availability of supported living and individualised funding arrangements, such as through increasing the number of agencies which offer these types of support and expanding their scope.  For example, it may extend eligibility for individualised funding to more disabled people who may not previously have fit the criteria, and support a wider range of activities and choices for them within this service delivery approach. 
    2. Removing barriers to people choosing their living arrangements through scoping a project to give providers more flexibility about the range of supports they are able to offer to disabled people.  This could include such things as allowing residential providers to offer supported living services, and using the flexibility that is now included in the home and community support services.  The move to increase flexibility in home and community support services was introduced when a joint ACC/ Ministry of Health service specification replaced more restrictive home based support service specifications.  Future work will be guided by a current evaluation of the implementation of the new service specification. 
    3. Scoping a project that has the goal of the majority of people with very high support needs living in supported independent living arrangements rather than in residential care within five years.  The Government will, however, continue to support people who choose to remain in residential care. 
    4. Giving disabled people who live in residential services a greater degree of choice and control than they have at present through, for example, giving them increased choice over who they live with.
13. The Ministry of Health is also scoping a project that has the goal of making realistic and affordable age-appropriate services available to all people with physical and neurological disabilities (aged under 65) and high support needs within 3 years (recommendation 8).  The number of younger people who live in aged care facilities has reduced in recent years.  The Ministry of Health's ability to implement this project will in part, however, depend on such things as the availability of accessible housing in suitable locations and the availability of funding. 

4. Support for carers and transitional arrangements (this section covers recommendations 9, 10 and 11)

Response

14. The Government agrees that better support for unpaid carers is important and is investigating the options for taking forward the Five-year Action Plan of the New Zealand Carers' Strategy (recommendation 11).
15. The original pilot for transition services for disabled people who are moving to post-school options such as employment, training or further education has been extended by the Ministry of Social Development and now extends to over 65 providers throughout the country who are providing services to students identified as having very high needs or high needs under the Ministry of Education's Ongoing Reviewable Resourcing Scheme (recommendation 10).  This has meant that all students receiving this service now have a choice of transition provider.  The new form of contract for transition services, with milestone payments at key stages in the transition process, assists with the monitoring process.

5. Improving disability services monitoring arrangements (this section covers recommendations 13, 14, 15 and 16)

Response

16. The Government agrees that monitoring of disability services should focus on quality of life outcomes for disabled people, rather than a "tick-box" approach.  This applies to both contract-based monitoring by the Ministry of Health and other agencies, and monitoring under the Health and Disability Services (Safety) Act 2001.  Monitoring under that Act is based on the Health and Disability Services Standards (which are also referred to in relevant Ministry of Health contracts). 
17. The Ministry of Health's Disability Services group's contract-based monitoring has already moved in this direction, with the Ministry's recent introduction of developmental evaluations that are focused on quality of life outcomes for disabled people.  A similar approach is applied by the Ministry of Social Development to its monitoring of community participation and employment services.  In these cases, disabled people and their families have central roles in the monitoring processes, and audit teams talk with all stakeholders, with a focus on the experiences of, and the outcomes for, people who use services.  This approach is consistent with the requirements of the United Nations Convention on the Rights of Persons with Disabilities. 
18. The Government will review the desirability and feasibility of, and the requirements for implementing, quality of life monitoring of residential disability care under the Health and Disability Services (Safety) Act 2001.  This review will also consider the role of disabled people and their families in the monitoring process (recommendations 13 and 15).  Any changes to the way in which residential disability care is monitored could, however, only be made after the consultation requirements that are set out in the Health and Disability Services (Safety) Act 2001 have been met (recommendations 13 and 14). 
19. The Ministry of Health is moving towards making audit reports of community disability services under the Health and Disability Services (Safety) Act 2001 publicly available.  These reports will be summaries that are designed to protect the privacy of service users and their families.  The Government has directed officials to consider whether it is possible to make contract-based development evaluations public in a way that adequately protects the privacy of service users and their families (recommendation 16).

6. Improving advocacy and complaints processes (this section covers recommendations 17, 18, 19, 20 and 21)

Response

20. The Health and Disability Commissioner's current Review of the Operation of the Health and Disability Commissioner Act 1994 (the Act) and the Code of Health and Disability Services Consumers' Rights includes many of the issues raised by these recommendations.  For example, the Commissioner is consulting on whether there should be a separate Disability Commissioner and whether that role should be able to consider complaints about funding issues and access to services.  The Government has also discussed with the Commissioner its pre-election commitment that a Deputy Commissioner be solely dedicated to disability issues.  The Government will take decisions on issues that are within the scope of the Commissioner's review of the Act and the Code after the Commissioner has completed his consultation process. 
21. The Government is, however, able to respond on several issues raised by these recommendations that are outside the scope of the Commissioner's review of the Act and the Code:
    1. The Government supports the principle that people who live with disability experience barriers in all areas of life - disability is not primarily a health matter (recommendation 17).  The government expects that all government agencies, including the Health and Disability Commissioner, and other organisations receiving government funding will be aware of this principle and act accordingly. 
    2. The need to strengthen the Health and Disability Commissioner's advocacy work has already been recognised, with the Commissioner's funding being increased with the aim of increasing the number of advocates from 34.5 in September 2008 to 41 in 2009/10 (recommendation 18).  The focus on advocacy reflects the fact that its face to face, supportive approach is often more suitable for people who need to build relationships with providers as they use supports on an ongoing basis, than a complaints process that focuses on specific concerns.  The Government notes that the advocacy service already addresses situations faced by individual consumers outside of the "health and disability" setting.  We await the Commissioner's advice on whether that needs to be better reflected in the Act's wording. 
    3. The Government recognises that, alongside the more formal advocacy and complaints services provided by Government, less formal advocacy options that enable disabled people and, similarly, their families, to make and communicate their decisions can be of considerable assistance to disabled people.  Many disabled people, however, do not have family and friends in a position to advocate for them and assist them to be heard, provide with the opportunity to make their own decisions and have greater control over their lives.  We have, therefore, directed officials to investigate whether and, if so, how these less formal types of advocacy might be supported. 
    4. All existing complaints services that are likely to be used by disabled people already accept verbal complaints (recommendation 19).  The Government is, however, keen for complaints services to have a greater profile and to be seen as disabled person friendly, and notes that there are existing initiatives to better inform consumers about these services.  We have instructed officials to report to the Government on how best to make the service(s) better known amongst disabled people and their families, and easier to use.  There is also likely to be benefit from further considering whether complaints services can be better coordinated to help improve disabled people's experience of them and to improve outcomes for disabled people. 
    5. Disabled people can currently ask their Needs Assessment and Service Coordination organisation or the Ministry of Health to review their support allocation.  We have asked officials to review these processes so that they provide people with greater assurance that services are allocated consistently and in accordance with government policy (recommendation 20).  Allowing independent reviews of funding decisions would, however, make it difficult for the Ministry of Health to manage within its available resources as this could move towards an 'entitlement' approach to services, which is difficult to manage within capped funding. 
    6. The Health and Disability Commissioner advises that he already has a process in place for following-up on his recommendations (recommendation 21).  Also, the Health and Disability Commissioner advises that in 2007/08, 99% of his recommendations were complied with.  It is, however, possible that not all parties interested in a particular complaint are aware of the results of the follow-up process.  The Government will, therefore, ask the Commissioner to ensure that all parties are made aware of the results. 

7. Implement a cross-sector workforce strategy (this section covers recommendation 22)

Response

22. The Government agrees that a strategic approach is needed if the care and support workforce is to effectively support disabled people to be independent and participate in society.  In accordance with this approach, the Ministry of Health has developed a Disability Services Workforce Strategy and Action Plan (for support that is funded by the Ministry of Health's Disability Services group).  This was prepared in consultation with a strategic sector reference group, and comment was sought from a range of organisations including groups representing disabled people, providers/ employers and support workers. 
23. The Workforce Strategy and Action Plan has the overall objective of improving the status and capability of the disability workforce, and enabling the disability sector to recruit and retain competent support workers and specialists.  Implementing the Action Plan from within existing resources will lead to providers being able to provide paid training for workers, the development of a structured career path and values-based training for all care and support workers. A skills-based pay system will be introduced as funding becomes available. In addition, the Tertiary Education Commission will be asked to review the relevance and appropriateness of current training programmes. The Government notes, however, that working conditions are negotiated between employers and employees and it is not normally appropriate for it to directly influence them. 
24. The Workforce Strategy and Action Plan is complemented by a cross-Health sector Care and Support Workforce initiative (including District Health Boards, the Ministry of Health and ACC).  That initiative seeks to address workforce issues for those who provide care and support to people of all ages.  The approach taken in these two work programmes is broadly similar, which reflects the fact that there are some close linkages between the aged care, mental health and disability support workforces. 
25. There is close collaboration between those working on these two work programmes to help support the development of consistent approaches.  It would, however, be difficult to combine these two work programmes or to expand them to cover other sectors, such as people employed in the education sector.  Doing that would make both of them unwieldy and jeopardise the progress that has been made to date.