13 Workforce issues
14.5Different levels of functional support need were used for different criteria:
• People requiring at least daily assistance with core activities (self-care, mobility
and communication) was used to estimate people with significant limitations with core activities.
• The ABS functional definition of people with a disability1 was used to assist in
proxying the number of people with an intellectual disability. This is because people with intellectual disability may not necessarily be restricted in core activities but may still require assistance with non-core activities, such as catching public transport, planning a day and paying a bill.
• The early intervention group includes people who are likely to require ongoing
low-level support, as well as people who need episodic support. For example, an early intervention for behavioural support may be time-limited, whereas an early intervention for a person with Multiple Sclerosis may be ongoing. In the latter case, the person with Multiple Sclerosis may not be at a stage where they require daily support. However, low-level support will assist with managing the condition in the immediate future. Hence, the ABS functional definition of people with a disability was used to estimate the number of people who may require early intervention.
A person’s main health condition was also used as a proxy in all of the criteria, as different support systems are more suited to assisting people with different health conditions. For example, a person with end-stage cancer may require daily assistance with core activities. However, the health and palliative care systems are better suited to assist these people.
1 Specifically, people with a disability who are not restricted in core activities but have schooling/ employment restrictions and people with either a profound, severe, moderate or mild core activity limitation was used in the modelling.
14.6 DISABILITY CARE AND SUPPORT
Table 14.1 Parameters used to proxy the number of people in tier 3
Criterion Functional support
need Health conditions included Health conditions excluded
People who have significant limitations with a core activity (self-care, mobility, communication)
A person needs assistance with at least one core activity (self-care, mobility, and/or communication) at least once a day
Intellectual disability, congenital malformations, deformations and chromosomal abnormalities Nervous system disorders (including multiple sclerosis, cerebral palsy and Parkinson’s disease) Sensory conditions (including hearing, vision and speech) Musculoskeletal disorders (including arthritis and back problems)
Injury (including head injury and
amputations) Autism and autism related disorders (including Rett's syndrome and Asperger's syndrome) Dementia and Alzheimer’s Disease Stroke Schizophrenia and psychosis Respiratory conditions (including asthma and emphysema) Diseases of the digestive system Diseases of the skin and subcutaneous tissue
Diseases of the genitourinary system Neoplasms (including breast cancer and prostate cancer) Diseases of the blood and blood forming organs (including haemophilia) Diabetes Obesity Mental health conditions not involving psychosis (including depression and eating disorders) Diseases of the circulatory system
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14.7
Table 14.1 (continued)
Criterion Functional support
need Health conditions included Health conditions excluded
Early intervention (not already captured in ‘significant
limitations with a core activity’)
People with a profound, severe, moderate or mild core activity limitation People with a
disability who are not restricted in core activities but have schooling/ employment restrictions Nervous system disorders (including multiple sclerosis, cerebral palsy and Parkinson’s disease) Autism and autism related disorders (including Rett's syndrome and
Asperger's syndrome) Acquired Brain Injury Stroke
Paralysis Dementia and Alzheimer’s Disease
All in ‘significant limitations with a core activity’ Schizophrenia and psychosis Musculoskeletal disorders Intellectual disability (not already captured in ‘significant
limitations with a core activity’)
People with a profound, severe, moderate or mild core activity limitation People with a
disability who are not restricted in core activities but have schooling/ employment restrictions Intellectual disability, congenital malformations, deformations and chromosomal abnormalities All in ‘significant limitations with a core activity’ and early intervention Nervous system disorders
Autism and autism related disorders
The fourth criterion for tier 3 supports (large identifiable benefits from support that would otherwise not be realised) has not been explicitly costed. It is assumed that the number of people in this group would be modest and would cover rare cases. An example would be someone with significant disfigurement who may not require assistance with core activities on a daily basis, but nonetheless requires some care and support to assist in participating in society. However, not all people with a significant disfigurement would require care and support. Accordingly, this group was not explicitly counted in costings. People eligible for tier 3 supports under criterion four would be assessed on a case-by-case basis.
It is estimated that 358 850 people (or 1.9 per cent of the population under the age of 65 years) would be in tier 3 of the NDIS in 2009 (table 14.2). Of these, 226 790 people require daily assistance with core activities, a further 81 740 would receive early intervention support and a further 50 320 would receive support due to their intellectual disability. The estimate of intellectual disability appears low compared with epidemiological estimates of intellectual disability (and the relative standard errors are also high for this group as the numbers are small, implying relatively
14.8 DISABILITY CARE AND SUPPORT
large uncertainty about the estimate). Some of this is due to people with intellectual disability being counted among the daily assistance group. However, even after accounting for this, the number still appears low. This is discussed in more detail later in this section. Section 14.6 includes a scenario that assumes a higher number of people with intellectual disability.
Table 14.2 Estimated number of people in tier 3a
2009
Criteria 0–14 years 14–49 years 50–64 years Total under 65 years
People who require daily assistance with core activities 77 320 (8.21%) 84 970 (6.72%) 64 500 (6.82%) 226 790 (4.33%) Early intervention 19 790 (17.51%) 38 480 (13.10%) 23 470 (13.60%) 81 740 (8.02%) Intellectual disability 23 850 (16.75%) 20 900 (19.83%) 5 570 (27.78%) 50 320 (12.06%) Total tier 3 120 960 144 350 93 540 358 850 Total population 4 145 000 10 838 000 3 883 000 18 866 000 % of total population 2.9 1.3 2.4 1.9
aRelative standard errors of estimate in brackets.
Source: Commission estimates based on ABS (2009a).
As a means of cross-checking the above numbers, the same criteria were applied to the 2003 ABS SDAC CURF (to the extent possible given data limitations). The estimates were adjusted to reflect changes in the population and demographic profile of Australians between 2003 and 2009 using ABS population estimates (ABS 2008d). The aggregate estimates of the number of people eligible for tier 3 in the proposed NDIS are very similar (349 020 in the 2003 SDAC compared to 358 850 in the 2009 SDAC). However, there are differences in the estimates by different criteria and ages. In particular, the estimates based on the two datasets diverge in terms of intellectual disability and for the 50–64 year age group. This may reflect overlapping classifications and co-morbidity. Nevertheless, the similarity of the aggregates suggest reasonable reliability of the overall estimate of the number of people in tier 3.
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14.9
Table 14.3 Estimated number of people in tier 3 2003 SDAC estimates inflated to 2009 values
Criteria 0–14 years 14–49 years 50–64 years Total under 65 years
People who require daily assistance with core activities 82 520 73 500 57 670 213 690 Early intervention 11 740 31 630 19 150 62 520 Intellectual disability 27 220 39 460 6 130 72 810 Total tier 3 121 480 144 590 82 950 349 020 Total population 4 145 000 10 838 000 3 883 000 18 866 000 % of total population 2.9% 1.3% 2.1% 1.8%
Source: Commission estimates based on ABS (2003) and ABS (2008d).
Severity hierarchy within the daily need for assistance group
People needing daily assistance with core activities have varying levels of need. For example, some people indicate that they need assistance with a core activity more than six times a day while others once a day. Hence, a further ‘severity’ hierarchy was derived, based on information in the 2009 SDAC. The hierarchy is as follows. People who need assistance with any core activity:
• more than six times a day are counted in the first category
• between three to five times a day are counted in the second category • twice a day are counted in the third category
• once a day are counted in the fourth category.
Generally speaking, people are reasonably evenly distributed across the categories, with slightly more people falling in the fourth category (needing assistance once a day) than the other categories (table 14.4). For example, in the 0–14 year age group, 28 per cent of people (or 21 430 people) need assistance at least six times a day with a least one core activity; 25 per cent of people (or 19 670 people) need assistance with at least one core activity between three and five times a day; 18 per cent of people (14 040 people) need assistance twice a day with at least one core activity; and 29 per cent of people (22 180 people) need assistance once a day with at least one core activity.
14.10 DISABILITY CARE AND SUPPORT
Table 14.4 Severity distribution of people in the daily assistance category 0–14 years 14–49 years 50–64 years Total under 65 years
Share of daily assistance population
people who need assistance more than six times a day with at least one core activity
28 27 20 25
people who need assistance three to five times a day with at least one core activity
25 25 21 24
people who need assistance twice a day with at least one core activity
18 16 20 18
people who need assistance once a day with at least one core activity
29 32 39 33
Number of people who require daily assistance
people who need assistance more than six times a day with at least one core activity
21 430 22 980 13 000 57 410 people who need assistance three to five times a day with at
least one core activity
19 670 21 510 13 370 54 550 people who need assistance twice a day with at least one
core activity
14 040 13 330 12 690 40 060 people who need assistance once a day with at least one
core activity
22 180 27 150 25 430 74 760
Total number of people who require daily assistance with core activities
77 320 84 970 64 490 226 780
Source: Commission estimates based on ABS (2009a).
Epidemiological data compared to SDAC data
Standard errors around the estimates of each of the tier 3 criteria are high, suggesting significant uncertainty about their accuracy (table 14.2). For this reason, the results were crossed checked against the 2003 Australian Burden of Disease (BoD) data (AIHW 2007b), which includes estimates of the prevalence of health conditions.
The BoD study analyses levels of death and disability from a comprehensive set of diseases, injuries and risks, which are combined to form an estimate of the total health ‘burden’. The classification of diseases is based on the International Classification of Disease – Version 10. The BoD study includes an extensive review of available data and literature. This has information on the incidence, prevalence, duration and relative risk of mortality for major diseases by age and sex.
However, while these data may present a more accurate estimate of the number of people with each health condition than the 2009 SDAC, they do not include any information on functional limitations for each condition, or on co-morbidity. This
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14.11