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Breaking Up Is Risky Business: Personalisation and Collaboration in a Marketised Disability Sector

Published online by Cambridge University Press:  10 October 2022

Eloise Hummell*
Affiliation:
The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia
Samantha J. Borg
Affiliation:
The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia
Michele Foster
Affiliation:
The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia
Karen R. Fisher
Affiliation:
Social Policy Research Centre, University of New South Wales, Sydney, New South Wales, Australia
Catherine Needham
Affiliation:
Health Services Management Centre, University of Birmingham, Birmingham, United Kingdom
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Abstract

The marketisation of disability support driven by individualised funding brings new dilemmas for multi-agency collaboration, in particular how to provide personalised supports while remaining commercially viable. This article explores the challenges, risks and adaptations of organisations to navigate the tensions of personalisation and collaboration. Framed by street-level research and using the context of Australia’s National Disability Insurance Scheme (NDIS), this article draws on interviews with twenty-eight organisational managers. Multi-agency challenges are highlighted when several providers are delivering parts of a NDIS participant’s plan, blurring organisational responsibilities and accountabilities. Interviews also revealed the paradox of organisational disconnection and organisational dependence concerning quality support provision and described the collaborative responses organisations implement to ensure their sustainability. There is commitment among organisations to build a trusted ecosystem of providers, but this is largely discretionary and there is a need for further policy mechanisms to enable organisations to negotiate a way through multi-agency dilemmas.

Type
Themed Section on Personalisation and Collaboration: Dual Tensions in Individualised Funding Policy for Older and Disabled Persons
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
© The Author(s), 2022. Published by Cambridge University Press

Introduction

Individualised funding and marketisation are dominant features of contemporary disability support, intended to deliver choice and control for people with disability.Footnote 1 In individualised funding systems, the person holds their support budget and can self-select providers to deliver personalised supports for their needs and goals (Fleming et al., Reference Fleming, McGilloway and Thomas2021). Such disability support models include direct payments, personal budgets, and consumer-directed care in the United Kingdom (UK) and Ireland (Ferguson, Reference Ferguson2012; Fleming et al., Reference Fleming, McGilloway and Barry2016; Pearson et al., Reference Pearson, Watson and Manji2018), and ‘cash-for-care’ in some European countries (Fisher et al., Reference Fisher, Gleeson, Edwards, Purcal, Sitek, Dinning, Laragy, D’Aegher and Thompson2010). Concurrent with the intended benefits of self-determined and personalised support is the challenge of seamlessly coordinating services within a marketised environment. Although personalisation and collaboration are not necessarily oppositional, in an individualised model there are inherent tensions that might engender ineffective, inefficient, and fragmented support for people with complex needs (see Needham et al., Reference Needham, Foster, Fisher and Hummell2022bFootnote 2 in this themed section). This raises critical concerns relating to quality, risk management, avoidance of practice failure and the balance of personal and public responsibilities for multi-agency provision (Foster et al., Reference Foster, Hummell, Fisher, Borg, Needham and Venning2021).

Individualised funding for disability supports was introduced in 2013 in Australia through the National Disability Insurance Scheme (NDIS). Similar to other systems, the NDIS enables greater choice and control for users of the Scheme (henceforth, participants) in their selection of service providers. Consequently, it is common for several organisations to provide support to a single participant (Foster et al., Reference Foster, Hummell, Fisher, Borg, Needham and Venning2021). This is a marked shift from previous block-funded organisations, where services were largely delivered to a person through one central organisation. Expectations set by the NDIS governing body – the National Disability Insurance Agency (NDIA) – are that organisations work together to provide cohesive support for participants. Yet little has been documented on how this is to be achieved in a marketised environment that fosters increased differentiation and financial competition between organisations (Foster et al., Reference Foster, Hummell, Fisher, Borg, Needham and Venning2021). In this context, we refer to multi-agency collaboration as agency-to-agency (or -agencies) coordination in the delivery of services. This includes agencies providing support within the disability sector and across sectors including health, education, and other government and non-government human service organisations (King and Meyer, Reference King and Meyer2006). This article focuses on multi-agency collaboration in the provision of disability supports, where providers may deliver a breadth of services.

The aim of this article is to explore the challenges and adaptations undertaken by organisations to navigate the dilemmas of personalisation and collaboration with an individualised funding model. First, the contemporary shift to individualised funding is summarised, followed by details of the NDIS as the context of this study. The qualitative approach and study findings are then outlined. The three themes denote the street-level complexity of multi-agency collaboration in a personalised support market. They highlight that the new NDIS marketised environment is both concealing and accentuating support inter-dependencies. The article concludes with a discussion considering policy tools and frameworks to promote and support effective multi-agency collaboration in individualised funding models.

Background

The provision of disability support services is complex, often requiring coordination and collaboration both within and across various human service sectors. Individualised funding has progressively been implemented in social services internationally, including for disability sectors within the UK, Europe, and Australia (Ferguson, Reference Ferguson2012; Fleming et al., Reference Fleming, McGilloway and Barry2016; Pearson et al., Reference Pearson, Watson and Manji2018). The individualised funding model is intended to promote the self-determination of people with disability and their rights to choose and control their lives (Earle and Boucher, Reference Earle and Boucher2020). It reflects international human rights commitments, including the United Nations Convention on the Rights of Persons with Disabilities (CRPD). However, the implementation of individualised funding also decentralises services, creating a commercialised and competitive market, often with a mix of government and non-government, for-profit and not-for-profit agencies (Green et al., Reference Green, Malbon, Carey, Dickinson and Reeders2018). Such shifts in the funding structures are extensive and change the nature of collaboration between agencies, particularly those within the same sector, who are thrust into an environment that requires collaboration to uphold safety and quality of service provision, while also directly driving competition between support providers (Green et al., Reference Green, Malbon, Carey, Dickinson and Reeders2018).

Organisations potentially face new challenges and sets of risks in dealing with individualised funding and the goal of both personalised and coordinated support. Unlike previous funding models, often with a primary provider who selected and coordinated supports, the Australian individualised funding model encourages multiple providers engaged in a specific financial transaction with the NDIS participant (Foster et al., Reference Foster, Hummell, Fisher, Borg, Needham and Venning2021). This is driven by the premise that multiple providers will result in tailored supports while also minimising conflict of interest and reducing the risk of institutionalised service provision. The resulting multi-agency dynamic impacts on communication, information availability and transparency, and the creation of mixed and diffused accountability (Malbon et al., Reference Malbon, Carey and Reeders2019). Thus, the empirical interest is in how the organisations deal with these new dilemmas and risks and what steps they take to collaborate to ensure service quality and participant safety.

The complexities and challenges of effective multi-agency collaboration where there are interconnected support needs are well-documented (Ansell and Gash, Reference Ansell and Gash2008; Ziviani et al., Reference Ziviani, Darlington, Feeney, Meredith and Head2013; Hummell et al., Reference Hummell, Venning, Foster, Fisher and Kuipers2021). However, effective collaborative mechanisms in the context of marketisation are less understood (Green et al., Reference Green, Malbon, Carey, Dickinson and Reeders2018). Specifically, there has been limited attention on how local markets might support personalisation, and the personal and joint responsibilities for multi-agency provision in a market environment (see Needham et al., Reference Needham, Allen, Burn, Hall, Mangan, Al-Janabi, Tahir, Carr, Glasby, Henwood and McKay2022a). Considering this gap and the risks associated with coordination failures – exacerbated when support needs are complex – it is vital to understand how collaboration is expressed in individualised disability funding environments. This study uses Australia’s NDIS as our case example to explore perspectives of disability support providers and other key organisations engaged by people with disability.

National Disability Insurance Scheme (NDIS)

The NDIS is Australia’s approach to personalised lifetime support for people with disability, funding supports for citizens with significant and permanent disability who enter the Scheme prior to the age of sixty-five. The Scheme is administered by the NDIA under the National Disability Insurance Scheme Act 2013 and was progressively rolled out from 2013 to 2020 (Purcal et al., Reference Purcal, Fisher, Meltzer, Fenger, Hudson and Needham2016). The Scheme introduced a market-based approach by placing purchasing power in the hands of participants to choose services and providers that are funded according to ‘reasonable and necessary’ criteria (Foster et al., Reference Foster, Henman, Tilse, Fleming, Allen and Harrington2016; Purcal et al., Reference Purcal, Fisher, Meltzer, Fenger, Hudson and Needham2016). However, the choice of multiple providers is not just driven by participants, it is actively promoted by the NDIA. For example, the case management role that traditionally existed in the Australian disability sector is not funded within the NDIS. If funded, participants can now opt for plan management, support coordination and direct service provision, undertaken by one or multiple separate providers. As such, individualised funding creates a diverse and complex ‘marketplace’ where services are delivered by a mix of state and non-state providers, with submarkets for different services and locations (Queensland Productivity Commission, 2020). Organisations can be complementary in the absence of overlapping services. However, direct competition may arise where there are multiple organisations that provide similar services, which can influence how organisations interact with one another. Embedded in this is the NDIA’s expectation that multiple providers collaborate to enhance quality, efficiency and sustainability and avoid fragmentation and duplication (Hawkins, Reference Hawkins2013; Australian Government, 2016). This expectation suggests that even in diverse and competitive markets, organisations have responsibility for personalisation and collaboration (Foster et al., Reference Foster, Henman, Tilse, Fleming, Allen and Harrington2016).

Concerns have been raised about failures of governance and associated risks and responsibility (Henman and Foster, Reference Henman and Foster2015), particularly where individualised funding may encourage boundary guarding for financial viability (Green et al., Reference Green, Malbon, Carey, Dickinson and Reeders2018; Malbon et al., Reference Malbon, Carey and Reeders2019). Recent findings reinforce this, with numerous NDIS providers increasingly aware of the financial transaction costs attached to service provision and adopting more commercial mindsets (Foster et al., Reference Foster, Hummell, Fisher, Borg, Needham and Venning2021). Concerns about low levels of collaboration among NDIS providers, predominantly restricted by a competitive market, have also been identified (Carey et al., Reference Carey, Weier, Malbon, Dickinson and Duff2020). In a survey of Australian disability service providers, Carey and colleagues (Reference Carey, Weier, Malbon, Dickinson and Duff2020) found that 42 per cent of organisations overall engaged in formalised collaborative arrangements (e.g. Memorandums of Understanding), with very smallFootnote 3 organisations less likely to engage in formal agreements than large organisations (17 per cent vs. 69 per cent) and less likely to collaborate for sector advocacy (50 per cent vs. 84 per cent). For NDIS participants and their families, the failures and risks of poor collaboration can be disproportionately experienced by those with complex support needs which involve engagement across various services and systems.

One mechanism included as part of the NDIS which may influence multi-agency collaboration is support coordination. Support coordinator responsibilities – which include connecting participants with NDIS providers and services, and building skills for coordinating services (NDIS, 2021b) – suggest a critical bridging role that could assist in facilitating collaboration and overcoming multi-agency failures. However, ongoing problems with the position such as role ambiguity, variable skill and quality, time-limited funding and inconsistencies in practice have been identified (NDIA, 2021; Hummell et al., Reference Hummell, Foster, Fisher, Needham, Borg and Venning2022). Furthermore, support coordination funding is provided when a participant has complex needs and meets ‘reasonable and necessary’ criteria, with less than half (43 per cent) of participants nationally receiving funding (NDIS, 2021a: 167). Consequently, the support coordinator role cannot be relied upon to solve multi-agency collaboration in the NDIS.

Another mechanism likely influencing multi-agency provision is the NDIS Quality and Safeguards Commission (henceforth NDIS Commission) – an independent agency designed to ‘provide national consistency, promote safety and quality services, resolve problems and identify areas for improvement’ (Department of Social Services, 2019). Considering the more recent shift towards improving the effectiveness and efficiency of the market, one facet of the NDIS Commission has been towards improving the Scheme’s governance to support enhanced oversight of performance monitoring (Queensland Productivity Commission, 2020). Currently, the NDIS Commission prioritises its compliance framework, responding to complaints primarily from participants. At the time of writing, proactive oversight of provider quality in service delivery has not been a focus of the NDIS Commission. Consequently, questions remain about how organisations are self-governing and arranging themselves to deliver multi-agency work within a marketised environment. This is particularly of interest due to the NDIS structure, the compartmentalised roles including support coordination, and the decentralised governing arrangements. Understanding the challenges to multi-agency collaboration and the adaptive mechanisms organisations are using for effective multi-agency work could lend valuable insight into policy implementation.

Approach and study design

The study was designed in the frame of street-level research, in recognition of the significance and uncertainties of policy implementation (Lipsky, Reference Lipsky1980). A street-level perspective offers a lens through which to understand policy in action, to explore the complexities of implementation. Drawing predominantly on Brodkin’s (Reference Brodkin2011; Reference Brodkin2016) notion of street-level organisations and their critical intermediary role in the implementation of policy (given government agencies increasingly devolve responsibility and accountability to other types of organisations), street-level organisations are not simply deliverers of policy, they produce and reproduce its practical meaning through their actions and organisational life. The more reformative or contentious the policy goals, the more likelihood of street-level tensions, inconsistencies, and resistances (Brodkin, Reference Brodkin2011). Designed to shift the locus of control and transform modes and practices of disability support governance (Henman and Foster, Reference Henman and Foster2015), the NDIS model is, arguably, a confronting reform for service organisations. Consequently, a street-level perspective aims to elicit how organisations are developing adaptive strategies that effectively constitute local governance of disability support.

A qualitative research design incorporating semi-structured interviews was used to elicit the perspectives of various service providers, peak organisationsFootnote 4 and advocacy bodies, with a focus on South-East Queensland representatives. Although the NDIS staged rollout commenced nationally from July 2016, South-East Queensland began in selected regional areas from January 2017, followed by the higher populated urban areas from July 2018. Consequently, at the time of study, South-East Queensland was early in the transition to individualised funding. The data presented in this article are part of a broader study, with interviews also conducted with frontline staff and NDIS participants and families to investigate the coordination of NDIS funded supports (see Foster et al., Reference Foster, Hummell, Fisher, Borg, Needham and Venning2021 and Hummell et al., Reference Hummell, Foster, Fisher, Needham, Borg and Venning2022). Ethical approval was gained from Griffith University Human Research Ethics Committee (GU 2019/406) and Metro South Hospital and Health Service Human Research Ethics Committee (HREC/2019/QMS/59522).

Recruitment

With the assistance of the team’s research and professional networks, a purposive sampling and a snowball approach were used to recruit a range of organisational managers from a diversity of organisational types, governance models (i.e. public, private, not-for-profit and social enterprise), geographic coverage and duration of operation in the disability sector. Individuals were eligible if they were eighteen or over and employed in a senior/managerial role within a NDIS registered provider, government agency, peak body or advocacy organisation supporting NDIS participants or NDIS providers in South-East Queensland. This region was deemed a critical study site for the broader research project to coincide with the early transition to individualised funding and emerging challenges, thereby providing a timely view of new policy implementation in action.

Research participants

Twenty-eight senior organisational representatives (henceforth managers), representing a diversity of organisational age, governance and geographical region, were recruited between December 2019 and September 2020 (see Table 1). The organisations represented a broad range of disability support services, including personal supports, allied health, transport, accommodation, support coordination, plan management, advocacy, information and service brokerage, skill development and community access. Consent was obtained in written form or recorded verbally prior to commencement of the interview.

Table 1 Organisational representatives (n = 28)

NDIS = National Disability Insurance Scheme.

Notes. Table representing the breakdown of organisational representatives (n=28) who participated in interviews, according to organisation type, governance model, established before or after the introduction of the NDIS, and the geographical coverage.

Data collection

Four members of the research team conducted semi-structured interviews using an interview guide consistent with the study aims. Managers were asked about how their organisations were: adapting to the NDIS; collaborating with other organisations in the coordination of funded supports; and perceiving challenges and opportunities for the collaborative management of funded supports. Interviews took approximately forty-five to sixty minutes, were audiotaped, transcribed and checked for accuracy.

Data analysis

An inductive thematic analysis was undertaken guided by a framework approach (Ritchie et al., Reference Ritchie, Spencer, O’Connor, Ritchie and Lewis2003) following completion of the interviews. Two of the four researchers initially read and independently open-coded the same four interview transcripts and then met to develop a preliminary coding framework comprising fourteen defined categories with descriptor codes. Using this framework, the same two researchers then coded three interview transcripts to assess inter-rater reliability and to ensure that the framework encapsulated the range of issues represented in the data (Hennink et al., Reference Hennink, Kaiser and Marconi2017). Coding discrepancies were discussed and resolved, resulting in a refined coding framework of twelve distinct categories. All transcripts were subsequently coded. Authors developed an overall analysis across all coded categories and subsequently interrogated in greater depth four categories specifically relevant to collaborative working – including those on risk management and multi-agency provision, quality and responsiveness of services, and system interfaces. The research team completed concept maps and workshops to interrogate the data and identify patterns and links between the various categories, as a basis for deriving the three themes. The quotations chosen during the process illustrated themes and overall patterns and discrepancies in the findings (Patton, Reference Patton2002). Quotes presented in the findings section are labelled to denote participant type (M: manager), organisation type (NFP: not-for-profit; Gov: government service provider; P: private for-profit; SE: social enterprise), and interview number (01–28).

Findings

The experience of multi-agency provision of funded supports in the NDIS is summed up in three main themes: disconnected support on the ground; interface dependencies; and discretion and diplomacy of multi-agency collaboration.

Theme One: Disconnected support on the ground

The first theme, disconnected support on the ground, reflects a general perception by managers that although individualised funding is intended to stimulate personalised support, it is also a force that can inhibit coordination between organisations. This tension derives from the involvement of multiple providers in a single participant’s support plan – for example, one organisation may provide personal care, whilst another might support community access. Risks arise when the organisations do not have ways to make connections between the parts of a participant’s support package.

Managers acknowledged that multi-agency involvement in the delivery of supports was not new practice, ‘We’ve never tried to be everything to everyone’ (MNGO22). Working cooperatively with many organisations was good practice and delivers benefits for participants:

We fundamentally believe as an organisation that – unless you’re needing only a very small amount of support or support on a transactional basis, that people are best served by having a few organisations in their life, not one organisation in their life. (MNGO24)

However, a general sentiment was that NDIS individualised funding had created a more challenging context for multi-agency provision of supports. The loss of role as a ‘financial delegate (MNGO06) and the apportioning of a plan across multiple, unknown providers created a sense of disconnection between the organisations delivering to a common participant on the ground, particularly when participants had complex health and social support needs. Managers felt they were delivering a service that someone else has arranged:

You used to be the case management service as well as the service provider. Now we are merely an arm of what the support coordinator has arranged. (MPriv21)

Participants who receive services from multiple providers rely on coordination between organisations to achieve a whole of life plan. A manager commented on what happens without that coordination:

Organisationally the connecting together of a single plan for a client, that governs their whole of life experience, isn’t there…NDIS planners…they are assessors, who really just decide what funding you get. The support coordinators try to broker and match supports. (MGov06)

The inference from these findings is that multi-agency provision was highly dependent on how the participant’s plan was established and the agreement and alignment of providers in a plan. The managers expressed concerns that the segmentation of plans and unclear lines of responsibility resulted in disjointed information sharing and communication, demonstrated in the first extract below. They felt the disconnection also increased risks for organisations and participants in the absence of effective interfaces and relationships, as the second extract reveals:

The challenge for service providers, I think, shouldn’t be a big one, but that’s about communicating with each other around any issues or if we have a joint support plan everybody follows and agrees to follow, there shouldn’t really be any problems. But the issues come when there’s a breakdown in communication or the support plan’s not set up well enough that everybody has access to it. (MNGO19)

Our obligation is when we are engaged by a customer, then we engage under an agreement and subsequently accept and take on risks attributed to providing high quality, appropriate supports for the person…the NDIS is premised on strong interfaces and relationships working across the board, right? And until that happens effectively, I think you will see increased risk. (MNGO10)

The theme of disconnection illustrates the unintended consequences of policy that can emerge at the implementation or delivery end. The evidence shows that although personalised support plans might rely on multi-agency provision, it also creates a sense of disconnection between the agencies – which may well be concealing and accentuating the risks from support inter-dependencies. The second theme elaborates on this idea.

Theme Two: Interface dependencies

The second theme, interface dependencies, draws attention to the consequences of disconnected support on the ground. As multi-agency provision in personalised support becomes compartmentalised in practice, paradoxically, organisations are also more dependent on each other for information and communication, and to clarify responsibilities to ensure quality support provision.

Most striking in this theme are the risks from dependencies that the managers highlighted in specific contexts, such as supported accommodation where multiple providers are involved with different components of support. A significant challenge was ‘making sure that all the boundaries are clear, there’s nothing blurry’ (MNGO22). The risks from poor quality collaboration in supported accommodation and support plans are summed up by this manager:

We might be the provider of the Supported Independent Living but they’ve got a different provider for community access and a different provider who does their behaviour support plan…Something can have occurred while a person was out on community access, that wasn’t a major incident or anything, but…there’s no need or investment or onus on them to be handing over good information around this is how that person went during the day. (MNGO29)

Other managers spoke about the complexities of multi-agency support for a participant with complex health and disability support needs. These managers pointed out the need for ‘good old client management but acknowledged the outcome depended on how ‘responsive and collaborative the other providers were (MPriv21) and ‘making consistent boundaries and approaches (MNGO08). Picking up on complex health and behavioural needs, another manager spoke about their role now being ‘just an implementing service’ (MNGO11) as a risk to quality multi-agency provision:

I think the challenge probably is more risk from behaviour because they’ve got multiple agencies, so to try and set up a quality of a plan is – and a consistent quality – is hard. So that’s probably more at risk. Because we had our own clinical team that did that when we were block-funded. And most big providers did. Now we don’t. (MNGO11)

Arguably, these extracts foreshadow challenges to achieving effective collaboration where multiple providers are disconnected when each is responsible for a part of a participant’s plan (theme one) and rely on mutual dependencies (e.g. communication, information, boundaries). Such challenges are brought into greater focus by two other storylines relating to risks from support inter-dependencies. The first echoes the disconnected support and concerns the perception that the consequences of the support inter-dependencies that are managed by organisations were risky for participants. Choice and control with multiple providers was described as a ‘new set of risks…coming into the sector’ (MNGO08):

But it’s an interesting set of risks to be able to manage, because again it does bring it back to choice and control. So the client has chosen to have three different agencies, so how can we work effectively together to do that? And how can we make sure that there is effective hand-over, especially if we’re managing risks, that we’re all managing risks in the same way. (MNGO08)

The second storyline relating to risks of support inter-dependencies is about how the managers operationalised the link between multi-agency obligations to collaborate and individualised funding policy. The managers’ comments suggested that they collaborated when it was consistent with their mission and values in each particular situation. Their stated values were about collaborating in the interests of the participants. Collaboration according to managers was related to: ‘the commitment I’m going to give [the participant] as part of our support and services (MPriv12), or perceived benefits for participants: ‘people do collaborate because they perceive a benefit in doing it’ (MNGO03), ‘we will gladly and willingly collaborate….to get a good outcome for people (MNGO04), or because it was ‘good business at the individual level for outcomes (MNGO09).

Situational collaboration was reflective in comments such as: ‘we are collaborative when we need to be, we’re isolated when we need to be (MPriv21) and collaboration was ‘on an as-needed basis around individual participants (MNGO04). While the general view was ‘you have to collaborate together to get a whole of life experience…it was in most cases…clunky (MGov06) and inevitably came with risks in multi-agency delivery. This variation in collaboration indicates that the organisations exercised discretion about when they collaborated within the individualised funding model.

With the shift of control towards NDIS participants and the subsequent diffusion of support provision to achieve more personalised support (theme one), the paradox is the greater need to collaborate (especially for complex needs or crisis situations) to avoid system failure (theme two). The third theme elaborates on how organisations are managing the challenges and risks of multi-agency work and the dilemmas of dependent disconnections on the ground with the goal of optimising the quality of supports and outcomes for participants.

Theme Three: Discretion and diplomacy of multi-agency collaboration

Managers’ comments on multi-agency provision in themes one and two illustrate the challenges and importance of organisational arrangements in the context of individualised funding. Theme three, discretion and diplomacy of multi-agency collaboration, reinforces the policy intermediary role that organisations continue to occupy despite a sense of losing organisational control, and how they are approaching delivery dilemmas. In the face of unclear policy or legislation about how to achieve collaboration of personalised supports, organisations are establishing and redefining multi-agency collaboration in discretionary and creative ways.

In response to the opposing forces of organisational disconnection and interface dependencies, managers proffered various actions about internal controls and risk management, and external controls based on critical dependencies and trusted networks. Examples of internal controls included systems and processes to determine ‘who’s good and who’s not if coordinating multiple providers (MPriv01), or whether the agency was the ‘appropriate provider…to safely meet (MNGO11) the support needs when providing part of the plan. Another example of internal controls for quality and safety included renewed emphasis on documentation: ‘we have everything documented…it’s really important that all that data actually equate to easily being able to see and assess changes occurring (MNGO14). The accent on internal controls with individualised funding was summed up by this manager, describing the intersections of participants’ best interests, internal procedures and collaboration in a business context:

…whatever happens we’re going to operate on the client’s best interest, so we’re going to put all our internal governance policies and procedures around our business interests, if it’s in the best interest of the client, and this is what we’re going to be doing as part of this collaboration as a guiding principle. (MPriv12)

Reaffirming the idea that disconnected multi-agency provision was challenging, they also took various actions to negotiate and manage inter-organisational relationships as part of a support plan. For example, some organisations preferred agreements about multi-agency support provision. One manager explained about holding the funds for a participant with complex health and disability needs: ‘that was a formal arrangement that we did subcontract them to come in and provide support to that young man’ (MNGO17). Similarly, they used service agreements with participants to authorise communication and collaboration with other providers:

When we sign up a new client…one of the legal agreements and authorities that we do get is the authority to communicate and collaborate with other health professionals and other providers. That gives us the gate or the door to make contact where we need to. (MPriv21)

However, as this manager intimated, although agreements about how organisations would collaborate in support provision were essential, the question was raised about whether this was currently a discretionary aspect of multi-agency provision rather than formal practice:

Every time that someone has an external or other provider, you almost need a service level agreement on how you will collaborate and what that means. So each of us, each organisation has their own agreement around what they’re doing. But I think…we’re going to need to formalise agreements between providers. (MNGO29)

The need to build a trusted ecosystem of providers and relationships was emphasised. As this manager pointed out: ‘you can hardly have a collaborative relationship without trust (MNGO17). For the most part, it was left to individual organisations to choose how they built trust and relationships for multi-agency provision but maintaining ‘continued relationships’ was the imperative (MNGO18). Examples included: ‘collaborative meetings happening’ at the network level (MPriv 25), or at the participant level, ‘regular meetings’ even ‘if it is over the phone’ (MNGO22). As another manager described, keeping other providers up to date was critical for meeting responsibilities:

We have to keep the other providers or the key people at a certain time up to date otherwise we are responsible for more than our remit allows us or expects us to do. (MPriv21)

The extract above also alludes to the continued need for organisations to acknowledge and work proactively with inter-dependent providers despite the tensions from individualised funding that may obscure and restrict this. This sentiment was summed up by another manager who compared the NDIS with the former system to reinforce networks of trust:

Because the former system was so driven by the provider, almost owning every bit of information about a person and having a whole lot of conversations between providers about the person, with the person not involved…it was then legislated the other way around, that no information could be exchanged without permission of the person. Now, I still fundamentally think that’s right, but it’s how to then make that work and how to facilitate a network of trust. (MNGO29)

It is striking in the extracts comprising theme three that there were few references to structural mechanisms to enable organisations to negotiate a way through multi-agency dilemmas associated with individualised funding. One manager expressed uncertainty about whether ‘you can regulate a good service’ (MNGO07). Nevertheless, others spoke about the function of overt mechanisms to create the conditions for quality multi-agency provision and effective collaboration. They held different opinions such as legislation ‘to promote good collaboration’ (MNGO18), or ‘faith in the Commission to actually make sure services deliver quality services and…help organisations be more collaborative’ (MNGO02), and an emphasis on rules, or ‘chaos would come’:

Quality compliance, rules and regulations really is a marriage of a good scheme, like, a good performing, thriving, quality scheme. (MPriv12)

Discussion

Available nationally since 2020, the NDIS continues to represent a significant shift in Australian disability funded support policy that parallels more established international personalised systems (Green et al., Reference Green, Malbon, Carey, Dickinson and Reeders2018; Needham and Dickinson, Reference Needham and Dickinson2018). The findings of this study show the street-level challenges of personalising and coordinating multi-agency supports with individualised funding. Indeed, these twin challenges are accentuating and concealing the risks of support inter-dependencies. The development of multi-agency collaboration and networks is both necessitated and constrained by NDIS design features as the findings also indicate. Although there is evidence of good multi-agency collaboration, consistent with previous reports (Malbon et al., Reference Malbon, Alexander, Carey, Reeders, Green, Dickinson and Kavanagh2018), this mainly involves local ad hoc practices and trust-based relationships, initiated by individual organisations committed to the provision of quality supports. In focusing on the tension between personalisation and collaboration with NDIS individualised funding, the article contributes to three key areas. Firstly, it exposes the challenges in a set of reforms that aim to tailor support around the individual through requiring that agencies both compete and collaborate. Market-based approaches to service delivery are not new and nor are the challenges of collaboration. However, reforms that give budgetary control – or at least oversight – to individuals generate a new set of integrative challenges. If the NDIS aims to provide tailored supports, then more attention needs to be given to this context, as people’s lives criss-cross a multiplicity of agencies.

Second, the findings draw attention to the advantages and disadvantages of developing a formal framework to operationalise local and system collaboration. Leaving agencies to develop ad hoc relationships at the frontline – as many do now – has advantages in being bottom-up and trust-based. This is consistent with van der Tier and colleagues’ (Reference van der Tier, Hermans and Potting2020) notion of relational agency, and reinforces that accountability is embedded in a web of inter-dependencies (Piore, Reference Piore2011). Nonetheless, there are risks in allowing such informality in relation to data sharing and handovers – and it was clear that some of our interviewees did want more formal arrangements. There was little evidence of a consistent and systematic approach (see McKenzie and Smith-Merry, Reference McKenzie and Smith-Merry2022 in this themed section for an evaluation and comparison of program-based responses to complex unmet need in the NDIS). A framework would guide the consistency and quality of the tasks of multi-agency street-level provision of funded supports in the NDIS. Managers considered that collaboration was a shared responsibility, although they were sceptical about solely relying on formal structures to incentivise collaboration. Likewise, Hummell and colleagues (Reference Hummell, Venning, Foster, Fisher and Kuipers2021) found, in their review of multi-agency collaboration, that creating the conditions for local organisations to lead bottom-up change and mutuality of purpose were equally important.

Consequently, a framework would need to bring some degree of structure to multi-agency collaboration, at the individual and system levels, while facilitating trust-based relationships between organisations. Such a framework would ideally encompass principles and mechanisms to address the multiple problems uncovered in this study and reinforced in the literature on multi-agency collaboration (Horwath and Morrison, Reference Horwath and Morrison2007; Solomon, Reference Solomon2019; Hummell et al., Reference Hummell, Venning, Foster, Fisher and Kuipers2021). These include quality sharing of information and communication between agencies, participants, and all those involved in plan implementation; clarity of roles and responsibilities in the provision and coordination of participants’ plans; clarity of accountabilities to participants, collaborating agencies and the NDIA; and reciprocal strategies to ensure competent and consistent service provision across plan implementation. Consideration would also need to be given to additional funding incentives to support dedicated time and engagement with the required principles and mechanisms.

The third contribution is on a policy level, suggesting the need for more explicit policy mechanisms (i.e. at the NDIS Scheme level) to support local collaboration efforts and operationalisation of the framework described above. Although the trajectories and maturity of individualised funding policy vary (between Australia and the UK, for example), systemic mechanisms to facilitate the complementarity of personalisation and collaboration have been widely used across the UK. Through varying reforms, England, Scotland, Wales and Northern Ireland have all prioritised the structural integration of health and social care systems, with different degrees of success and outcomes (Reed et al., Reference Reed, Oung, Davies, Dayan and Scobie2021). Miller and colleagues’ (Reference Miller, Glasby and Dickinson2021) review of England’s structural integration asserts that the overly ‘macro’ level focus has however come at the cost of developing other forms of partnership working (see also Allen et al., Reference Allen, Mangan, Burn, Hall and Needham2022 and Rummery et al., Reference Rummery, Lawrence and Russell2022 in this themed section for case studies on England and Scotland respectively). Given the potentially fragmenting forces of NDIS individualised funding the authors noted that market stewardship and regulatory arrangements to address the dual tasks of personalisation and collaboration require further consideration (Carey et al., Reference Carey, Dickinson, Malbon and Reeders2018). These types of policy tools are particularly critical for persuading change where there are multiple organisations and sectors involved (Head, Reference Head2019). Policy level strategies could include incorporating localised collaboration in the NDIA’s market stewardship function, as well as explicitly addressing collaboration in the NDIS legislation. The NDIS Commission could be empowered to have regard for relevant governance arrangements in response to complaints about service provision and plan implementation, particularly when these arise at critical interfaces between systems and services, and to undertake quality audits of provider organisations.

The study provided rich data about the organisational challenges of enhancing personalisation and collaboration in a system that simultaneously creates more fragmentation between services. However, the small sample size from South-East Queensland, which was early in transition to the NDIS at the time of study, limits the generalisability of findings. Further research should account for broader experiences across diverse geographical regions, including regional and remote, and across different states and territories, and highlight patterns of collaboration according to organisation characteristics (e.g. size, age, services). Contemporary comparisons across Australia would extend understandings of the shifting challenges of multi-agency collaboration and adaptive mechanisms and better inform potential policy tools. A further limitation of the article is the focus only on organisational representatives, as this offers a partial view of the street-level construction of policy. With NDIS participants as active agents in their choice of providers and financial control, it is critical to explore their views of and roles in multi-agency collaboration.

Conclusion

Individualised funding and the marketised environment of disability support has brought the tensions of personalisation and collaboration into focus for organisations operating in the NDIS environment in Australia. This article addresses the interplay of these dual forces as a critical problem in both the NDIS policy conception and its unintended implementation consequences. Further, it articulates the challenges for organisations required to collaborate in a more fragmented and marketised system, and the risks of poor collaboration for NDIS participants. The extent to which the tension between the forces is inherent remains a key debate. The findings also enhance understandings of the adaptive mechanisms organisations are using for multi-agency work in the NDIS, lending insights into local and systemic policy tools that could enhance collaboration alongside personalisation.

Acknowledgements

The broader project is funded by an Australian Research Council (ARC) Discovery Project (ARCDP190102711) grant.

Footnotes

1 People with disability is the preferred advocacy and policy language in Australia.

2 Needham and colleagues provide an overview of the interplay between personalisation and collaboration across disability and aged care systems in the UK (England, Scotland, Wales and Northern Ireland) and Australia, questioning how tensions between these dual forces operating in different contexts can be mitigated.

3 In this survey, ‘Organisation size was determined by reported annual income: very small organisations reported income of less than $1M; small organisations reported income between $1M and $5M; medium sized organisations reported income between $5M and $20M; and large organisations reported income of $20M or more’ (Carey et al., Reference Carey, Weier, Malbon, Dickinson and Duff2020: 13). Amounts in AUD.

4 A ‘peak organisation’ or ‘peak body’ is an Australian term to describe a non-government organisation which represents the allied interests of a sector, industry or community, often to advocate for their members’ interests to government.

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Figure 0

Table 1 Organisational representatives (n = 28)