Inquiry into Implementation of the National Disability Insurance Scheme and the Provision of Disability Services in New South Wales
Organisation: One Door Mental Health Date Received: 1 August 2018
Inquiry into the implementation of the National Disability Insurance Scheme and the provision of disability services in New South Wales
One Door Mental Health
Executive Summary
As a grass roots community mental health organisation and an NDIS service provider for people with psychosocial disability, One Door is well placed to provide feedback on the implementation of the National Disability Insurance Scheme and the provision of disability services in New South Wales.
In Australia and New South Wales, mental health - psychosocial disability - has been, and continues to be, grossly under-funded despite the clear economic and societal benefits of investment. The NDIS is one of the most important social reforms in Australian history alongside the introduction of Medicare with the great potential to address the critical unmet need to support those with a psychosocial disability.
The experience of One Door Mental Health suggests that the National Disability Insurance Scheme has proven to be a heavily qualified success in providing choice and control for people with psychosocial disability. Whilst many people with psychosocial disability occasioning severe and permanent disability have benefited from support under the scheme, there are currently an unacceptably high number of people who are eligible for the scheme and are not getting adequate support. Reasons for this problem include administrative breakdowns at the National Disability Insurance agencies, financial and institutional problems arising out of the privatization of the disability and NDIS sectors and the complex needs and challenges facing those with psychosocial disability. There are also significant concerns that adequate supports are not, and will not be, in place for people with psychosocial disability who are not eligible for the NDIS. This all has significant implications for the implementation, performance and governance of the NDIS and the disability sector more widely.
One Door would welcome the opportunity to present our experiences in the appropriate forums to inform improvements to NDIS implementation and psychosocial disability supports.
Yours sincerely,
Rob Ramjan CEO
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About One Door Mental Health
One Door Mental Health is a specialist mental health recovery organisation, with a 33 year history, committed to improving access to services and the circumstances of people living with severe and complex mental illness. One Door currently delivers trauma-informed recovery-oriented support through the NDIS for people with psychosocial disability.
In the past One Door has provided psychosocial community mental health programs, specialist mental health Disability Employment Services (DES), care coordination, housing, clinical and peer supported services. One Door has delivered services and coordinated community psychosocial care for people across silos of sectors, funding and policy through the building of relationships and trust with other providers, funding bodies and most importantly, individuals and the communities in which they live.
The experience One Door has in delivering this support for psychosocial disability under the NDIS, as well as One Door’s extensive experience in the psychosocial disability sector, position us well to comment on the implementation of the National Disability Insurance Scheme and the provision of disability services for people with psychosocial disability in New South Wales.
Who are we?
33 years of serving people with a mental illness and their carers
289 staff members
400 More than 40 active volunteer workers
More than 10,000 people accessed our services in the last 12 months
93% job satisfaction
74% of staff have lived experience as a consumer or carer
More than 8,300 outreach calls made
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Welcome News
Whilst the thrust of this submission is critical of psychosocial disability services both within and outside the NDIS, there is some positive movement in the sector that should be acknowledged.
In the context of disability generally, One Door Mental Health welcomes the NSW Government Transitional Advocacy Funding Supplement announced this year that will provide up to $26 million in disability advocacy funding until 2020, with a key focus on activities and support inclusion of people with disability in their communities. However, there does not to date exist Transitional Advocacy Fund specifically designed for people with psychosocial disability. This is a serious problem, as many of the advocacy issues that arise around psychosocial disability vary significantly from issues arising around general disability.
In the context of psychosocial disability, One Door welcomes the additional $82.5 million pledged to mental health in the last NSW budget, including the $42 million of which will be invested in community based services and supports. One Door welcomes the $100 million recurrent investment per annum to implement the NSW Government’s mental health reforms, including strengthening early intervention and specialist community mental health teams, enhance psychosocial supports, and transition long-stay patients into the community. One Door also welcomes the NSW Government supporting the value of lived experience by announcing $2.7 million to fund an additional 30 mental health peer workers across NSW for 2017/18 in November last year. As part of the $100 million in recurrent funding to deliver the NSW Government’s mental health reforms, One Door understands that 265 full time equivalent mental health worker positions will be created in 2018/19.
Administrative Issues in the NDIS
The experience of workers and clients at One Door Mental Health suggest that there are currently a number of administrative issues facing the NDIS that impact negatively upon the ability of the scheme to provide choice and control for all eligible people with psychosocial disability.
These issues include conflicting or changing indications from the National Disability Insurance Agency (NDIA) about such issues as how plans work under the NDIS, how and when plans can be reviewed, how self-management works, and what particular supports may be “in” or “out” in terms of service provision. There has been lack of clarity about reviews of plans under the NDIS, with requests for unscheduled plan reviews being confused with requests for internal reviews of a decision to approve supports. In some cases the NDIA has not given sufficient and clear information to applicants for key decisions. There has been a lack of communication about plans and reviews and slowness acknowledging requests and responding to enquiries. There have been inconsistent plans issued for people facing similar challenges and issues.
There have been reports of very long wait times between the time of application with the NDIS and the time of acceptance. There have also been reports of very long wait times between requests for plan reviews and reviews taking place, with the NDIS suffering a severe review backlog. These wait times effectively leave people with significant psychosocial disability challenges in “limbo”, without the supports they desperately need and not knowing when the NDIS processes may work for their benefit. These situations are exacerbated by a lack of triage processes within the NDIA to sort more urgent from less urgent requests for review.
One Door has knowledge of a significant number of cases that illustrate problems of access and review for people with psychosocial disability. For example, one consumer with an acquired brain injury required a change of circumstances on his NDIS plan as he needed extra support with commencing a TAFE course; he needed help with transport due to the occurrence of seizures that made him unfit to drive a motor vehicle. A Change of Circumstances form was submitted for the consumer on 22nd February 2018 and as of 17th July the NDIS review has still not occurred. Problems of access and review are further illustrated in a number of case studies summarized in Appendix A, Appendix B and Appendix C of this document and in a Commonwealth Ombudsman Report1. More broadly, NDIA processes have been slammed by Gary Humphries, Deputy President of the Administrative Appeals Tribunal. Mr Humphries described NDIS decision-making processes as slow and difficult to interpret; leading to an “unsatisfactory state of affairs”. He stated that:
“[i]t seems to the Tribunal entirely inappropriate that a Participant, working with finite resources and coping with the added burden of a disability, should need to be left in doubt as to the status of decisions made affecting his or her entitlement to the benefits conferred by the legislation, yet this is precisely the situation many applicants to the Tribunal have found themselves in recently,”2
There have been further reports that a significant number of NDIA staff are not sufficiently informed about the nature of psychosocial disability, and this can have a very negative impact upon the application and review outcomes for people with psychosocial disability otherwise eligible for the NDIS.
Workforce issues
One Door experience suggests that there is a significant paucity of skilled, qualified and eager people to work in a mature market for psychosocial disability support under the NDIS. In the context of the NDIS, quality-of-workforce issues are being exacerbated by low cost estimations
1 Commonwealth Ombudsman (2018) Administrative Reviews under the National Disability Insurance Scheme Act 2013: Report on the National Disability Insurance Agency’s Handling of Reviews. Online at
http://www.ombudsman.gov.au/__data/assets/pdf_file/0029/83981/NDIS-NDIA-Final-report-on-administration-of-reviews-under-the-Act.pdf; accessed on 9/7/2018.
2 Gingold, S. (2018) The AAT Slams the NDIA’s “Unsatisfactory State of Affairs”. Online at http://www.disabilityservicesconsulting.com.au/resources/aat-slams-ndia; accessed on 18/7/2018.
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being used by the NDIA to reimburse service provision. With these low rates of reimbursement there are insufficient funds for service providers of the highest relevant qualification to provide the best quality of service to clients. For example, many One Door employees working in the NDIS with the SCHADS qualification at 4-7 have been replaced by employees with SCHADS at 2- 3.
There has also been a de-skilling of the psychosocial disability workforce caused by drift out of the sector. Of 25 redundancies made recently at One Door adapting to NDIS, all but 1 person found work outside the mental health sector. In many situations, these employees are those in whom One Door has invested significant time and money training.
Privatizing government disability services and market readiness for the NDIS
The process of privatizing government disability services is a complex, often fraught issue. Organisations are undergoing fundamental transitions from assured block funding to fee-for- service financial models; transitions which have challenged established institutional cultures and behaviours. This process of privatisation reflects issues around wider market readiness for the NDIS. Again, One Door experience suggests that a number of mental health service organisations are struggling with the transition from the traditional block funding model to a sustainable fee-for-service model. Their internal established practices have often proven antithetical to a market-based model, and a number of organisations previously providing psychosocial disability services have had to close due to inadequate funding through the NDIS system.
Indeed, there appears to be a lack of market readiness throughout the NDIS psychosocial disability sector. There is significant instability and change in the economic and institutional parameters of the market. There has been a lack of clear indication from governments or the NDIA about the nature of the emerging deregulated market for psychosocial disability support services. Although estimations have been made, it is still unclear how many people with psychosocial disability will participate in the NDIS; the kinds of functional impacts relating to psychosocial disability that participants will have; and the location and nature of thin markets.
Specific issues for people with psychosocial disability eligible for the NDIS
People with psychosocial disability eligible for support from the NDIS typically have complex care and support needs. This can make it difficult to develop, act on and review suitable plans. We have already noted that some NDIA staff are not well informed about the nature and needs of people with psychosocial disability. People with psychosocial disability, and their families and carers, very often do not understand what the NDIS is and how its processes work. People with psychosocial disability will generally rely heavily on carers or advocates to do the background work of gathering reports and statements about the client’s specific needs, which may require some travel and cost. With the severity and complexity of service needs also comes increased risk and cost to service providers, which may not be wholly remunerated under the NDIS.
Another problem arises where a person with psychosocial disability may need coordination of support (COS) from the NDIS beyond the first year of their package; typically COS is only engaged in the first year of NDIS support. Ongoing need for COS may arise particularly in the context of episodic or fluctuating illness. One Door experience suggests that Partners in Recovery organisations across NSW are experiencing a high number of clients with a 2″ or subsequent individually funded package that includes insufficient levels of COS, compared to the level of supports provided in the previous year.
Issues also arise in the circumstances where a person with psychosocial disability is eligible for the NDIS, but does not apply for a plan - a failure to provide choice and control. This can happen for a variety of reasons, including not being “customer ready”; anasognosia; a symptom of this illness, such as paranoia or hallucination; not wanting to agree that they have or be labeled with a life-long disability; or otherwise impaired decision making ability. One Door statistics indicate that 88 clients from Partners in Recovery South-West Sydney (24% of the total) have declined to apply for NDIS. Of this number, 3 were not well enough, 57 were not interested, 7 were undecided and 21 were “other”. Common reasons for “other” were homelessness or unstable accommodation.
Some people with psychosocial disability applying for NDIS may not have the executive skills or personal capabilities to advocate well for themselves, and may end up with plans that are less than adequate.
These problems are further entrenched in rural and remote, Aboriginal and Torres Strait Islander and culturally and linguistically diverse communities. They are also reinforced by situations where the person with psychosocial disability does not have a primary carer, where they are homeless or isolated, have drug and alcohol abuse problems, poverty, poor education and/or criminal justice contact.
It has been suggested that some of the emerging problems for people with psychosocial disability and eligible for NDIS could be addressed through the creation of a dedicated “psychosocial pathway” into the NDIS. One Door recognizes that the NDIA is currently trialing such an idea, but also notes that the results from the trial and follow-up trial will not be available for quite some time.
Issues for people with psychosocial disability ineligible for the NDIS
Whilst some people with psychosocial disability have been eligible for NDIS and received support plans, there is a very large residual category of people with psychosocial disability who are not eligible and are relying on existing Support and care institutions or programs. Although it is unclear just how many of such people are affected, estimations have been made of several hundred thousand. Statistics from One Door suggest that of 222 applicants with psychosocial disability from Partners in Recovery South-West Sydney, only 96 (43%) have been found eligible. 60 (27%) have been found ineligible, almost all because the NDIA stated that permanency of
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disability had not been established; 56 (23%) are pending and 10 (5%) are no longer contactable.
Unfortunately a number of the institutions or programs these people rely on are being wound back in order for State and Federal governments to finance the NDIS. Established programs such as Partners in Recovery, Personal Helpers and Mentors or Day2Day Living are in the sights to be defunded. Organisations like One Door itself have had government block funding severely curtailed, impacting hugely on service delivery capability. One Door is very concerned that the closure of programs and organizations like these will mean fewer services for those who desperately need it, and severe flow-on costs in time that are humane, financial, social and political.
Regulation and oversight mechanisms for the NDIS and disability sector
One Door recognizes that the NDIS, and the disability sector more widely, require clear, transparent and effective regulation oversight mechanisms.
In the context of the NDIS the counters of an emerging market suggest that a financial oversight mechanism, or “market steward”, could be invaluable. This steward could monitor and inform price-setting, market flexibility and market failures. It could report on areas of thin markets needing additional incentive to be serviced. It could also monitor and regulate service provider organizations for compliance with relevant legislation and policies.
Outside the NDIS, The psychosocial disability sector currently has some oversight in State and National Mental Health Commissions. Reform of psychosocial disability regulation or oversight would do well to work through these existing organizations.
The disability sector more widely could also benefit from a more effective regulation and oversight mechanism. This benefit is all the more urgent in a context where from 30 June 2018 NSW will no longer have a dedicated Minister or Department responsible for disability issues, and there is significant reform to the Department of Ageing and Disability Home Care. It has been acknowledged by NCOSS? that independent disability advocacy and_ information organizations have played a critical role assisting individuals with disability to solve problems and negotiate barriers and systems; identifying systemic barriers and working with Governments to build inclusive solutions and representing the voice of people with disability in policy development, drawing on a wide range of experiences. A recent cost-benefit analysis has shown
3 https://www.ncoss.org.au/sites/default/files/public/policy/2018%20ADHC%20gaps%20report%20- %20Final%20approved%20version 0.pdf
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that investment in disability advocacy results in substantial cost savings to Government while creating benefits for people with disability across their lifespan.⁴
⁴ Daly, A and Barett, G (2017) “A Cost Benefit Analysis of Australian Independent Disability Advocacy Agencies”. Available online at https://www.pc.gov.au/__data/assets/pdf_file/0016/222136/subpp0371-ndis-costs-attachment1.pdf; accessed on 27/6/2018.
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