Submission No 225
INQUIRY INTO IMPLEMENTATION OF THE NATIONAL DISABILITY INSURANCE SCHEME AND THE PROVISION OF DISABILITY SERVICES IN NEW SOUTH WALES
Organisation: Mental Health Coordinating Council Date Received: 9 August 2018
9 August 2018
Public Submission: Implementation of the National Disability Insurance Scheme (NDIS) and the Provision of Disability Services in NSW
Overview
The Mental Health Coordinating Council (MHCC) is the peak body representing community managed organisations (CMOs) in NSW that provide services to people living with mental health conditions that may also have, or be at risk to develop, psychosocial disability. Our members deliver a range of psychosocial disability support programs and services including housing, employment and community inclusion activities, in addition to treatment (clinical) and peer support services, with a focus on trauma-informed recovery-oriented practice.
MHCC works in partnership with both State and Commonwealth Governments and the public/mainstream, primary healthcare, community and private sectors in order to effect systemic change in how human services respond to people living with mental health conditions. Thank you for the opportunity to provide this public response to the NSW Government’s Inquiry into the Implementation of the NDIS and the Provision of Disability Services in NSW.
MHCC recognises the NDIS provides opportunities for greater choice and control and there are many positive stories of people’s lives being changed through the NDIS. The scheme is still in transition and challenges and difficulties are to be expected as the scheme is bedded down. However, MHCC are concerned that after five years of NSW NDIS trial and implementation people with mental health conditions/psychosocial disability have been disadvantaged in their access to, and planning within, the NDIS environment. The NSW Government priority has been the access of the 86,000 people who were clients of the previous Department of Aging, Disability and Homecare (ADHC: Department of Family and Community Services/FaCS). Few of these people have primary mental health conditions due to the structural siloing created through the 1993 NSW Disability Services Act where responsibilities sat with the NSW Ministry of Health. The new 2014 Disability Inclusion Act lacks clarity about accountabilities for services for people with mental health conditions who may not have a sufficient level of impairment to access NDIS funded supports and services but that are at risk of developing high levels of psychosocial disability without early help.
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This is not consistent with the government’s priorities as stated in “Living Well: A Strategic Plan for Mental Health in NSW” (NSW Mental Health Commission, 2014) which include consumer and carer participation at all levels, a revitalised community based mental health system, better integration of care and coordinated responses across human services. NDIS implementation is a shared Commonwealth and NSW government responsibility and both Governments need to ensure a strategic direction consistent with both “Living Well” and the Fifth National Mental Health Plan. NSW NDIS access by people with high levels of psychosocial disability related to a mental health condition is just 7% (Diagram 1). This is far short of the 13.9% recommended by the Australian Government Productivity Commission.
Diagram 1: Access by People with a Primary Mental Health Condition to the NDIS in NSW Against Productivity Commission Estimates
The March 2018 National Disability Insurance Agency (NDIA) Quarterly Report advises the 14% figure is closer in the more mature Hunter trial site. No NSW specific regional data is available to MHCC to substantiate this.
Despite the above trend, the numbers of people with mental health conditions accessing NDIS funded services and supports in NSW is far short of optimal (Diagram 2).
Diagram 2: Access by People with a Primary Mental Health Condition to the NDIS in NSW and Nationally
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The NDIS is an important opportunity for the NSW Government to increase the disability support services and supports available to people with severe mental health conditions. An assertive outreach and engagement strategy to identify people with mental health conditions eligible for the NDIS is required. This will help people to live well in the community and take pressure off the already overburdened acute/public mental health services system.
MHCC provides further comments attached in response to the NSW Government’s inquiry Terms of Reference. We welcome any opportunity to discuss our thoughts with you.
Please do not hesitate to contact either myself or Tina Smith, Senior Advisor – Sector and Workforce Development , for further information.
Kind regards,
Carmel Tebbutt CEO Mental Health Coordinating Council
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MHCC Submission: Implementation of the NDIS and the provision of Disability Services in NSW
9 August 2018
a) The implementation of the NDIS and its success or otherwise in providing choice and control for people with disability
Choice and control is a great ambition of the NDIS. However, many people with cognitive impairments, including mental health conditions, need support to achieve self-determination and to develop the skills to realise this ambition. These skills include:
- Supported decision-making
- Self-advocacy, and
- NDIS/recovery plan management.
People both with and without NDIS funded services and their supporters (family/friends and paid health professionals, Community Workers, volunteers and peers) need the above skills to navigate the NDIS and other human service systems. When these skills are in place then choice and control creates meaningful outcomes for NDIS participants
The NDIS have some support line items to help develop these skills but only if people know to ask for it. NSW health professionals, disability and community workers, and peers (families and friends) need to know how to support people to ask for this help.
(b) The experience of people with complex care and support needs in developing, enacting and reviewing NDIS plans
People with complex and diverse health and social needs, including mental health problems, are having great difficulty navigating the NDIS for both access and planning. Health, disability and Community Workers supporting people with mental health problems to access the NDIS are experiencing mixed messages from the NDIA about eligibility and observing people with similar support needs get disparate, or no, plans. People with a mental health condition that have very high levels of psychosocial disability are missing out on plans because the NDIA does not understand the functional impacts of mental health conditions/cognitive-behavioural impairments. NDIS access challenges are placing great stress/trauma on individuals, their families and workers. The NDIA needs to improve its understanding of trauma-informed and recovery-oriented practise for both access and planning. Plan agreement/sign-off processes need strengthening and many people are getting plans that do not make sense against their needs. The lack of plan management skills or supports hinders plan implementation. The NDIS and health/mental health interface requires greater operationalisation. Where plans are working well there seems to be a strong reliance on NDIS ‘health and wellbeing’ line items (i.e., a health and wellbeing ‘advance directive’ that sits parallel to the NDIS funded disability services and supports).
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(c) The accessibility of early intervention supports for children
Section 25 of the NDIS Act allows for an early intervention pathway for people of all ages. It is our understanding the Commonwealth Government and Productivity Commission do not act on this in the NDIS context because of the potential cost/pricing impacts which could be significant. (i.e., with more than 75% of mental disorders having their onset with people 25 years and younger). There is a lack of clarity about inter-sectoral roles/functions for either early intervention (for young people) or intervening early (for people of all ages) following the initial onset of a mental health condition. The health/mental health interface lacks clarity despite the “Operational Guidance for NSW Mainstream Services on the Interface with the National Disability Insurance Scheme” (2017). It is unclear what role NSW Health public mental health services and/or funded CMO mental health services and Primary Health Network (PHN) commissioned services play in intervening early around the onset of mental health conditions (i.e., which jurisdiction has responsibility for community-based prevention, promotion and early intervention services)
(d) The effectiveness and impact of privatising government-run disability services
The demand side of this privatisation needs adequate transitional support. While the NSW Government has provided support through FaCS and/or National Disability Services to disability support providers in transition to NDIS funding arrangements, this has not occurred for all mental health/psychosocial disability providers and especially those that are NSW Health funded. MHCC has been advocating about this issue for five years without success. Many psychosocial disability support providers are reporting that they are struggling to provide under-priced NDIS related services and at risk of becoming financially insolvent within the next two years. This will affect their financial viability to provide NSW Ministry of Health funded prevention, promotion, early intervention and mental health recovery/disability support services.
An additional and very important concern is that disability support provider ‘of last resort’ arrangements for NSW and ‘Continuity of Care’ arrangements are unknown.
(e) The provision of support services, including accommodation services, for people
with disability regardless of whether they are eligible or ineligible to participate in the NDIS
NSW continues to be one of the least funded states/territories for mental health support services as a proportion of mental health budgets nationally. MHCC acknowledges NSW Government funding increases to the NSW Health CMO delivered mental health programs through the Housing and Accommodation Support Initiative (HASI), Community Living Supports (CLS) program and Pathways to Community Living (PCL) etc. but these remain inadequate to meet population mental health need. MHCC strongly supports the NSW Governments decision to not roll these programs into the NDIS.
Furthermore, the NSW Government must address the community living needs of people residing in the FaCS Stockton, Kanangra/Morisset and Tomaree/Port Stephens institutional facilities. These people, many of whom have co-existing mental health conditions, were to transition to community living during the Hunter NDIS trial but still remain in institutional care.
(f) The adequacy of current regulations and oversight mechanisms in relation to disability service providers
It is premature for MHCC to comment on the adequacy of current regulations and oversight mechanisms of the NDIS Quality and Safeguards Commission as they only commenced NSW operations on 1 July 2018. The NSW Ombudsman’s Office formerly had an important role in overseeing NDIS services and supports. MHCC is about to commence a project examining the monitoring and safeguard mechanisms for mental health community managed services that sit outside the remit of the Commission.
(g) Workforce issues impacting on the delivery of disability services
MHCC has observed a skills reduction in the community managed mental health sector. CMOs are reporting major challenges in recruiting staff who have the skills/ experience/capabilities in working with people with mental health conditions (and complex and diverse health and social problems) against NDIS prices.
The pricing framework of the NDIS is undermining workforce capabilities and ten years of strategic work that MHCC has undertaken to support community sector mental health workforce development. For psychosocial disability services, the pricing structure has reduced providers’ resources and presented challenges to working within a recovery framework. It has placed a downward pressure on wages, which has negatively affected organisations’ capacity to attract, retain, train and develop a workforce that can deliver safe, quality outcomes.
The NDIS pricing framework is inadequate to cover increased administrative costs and corporate overheads for organisations providing services under the NDIS. There is significant cost and risk shifting to service providers in particular, but also to consumers and carers. In order to address the cost shifting, service providers have had to find other ways to cross-subsidise NDIS services including funding from reserves or debt. Managing risk has been challenging as the constraints on resources make it difficult to implement recognised best-practice approaches to service provision.
(h) Challenges facing disability service providers and their sustainability
NDIS pricing to support people with complex and diverse health and social needs - including people living with mental health conditions and with, or at risk to develop, psychosocial disability - is inadequate. CMOs are struggling to provide sustainable services and many are operating at a loss.
This means that the quality of services is deteriorating placing pressure on acute-care public mental health services, both hospital and community-based.
(i) Incidents where inadequate disability supports result in greater strain on other community services, such as justice and health services
Low NDIS pricing and reduced staff capabilities for working with people with complex needs mean that people are unsupported and become unwell placing strain on public acute mental health services and primary care providers (i.e., GPs).
The unclear health/mental health and NDIS interface is especially problematic in relation to psychological/talking therapies (e.g., where a person who requires psychology/talking therapies for capacity building purposes and doesn’t meet the criteria for public mental health community team or a GP mental health care plan).
(j) Policies, regulation or oversight mechanisms that could improve the provision and accessibility of disability services across NSW
The division between health/mental health and disability/social support services continue to be an area of concern. Shared health/mental health and social/disability policy and practice directions are required to remedy this.