Submission to the Parliament of South Australia, Social Development Committee: Inquiry into Mental Health Services the NDIS | External submission

Received 29/10/18 012

Submission to the Parliament of South Australia, Social Development Committee

Inquiry into Mental Health Services the NDIS

UnitingSA – October 2018

Preamble

UnitingSA, formerly UnitingCare Wesley Port Adelaide, was established in 1919 and provides housing, aged care and community services to support people right across South Australia. We provide extensive mental health support through a variety of programs to improve people’s wellbeing, independence and inclusion.

UnitingSA operates from more than 30 locations across the State, with more than 1000 employees and volunteers supporting people from diverse backgrounds. In 2017-18, we supported more than 1000 people through our Mental Health Services in metropolitan and regional areas.

We are the first agency in South Australia, and one of the few across Australia, to be fully accredited under the Mental Health Coalition’s Lived Experience audit process.

In making this submission, UnitingSA congratulates the Government on the appointment of Dr John Brayley as the SA Chief Psychiatrist and welcomes the work being undertaken through his office. We believe Dr Brayley’s appointment will ensure that the State has clear leadership in the mental health sector and enable a good working partnership between Government Clinical Services and NGO Psychosocial Support Services.

UnitingSA is well represented on the SA NDIS Psychosocial Disability Transition Taskforce, chaired by Dr Brayley.

We support the work of this Taskforce, which is:

To monitor the impact of the NDIS transition arrangements on clients and service providers, with a particular focus on ensuring continuity of service to clients.
To advise on appropriate action to address continuity of service issues. This will include remedial action necessary by services, programs and jurisdictions.
To develop solutions and advise on appropriate action.
To identify future issues that may arise.

Notwithstanding Dr Brayley’s appointment and the important work currently being undertaken, we see this Inquiry as an opportunity for organisations such as ours to better inform the Parliament on matters of concern in regards to mental health services and the impact of the NDIS.

The likely impact of mental health on the social and economic development of the State has been well documented. We believe it is vital the State Parliament and the State Government take a lead role in ensuring mental health issues are well recognised in public policy and that preventable gaps in service between the changes being experienced in existing support structures and the roll out of the NDIS are minimised or eliminated.

We wish to endorse the views expressed by the SA Mental Health Commissioner, Chris Burns, in his recent 57th Barton Pope Lecture, delivered during 2018 Mental Health Week. He outlined that ‘when you analyse the 2015-16 data, our state is well served in terms of mental health specialists.

By comparison with all other states on a per head of population basis we are second only to the ACT in specialised mental health care Salaried Medical Officers. We blitz the other states with the highest number of mental health nurses per head of population. And we just pip the westies with the highest number of mental health related allied health workers per head of population.

The figures show that South Australia spends 14% more than the national average on a per capita basis on mental health services. In South Australia the average length of stay is 10.5 days across acute inpatient units compared to the national average of 13.2 days. According to the Australian Institute of Health and Wellbeing’s latest statistics, South Australia had 39.4 inpatient and residential beds per 100,000 of population compared to the national average of 36.7 beds.

Interestingly, South Australia has the highest rate of mental health presentations to emergency departments in Australia at 4.8% versus the national average of 3.6%. So, by almost all measures our state has the resources it needs to run a good mental health service. Which begs the question – why are our clinicians and medical staff so stretched?’

In this lecture, Commissioner Burns described the ‘need for looking at the issue of mental health and wellbeing across the complete prevalence spectrum and not just focusing on the three percent of the population in need of acute, tertiary and inpatient care.’

Commissioner Burns said ‘20%, one in five, South Australians have experienced a diagnosable mental illness in the last year. And, in the course of their lives, 45% of South Australians, almost half the population, will experience a diagnosable mental illness. Sadly, for those who do experience a diagnosable mental illness, more than 65% of them can’t or, importantly, don’t access the services and supports they need to manage their ill-health effectively’.

With over 22 years of experience in providing mental health Services, UnitingSA is in a unique position to provide a submission. Our extensive specialist mental health service work alongside other community and emergency relief services, housing and aged care. This allows us to provide invaluable wrap-around support to people in need across South Australia.

With this in mind, the following addresses each of the Terms of Reference of this Inquiry.

The gap between the Federal Government’s predicted and realised percentages of mental health clients receiving NDIS support:

UnitingSA is bearing significant additional cost in providing support and individual advocacy for people who are in the process of having their eligibility for the NDIS tested. Our experience has been that the assessment process, while improving, has been time-consuming, slow and often inadequately resourced from the assessment body. It is not clear as to who, out of those we currently support, will ultimately be assessed as eligible for the NDIS.

At this stage, UnitingSA is seeing between 25-50% of consumers assessed as eligible for the NDIS. The variance seems largely dependent upon which program the individual is currently supported through.

We have questions about the types of plans people are receiving. When a person has predictable support needs (i.e. activities of daily living ‘ADL’), NDIS plans are able to adequately support the person’s requirements.

When a person has complex, changeable needs and limited insight, the NDIS plans do not allow agencies to allocate suitably qualified psychosocial and lived experienced support workers to provide that support. This may be a factor of the limited ability of the assessment agencies in areas of psychosocial need and/or attributed to the seeming inflexibility of the NDIS arrangements themselves.

We believe the State has an ongoing responsibility for the health and welfare of all consumers and will need to fund services for those who are not able to access the NDIS, or where the NDIS plan does not meet all of a consumer’s needs.

The reduction in funding to the PHaMs program and Mental Health Respite Carer Support program and the impact this will have on people with a mental illness:

We provide one PHaMs program and have not received additional funding to continue beyond June 2019. Currently we have 2.2 staff supporting 44 people; all are in the process of testing their NDIS eligibility, only two have NDIS plans, and all have ongoing needs that require regular support.

People accessing PHaMs are in mental distress and cannot access other supports because they are not consumers of State Mental Health Services. There is an ongoing demand for PHaMs to ensure the needs of this client group are met.

With the defunding of PHaMs and Partners in Recovery (PIR), and people either not being eligible or having difficulty accessing the NDIS, there is an emerging service gap.

While we are not a provider of Mental Health Carer Respite we are concerned about the defunding, as it is an important service provided by organisations such as Carers SA, UnitingCare Wesley Bowden and Skylight.

Mental Health Carer Respite programs provide social and emotional support to carers, as well as practical respite. Without funding, this support will cease to exist, leaving another significant service gap. Not only will this impact on carers and their own mental health, but also on the people they care for.

The ongoing requirements for block funded mental health services provided by the State Government after the NDIS transition:

We provide seven SA Health and Wellbeing block funded mental health psychosocial support services:

Service	Consumers Supported at Any One Time
IPRSS Northern Country	90
IPRSS North East	90
IPRSS West	120
IPRSS Outer South	80
GP Access West	45
GP Access South	40

| Avalon | 9 | | Total | 474 |

We are unsure how many of these consumers will transition to the NDIS. All, except a small number choosing not to, are having their NDIS eligibility tested.

Those who receive NDIS plans may require additional support due to the complexity of their needs and risks to community tenure. In such instances an ongoing block funded psychosocial support service is required as a supplement to their NDIS plans.

For consumers assessed as ineligible for the NDIS, ongoing block funded psychosocial support services are crucial to ensure their needs are met.

There is also demand from people currently on the waiting list to access our block funded services. As some consumers transition to the NDIS, those on the waiting lists can be accepted into the block funded services.

We also provide three DHS funded services:

Service	Consumers Supported at Any One Time
Metro Options	16
Metro Adelaide Community Living	11
Whyalla Community Living	18
Total	45

All consumers in these services are considered to be in ‘defined’ programs, so they are eligible for the NDIS and will transition.

Most consumers in these services have additional needs to those identified in their NDIS plans, due to the complexity of their situations. In these cases, an ongoing block funded psychosocial support service with care coordination responsibilities is required.

We have concerns about NDIS Support Coordination and Specialist Support Coordination. It is either absent from plans, not well funded, or does not guarantee that consumers can have their support coordination needs met in a timely and flexible way.

Currently UnitingSA, and we believe other NGOs, are continuing to provide support and support coordination for consumers with NDIS plans because the Support Coordination Component is insufficient and limited in its role.

The NDIS plans our consumers have received have limited Support Coordination (30 hours to 100 hours per annum), mainly for the purposes of organising and contracting core supports. The Support Coordination does not account for delivery of flexible and intensive coordination as consumers experience regular situational crises.

Such consumers need regular visits from a support coordinator who is able to respond to immediate and serious needs on a daily or weekly basis, and provide an assertive type of support as required.

The effects on South Australians with mental health issues who are deemed ineligible to receive NDIS funding:

In the case of people currently supported through Commonwealth funded programs, such as PHaMs and PIR, the effects of being ineligible for the NDIS could be dire. If the programs do not exist beyond June 2019, we are unsure of the capacity of the Continuation of Service and Psychosocial Supports that will be funded via Primary Health Networks to fill this gap.

Consumers could be left without support and in desperate circumstances resulting in the potential loss of housing, entry into the corrections system, acute/sub-acute mental health episodes and presentation to clinical services.

In the case of consumers not being eligible for the NDIS, or experiencing long waiting times for NDIS processes, PHaMs and PIR are ideal alternatives for consumers who fall into a service gap.

In regards to State funded programs, such as IPRSS, GP Access and Avalon being defunded or diminished, the effects will be as dire as previously mentioned.

If State funded programs continue, the impacts on those who are ineligible for the NDIS will be minimal.

The sufficiency of services provided to people with mental illness who are accepted into the NDIS:

For consumers with predictable disability support needs (i.e. ADLs and community activities) the NDIS will sufficiently meet their requirements.

For consumers who receive NDIS plans and have additional needs due to the complexity of their illness and life situation, the NDIS will not adequately provide the support needed.

Consumers in this situation will find their community tenure at constant risk; they may have frequent acute or sub-acute presentations, make poor or impulsive decisions, be at risk of eviction, experience poor physical health, and be at risk of offending.

Block funded programs with suitably qualified and supported staff are best able to meet the needs of this cohort.

The NDIS is not sufficient in its flexibility for consumers who have had an acute episode and require a rehabilitation and recovery focused service that works in partnership with clinical services.

As stated in Reference 3, ‘the ongoing requirements for block funded mental health services provided by the State Government after the NDIS transition’: we are concerned there is insufficient Support Coordination and Specialist Support Coordination. It is either absent in plans, not well funded, or doesn’t guarantee that consumers can have their support coordination needs met in a timely and flexible way.

NDIS Support Co-ordination and Specialist Support Coordination is time limited and focuses on addressing barriers and reducing complexity in the support environment, while assisting the participant to connect with supports and build capacity and resilience; this doesn’t fully meet the needs of a consumer with ongoing complex needs and has little insight into their situation.

Such consumers need regular visits from a support coordinator who is able to respond to immediate and serious needs on a daily or weekly basis, and provide an assertive type of support as required.

Currently UnitingSA, and we believe other NGOs, are continuing to provide support and support coordination for consumers with NDIS plans because the support coordination component is insufficient and limited in its role. This arrangement, while assisting to meet the needs of consumers, is quite unsustainable.

The effects on South Australians with mental health issues undertaking the application process for the NDIS:

We are seeing examples of consumers becoming very distressed by the process and highlight recent cases where it has led to inpatient stays.

From our PHaMs program:

We are in the process of applying for the NDIS for all of our 46 clients. The process is causing distress to the vast majority of our clients because of the uncertainty of their future care and the certainty of losing their PhaMs worker.

The assessments the clients are completing are directing them to focus on their poor mental health and think about their past. We currently have two clients in hospital as a direct result of the NDIS application stress.

The clients are viewing the process of applying for the NDIS as the same as when they applied for the Disability Support Pension; the onus is on them to prove their eligibility.

So far we have as many not eligible as eligible, which creates uncertainty. We have not had enough plans to be able to ascertain if the plans are providing adequate psychosocial support for the clients. We are concerned about our PhaMs clients’ future under the NDIS.

In addition, the PhaMs service has had its funding halved and its staffing level reduced accordingly and this is exacerbating the stress for clients and staff alike.

From our IPRSS North East program:

Returning Home client

MB is a 45-year-old male who transitioned to IPRSS in 2015 after being an inpatient at Glenside. MB had a history of violent behaviour, unmanaged diabetes, non-compliance with medication, severe schizophrenia disorganised type and morbid obesity. MB had continuous admissions to hospital and a lengthy stay in an acute mental health facility (about 100 days in the year prior to UnitingSA involvement) and was unable to accept supports.

IPRSS has worked with MB to help him maintain his tenancy, develop skills to manage his diabetes and successfully reduced his hospital admissions to short stays of three days. The length between his admissions has also decreased. We have also assisted MB with daily living skills and social activities. He currently receives around 110 hours per month of support. MB was very reluctant in the beginning to even accept supports.

Staff now work with MB over six days per week ensuring he is taken to the GP each morning to administer insulin. A State Mental Health worker provides support on the seventh day to ensure insulin is taken. Staff are able to act quickly if there are signs of him becoming unwell and MH services intervention is responsive to this.

MB recently had a planning meeting for the NDIS at our office in September with the State mental health worker present, a UnitingSA Coordinator and his UnitingSA support worker. MB coped quite well with the meeting.

However, over the following weekend MB started to dwell on issues from that meeting and became unwell. His mother contacted ACIS and MB was transferred to hospital where he stayed for 3 days. MB is concerned that the support workers he has in place with the UnitingSA IPRSS program will change and he will not cope.

In our experience, most current mental health service consumers and their carers who are going through the NDIS process would prefer to continue to receive support from the same agency and workers. However, this is very unlikely as most plans are based on Core Support hours and funds, which will not continue the funding levels sufficient for their current workers.

Some consumers (and in some situations carers) are slow to, or do not want to, implement their plan because of the requirement to change services and workers. They have a genuine concern that this major change might not work for them and could further affect their mental health.

The transition from existing services to the NDIS is causing distress for a great portion of consumers and their carers.

Any other relevant matters;

We are very concerned for people in the community who are distressed and need a service now, but can no longer self-refer or be supported to access a block funded Commonwealth service such as PHaMs and PIR.

The NDIS is a complex and rigorous process which requires an experienced worker to assist a consumer through the process, and then they might be found ineligible.

It was thought that the Local Area Coordination (LAC) would support people to access the NDIS, and if eligible the LAC would support them to implement their plan. However, our observation is that the LACs are entirely focused on NDIS assessments and do not have the capacity to offer the other roles.

Consumers who are transitioning from established programs to the NDIS are receiving reasonable supports to do so; however people with no connection to a service are facing extreme obstacles in accessing support, and they are experiencing a gap in services.

We believe that programs such as GP Access, PIR and PHaMs – all successful programs with the ability to support people in distress who have no other service connection – should receive ongoing funding and be part of a continuum of care that includes the NDIS and other State block funded programs.

Our current range of services, with the addition of the NDIS, means we have a continuum of services that minimises gaps; however the defunding of programs to fund the NDIS will create service gaps and ultimately affect people’s quality of life.

Conclusion

We are confident that over time the NDIS will deliver the level of support needed for most people with disabilities. We support the NDIS principles of client directed care, however the practice to date is not well geared to people with higher levels of psychosocial need.

We are concerned that further withdrawal of block funded programs in the immediate future will compromise the level of care that many people require. The NDIS may well be able to address this in the future but we believe this could be some years away given the difficulties in NDIS implementation.

We believe the first and only concern of the NDIS assessment bodies should be on the provision of the best possible support. Too often it seems that the focus is an adequate level of care, but with cost as a primary concern.

The State has an ongoing role in the provision of mental health services, whether as a compliment to NDIS services or as stand-alone responses. The mix of this will take some time to resolve and in the meantime, we are finding high levels of distress in people requiring mental health support in having to ‘prove’ what they need.

The immediate impacts of not clearly addressing the transition and ongoing gaps in services may be severe. We note that there is anecdotal evidence from other jurisdictions that levels of homelessness may be rising in areas where the NDIS is more fully rolled out. A cause and effect relationship between the NDIS and levels of homelessness has not been established, however this warrants further monitoring and review.

Our experience tells us that pressures on families and carers, breakdown of housing tenancies, greater exposure to the criminal justice system, self-harm and suicides may well occur if matters are not addressed with some urgency.