Received 10/10/18 via email 002
SUBMISSION
Parliament of South Australia: Social Development
Committee
The provision of services for people with mental illness under the transition to the National Disability Insurance Scheme (NDIS).
October 2018
DETAILS
Bill Miliotis
SUMMARY
The National Disability Insurance Scheme (NDIS) is a massive and complex social reform, the largest social reform since the introduction of Medicare1. As with any large-scale social reform, challenges are to be expected. The NDIS is continually learning and adapting throughout the transition, particularly in relation to learning as it pertains to people with a psycho-social disability.
Across the items contained in the Terms of Reference (ToR), recommendations are provided in two categories, conservative and radical.
The recommendations are intended to inform broader system architecture thinking, with holistic person-centred practice, access, availability and affordability as the basis of action.
INTRODUCTION
Thank you for the opportunity to provide a submission on the provision of services for people with mental illness under the transition to the National Disability Insurance Scheme (NDIS).
Transitioning to the NDIS is difficult and complex. For this reason, the early opportunity to identify and address the impacts the transition is having on people with a mental illness, services providers and the health, social and welfare sectors is particularly welcomed and appreciated.
I write from the perspective of an independent organisational architect and change/reform agent with approximately 25 years’ experience in social, health and welfare, private and public; more recently as the Manager of Central Adelaide and Hills Partners in Recovery (CAH PIR). The Department of Health (DoH) notes:
PIR aims to better support people with severe and persistent mental illness with complex needs and their carers and families, by getting multiple sectors, services and supports they may come into contact with (and could benefit from) to work in a more collaborative, coordinated, and integrated way.
Through system collaboration, PIR promotes collective ownership and encourages innovative solutions to ensure effective and timely access to the services and supports required by people with severe and persistent mental illness with complex needs to sustain optimal health and wellbeing.
Objectives of PIR
The ultimate objective of the initiative is to improve the system response to, and outcomes for, people with severe and persistent mental illness who have complex needs by:
1 https://www.pc.gov.au/news-media/pc-news/pc-news-august-2017/ndis-costs
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facilitating better coordination of clinical and other supports and services to deliver person centred support individually tailored to the person’s needs;
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strengthening partnerships and building better links between various clinical and community support organisations responsible for delivering services to the PIR target group;
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improving referral pathways that facilitate access to the range of services and supports needed by the PIR target group; and
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promoting a community-based recovery model to underpin all clinical and community support services delivered to people experiencing severe and persistent mental illness with complex needs2.
ABOUT THIS SUBMISSION
There is in principle support for the National Disability Insurance Scheme (NDIS) and belief that, when at full implementation, the lives of people eligible will be positively affected.
A comprehensive response to the issues of availability, accessibility and affordability of services for people with a mental illness will enable recovery and participation in education, employment and community connectedness, ultimately improving the social and economic outcomes for people with mental illness.
These issues are best addressed by a ‘system’ that has the right balance and network of clinical treatment, community psychosocial rehabilitation and disability support.
This submission recognises the establishment and role of the Primary Health Networks (PHN), state and commonwealth health, social, welfare and aged care reforms, commitments of both state and federally funded mental health programs to ‘continuity of support’, and the challenges in finding a balance between efficiency, costs and sustainability from the perspective of the South Australian Government.
This submission further recognises and acknowledges many organisations, people with a mental illness, carers and peak bodies will provide their current experiences of the transition, application process, and quality of, and access to, NDIS providers to the Social Development Committee. With this is mind, this submission focuses on three of the seven Terms of Reference (ToR) items.
ToR 3: The ongoing requirements for block funded mental health services provided by the State Government after the NDIS transition.
The underlying rationale for moving to individualised funding is to give people with disability greater control and choice about how they are supported. It was never the intention of the Productivity Commission to deregulate the market, but to determine efficient pricing3.
2 http://www.health.gov.au/internet/main/publishing.nsf/content/mental-pir-about. Accessed 8th October 2018. 3 Productivity Commission Inquiry Report Volume 1, p 36, 39
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The Australian Medical Association notes an efficient price may work within a relatively small area but will struggle to be as rational across multiple jurisdictions, even when modified to take into account factors such as location, age and background. Equality of funding is not necessarily equity4.
Mental health services are undoubtedly undergoing significant structural and process changes as a result of the move to individualised funding. Streamlining services, marketing and competitive edge, staff retention, quality of service delivery and ultimate sustainability in the current market are at the forefront of every non-government organisation seeking to provide services/supports the National Disability Insurance Scheme. Central to these challenges is the move from block funding to individualised funding.
The primary benefits of ‘block funding’ cannot be overlooked. Essentially: block funding ensures:
- Service availability;
- The person is guaranteed hours of service;
- Access in the community;
- The service provider receives funding which is adequate to cover the cost of service provision. Programs should not be block funded simply to ensure service sustainability. However, without some sort of adequate cover, services will close.
Block funding some psychosocial supports will ensure people with a mental illness have access to a strong and sustainable specialist NGO sector, one that includes choice of providers (more than 2-3), understands and has experience in the needs, journey and recovery for people with a mental illness and their carers; that is, not a ‘generalist’ NGO.
RECOMMENDATIONS
CONSERVATIVE:
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Move to a hybrid model of ‘block funding’ (guarantee of service hours, type), and individualised funding (variable funding packages) to ensure service access, availability and affordability.
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SA Health recognises the need for on-going block funding for some clinical services, as per the National Health Reform; criteria to determine types of psychosocial mental health services to be block funded could be explored with the Mental Health Coalition of SA (MHCSA), the Mental Health Commission and consumer and carer representative groups.
4 https://ama.com.au/ausmed/activity-based-funding-here. Accessed 7th October 2018.
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RADICAL:
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Make state funded Individual Psychosocial Rehabilitation Support Services (IPRSS) type service/supports available to consumers who are not ‘active’ with community mental health teams but still require this level of support.
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Consider a state funded insurance model for people not accessing the NDIS ToR 4: The effects on South Australians with mental health issues who are deemed ineligible to receive NDIS funding.
This is of significant concern.
The NDIS is clear in relation to its expectations and responsibilities of the NDIS and other service systems5. However, the NDIS is one part of the health, social and welfare system, and people accessing the NDIS will likely still require state funded mental health treatment – the numbers accessing treatment services is not going to decrease.
Even now, there are many people with mental illness who are unable to access the public mental health system. With approximately 4,5006 people with a psychosocial disability in South Australia being eligible for the NDIS, this will leave a significant proportion of South Australians with a mental illness still requiring some form of clinical, psychosocial and disability support.
South Australians with a mental illness currently testing their eligibility are experiencing inconsistent approaches in both eligibility and support needs. In part, this is because the assessment and planning is not undertaken by a person with the required professional expertise.
As we transition into the NDIS, people with a mental illness need to be aware of, and understand the eligibility, referral process and roles of 1) the NDIS, 2) the PHNs, 3) state funded mental health services, 4) GP services, 5) other community centres, each with their idiosyncratic decision making. A person may find they are deemed ineligible for NDIS, don’t meet eligibility criteria for PHN commissioned services, don’t require treatment as defined by the community mental health team etc. but still require support and have psychosocial needs that remain unaddressed.
Further, there is a ‘systems’ challenge when services make decisions around support and care independent of the other components of the system. For example, when one service provider exits/discharges the consumer, other components of the system are expected to pick-up or follow on with the support/care even though they may not have been included in the decision making or planning. This role was formally provided by Partners in Recovery that looked at addressing these pathways and improving collaboration between services. Funding for Partners in Recovery is transitioning into the NDIS.
Other-Service.pdf
6 https://www.pc.gov.au/__data/assets/pdf_file/0016/217204/sub0203-ndis-costs.pdf
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Both the Commonwealth and State government have committed to continuity of support for existing clients. Details on the definition, process and impacts for people with a mental illness are not inclusive enough as they simply addresses current clients, not those in need of services but who are unable to access due to waiting lists, stigma, service availability etc.
RECOMMENDATIONS
CONSERVATIVE:
- A clear plan and commitment to the sustainability of South Australian Non– Government Organisation (NGO) funded programs.
RADICAL:
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Change our thinking, language and approaches – by acknowledging that the NDIS is one component of our social, health and welfare system. An NDIS centric approach is limited and limiting.
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Establish clear roles, boundaries, expectations and reporting at the operational level across the whole health, social and welfare system, around who provides what, when and to whom.
ToR 7: Any other relevant matters.
We have a system with confusing role/service titles. For example, the PHN, NDIS and state funded community mental health teams all have the role “Care Coordinator” - a title with different roles, expectations and functions. This is confusing and adds additional challenges for people needing to access the right services at the right time with the right expectations.
We currently define ‘integrated’ and ‘coordinated’ from the perspectives of the service provider; before consumers want their care to be ‘integrated’ or better ‘coordinated’ (in the way the system perceives these), they want it to be truly person-centred.
Every consumer is different, and we need to develop patient-centred services tailored to individual needs which allow consumers to be involved in their own care. This requires several steps. The first point of call must include:
- Clinical services giving up some control;
- Focus on the outcomes of the people we are here to serve as the driver of service delivery.
Components necessary to achieve effective systems:
- Person-centred models of care; Page 6 of 8
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Incentives to deliver better, flexible services (incentives inherent in the current funding and financing arrangements are not aligned to consumer outcomes;
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Committed leadership;
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Transparent data and interoperable technology;
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Person-driven workforce capabilities;
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Collaborative culture. Outcomes:
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One action plan for the client, developed jointly with the consumer, their carers and all the current service providers;
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Easy for consumer to navigate – single point of contact;
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Improved consumer experience and outcomes. Once NDIS is fully rolled out the following options will be available:
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Clinical Mental Health Services (acute assessment and treatment);
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NDIS (functional impairment);
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Primary Health Network (low intensity and complex management);
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GP (Psychological services). With each program/service using differing language and inclusion criteria it is virtually impossible to create a map to assist a person to navigate through the system. Ultimately, the onus is on each individual and/or their families to navigate the system and work out which supports they may be eligible for7.
ONE PERSON supported by people acting as ONE TEAM from organisations behaving as ONE SYSTEM8. Essentially; focus on the people we are here to serve first and build our systems, approaches from there.
Ultimately, this is what we are striving for. We don’t have to build new systems, but we do need to be honest with ourselves as service providers and we need shared responsibility and accountability.
Finally, we need to be truly person centred and inclusive of carers, family and significant others.
RECOMMENDATIONS
CONSERVATIVE:
- A system with the following characteristics: 7 http://www.disabilityservicesconsulting.com.au/resources/mental-health-programs-transition. Accessed 8th October 2018 8 Report of the Independent Commission on Whole Person Care for the Labour Party February 2014
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- Person centred;
- Clear agreements over who holds clinical responsibility;
- Needs of carers and significant others;
- Utilise peer workforce;
- Trust, openness and transparency across services;
- Effective communication;
- Shared data, knowledge, protocols;
- Reduced costs;
- Monitoring and evaluation – performance measure, outcomes (person – centred) and quality of collaboration, integration, partnership and reduced duplication.
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Invest in increasing the peer workforce. There is overwhelming evidence on the value of this workforce, and it is therefore disappointing some community mental health teams still don’t have one single peer worker employed.
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Move from data driven systems to person driven systems. RADICAL:
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Agree on one definition of ‘no wrong door’ including roles, expectations and requirements of services receiving referrals.
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Exiting services to only cease service when continuity of service is assured.
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Develop the concept of a ‘network of services’ which includes a clear understanding of what happens when a person presents to GP, PHN commissioned services, MH, NDIS and doesn’t meet the criteria there: describe how they move forward, and to where, and describe it from the customer perspective.
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Cease using language like the system will be better coordinated, integrated or seamless, unless this is described from the perspective of the consumer.
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Develop a health, social and welfare system that is laterally scaled (a network), not vertically scaled. A system that responds/changes according to the needs of the consumer, a system that is flexible, adaptive and agile.
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Consider a Partners in Recovery type model where people with a mental illness have dedicated resources to navigate the system and have one contact point who pulls-in services as required, whilst maintaining the central tenants of PIR; that is, providing assertive outreach, and facilitating ‘wrap-around- supports.
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