NDIA Accountability Project

Mission Australia submission on the provision of services for people with mental illness under the NDIS

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NDIS in SAin 2018 kien Oa

Submission

Provision of services for people with mental illness under the transition to the NDIS in SA

Introduction

Mission Australia is a national non-denominational Christian organisation that delivers evidence-based, consumer-centred community services. In the 2016-17 financial year we supported nearly 6,000 individuals through 40 programs and services in South Australia (SA).1 We work with individuals, families and children, young people and people experiencing homelessness and also provide specialist services for mental health, disability and alcohol and drug issues.

We deliver community mental health services including the Commonwealth Government funded Personal Helpers and Mentors (PHaMs), Partners in Recovery (PIR) and Family Mental Health Support Services (FMHSS) in SA. In addition to these, Mission Australia is a Local Area Coordinator (LAC) provider in SA, Tasmania and Queensland and an Early Childhood Education Intervention (ECEI) provider in NSW and Tasmania.

Mission Australia welcomes the opportunity to provide input into the inquiry into the provision of services for people with mental illness under the transition to the National Disability Insurance Scheme (NDIS). This submission is based on a combination of research and insights from direct service provision across SA.

Recommendations

The Commonwealth and SA Governments should work together to ensure adequate service provision for people with mental illness under the transition to the NDIS as follows:

  • Additional block-funding should be allocated to existing community mental health organisations to maintain delivery of services in local communities to support people with psychosocial disability who may otherwise miss out on vital services.
  • Community based, culturally sensitive rehabilitation and recovery oriented mental health services should be developed in consultation and collaboration with local community mental health providers, people with lived experience and the relevant peak advocacy bodies.2 This should be conducted in a manner that causes minimal disruptions to current recipients of services.

1 Mission Australia, Annual Report, 2017, p. 28, accessible at: https://www.missionaustralia.com.au/publications/annual-reports/annual-report-2017 2 South Australia PiR Mental Health Consortium, Submission to the provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition, 2017, p 4-5.

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  • Current PHaMs and PiR clients who are ineligible or not accessing the NDIS should be guaranteed support under the PHN commissioning framework without having to undergo a complex process to ascertain eligibility.
  • The existing PHaMs contracts should be extended to support people who are not eligible for the NDIS at least until 2020 or until the PHN commissioning framework is scoped and the needs are identified in local communities to ensure a smooth transition between services.
  • The new NDIS psychosocial disability stream should be implemented as a matter of priority and information about this stream should be shared and communicated widely across the State.
  • Measures should be adopted to simplify evidence required to support NDIS applications and provide consistency whilst taking into account the challenges of gathering evidence in rural and remote areas.
  • NDIA should fund a panel of service providers who are required to guarantee services to NDIS participants to ensure the participants in rural, remote and very remote areas are able to access high quality, clinically trained and therapeutic supports to prevent and mitigate the impact of market failure in rural and remote areas.
  • A holistic, whole of government strategy for the SA Government should be implemented to promote better coordination and collaboration between different government departments and services to ensure people with disability who are ineligible for the NDIS are continuously supported in community and mainstream services.

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

It is estimated that, over 32,000 South Australians will transition to the NDIS at the completion of the full rollout.3 According to the Australian Bureau of Statistics (ABS) Survey of Disability, Ageing and Carers 2015, there are almost 400,000 people with a reported disability in SA. Of these, around 120,000 people have a profound or severe core activity limitation.4 This means a large proportion of people in SA who are ineligible for the NDIS will require continuity of support.

According to available data, psychoses and mood affective disorders were the second largest long-term health condition in Australia.5 Furthermore, mental ill health/psychosocial disability causes the third

3 Department of Human Services (SA), Next Phase of the NDIS in SA, accessible at: https://dhs.sa.gov.au/services/latest-news/media-releases-2017/next-phase-of-ndis-in-south-australia 4 Australian Bureau of Statistics, 4430.0 - Disability, Ageing and Carers, Australia: Summary of Findings, 2015, SA, accessible at: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4430.02015?OpenDocument 5 Australian Bureau of statistics, Disability, 4430.0 - Disability, Ageing and Carers, Australia: Summary of Findings, 2015, accessible at: http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/4430.0Main%20Features202015?opendocument&tabname=Summary&prodno=4430.0&issue=2015&num=&view=

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largest disease burden in Australia, behind cardiovascular disease and cancer.6 However, only 10% of the total NDIS participants with approved NDIS packages identify psychosocial disability as their primary disability.7 Although this is an improvement in the last quarter compared to previous quarters (combined average of 7%), the Agency acknowledges that the proportion of participants who have a psychosocial disability is lower than expected.8

The most recent data from the NDIA indicates that, as of 30th June 2018, there were 17,751 active participants with approved plans in SA. However, only 227 or 1% of them were participants with psychosocial disability as their primary disability9 and it is possible that there are participants with both physical and psychological disabilities with unmet psychosocial supports under their NDIS packages. We understand that this could be a result of the staged transition approach whereby people with psychosocial disabilities were one of the last cohorts to enter into the NDIS. However, it is also estimated that approximately 53,000 South Australians experience severe mental illness in any twelve-month period, either episodic or chronic, often with substantial effects on ability to function in society and at home, and in great need of care and support.10

These statistics demonstrate that a significant proportion of people will need access to mental health supports outside of the NDIS framework. Lack of investment in additional mental health services for those who are ineligible for the NDIS may result in adding further strain on mainstream services such as health, justice, child protection and community service systems. Thus, there needs to be better coordination and collaboration between different government departments and services through a holistic, whole of government framework to ensure people with disability who are ineligible for the NDIS are supported.

The reduction in funding to the Personal Helpers and Mentors program and Mental Health Respite Carer Support program and the impact this will have on people with mental illness

Mission Australia delivers PHaMs in Hindmarsh, Port Augusta and Whyalla. In 2014-15, Mission Australia implemented a Client Wellbeing pilot which showed significant improvements in wellbeing of the PHaMs clients across a range of domains and self-reported measures after eight months in the

6 Australian Institute of Health and Welfare (AIHW) 2016. Australian Burden of Disease Study: Impact and causes of illness and death in Australia 2011. Australian Burden of Disease Study series no. 3. BOD 4. Canberra: AIHW. 7 National Disability Insurance Scheme, COAG Disability Reform Council Quarterly Report 30 June 2018, p.10 accessible at: https://www.ndis.gov.au/medias/documents/coag-report-q4-y5-full/2018-Q4-June-COAG-report-Full.pdf 8 Ibid 9 National Disability Insurance Agency, Quarterly reports: SA Dash Board as at 30 June 2018, accessible at: https://www.ndis.gov.au/medias/documents/sa-dashboard-aug18/SA-Dashboard.pdf 10 South Australian Mental Health Commission, South Australian Mental Health Strategic Plan 2017–2022, p.14, accessible at: https://samentalhealthcommission.com.au/wp-content/uploads/SA-Mental-Health-Strategic-Plan-2017%E2%80%932022.pdf

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program.11 One of the reasons for the positive outcomes for clients in PHaMs services is the flexibility to support people without requiring a formal diagnosis of mental health including the ability to engage and support those who are not captured by the clinical supports for mental health.

By design, PHaMs services are available to people without the strict requirements to have formal diagnosis or record of mental illness. Thus, the NDIS application process itself is challenging for the majority of PHaMs clients as they are unlikely to identify as people with mental illness and have a medical history to demonstrate their support needs.

With the rollout of the NDIS, PHaMs services are currently operating with limited financial capacity. For example, the aforementioned PHaMs services assisted 253 individuals during the 2016/17 financial year and 212 clients during the 2017/18 financial year. However, during 2017/18 financial year funding for PHaMs services were significantly reduced despite the high caseload, and continuous demonstrable community demand for service. The staff are currently experiencing increased workloads due to assisting people with gathering evidence for NDIS access requests in addition to providing supports under the PHaMs program. The guidelines for PHaMs services have gradually changed to provide more support for clients with their NDIS eligibility assessments although there is no additional funding for these services.

Case study

Ben* is a 36 years old man from Adelaide who was referred to PHaMs program. He has a longstanding mental health condition stretching back to his formative years. He has a history of seizures, requiring treatment with anticonvulsant medications; and has been treated with antipsychotic medications since he was thirteen years old. He is a Disability Support Pension (DSP) recipient. In addition to his challenges with mental health, Ben was also diagnosed with collapsed discs in the lower spine – lumbar-sacral area, which was corrected by surgical intervention. Examinations prior to surgery showed that he has scoliosis, which is considered permanent and progressive. More recently he has been diagnosed with osteoporosis, which is affecting his spine and hips.

Ben’s PHaMs case worker supported him with his NDIS access request. On presenting the Access Request – Supporting Evidence Form to his GP, the GP admitted that he had no knowledge of the NDIS requirements. The case worker worked with the GP to compile evidence for Ben’s application. His mental health condition was submitted as his primary disability and based on recently obtained medical reports, the recent physical issues were submitted as a secondary disability. The only clinical evidence of the mental health condition consisted of old medical summaries, with no recent reports available, as he has had no follow-up other than having his medications managed by a GP.

11 Mission Australia, Impact Measurement and Client Wellbeing, 2015, accessible at: https://www.missionaustralia.com.au/publications/research/children-families-research/449-impact-measurement-and-client-wellbeing-report-2015

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Ben’s NDIS application was rejected and he returned to his GP to request that he be referred to a psychiatrist for a review of his condition, to be submitted as part of the review process. However, Ben does not have financial capacity to pay for the appointments with specialists such as psychiatrists and there is no funding under the PHaMs program to support clients with their medical appointments. The case worker is looking for the possibility of referring him to PiR service which has funding to provide financial assistance to people to obtain medical evidence of this nature.

*Name has been changed to protect confidentiality

The uncertainty and the reduction of funding levels have also given rise to a number of workforce related issues as the services are only able to offer staff members short term contracts. This has a negative impact on the workforce in the mental health sector and the increase in staff turnover ratios has a negative impact on clients who need to re-build relationships.

The Federal Government announced two separate funding streams during the last two budget announcements to provide mental health supports in addition to the NDIS. In the last year’s federal budget, the Government committed an additional $92.1 million over five years from 2017-18 to ensure continuity of support for people who are not eligible for the NDIS, but are currently receiving support under programs that are transitioning to the NDIS including PHaMs and Partners in Recovery (PiR). This funding is expected to be delivered through a Primary Health Networks (PHN) commissioning framework.12

The commissioning framework of the PHN will be useful in designing services that are appropriate for the local community. However, this also means that there will be a lack of consistency in services across the State. Currently there is little information available as to the service model, and service locations. There are only two PHNs for SA, with one PHN covering the whole of Country SA. The challenges of delivering mental health supports across a large geographic area with significant travel times between regions and limited access to qualified mental health professionals will need to be considered in the service model.

Considering the effectiveness of a recovery oriented, strengths based model such as PHaMs, it is imperative that there be limited disruptions to the service provision to people who are ineligible for the NDIS. Therefore, until the PHNs conduct further analysis into the service delivery model, scope and scale of services needed and how best to provide continuity of support, it would be pragmatic to extend funding for the existing PHaMs services until 2020. A similar approach was adopted by the Government in delivering Non-government Organisation Treatment Grants and Substance Misuse Service Delivery Grants program whereby the existing services were extended and continuously funded until the new services were equipped to deliver services in the local communities.

12 The Treasury (Cth), Budget Measures, Budget Paper No. 2 2018-19, pp175-176.

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It is also imperative that current PHaMs clients who are ineligible for the NDIS are guaranteed support under the PHN commissioning framework without having to undergo a complex application process to ascertain eligibility. This is consistent with the Government’s commitment to provide continuity of support to people with a psychosocial disability and to ensure that they are not disadvantaged by the transition to the NDIS.13

Informal carers play an integral role in the lives of people with disability. Currently, carers are able to receive supports under the NDIS through ‘sustained informal supports’ where funding will be available for informal carers in limited and specified circumstances.14 Some supports will also be available for carers under the Commonwealth Government’s integrated carer support program. Considering the need to maintain support for informal carers, it is imperative that the SA Government provide ongoing funding to the State funded carer services.

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

Numerous gaps in service delivery within and outside the NDIS have already been identified.15 Some of these gaps such as the need for crisis support services within the NDIS are being addressed through an NDIS after hours crisis service. However, it is clear that there might be a large number of people with disabilities in SA with NDIS packages who do not have access to qualified and appropriate service providers due to market failure or areas with thin markets. People who experience market failure may include participants who cannot attract service providers to give them the necessary support or attract providers to coordinate their home supports; are imprisoned or likely to be in remand custody; people at increased risk of physical harm to themselves or others and people living in rural or remote geographic locations.16

People living in rural and remote areas experience a higher prevalence of deprivation, generally higher rates of social disengagement, the highest rates of service exclusion, and higher rates of economic exclusion compared to those living in inner cities.17 According to the ABS, unlike most other States and Territories, only about 3% of the population in SA live in remote or very remote areas and 23% in inner or outer regional areas.18 The majority of the NDIS service providers are likely to be based in and provide services to NDIS participants in metropolitan or major city areas. Thus, there will be areas/smaller

13 Ibid 14 NDIS, Sustaining informal supports, accessible at: https://www.ndis.gov.au/Operational-Guideline/including-11 15 Smith-Merry, J, N. Hancock, A. Bresnan, I. Yen, J. Gilroy, G. Llewellyn, Mind the Gap: The National Disability Insurance Scheme and psychosocial disability, Final Report: Stakeholder identified gaps and solutions, University of Sydney, 2018 16 See further: Victoria Legal Aid, Explainer – the NDIS and the need for a provider of last resort, accessible at: https://www.legalaid.vic.gov.au/about-us/news/explainer-ndis-and-need-for-provider-of-last-resort 17 Australian Institute of Health and Welfare, Australia’s Welfare 2017, July 2017, accessible at: https://www.aihw.gov.au/getmedia/088848dc-906d-4a8b-aa09-79df0f943984/aihw-aus-214-aw17.pdf.aspx?inline=true 18 ABS, Regional Population Growth, 3218.0 - Regional Population Growth, Australia, 2016-17, accessible at: http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/3218.0Main+Features12016-17?OpenDocument

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communities where there are participants with limited access to established NDIS service providers or unlikely to attract service providers. Some measures are in place to incentivise and stimulate the markets in these areas such as financial incentives for service providers to travel to these areas, provide supports for providers to develop business plans, etc. These measures alone will not be sufficient to address the service gap. Thus, targeted strategies should be implemented to prevent NDIS market failure, particularly in rural and remote areas.

A sustainable approach to address the market failure would be for the NDIA to appoint and fund a panel of service providers who would be required to guarantee service provision to NDIS participants to ensure that the participants in the identified rural, remote and very remote areas are able to access high quality, clinically trained and therapeutic supports. This could be developed similar to the service model currently in place to provide the ‘NDIS after hour crisis support service’ in SA.

A block-funded service could also provide access to community events and group activities which will be difficult to sustain through individualised funding. Community support programs such as Day to Day Living that promoted opportunities to participate in social events and engage in group activities such as cooking to improve life skills have been an important element for many people with mental illness. Avenues to provide similar block funded services should be pursued.

Housing supports for people experiencing mental illness are also essential to reducing homelessness and can be provided through block funding. In NSW, people with mental health issues have access to block funded accommodation support in addition to the NDIS through Housing and Accommodation Support Initiative (HASI) and Enhanced Adult Community Living Supports (EACLS) and a similar model could be adopted in SA.

Further, considering the cost and resource intensiveness of accessing Emergency Departments during a crisis, community mental health services should be block-funded to ensure that people with mental illnesses are able to access more appropriate community services rather than having to access in Emergency Departments.

A recently released report indicated that nationally 90% of the Emergency Department patients left within 7 hours while on average, but for people presenting with acute mental health crises this figure was 11.5 hours.19 Alarmingly, SA has the longest wait period with 90% of people with mental health presentations leaving the Emergency Department within 16.5 hours – 5 hours more than the national average.20 The report also identified that there is a significant lack of community mental health services to prevent people with mental illnesses ending up at emergency.

19 Australian College of Emergency Medicine, The Long Wait: An Analysis of Mental Health Presentations to Australian Emergency Departments, October 2018, p.2. 20 Ibid

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A consortium of mental health services in SA, including Mission Australia recommended that a community based rehabilitation and recovery service incorporate the following for people with mental illness21 -

  • Support with service co-ordination and system navigation
  • Access to appropriate accommodation options
  • Advocacy and case management
  • One on one short term coaching/mentoring
  • Peer/lived experience services
  • Social connections/support
  • Financial literacy/budgeting support
  • Support for families/carers
  • Responsive and timely intervention
  • Life skills training and support

We reiterate the importance of implementing such a model. This should be developed with community organisations and all endeavours must be made to ensure that the services are culturally sensitive and appropriate, acknowledge and remedy the challenges experienced by Aboriginal and Torres Strait Islander people, people from culturally and linguistically diverse backgrounds, LGBTIQ people, and other similar cohorts.

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

Many people accessing Mission Australia’s mental health services feel overwhelmed by the NDIS application process. Concerningly, a significant number of people with complex needs are not applying for NDIS due to the challenges of the access process, despite their case workers acting as a tailored source of support to assist them throughout the application process.

In many sites, a number of people have been rejected due to their mental health issues not meeting the permanent and significant condition criterion, despite having accessed mental health services for a long period of time or not having a formal diagnosis, limiting their ability to access supports through the NDIS.

“A number of people we support feel that it’s a personal rejection, like they are not believed by the authorities. This can cause a lot of distress.”

Mission Australia, Program Manager SA

21 South Australia PiR Mental Health Consortium, Submission to the provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition, 2017, p 4-5.

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Numerous studies and research projects have demonstrated that providing people with the necessary holistic, wrap-around supports has significant financial benefits and positively impacts on the health and wellbeing of the individuals.22 However, with the challenges created by the rollout of the NDIS, other mainstream services including community support services, health system and homelessness services are under further pressure to support those who fall through the cracks without additional funding or access to resources.

Case Study

Mary* is a PHaMs participant in Metro SA with a number of mental health issues. She has been involved in the program for 13 months. Her General Practitioner has given her a Centrelink Medical Exemption from job seeking responsibilities every 3 months for the entire support period. Mary engages proactively and regularly in the PHaMs program and with her clinical mental health supports, a psychologist via a mental health care plan and her General Practitioner.

She was initially not planning on applying for the NDIS but later changed her mind due to the fear that she may not have access to any supports when the funding for PHaMs ends. She mentioned that she felt concerned by the changes to government policies and the transition of PHaMs to the NDIS when she is already very vulnerable. After Mary’s PHaMs case worker explained the options, she decided to apply for the NDIS over the phone. The case worker offered to advocate on her behalf with the application process, however, Mary said she was confident to go through the process herself.

Prior to the appointment with the assessor, the case worker spent a considerable amount of time with her preparing for the phone assessment. However, Mary found the conversation overwhelming and traumatising as she found the questions confronting although the assessor was friendly and sympathetic to her life story.

She told the case worker that she was not clear about how to answer some questions because they were technical. At the end of the assessment call she told the case worker that she ‘felt useless and incapable of being independent, maybe things were never going to get better’. The method of questions made her feel like she had to prove and justify how she felt, in order to get support causing distress and anxiety. The case worker had to spend over 2 hours after the conversation to help her calm down as the conversation triggered many traumatic memories.

Mary’s mental health issues depend on situational stressors which can result in her feeling so debilitated that she cannot leave the house for days. However, Mary stated that she felt that her ‘PTSD would never be recognised as a disabling condition because in between the days she feels so terribly low and helpless there can be a few good days where she’s able to get on with her life’.

22 See further: Mission Australia, From Homelessness to Sustained Housing, 2010 – 2013, MISHA research report, accessible at: https://www.missionaustralia.com.au/documents/279-from-homelessness-to-sustained-housing-2010-2013-misha-research-report-2014/file

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There are a number of constant stressors in her life including a dispute with her neighbour. Mary has not been able to continue so far with the submission of her supporting evidence to go with her appeal due to significant stressors in her life. Her current priority is for safety and housing stability and she is due to call the NDIA and request an extension for her appeal.

*Name has been changed to protect confidentiality

Once the application is rejected, the majority of clients decide not to seek a review the NDIA’s access decision or reapply even with the support of PHaMs staff, despite their PHaMs case managers strongly believing that they may be eligible for the NDIS. This is largely due to the stressful and protracted application process.

Case Study

Amy* a PHaMs client from remote SA first made an intent to claim application in July 2017. Her PHaMs case management team gathered all required evidence of disability and submitted the application for NDIS in September 2017.

Her PHaMs case management team contacted the NDIA on a regular basis via telephone and email to follow up on the application. During this period while waiting for the approval process Amy’s mental health deteriorated as she was concerned about the sensitive information that was enclosed in reports detailing trauma she experienced as a child. However, Amy was positive about how the NDIS was going to support her as she was aware that PHaMs services were going to end next year.

Amy’s PHaMs case management team contacted NDIS each month for an update on the NDIS application and were informed that the client’s application was still in progress. After 8 months of lodging the application, in May 2018 Amy was asked to provide more information to support her application. She was supported by PHaMs to compile all the necessary paperwork.

In June 2018 she was informed that she was not eligible for the NDIS. This had a serious impact on Amy and she felt that she will not be supported within the community around her mental health issues. She also stated that she is unable to access services due to her usual service provider moving to a fee for service model for NDIS participants.

Amy declined the offer to support her with a request to review the NDIA’s access decision due to the impact this will have on her mental health as she feels that there is no use and that most people she knows had been unsuccessful.

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She has concerns around whether she will be able to access services after PHaMs ends in June 2019 as she has no informal supports within the community (outside of PHaMs) and all of her family live out of town.

*Name has been changed to protect confidentiality

Inability to access the NDIS or other disability supports can increase the risk of homelessness among people with disabilities. This risk is higher among people exiting institutions such as hospitals, rehabilitation facilities, prisons or other similar institutional settings. The delays in accessing the NDIS can also place people with disability at higher risk of experiencing homelessness. All these challenges can contribute to aggravating the mental health conditions.

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

Numerous reports have demonstrated the inadequacy of funded supports for people with disabilities, particularly people with psychosocial disabilities to meet their needs.23 Even in instances where people are provided with funding in their NDIS packages for mental health supports, they may not have access to trained and qualified staff to deliver those services in areas where the markets are thin.24

In situations where people with both physical and mental health issues were approved by the NDIA, in some cases their mental health needs were not covered by the packages. This results in participants appealing the decisions to obtain more funding for their mental health services. In some cases, where the initial application for both physical and mental health supports were declined, clients have decided to reapply/appeal based on their physical condition, leaving out the need for mental health supports. The ability to access both physical and mental health services under the NDIS is imperative to ensure the participants are able to receive meaningful supports to achieve greater independence, community involvement, employment and improved wellbeing.

Although the planning process of the NDIS takes into account the day to day needs of the person with disability and support them to achieve their long-term goals, the funding is structured in such a way that everything is measured by hours and may not be able to meet the immediate needs of the individual due to funding constraints.

23 See further: Smith-Merry, J, N. Hancock, A. Bresnan, I. Yen, J. Gilroy, G. Llewellyn, Mind the Gap: The National Disability Insurance Scheme and psychosocial disability, Final Report: Stakeholder identified gaps and solutions, University of Sydney, 2018 and ABC Sydney, B. Evans, Call for review as Adelaide Hills disabled man’s support halved in transition NDIS, 18 October 2018, accessible at: https://www.abc.net.au/news/2018-10-18/disabled-adelaide-mans-support-halved-ndis/10388620, 24 Smith-Merry, J, N. Hancock, A. Bresnan, I. Yen, J. Gilroy, G. Llewellyn, Mind the Gap: The National Disability Insurance Scheme and psychosocial disability, Final Report: Stakeholder identified gaps and solutions, University of Sydney, 2018.

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“When we have block funding, we can dedicate staff members to provide supports and meet their (client’s) needs, if there is a crisis we usually stay with the client until the issues are resolved … This can significantly reduce resources from the State health sector as we meet clients on release from hospital, transport and often work to avoid crises – such as hospitalisation. We can do all this because there is block funding for these services.”

Mission Australia, Program Manager SA

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

The NDIS application process has been criticised for lack of consistency of evidence required and approvals of people with the same or similar disability. Mission Australia staff working in the sector also observed that, although the NDIS is expected to focus on functional impairment during the assessment process, the assessors pay more attention to medical evidence and documents provided by medical professionals. This disadvantages people with mental health concerns who have not been accessing formal mental health services.

For example, PiR services are no longer able to obtain services from Occupational Therapists (OTs) to support the NDIS applications despite OTs being listed as professionals who can provide evidence of the disability.25 The Department of Health has informed the PiR services that the PiR Support Facilitators are experienced enough to provide statements in relation to the client’s level of functional impairment. However, services have witnessed that additional evidence to support the Access Request Forms (ARFs) are highly likely to work in favour of clients. There is a possibility that people with financial means who pay privately to obtain supporting documents including assessments by OTs may receive favourable assessment outcomes compared to those who are unable to do so.

There is a need for greater consistency in evidence required as some applications have only required a single supporting report from a General Practitioner or Psychiatrist as evidence of the consumer’s disability, while others have required up to five or more reports from different services. It is important that this process is streamlined as much as possible. Burdensome and inflexible evidence requirements may result in consumers being excluded from the NDIS because they do not have the support and assistance required to complete the exhaustive assessment process. It may also place an excessive burden on their carers.

25 NDIS, Providing evidence of your disability, accessible at: https://www.ndis.gov.au/people-with-disability/access-requirements/completing-your-access-request-form/evidence-of-disability

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Case study

Abby* is a PHaMs participant from Adelaide who was a survivor of family violence. She is receiving treatment for an acquired brain injury (ABI) as a result of the abuse she endured during her relationship with the perpetrator. She was receiving supports from a rehabilitation support service where she saw a neuropsychiatrist and underwent various forms of assessments. Although she was being supported by the rehabilitation service and PHaMs, she does not have a formal diagnosis. The rehabilitation service is now refusing to provide further support without a formal diagnosis.

Due to her ABI, she is unable to retain short term memory at times. She prefers to have in home support so that she can manage her day to day activities, however, is worried about simple tasks such as cooking as she states ‘she might forget about the stove and burn the house down’. It is also difficult to have a phone conversation with her due to her disabilities. She has limited family and friends to support her. In addition to accessing PHaMs, Abby is currently receiving supports from a homelessness support service.

Due to external factors such as housing and other challenges in her life, Abby has not started on the NDIS application process which she believes to be a complex and tiring process.

*Name has been changed to protect confidentiality

Currently there are significant delays between lodging the NDIS application and having the assessed and the outcome communicated to the people with disability.

“We know of clients who are still waiting to hear about the outcomes. We have clients who have patiently waited for over 250 days to hear whether or not their application has been approved or rejected. It’s disheartening to see clients go through this experience … it adds unnecessary pressure and affect their mental health.”

Mission Australia, Program Manager SA

Some communities rely on medical and allied health professionals who visit intermittently, or who are on short term contracts, which affects continuity of care and protracts the NDIS application. Some clients have to travel long distances to see professionals such as psychiatrists to obtain supporting evidence.

“There’s a 6-8 week wait to see any specialist in Whyalla. People either have to wait or spend an exorbitant amount on travelling to get these documents. All these add to the frustrations people experience and unnecessarily complicate the application process.”

Mission Australia, Program Manager SA

Currently, due to significant workloads the planners are expected to achieve outcome targets which adds further pressure on them. There has been some discussion in relation to lifting the cap on NDIA

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staffing levels. Mission Australia believes that the staff levels should be increased to meet the growing number of people accessing the NDIS.

Often, at the request of additional documents or the initial rejection, people give up on the NDIS application process unless they have access to a support from family, carers or service providers. Some people in the community are not aware of the availability of organisations that are funded provide advocacy services.

Case study

Mark* is a 61 year old who was referred from Community Mental Health in remote SA in March 2018. He was a victim of an online scam and had lost $60,000. The investigation is ongoing and this has a significant impact on Mark’s mental health.

After accessing the Mental Health service, Mark was referred to a GP who diagnosed him with early onset dementia. Mark was referred to get an Aged Care Assessment however he was ineligible for the assessment because of his age. His case manager worked with the health services to get him a referral to see a Geriatrician, obtained the appointment, and accompanied him to the appointment.

His Case Manager contacted the local dementia worker who provided information around supporting Mark with his medical condition. Together with the Dementia support worker, they gathered evidence for the NDIS application, while supporting the client with his day to day functioning. The evidence gathering process took about 2 to 3 months.

The application was rejected in June 2018. The case manager worked closely with the GP, Dementia Australia, family members and other specialists to gather further evidence on the impact of his disabilities on his day to day living. At Mark’s request, the case manager also organised a meeting with Legal Aid to assist with the appeal process. After lengthy discussions and email and phone correspondence, Mark’s application was approved by the NDIA. This application approval was on the basis of Mark’s dementia and not mental ill-health.

The case managers also assisted him with the appointments with Local Area Coordinators and his plan is now complete and approved. Mark is currently waiting for the implementation of the plan.

*Name has been changed to protect confidentiality

This demonstrates that one NDIS application requires a significant amount of time investment and advocacy. In instances where people are unable to find such advocacy support, they are likely to accept their rejection and not receive the supports they are entitled to.

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Another challenge for people with disabilities and services that support people with their NDIS applications is the complexity of the application process that is exacerbated by the constant changes to NDIS policies and guidelines.26

“The changes can be confusing for clients and services. The NDIA makes an announcement about some guideline but it doesn’t filter through to the NDIA staff on the ground. This can be very frustrating for a lot of people because they have been given conflicting opinions.”

Mission Australia, Program Manager SA

Following consistent advocacy from the sector organisations and peak bodies, the Federal government recently announced a new ‘psychosocial disability stream’.27 This new stream is expected to be implemented progressively and includes, employing specialised planners and Local Area Coordinators; better linkages between mental health services and National Disability Insurance Agency (NDIA) staff, partners and a focus on recovery-based planning and episodic needs. It is important that information such as structure, timelines and other relevant information is made public in a timely manner. This approach may address the majority of challenges experienced by people with psychosocial disabilities who are likely to be eligible for the NDIS. There is also needs to be better clarity in relation to what supports will be available under this stream for people who were deemed ineligible and have disengaged from mental health services.

26 Smith-Merry, J, N. Hancock, A. Bresnan, I. Yen, J. Gilroy, G. Llewellyn, Mind the Gap: The National Disability Insurance Scheme and psychosocial disability, Final Report: Stakeholder identified gaps and solutions, University of Sydney, 2018. 27 Department of Social Services, Media Release: Government announces improved NDIS mental health support, 10 October 2018, accessible at: https://ministers.dss.gov.au/media-releases/3691

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