Received 7/11/18 025
Confidential until approved for publication
On 10 October 2018, World Mental Health Day, the Government announced improved NDIS mental health support through a new ‘psychosocial disability stream’ to improve the experience of people with severe mental health-related disability in accessing the NDIS. DSS, DoH and the NDIA are confident the reforms will go a long way in addressing
a number of the Committee’s terms of reference, with more detail in our response.
If the Committee has any follow-up questions, please contact Ms Eliza Strapp, Branch Manager, NDIS Program Transition via email at Eliza.Strapp@dss.gov.au.
Yours sincerely
Kathryn Campbell November 2018
Joint Response to the South Australian Parliamentary Inquiry on Mental Health Services and the NDIS
Statements addressing terms of reference
The Committee inquire into, and report on the provision of services for people with mental illness under the transition to the National Disability Insurance Scheme (NDIS) with particular reference to the following Terms of Reference (ToR):
- The gap between the Federal Government’s predicted and realised percentages of mental health clients receiving NDIS support.
The Productivity Commission (PC) projected that the number of participants at full scheme with severe and permanent psychiatric conditions would be approximately 57,000. The National Disability Insurance Agency (NDIA) estimates this number will increase to approximately 64,000 at full scheme1, which equates to 13.9 per cent of people with a primary psychosocial disability estimated to be NDIS participants at full scheme.
As at 30 June 2018, there are around 18,207 NDIS participants with psychosocial disability listed as their primary disability. This represents 28 per cent of the 64,000 participants with primary psychosocial disability estimated to be in the Scheme by 2019–202.
The number of participants assessed as eligible for the Scheme with psychosocial disability (primary or secondary) in the Scheme increased from 28,433 (15.0 per cent of total participants) at 30 April 2018 to 34,966 (15.6 per cent of total participants) by 30 June 2018.
In mature trial site locations the population with a primary psychosocial disability is in line with PC estimates with the ACT at 13.4 per cent, New South Wales (Hunter area) at 12.6 per cent and Victoria (Barwon area) at 13.5 per cent. 3
South Australia (SA) is still in the process of transitioning to the NDIS, noting transition in SA commenced with the youngest people with a disability (who are less likely to have a permanent psychosocial disability). The majority of state and Commonwealth clients with psychosocial disability are expected to join the Scheme in 2018–19, as per the bilateral agreement between the Australian Commonwealth and SA Governments.
The proportion of participants who have a primary psychosocial disability in SA is now rising rapidly from 2.5 per cent to 3.5 per cent in the last reporting period (1 May 2018 to 30 June 2018).4
1 National Disability Insurance Agency 2016, Towards an ordinary life: annual report 2015–16, NDIA, Geelong, Vic, p.26 2 Office of Scheme Actuary 3 Ibid 4 Ibid
Overall, in SA, the total number of active participants with a primary psychosocial disability with approved plans was 227 at 30 June 2018. This was an increase of 104 active participants over the last quarter.
It is too early to make a judgement about any possible gap regarding predicted and realised percentages of mental health clients receiving NDIS support for the reasons outlined above. In addition, and as noted further below, SA and the Commonwealth are continuing to assist clients to test their access, particularly where this cohort of clients may not have progressed through the access process for a variety of reasons. This includes where the NDIA has been unable to contact them, or where potential participants have not submitted access request forms or further evidence when requested.
In the context of this Inquiry, it is important to understand what the differences between predicted and realised percentages means. The NDIA based its calculations for the predicted number of participants in the Scheme on the estimates of the PC in 2011. The PC based its estimates on specialised advice from experts at that time.
Based on this national projection and using a proportional population approach, the NDIA Scheme Actuary estimates there will be approximately 4,500 participants in the Scheme with a primary psychosocial disability at full Scheme in SA. However, this number is not a target or a cap. All people with psychosocial disability who meet the access criteria are eligible to be in the scheme.
The realised numbers of people who will be eligible for NDIS support is dependent upon the following factors:
a. an assessment by a qualified mental health or health professional that the person has a severe and persistent mental illness b. a judgement by a delegate of the NDIA Chief Executive that the applicant has provided sufficient evidence to meet the criteria in section 24 or section 25 of the National Disability Insurance Scheme Act 2013 (NDIS Act) c. South Australians with severe and persistent mental illness being aware of the NDIS and being interested and willing to apply for access, and d. the role of South Australian Health, non-government organisations, NDIA planners and Partners Local Area Coordinators (LACs) and Commonwealth mental health providers in informing people with mental health issues about the NDIS and what it can offer, and encouraging them to apply.
The NDIA is progressively rolling out a series of enhancements to the pathways for people entering into the Scheme and for their ongoing use of NDIS supports. These enhancements specifically address factors c. and d. in the list above. The likelihood of reaching the projected figures will be dependent upon how these factors evolve in SA.
An example of the work the Agency is doing to address factor d. is the publication of the access snap shots to the NDIA website and our funding of the reimagine.today website as a key source of information for service providers, people with serious mental illness and families and carers.
It is important to note the NDIS Act specifies that anyone who meets the eligibility criteria, as set out in sections 24 and 25, will be admitted to the Scheme regardless of projected numbers, i.e. these do not constitute a cap. The NDIA is implementing the intent of the legislation on this matter.
- 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
All Commonwealth-funded South Australian providers have agreements in place to support transition to 30 June 2019, and the bulk of Commonwealth clients with psychosocial disability are expected to phase into the NDIS in 2018–19.
Funding for DSS-funded Personal Helpers and Mentors (PHaMs) and Mental Health Respite: Carer Support (MHR:CS) providers in SA is based on anticipated rates of clients transitioning to the NDIS, as outlined in the bilateral agreement.
DSS funding agreements incorporate staggered reductions in funding amounts, which reflect the number of program participants expected to leave the programs as they become NDIS participants, and when providers can pick up NDIS business (with existing and new clients).
When providers were offered three-year grant agreements in 2016, they were advised they were expected to manage their funding over the entire activity period to 30 June 2019. DSS has provided as much flexibility as possible, including allowing funds to be carried from one year to the next or to front-load payments in the start of the year to allow providers to manage their budgets more easily.
Concerns raised specifically in SA appear to be about the reductions in funding for the PHaMs and MHR:CS programs in 2018–19, due to the later rollout of clients with psychosocial disability in this state. For the first two years of the transition period, Commonwealth–funded South Australian providers had relatively stable block funding with minor reductions. This period allowed providers in SA time to learn from other jurisdictional experiences while also providing a longer period to support clients transition, including engaging them on the NDIS and gathering the necessary evidence for the access process.
DSS, DoH and the NDIA are closely monitoring transition to ensure clients who experience delays in accessing the NDIS continue to be supported. Where transition does not occur as expected, the Australian Government has capacity, where funds are returned from the NDIS, to provide additional funding to organisations so they can maintain services for their Commonwealth clients.
On 13 July 2018, the former Minister for Social Services, the Hon Dan Tehan MP, wrote to all PHaMs and MHR:CS providers providing a guarantee that Commonwealth-funded providers will have continued funding to support their clients, no matter where they are in the process.
DSS provided an additional $960,000 in 2017–18 to South Australian providers and has offered a further $1,658,000 so far in 2018–19, to ensure all providers can continue to support their clients as they transition, or until longer-term continuity of support arrangements commence.
There is not expected to be a gap in support for South Australians as a consequence of funding for mental health programs rolling into the NDIS. The expectation is that Commonwealth-funded mental health providers will replace block grant funding with NDIS payments for services. It is anticipated that providers participating in the NDIS would maintain or increase their income through the NDIS.
- The ongoing requirements for block funded mental health services provided by the State Government after the NDIS transition
For the NDIS to be successful, it requires state and territory governments to continue funding services for people with psychosocial needs into the future.
The NDIS was designed to complement, not replace, existing government services by providing supports that are reasonable and necessary to enable individuals to achieve their goals. It was intended for individuals with a severe and enduring mental health condition and who have significant impairments in social, personal and occupational functioning that require intensive, ongoing support.
Modelling undertaken in 2016 using the National Mental Health Service Planning Framework (NMHSPF) estimates that 281,840 people aged 0-64 years would have a severe disorder requiring psychosocial supports.
However, not all these individuals would meet NDIS eligibility requirements around the severity or permanence of disability, and complex care and supports requirements. The NMHSPF estimates that 91,916 people with severe and complex disorders would most closely align with the NDIS Tier 3 population. This would include the 64,000 with a primary psychosocial disability and an additional number with a secondary psychosocial disability. The remaining cohort would require lower levels of assistance.
Figure 1: NMHSPF Prevalence Modelling – Number of People Requiring Psychosocial Supports5
5 Department of Health internal modelling 2016
The number of people Australia-wide with some form of severe mental illness as described in Figure 1 validates an ongoing role for state and territory governments in this area.
While recognising the ongoing primary role of state and territory governments in the provision of services for people with psychosocial disability outside the NDIS, the Australian Government committed $80 million over four years for a new National Psychosocial Support measure (NPS) in the 2017-18 Federal Budget to be matched by all states and territories. Bilateral agreements between the Australian Government and all jurisdictions were finalised by June 2018. The purpose of the program is to provide community-based, non-clinical support services to assist people with severe mental illness and psychosocial disability who are not eligible for the NDIS.
The Commonwealth component of the measure will be implemented through Primary Health Networks (PHNs), with PHN-commissioned services implemented in a flexible way to complement the State and Territory funded psychosocial support services. The funding for the NPS measure is to support new clients, rather than those currently accessing Commonwealth transitioning programs, with the new PHN-commissioned services set to commence from January 2019.
- The effects on South Australians with mental health issues who are deemed ineligible to receive NDIS funding
While it is recognised people with mental health issues found to be ineligible for the NDIS may be unhappy with a decision about eligibility, the Scheme relies on the professional assessments of mental health and health professionals, in particular psychiatrists and doctors in forming a judgement about eligibility.
Feedback from the NDIA’s national pathway consultations on psychosocial disability found that some people who were not found eligible for the NDIS found the experience to be difficult. While the NDIA understands and is working to ameliorate this impact, it has an obligation to act in accordance with the requirements of the NDIS legislation.
The NDIA’s work on pathway enhancements for psychosocial disability is seeking to address this specific issue through the following four strategies:
- Improved information (and dissemination of information) clarifying eligibility and evidence requirements for participants, families and carers and health professionals – which may reduce the numbers of people who test their eligibility and are not found eligible.
- Revised letter advising of ineligibility - the NDIA is re-drafting the letter to offer information on alternative sources of support through PHNs and existing state and territory government support programs. It will also outline the role that Local Area Coordinators (LAC) can play in assisting the applicant to navigate all sources of assistance with their mental health and psychosocial needs.
- Navigation, Linkage and Referral Function - the NDIA is collaborating with Mental Health Australia (MHA) and jurisdictions on the design of a navigation, linkage and referral function as one element of the pathways enhancement work.
- Outreach Function – the NDIA will develop an outreach approach to working with people who are identified as likely to be eligible but unlikely to apply for the Scheme.
NDIA planners and Partner organisations will play a role in working with such people to encourage their access to the Scheme.
Additionally, the Information, Linkages and Capacity building (ILC) component of the NDIS has an important role in supporting all people with disability, irrespective of whether they are eligible for NDIS packages of support, and to link people to mainstream inclusive services. Improving linkages between the NDIS and mainstream services may reduce anxiety around NDIS ineligibility. More than $7 million has been invested to date in grants targeting improved information, linkages and capacity building for people with psychosocial disability.
Both the Australian Commonwealth and State and Territory Governments made a commitment that existing clients of mental health services who are found ineligible for the NDIS will continue to receive support, through continuity of support arrangements.
In the 2018–19 Budget, the Australian Government announced funding for the Commonwealth Community Mental Health continuity of support program. From 1 July 2019, $109.8 million over three years will be provided for clients from PHaMs, Partners in Recovery (PIR) and Support for Day to Day Living in the Community (D2DL) who are found to be ineligible for the NDIS.
Under the continuity of support funding arrangements, PHNs, in consultation with providers, consumers and carers, will commission and coordinate services based on local needs, taking into account what services and supports are already available. The program will align with the delivery of the NPS measure.
Further funding of $19.1 million to 30 June 2020 will support PHNs in the establishment of continuity of support for PIR, D2DL and PHaMs clients, and the transition of continuity of support clients to those new arrangements. It will also support PHNs in developing an effective interface between the mainstream service system and the NDIS, to ensure that people move smoothly through the health and disability systems.
Current clients of the MHR:CS program whose care recipients are not eligible for the NDIS, will receive continuity of support through the Integrated Carer Support Service from late 2019.
- The sufficiency of services provided to people with mental illness who are accepted into the NDIS
At this point in time, the NDIA considers that its packages are sufficient to meet the reasonable and necessary needs of participants with mental health issues. The NDIA is committed to continued monitoring and evaluation of reasonable and necessary support packages and is open to further consideration of the support items funded, the levels of support and the likely impacts of a different mix of funded supports on outcomes for participants in this cohort.
The NDIA uses four complementary and cumulative methods in its process of determining the value of packages allocated to participants with psychosocial disability. Firstly, the use of a validated functional assessment instrument.
The two instruments used predominantly are the World Health Organisation’s Disability Assessment Schedule (WHODAS 2.0) and the Australian Mental Health Outcomes and Classification Network’s Living Skills Profile (LSP-16). Secondly, the use of guided questions that collect information in regard to eight domains.
Thirdly, participant goals as specified in their NDIS plans. Fourthly, a conversation between the participant, the NDIA planner and/or LAC on what the person wants and needs, and judgements by the planner or LAC about what is reasonable and necessary. The plan and the package value is reviewed periodically and unscheduled reviews can be requested if required.
The NDIA does adjust packages based on plan reviews and conversations with participants. This includes additions and reductions in plan funding. Such an approach is consistent with a Scheme based on insurance principles.
The Australian Government recognises the difficulties for people living in rural and remote areas needing to access mental health services. The Australian Government encourages innovative solutions to resolve the longstanding, and well documented, lack of psychosocial disability services in rural and remote areas and is working to ensure greater coordination of existing and new services across jurisdictions by creating a ‘one door’ approach to mental health.
There are a range of Australian Government initiatives under way to understand and address issues for thin, and rural and remote markets:
- targeted Information Linkages and Capacity Building programs
- implementation of the Independent Pricing Review (IPR) recommendations, including price increases for rural and remote travel
- research and consultation to gain further insight about challenges for rural and regional service provision and potential market responses to ensure supply
- initiatives to boost the workforce and enhance the capability of businesses to deliver services.
In addition, the Australian Government has added a further:
- $45 million through the Jobs and Market Fund to fund targeted programs to support jobs and market growth in the disability sector, particularly in rural, regional and remote Australia
- $33 million through the Boosting the Local Care Workforce Program to develop the capacity of disability and aged care service providers to operate effectively and expand their workforces, with a particular focus on regional Australia.
- Under this program, a number of skilled Regional Coordinators have already commenced in key locations, including in SA, (Adelaide, Port Augusta and Mount Gambier) with all coordinators, including specialist coordinators, in place by the end of October 2018.
- Another key element of the Program is the Sector Transition and Employer Support Initiative. Eligible disability service providers will be assisted financially to access relevant professional services and grants up to the value of $20,833 to help prepare their businesses to deliver services under the NDIS. The first grants round is expected to open in early 2019.
The Australian Government will continue to work closely with state and territory governments and providers to ensure the market is supported to meet the growing demand for mental health services.
The monitoring of services will also be enhanced through the new NDIS Quality and Safeguards Commission (the NDIS Commission) established to ensure quality of supports, including for people with psychosocial disability.
The NDIS represents a fundamental change to the way people with disability are supported in their everyday lives. This change requires the right systems and protections to support quality and safety in NDIS services and supports, even though those supports and services can be for people with different types of disability, including people with psychosocial disability.
The NDIS Commission works to improve the quality and safety of NDIS services and supports, investigates and resolves problems, and strengthens the skills and knowledge of providers and participants across Australia.
The NDIS Commission focuses on education as well as compliance and monitoring, and works with people with disability, NDIS providers and workers to improve their skills and knowledge.
- The effects on South Australians with mental health issues undertaking the application process for the NDIS
The NDIA is working proactively with participants to deliver quality plans that support them to live an ordinary life. This means delivering a person-focused, outcomes oriented, quality planning experience that is fair, equitable and delivers reasonable and necessary supports.
The NDIA has already implemented a series of immediate actions to improve the participant planning experience following the announcement of pathway improvements in early 2018. This includes face-to-face planning for participants as a default (where this is the person’s preference), a number of portal improvements for participants and providers, and new communications products and tools to support the planning process.
The NDIA undertook national consultations with participants with psychosocial disability, families and carers, advocates, service providers and sector peak organisations, and worked closely with MHA.
As a result of the consultations, on 10 October 2018 the Minister for Families and Social Services, the Hon Paul Fletcher MP, and the Assistant Minister for Social Services, Housing and Disability Services, the Hon Sarah Henderson MP, announced the implementation of the targeted psychosocial disability stream. The Australian Government, with the NDIA, will continue to monitor and adjust the psychosocial disability stream as needed, and to be responsive to concerns raised by clients and providers.
The key components of the psychosocial disability stream include:
- employing specialised planners and LACs to ensure participants have access to psychosocial expertise
- building workforce capability through training and the establishment of teams that include mental health expertise to support people to engage with the NDIS and access the Scheme
- strengthening the connection between existing mental health services and NDIA staff and partners
- focusing on recovery-based planning and episodic needs
- assisting potential participants who are hard to reach to engage with the NDIA.
This reform is a critical step forward. It addresses the sector’s key concerns and outlines a better way forward for the NDIS, based on recovery principles. It will prioritise the development of staff skill sets pertinent to the needs of people requiring mental health support.
Importantly, the design of the new stream is the result of successful collaboration with MHA and extensive engagement with participants, families and carers, government services, NDIA partners and providers. With the sector’s ongoing support, there is a level of confidence the NDIS will now more specifically address the support and communication needs of participants with psychosocial disability.
The NDIA is also committed to improving its engagement with disability groups to leverage their significant understanding and commitment to the sector and the Scheme.
DSS, DoH and the NDIA have listened to concerns about difficulties experienced by Commonwealth mental health clients trying to navigate NDIS access processes.
In response, new streamlined processes have been implemented to make it easier for Commonwealth mental health providers to help clients who find it difficult to represent themselves, through the NDIA access process.
The new streamlined approach for Commonwealth mental health clients relies on a trusted support worker to act as the NDIA contact on behalf of the client throughout the access process, and to provide assistance as requested by the client.
The worker, with the client present, can contact a dedicated NDIA access line, and can help the client through the process more quickly and more simply.
In addition, a new targeted Mental Health Evidence of Disability form for Commonwealth transitioning clients has been developed to ensure the most appropriate evidence is gathered and submitted to the NDIA’s National Access Team.
Commonwealth mental health providers are funded to undertake this transition work. The focus on service delivery for providers to 30 June 2019 is to assist clients to prepare and access the NDIS and to position themselves as NDIS providers.
Any other relevant matters
Workforce growth
The NDIS presents an immense opportunity for the mental health sector, with projections that up to 90,000 full-time equivalent workers will be required across Australia over the next five years.
In SA, annual expenditure is expected to grow from $760 million to $1.5 billion under the NDIS, which is a significant increase and represents a doubling of funding. This pattern of growth will see the state’s workforce grow to approximately 12,500.
Some mental health providers in jurisdictions which are further progressed in the transition report positive outcomes in the movement from block funding arrangements to the NDIS fee-for-service model, including a doubling of their workforce.
Mental health providers now operating under the NDIS are seeing the benefits of a person centred care approach, with participants satisfied with their opportunity to access services and supports they want and need, rather than having to be content with whatever was on offer under block funding within defined outputs.
Commitment outside the NDIS in mental health
Outside of the NDIS, the Australian Government is making a substantial investment in mental health, transforming the way mental health care is delivered, and providing additional frontline services across the country. In 2018–19, total expenditure for mental health is estimated at $4.7 billion (direct and indirect). In addition to support through the Medicare Benefits Schedule (MBS), Pharmaceutical Benefits Scheme (the PBS), and departmental projects, including the new national psychosocial support measure for mental health clients, the Australian Government is providing over $1.28 billion over three years from 2016–17 to 2018–19 to 31 PHNs to commission mental health and suicide prevention services at a regional level.
PHNs, as leaders in regional planning, coordinated funding and commissioning of mental health services, play a key role in mental health reforms. PHNs are required to tailor services to local needs, making this an important development for accessibility and quality of mental health services across Australia.
In August 2017, all levels of government endorsed the Fifth National Mental Health and Suicide Prevention Plan for national mental health reform activity over the five-year period from 2017 to 2022. In doing so, each agreed to a collaborative approach to provide better mental health and suicide prevention services in Australia.
The Fifth Plan contains eight priority areas:
- achieving integrated regional planning and service delivery
- effective suicide prevention
- coordinated treatment and supports for people with severe and complex mental illness
- improving Aboriginal and Torres Strait Islander mental health and suicide prevention
- improving the physical health of people living with mental illness and reducing early mortality
- reducing stigma and discrimination
- making safety and quality central to mental health service delivery
- ensuring that the enablers of effective system performance and system improvement are in place.
In relation to priority area 3 (coordinated treatment and supports for people with severe and complex mental illness), there are a number of key activities:
- The Commonwealth and all states and territories have committed to maintain community mental health supports for people with severe mental illness through the NPS measure and continuity of arrangements.
- The Fifth Plan directs PHNs and Local Hospital Networks (LHNs) to prioritise coordinated treatment and supports for people with severe and complex mental illness. This has been highlighted in the guidance material that has been prepared by governments to assist PHNs and LHNs to undertake joint planning at a regional level, which are anticipated to be finalised shortly.
The Fifth Plan also commits governments to work together to develop, implement and monitor national guidelines that clarify the roles and responsibilities of Commonwealth and state and territory governments across the health and community support service sectors and seek to resolve issues of duplication and gaps in services.
The emerging architecture of psychosocial disability services in Australia has four entry points for accessing or referral to psychosocial services. These are:
- NDIS supports for people whose disabilities are associated with severe and persistent mental illness.
- State and territory government funding of psychosocial disability services
- Primary Health Networks (PHNs) – funding of psychosocial disability services
- Integrated Carer Support Service – support for families and carers of people with disability, including psychosocial disability.