National Disability Insurance Scheme (NDIS) Costs
Productivity Commission Position Paper
Overview & Recommendations
Jenny Hall
Acting Chief Executive Officer
July 2017
neaminational.org.au
Acknowledgments
Many thanks to everyone who contributed.
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Introduction
Neami National would like to thank the Productivity Commission for the opportunity to respond and make a submission to the National Disability Insurance Scheme (NDIS) Costs – Productivity Commission Position Paper.
Neami wishes to acknowledge and commend the Productivity Commission for the Position Paper, the key points outlined, the draft recommendation, findings and requests for information made in the paper. In our view the position paper demonstrates the Productivity Commission has duly analysed, considered and understood the issues facing the NDIS, the participants, their carers and providers. Neami is in general agreement with the thrust of the majority of the draft recommendations contained in the paper.
Neami is a specialist community mental health organisation that delivers a broad range of recovery oriented programs for people living in the community with a serious mental illness. We provide services across Queensland, New South Wales, South Australia, Western Australia and Victoria. We work with people across the full spectrum of need and are particularly committed to those who exhibit the most complex needs, including people who have experienced long periods of hospitalisation and have been assessed as requiring extensive support to develop life skills and embark on a recovery journey.
Our response to the Position Paper will address the key points raised in the document and specific draft recommendations and requests for information that we consider most pertinent to the needs of people with a psychosocial disability. We will also comment specifically on two key issues, a proposal for a specialist Psychosocial Support Gateway to ensure improved engagement, assessment and planning for people with a psychosocial disability and secondly our endorsement of the need for independent price regulation.
Position Paper Key Points
Neami concurs with the key points highlighted in the overview of the position paper. Neami agrees that if implemented correctly the NDIS has the potential to substantially improve the wellbeing of people with a disability, including those with a psychosocial disability, and these benefits would flow through Australian society more generally.
Neami agrees that the rollout of the NDIS has occurred at too great a pace and this has threated the viability of the scheme due to a focus on numbers of plans processed at the expense of having adequate planning processes, infrastructure and market development. Neami has witnessed the poor outcomes of inadequate and poor planning and assessment for people with a psychosocial disability resulting in inappropriate, and unhelpful plans that are not tailored to the person’s genuine needs or aspirations.
We wish to highlight the inadequacies of the intake, assessment and planning process for individuals with a psychosocial disability. Whilst a large proportion of participants have had a good experience and outcomes, there are many people with a psychosocial disability who have had a negative experience. We can cite many examples where participants report the experience of intake, assessment and planning as distressing, confusing, rigid, and being misunderstood. The outcome has been that participants consider the plans are not aligned with their needs and aspirations. We know of participants who experienced the process as so stressful that there was a recurrence of the person’s underlying illness.
A key concern for Neami and for participants is the knowledge, skills and experience of planners in relation to mental health and psychosocial disability. A significant proportion of people with mental illness and related psychosocial disability experience conditions that can present as complex due to factors including:
- the fluctuating and episodic nature of their condition;
- difficulties engaging in assessment or service provisions;
- cognitive deficits that are not necessarily apparent.
To ensure effective planning occurs, planners require specific knowledge, skills and experience in engaging and working with people with mental illness and related psychosocial disability. It is our opinion that a specialist access “Gateway” similar to the Early Childhood Early Intervention (ECEI) model is required to ensure improved engagement, assessment and planning for people with mental illness and related psychosocial disability. We will outline how a Psychosocial Support Gateway could lead to improved outcomes for people with psychosocial disability later in this submission.
Draft recommendation, findings and information requests
How is the scheme tracking?
Draft Finding 2.4 states that early evidence suggests the NDIS is improving the lives of many participants and their families and carers. The finding does note however, that not all participants are benefiting from the scheme and identifies participants with a psychosocial disability as one group most at risk of experiencing poor outcomes.
Neami shares this concern and as stated previously, is of the opinion that the unique nature of mental illness and related psychosocial disability requires a specialist knowledge, skillset and approach to effectively engage participants, assess their capacity and support needs, and to develop high-quality individualised support plans. There are several unique factors that differentiate psychosocial disability from other disabilities, including complexity due to the fluctuating and episodic nature of their condition, difficulty engaging some people in assessment or service provision, cognitive deficits that are not necessarily apparent, some people’s belief they do not have an illness or disability, and many people having multiple and complex needs.
Scheme supports
Draft Recommendation 4.1.
This recommendation identifies a number of actions the NDIS should undertake in relation to planning, plan review, telephone planning, information regarding planning processes and LACs.
Neami is in agreement with this recommendation.
Draft Recommendation 4.2 proposes NDIS planners have a general understanding about different types of disability. The recommendation states that for types of disability that require specialist knowledge (such as psychosocial disability), there should be specialist planning teams and/or more use of industry knowledge and experience.
Neami strongly agrees with and supports this recommendation. Given people with mental illness and related psychosocial disability are at high risk of poor outcomes, we are of the opinion that access through a specialist psychosocial support gateway would improve the engagement, assessment, planning and support to people with psychosocial disability who are eligible for the NDIS, and referral to appropriate supports for people who are ineligible.
Provider readiness
Draft Recommendation 6.1 advocates for the introduction of an independent price monitor to review the transitional and efficient maximum prices for scheme supports set by the NDIA.
Neami is in agreement with this recommendation. As a specialist mental health provider, Neami is cognisant of the limitations and constraints factored into the pricing by the NDIA. NDIA pricing places great strain on specialist service providers to operate viably within the scheme. Neami is committed to the provision of high quality specialist mental health services and to do so requires investment in training and ongoing development of staff, research and quality assurance. These factors need to be considered when reviewing price. Draft finding 6.1 raises concerns about thin markets and the impact this will have on participants, including those participants with complex, specialised or high intensity needs or very challenging behaviour. A cohort of people with mental illness and associated psychosocial disability fit squarely in this category. To provide a quality, specialised service to these
participants, the scheme must ensure that providers can viably deliver services; a failure to do so will result in market failure and poor outcomes for some of the most vulnerable participants.
Participant readiness
Information request 8.1 poses the question is support coordination being appropriately targeted to meet the aims for which it was designed?
We believe that the majority of participants with a psychosocial disability who have complex needs require active Coordination of Supports (CoS). CoS provides the capacity to actively manage and support individuals who experience fluctuations in mental state, disability or need, are difficult to engage and have multiple provider involvement. This includes rapidly scaling up support in a period of crisis or scaling down supports when people have less need and are seeking to do more for themselves towards their own recovery.
To ensure more equitable outcomes for people with a psychosocial disability, we advocate for increased consistency in the allocation of Coordination of Supports. This will require greater sharing of experience between planning organisations and between regions. Improved consistency of support packages could also be improved through ensuring planners have the requisite skills, knowledge and experience in relation to people with mental illness and related psychosocial disability.
NDIS Psychosocial Support Gateway
The National Disability Insurance Scheme (NDIS) Costs – Productivity Commission Position Paper draft findings identify that despite evidence that the NDIS is improving the lives of many participants, their families and carers, not all participants are benefiting from the scheme. The paper identified that some people are experiencing poorer outcomes and were receiving fewer supports than they had previously. This group included people who cannot effectively advocate themselves, particularly people with a psychosocial disability.
The Productivity Commission recognises the need for NDIS planners to have a general understanding about different types of disability and identifies that, for types of disability that require specialist knowledge (such as psychosocial disability), there should be specialist planning teams and/or more use of industry knowledge and experience.
In our submission to the Productivity Commission on NDIS Costs Neami identified difficulties experienced by a cohort of participants with mental illness and related psychosocial disability in accessing the NDIS and obtaining appropriate plans aligned to their needs and aspirations. We identified a number of factors whose convergence resulted in poor outcomes for participants and a failure of the scheme to achieve its objectives. These factors include:
- The often fluctuating and episodic nature of mental illness and psychosocial disability;
- Participants who can be reluctant or difficult to engage;
- Participants who do not recognise their needs for support;
- Participants with multiple and complex needs;
- Participants with cognitive impairment;
- Participants who present as having minimal disability but actually have high levels of disability;
- Participants who require assertive outreach and a flexible period of relationship building before they are ready to engage;
- Planners who do not have the skills, knowledge and experience required to work effectively with people experiencing mental illness and psychosocial disability.
Neami proposes that an access pathway, similar to the Early Childhood Early Intervention (ECEI) initiative, be established to facilitate better outcomes for people with mental illness and associated psychosocial disability. We believe the NDIS Psychosocial Support Gateway will achieve better outcomes for people with psychiatric disability through:
- Partnering with experienced industry providers with strong local knowledge;
- Ensuring access, engagement, assessment and planning is conducted by experienced practitioners with specialist training, knowledge and skills in mental health and associated psychosocial disability;
- Matching relevant supports to needs that are identified through thorough investigation of people’s disability and life situation. This will increase likelihood of people receiving supports of appropriate type, intensity and frequency to best meet their needs, thus optimising outcomes for participants;
- Using evidence based approaches to engage with the person at a pace acceptable to the individual. This will mean those most in need will be able to access the scheme and will be more likely to utilise relevant supports;
- Have the skills, knowledge, experience and capacity to work with participants who are reluctant to engage, have multiple and complex needs, are homeless, etc., that NDIS currently is unable to effectively service;
- Supporting appropriate referral/ linkage to alternative supports for people who are either ineligible for the NDIS, or whose needs would be better addressed through supports outside the scheme.
It is proposed that, like in the ECEI, the NDIS partner with psychosocial providers who are experienced in intake, assessment, planning and service provision for people with mental illness and associated psychosocial disability. These providers would be the “access partners” in the psychosocial support gateway.
People with psychosocial disability would meet with the access partner to discuss their needs. The access partner would draw on their specialist experience in mental health, including developing relationships and exploring needs, to determine the most appropriate supports to meet the person’s needs. The most appropriate supports may include:
- referral to local community agencies;
- referral to mainstream clinical services;
- an NDIS plan.
People who require a NDIS support plan will work with the access partner to develop a plan that is submitted to the NDIA for approval. Once a plan is approved NDIS participants will choose who will provide their allocated supports. Participants will be able to use the local knowledge of the access partners to guide their choice of provider if they desire.
Potential conflicts of interest for access partners who are also NDIS providers can be mitigated and managed through a) the plan approval process being managed by the NDIA, and b) participants being offered a range of providers to choose from.
The NDIS Psychosocial Support Gateway approach can be summarised as follows:
- Person meets with experienced mental health specialist provider to discuss their needs. This meeting may include any relevant support people (professional or natural supports);
- The access partner works with the person to understand their needs and determine the most appropriate supports. This may include:
- Information services, support or referral to a mainstream service;
- Short to medium-term supports or longer term psychosocial disability supports;
- Support to submit documents to determine NDIS eligibility;
- Extended engagement process at a pace the person can tolerate;
- If the participant is determined eligible for the NDIS, the access partner will collaborate with them to complete a support plan to meet their needs and submit it to the NDIA for approval;
- Upon plan approval the participant will choose the support provider(s) they wish to work with and provision of supports will commence.
Diagram 1: NDIS Psychosocial Support Gateway
New and existing participants
Access partner: Determines best way to proceed with assessment
Access Partner: Provides range of engagement strategies and responses to participants
Assessment: Information and referrals. Non specialist psychosocial disability. To LAC or mainstream services.
Assessment: Ongoing psychosocial disability supports required
Supports received through NDIS
Participant chooses providers
NDIA approves plan
Access partner supports participant to complete plan
NDIA national access team
Neami believes the creation of an NDIS Psychosocial Support Gateway as outlined above will lead to better outcomes for participants by ensuring access, engagement, assessment and planning is conducted by experienced practitioners with expertise in working with people with psychosocial disability. The use of evidence-based approaches will facilitate greater participant engagement and result in plans that are aligned with participants’ needs and aspirations.
Neami acknowledges the conceptual nature of the proposed NDIS Psychosocial Support Gateway and that the approach requires further development, refinement and consultation with key stakeholders. Neami is willing to partner with the NDIA to progress the development of an NDIS Psychosocial Support Gateway approach.