NDIA Accountability Project

Submission on improving psychosocial support within the National Disability Insurance Scheme

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Submission to the Joint Standing Committee
on the National Disability Insurance Scheme:
Current Scheme Implementation and Forecasting
for the NDIS

Interim Submission | 28 October 2021

President: Mick Reid AM

Introduction

We would like to thank the Joint Standing Committee on the NDIS for the opportunity to provide input into the Committee’s Inquiry into Scheme implementation and forecasting. We welcome the opportunity to provide advice in this interim report, with a view to providing additional information following engagement with our MIFA Member organisations in a final report to the Committee in February 2022.

MIFA is committed to working with the Government and the NDIA to ensure that NDIS participants with psychosocial disability experience quality care, better outcomes, enhanced choice and control, and recovery-oriented psychosocial supports in the NDIS. MIFA contends that there are issues unique to this cohort of people that must be addressed separately as part of NDIS service planning, design, development and implementation.

We recognise that significant improvements have been implemented within the NDIS, whilst others are underway, to enhance the NDIS experience for participants with psychosocial disability. These improvements include the NDIS Participant Service Charter, the Service Improvement Plan, the introduction of Psychosocial Recovery Coaches, the development of the NDIS Psychosocial Disability Recovery Framework, and the review of the NDIS Act 2013 (Cth) to implement recommendations from the Tune Review (2019). We commend the Government and the NDIA for recognising that improvements needed to be made in these areas to promote better experiences and outcomes for participants with psychosocial disability. In this submission, we will highlight areas where further development and refinement is needed in the implementation of the NDIS.

Fundamental Principles

MIFA contends that there are fundamental principles that apply in the delivery of services for people with psychosocial disability that must be understood and embraced to support the effective implementation and performance of the NDIS for people with psychosocial disability. Fundamental principles of mental health care reform have recently been examined by the Productivity Commission and they apply equally well to NDIS reforms for people with psychosocial disability.

The Final Report for the Productivity Commission’s Inquiry into Mental Health in Australia concludes that mental health system reform in Australia would produce large benefits, mainly for people’s quality of life and economic participation. A person-led mental health system is the key ingredient for this reform. Australia needs reforms that focus on prevention and early intervention, provide the right healthcare at the right time, promote effective services that support recovery in the community, and provide seamless and integrated care, regardless of the level of government providing the funding or service.

The key recommendations to note from the Productivity Commission’s Final Report include:

  • creating a person-centred mental health system based on autonomy and choice
  • supporting the social inclusion of people living with mental illness
  • addressing the healthcare gaps in community mental healthcare
  • linking consumers with the services they need
  • improving the availability of psychosocial supports
  • providing support for families and carers
  • ensuring best practice governance to guide a whole-of-government approach
  • funding arrangements to support efficient and equitable service provision
  • providing regional planning and commissioning that support local responsiveness.

The NDIS is an important piece of the puzzle in these mental health system reforms. The Scheme will support 64,000 people with primary psychosocial disability at full rollout. These are individuals with the greatest levels of complexity and reduced functional capacity, many of whom may be accessing services across multiple sectors and service systems. To achieve these mental health system reforms, agreement must be achieved at the Commonwealth and State and Territory levels of government, and government roles and responsibilities for mental healthcare and psychosocial supports must be clarified. Achieving a whole-of-government approach to the delivery of psychosocial supports both within and outside of the NDIS, with integrated services across multiple disciplines, is critical to the long-term effectiveness and sustainability of psychosocial supports.

MIFA has written extensively about the importance of psychosocial supports in our mental health ecosystem (a short summary is provided in Appendix A). The Productivity Commission was clear that we must improve both access to and delivery of psychosocial supports in Australia. As a fundamental principle, Governments should ensure that all people who have psychosocial needs arising from mental illness receive adequate psychosocial support.

Interfaces of NDIS Service Provision

Lack of access to community-based psychosocial supports

Lack of access to suitable services continues to be an ongoing concern for many NDIS participants with psychosocial disability. As the Productivity Commission notes, “participants sometimes find it difficult to purchase needed supports as they may not exist in their community or may be ill-suited to their needs”. The Productivity Commission states that lack of access to psychosocial supports may result from NDIA pricing for services being set too low and markets being too thin in certain regions.

NDIA pricing for services being set too low

Many organisations are unable to provide viable psychosocial support services in the NDIS market. MIFA is aware of many service providers, small and large, who have pulled out of offering psychosocial supports in the NDIS because they cannot maintain viable services without compromising long-term organisational sustainability. MIFA is aware that some organisations maintain their NDIS service offering through cross-subsidisation from other income streams, whilst others have decided that offering core supports is untenable in a recovery-oriented service framework that provides quality and safe services.

MIFA continues to urge the NDIA to engage with the mental health sector to determine appropriate pricing for psychosocial support services in the NDIS market as part of the NDIA’s market stewardship role.

More psychosocial supports are needed outside of the NDIS

In future, it is important that the Australian mental health system reaches a stage where regardless of their NDIS status, people are able to access the supports they need.

We are united in the sector in our agreement on this fundamental principle for reform – that we must build and strengthen psychosocial supports in the community. We commend NDIS Minister, Senator the Hon Linda Reynolds CSC, for her commitment to everyone with disability, not just those within the NDIS at any one point in time. We also support the action underway following the Victorian Royal Commission’s commitment to a future mental health and wellbeing system that is restructured around a community-based model of care, where people can access treatment, care and support close to their homes and in their communities. We congratulate the Victorian Government for taking on this leadership role in mental health reform and, whilst this is a great start, there is much more to be done to ensure we are designing and delivering reforms that meet the psychosocial support needs of all Australians.

The Productivity Commission estimates that about 690,000 people in Australia with a mental illness are likely to benefit from access to psychosocial support services. Of those, 290,000 people experience persistent, severe and complex mental health conditions, and require psychosocial support. However, many of these people do not receive any support or the level of support falls short of what is needed. The Productivity Commission notes that:

  • Australia has long suffered a shortfall in the provision of psychosocial support. Only about 110 000 people were receiving psychosocial supports in 2019-20 (both within and outside of the NDIS), well short of the 290 000 people estimated by the NMHSPF to have severe and persistent mental illness who are most in need of psychosocial supports.

As of 30 June 2021, there were 52,913 people with primary psychosocial disability receiving supports under the NDIS (up from 50,351 in the previous quarter).7 The Productivity Commission estimates that about 75,000 people are supported by non-NDIS Federal and State/Territory services. Assuming the original estimate for the NDIS (64,000 people) will be met at some point in the future and the provision of supports outside of the NDIS remains constant, about 151,000 people with severe and complex mental health conditions (the PC Report calculates this as 154,000 people) will not be able to access the psychosocial support services they require if the

current policy settings continue.

MIFA continues to highlight the need to address this gap in

psyc hosocia l suppor t provision by providing enhanced community-based mental health serv ice s to su pport people to live well an d recover i n their communi ty .

The provi si on o f ps ychos ocial supp or ts will be governed b y th e Nat iona l Ment al Healt h an d Suic ide Prev ention Agre ement (the ‘Nat io nal Agree ment’). With res pec t to fund ing under the Natio na l Agreement , MI FA suppo rts the pro v isio n of fun din g by the Comm ons wath a nd the States and Territo ries based on nat ion ally agreed contrib ut ions. The funding alloc ation un der the Nationa l A greement is best det ermin ed acc ordin g to loca l nee ds.

Until a new Nati onal Agr ee men t is funded and implem en ted, there is a need to immediat ely enhance Commo ns wealth fu nding arrange ments for the Commonwe alt h Psychosocial Supp ort Program (funded by the Departmen t of Health) to provide support outside of the ND IS. W ith add itional fund in g, this program could expand to s up port more people through a person-led, rec overy-orient ed approach to mental health care, enabling community me ntal healt h organisations to su pport individuals to live well i n their local communi ty . Enhancing thi s nation al psy ch osocia l pr ogram would arguably reduce pressure on th e NDIS ov er time.

MIFA is concerned that if the National Agreement does not clearly define the roles an d responsibilities fo r these cohorts of peo ple , and reach agreement on jurisdic ti onal f und ing allocations, this will lead to prolonged disadv antage, vulnerability and crises. Prolonged deteriorating ment al heal th, increased isolation and lack of recovery supports all increase depe ndency on the mor e expensive acute men tal helth services and poten tially on the NDIS if psychoso cial suppor t needs increas e over the lifespan.

A proac tive approa ch tha t supp or ts m ental he alt h recove ry has soc ia l and economic value. As a solu tion, M IFA advo cat es for the developm en t and implemen taion of a Nationa l Psychosocial Supp ort Program that extends the existing Commonwea lt h and State and Terr itory programs and invests in new ps ych osci al su pports (see D iagram 1).

Recommendation 1

We recommend that the Select Committee support s the development and implementation o f a Natio nal Psy chocia l Suppo rt Progr am that ext ends the ex isting Comm ons wealth an d St ate an d Territory program s and invests in ne w psy cho social sup ports , to ensure that all Austr ali ans with psycho so cial sup port need s both ins ide and outsi de of th e NDIS have access to serv ice s when they n ee d them .

Diagram 1: Summary of the National Psychosychological Support Program

Extend existing programs Invest in new psychosocial support

  • Continuity of Support • ‘All people who have psychosocial needs arising
  • National Psychosocial Measure from mental illness should receive adequate
  • Transition psychosocial supports’ PC Report
  • 10,000 people • Significant improvement in the quality of life of
  • $100M pa; $400M over 4 years people Improve • 154,000 people
  • $610M pa; $1.62B over 4 years • Governance, planning and commissioning
  • Invest now – adjust later as jurisdictional changes • Regional planning for regional responsiveness guide are worked through • National planning framework for national equity
  • Recovery-oriented, person-led, community- • Outcomes measurement managed services • Service delivery models
  • Develop the peer workforce

MIFA Submission: NDIS Implementation and Forecasting Page | 7

NDIS Modelling and Forecasting

For some time now, MIFA has been advocating that we must revise the underlying assumptions and methodologies used when setting pricing and making projections about psychosocial support services in the NDIS. With the development of the NDIS Recovery Framework for psychosocial disability (the ‘Recovery Framework’), it is now critical that the Select Committee, the NDIA and Government consider the long-term impact of a recovery approach in the NDIS and how this can positively impact Scheme sustainability. We would argue the need to immediately invest in quality, recovery-oriented psychosocial supports and in psychosocial support workforce development to create long-term positive returns on investment as people with psychosocial disability are supported to lead contributing lives in the community through a recovery approach.

Enhancing the sustainability of the Scheme through a recovery approach

MIFA notes the recent concerns of Government about the long-term sustainability of the Scheme. There have been multiple references to ‘cost blow-outs’ by members of Cabinet and the Prime Minister, and concerns that the most recent Scheme Actuary projections show long-term challenges with the affordability of the NDIS. With sustainability concerns front and centre, it is timely for the Joint Standing Committee and the Government to consider the positive social and economic impacts of a recovery-oriented approach to psychosocial support delivery through the implementation of the Recovery Framework.

The NDIA is showing commitment to developing a stronger focus on recovery for NDIS participants living with psychosocial disability.1 As a member of the Mental Health Working Group – Stakeholder Reference Group, MIFA is contributing to the development of the Recovery Framework to support better outcomes and enhanced economic and social participation for NDIS participants with psychosocial disability. Greater understanding of and support for a recovery- oriented approach is needed at the Commonwealth and State and Territory levels. There is direct economic benefit in developing and implementing a recovery approach at all levels of the mental health ecosystem.

The most effective responses to people with severe mental illness and psychosocial disability are those that are flexible, holistic, integrated, supportive of recovery outcomes, and delivered within a recovery-oriented framework.2 A commonly cited definition of recovery is the one articulated by William Anthony:

 [Recovery is] a deeply personal, unique process of changing one’s attitudes, values,
  feelings, goals, skills and/or roles.  It is a way of living a satisfying, hopeful, and
  contributing life even with the limitations caused by the illness. Recovery involves the
 development of new meaning and purpose in one’s life as one grows beyond the
  catastrophic effects of mental illness.3

The National Framework for Recovery-Oriented Practice

The National Framework for Recovery-Oriented Practice recognises and embraces the possibilities for recovery and wellbeing created by the inherent strength and capacity of all people experiencing mental health issues. There is a focus on maximising self-determination and self-management of mental health and wellbeing and assisting families and loved ones to understand the challenges and opportunities arising from a person’s mental health experiences.

A recovery approach empowers individuals to contribute to and live well in their community. This approach supports the enhanced social and economic participation of people with mental ill health. Over time, this decreases Government outlays by reducing access to more expensive acute mental health services, whilst encouraging involvement in volunteering, education and training, and employment over the lifespan. This philosophy aligns with the true spirit and intent of the NDIS. Optimising the impact of a Recovery Framework within the NDIS will naturally support a reduction in funding over time for participants with psychosocial disability as individuals become more connected to community, employment, and strengthen their ability to manage their own recovery.

The implementation of a recovery approach for psychosocial disability within the NDIS will require different price modelling. For years, MIFA has been advocating for changes to the current NDIS pricing models to support the delivery of psychosocial support services and quality assurance activities by community-based service providers. For sustainable growth within the NDIS psychosocial disability market, psychosocial disability service providers must be financially viable, be able to attract and retain skilled and qualified staff, and be supported to invest in innovative, integrated and quality supports that deliver better long-term outcomes for participants. Community mental health workers support individuals with complex needs, often integrating their supports across multiple sectors and systems. This work requires a high level of skill and competency, compassion and resilience that is developed and strengthened over time. Better outcomes for participants, including enhanced social and economic participation, require significant investment in the workforce, especially the peer workforce, to enable the transformative change that supports lifelong recovery.

MIFA recommends reassessing the application of the Reasonable Cost Model to psychosocial disability supports, as there are simple cost-drivers of service delivery that are not adequately accounted for in NDIS funding models. These cost-drivers are primarily:9

  • providing an hourly rate that supports the attraction and recruitment of competent, qualified and skilled staff, and supports ongoing training and professional development for staff entering the sector for the first time
  • providing an hourly rate that supports ongoing supervision and professional development
  • revising the assumptions around the appropriate ‘billable’ hours for face-to-face service delivery
  • revising the allocation to overheads to support investment in innovation, quality improvement and systems that support service delivery in a post-pandemic market.

More broadly, MIFA contends that further work is needed to understand how a recovery approach can contribute to cost efficiencies over time for people with psychosocial disability. More grounded research on the impact of psychosocial support for this cohort will inform the co-design of service-types and cost drivers that can be applied to the NDIS. This will assist the sector and the NDIA to work together to develop separate pricing structures for psychosocial disability that achieve the objectives of the NDIS, support participants to achieve better outcomes, promote quality service provision, and support the sustainability of NDIS service providers.

To understand the economic benefits of a recovery approach within the NDIS, MIFA recommends that the Scheme Actuary undertake an analysis of the cost projections before and post the implementation of the Recovery Framework. This will support the identification of potential cost savings from optimising recovery within the NDIS for participants with psychosocial disability. As a start, we would encourage the Scheme Actuary to undertake this work based on what the NDIA’s evidence says about the impact of a recovery approach over time. We also recommend that the Scheme Actuary engage with people with psychosocial disability, mental health service providers, and researchers and academics to enable more comprehensive modelling and more accurate long-term Scheme projections to support the spirit and intent of the NDIS.

Recommendation 2 We recommend that the Select Committee support a review of the underlying assumptions, cost-drivers and methodologies used when setting pricing and making projections about psychosocial support services in the NDIS to incorporate a recovery-oriented approach to service delivery.

Recommendation 3 We recommend that the Select Committee ask the Scheme Actuary to (a) consider the impact of mental health recovery on psychosocial support needs over time and (b) engage with people with psychosocial disability, the sector, researchers and academics to enable more comprehensive modelling and more accurate long-term Scheme projections for psychosocial disability.

Inclusion of the Recovery Framework in NDIS policy planning

Policies for personalised budgets and plan flexibility for participants with psychosocial disability must align with the NDIS Recovery Framework. This means adopting a new recovery-oriented practice framework within the NDIA to ensure that NDIA staff understand how recovery-oriented

Practice Framework

practice shall be applied to the planning and budgeting process for participants with psychosocial disability to support better participant outcomes. This practice framework must have the participant at the centre, include a family and carer component, and then extend to community connections (to encompass the social determinants of mental health), identifying where participants can connect to their natural and community supports to strengthen ongoing recovery.

Recommendation 4

We recommend that the Select Committee approve that policies for personalised budgets and plan flexibility for participants with psychosocial disability align with the NDIS Recovery Framework and that the NDIA adopt appropriate operational guidelines and internal practice frameworks to support this.

The need for increased flexibility

It is critical that policy planning for the psychosocial disability cohort embraces flexibility. Flexibility is a core tenet of recovery-oriented service provision due to the fluctuating needs of people as their mental health state and function varies over time. Plans that are inflexible and made at a point in time may be under- or over-resourced.

The complexities of supporting people with psychosocial disability point to a critical need for flexible and responsive NDIS supports for this cohort. Access and support must be timely and crisis responsive. Support systems and processes must be flexible enough to fluctuate with the changing support needs of the individual and respond to increased vulnerability and need (e.g., in times of crisis, during significant mental health decline, or during enforced isolation or self-isolation).

To enable flexibility for NDIS participants with psychosocial disability, MIFA recommends the following broad changes in NDIS service design and delivery:

  • Packages should contain adequate hours of support, including support coordination and/or psychosocial recovery coaching, to allow for flexible service delivery, such that support can be front-ended at the beginning of support and taper off. Packages should allow for a rapid increase in support during a crisis.
  • Plans must be able to be reviewed rapidly where circumstances change and additional supports are required.
  • Continuity of care when people are in a hospital/acute setting is essential in ensuring workers can maintain contact and be involved in the discharge process. This service must be allowed to be provided under all support line items, including core and capacity building supports.
  • Flexibility could be provided through alternative funding arrangements for certain activities, such as group programs. These could include subscriptions, memberships, full course fees, bulk buying of support incidences in advance and/or much more lenient cancellation policies.

MIFA Submission: NDIS Implementation and Forecasting Page | 11

Without this flexibility, service providers may choose to cease providing these services altogether.

MIFA contends that these broader systemic changes around flexibility must be incorporated to provide better supports for NDIS participants with psychosocial disability.

Recommendation 5 We recommend that the Select Committee recognise that NDIS system design principles must enable appropriate levels of flexibility in the type, range and length of supports offered to individuals with psychosocial disability to address fluctuating needs over the lifespan.

NDIS Data Transparency

To support Scheme improvement, quality outcomes for participants and enhanced service provision, it is essential that Scheme Actuary data reporting is expanded and made publicly available. As a start, MIFA sees great value in providing the data for ineligible access decisions for people with psychosocial disability. Of those who test their eligibility to the NDIS, only 33% of people with a psychosocial disability are accepted or found eligible. The rate of ineligibility is significantly higher for people with psychosocial disability than for any other disability cohort. The reasons people do not meet eligibility cannot currently be obtained. Understanding why psychosocial disability access applications result in the highest ineligibility rate will support service providers and potential participants to navigate the process. Enhanced knowledge about eligibility decisions can support the sector to better assist potential NDIS participants throughout the access and evidence gathering process, leading to more efficient practices and potentially enhanced success rates amongst this cohort.

Recommendation 6 We recommend that the Select Committee support greater data transparency and public reporting of Scheme Actuary data each quarter, starting with access decision data for different disability cohorts.

We thank the Joint Standing Committee on the NDIS for the opportunity to provide input into their current inquiry on NDIS implementation and forecasting. We look forward to assisting the Select Committee further.

Hancock, N., Gye, B., Digolis, C., Smith-Merry, J., Borilovic, J. & De Vries, J. (2019). Commonwealth Mental Health Programs Monitoring Project: Tracking transitions of people from PIR, PHaMs and D2DL into the NDIS. Final report. The University of Sydney & Community Mental Health Australia, Sydney, p. 17.

MIFA Submission: NDIS Implementation and Forecasting Page | 12

About MIFA

MIFA is a federation of seven long-standing member organisations, established in 1986. Our members deliver specialist services for individuals living with severe mental ill-health and their carers, friends and families, out of nearly 60 ‘front doors’ in metropolitan and regional areas, to over 20,000 people each year. Our membership has a strong focus on building community, valuing peer support and lived experience, and supporting recovery. We have substantial experience delivering specialist, place-based, community-building programs to those experiencing mental illness, and 60% of our workforce has a lived experience as a consumer or carer.

Our vision is that Australians have the best possible mental health and quality of life. We know from experience that recovery of a better quality of life is possible for everyone affected by mental illness. We work with individuals and families in their journey to recover mental health, physical health, social connectedness and equal opportunity in all aspects of life. MIFA’s core strength lies in amplifying the voice of people affected by severe mental illness, their families and friends. We advocate for positive changes in all areas of social and public policy that impact on the quality of life of people with lived experience of mental illness. We create collaborative projects and communities of practice that support our MIFA member organisations.

MIFA’s current member organisations operating across Australia are BRIDGES Health & Community Care, Mental Health Foundation ACT, Mental Illness Fellowship Australia (NT), Mental Illness Fellowship of WA, One Door Mental Health, selectability and Skylight Mental Health.

Disclaimer

This submission represents the position of MIFA. The views of MIFA members may vary.

Contact

Tony Stevenson – National CEO – MIFA

Appendix A

What is psychosocial support?

The following extract is taken from the Productivity Commission’s Mental Health in Australia Final Report to describe what is meant by psychosocial support:

A summary: The importance of psychosocial support

Psychosocial support facilitates recovery in the community for people experiencing mental ill health. It helps people manage daily activities, rebuild and maintain connections, build social skills, and participate in education and employment.

Psychosocial support plays a vital role in enabling those living with mental illness to live well, to recover in their communities, and to counter stigma and discrimination. Psychosocial support also empowers people to achieve independence, increase control over daily life, promote self- determination and enables people to make a greater contribution to their community through employment and volunteering. Culturally capable psychosocial supports can be particularly

effective in preventing relapse in people from culturally and linguistically diverse

(CALD) backgrounds and can enhance social inclusion and participation.

Currently, there is an overreliance on crisis services, emergency departments and admission to acute or inpatient facilities. Psychosocial support services complement and support clinical interventions and, particularly when applied early, can reduce the demand for mental health- terated hospital admissions and decrease the average length of hospital stay.