Submission to the Joint Standing Committee on the NDIS

Inquiry into Current Scheme Implementation and Forecasting for the NDIS

29 October 2021

Introduction

As the peak national body for the mental health sector, Mental Health Australia provides this submission focusing on the experiences of people with psychosocial disability. Psychosocial disability is a term used to describe the disability experience of impairments and participation restrictions related to mental health conditions.

Over one million Australians live with psychosocial disability, and people with psychosocial disability make up nearly a quarter (26%) of all people with disability.

The NDIS has been life-changing for many Australians. However people with psychosocial disability have faced particular barriers in accessing the Scheme and implementing appropriate NDIS supports.

Mental Health Australia is pleased to provide this submission to the NDIS Joint Standing Committee’s inquiry, and looks forward to continue to working with the Australian Government to support reforms to improve the NDIS for people with psychosocial disability and ensure the Scheme’s ongoing sustainability.

Availability of supports outside the NDIS for people with disability

Psychosocial support services

Mental Health Australia has long-advocated that lack of “a well-functioning and effective mainstream system for providing psychosocial supports for people not eligible for the NDIS” is a key risk in containing the long-term costs of the NDIS.

Recovery-oriented psychosocial services support people to develop skills, capacity and connections to improve wellbeing and live a meaningful and contributing life. These services are critical in supporting people with psychosocial disability to maintain their wellbeing in the community, avoiding reliance on more costly acute hospital and clinical services, and interactions with the justice system. Timely access to psychosocial services is extremely important in preventing potential deterioration of people’s functional capacity, to the point where they may need and qualify for long term supports under the NDIS. Further, without available alternate services, there is a strong incentive for people with psychosocial disability to apply for the NDIS even if it is not the most appropriate service.

As the Productivity Commission observed in its review of the mental health system,

“Australia has long suffered a shortfall in the provision of psychosocial support”.¤ The previous system of funding for psychosocial services underwent upheaval in transition to the NDIS. State and Territory Governments, to varying degrees, rolled funding for psychosocial service programs into the NDIS, and the three Australian Government-funded psychosocial programs were also transitioned into the NDIS.

The Australian Government has funded a new National Psychosocial Support Measure to provide support for people with severe mental illness who are not eligible for the NDIS and not accessing state or territory funded services. However, the total Australian, State and territory government-funded psychosocial services available outside the NDIS are still not adequate to meet the level of need. The Productivity Commission estimated that 154,000 people with severe and persistent mental illness are not able to access the psychosocial services they require under current policy settings, where the NDIS is not appropriate for their needs but other supports do not exist.¥

Mental Health Australia strongly supports the Productivity Commission’s recommendation that as a priority governments should ensure that all people who have psychosocial support needs arising from mental illness receive adequate psychosocial support, by estimating the shortfall of psychosocial supports outside of the NDIS and increasing the quantum of funding to meet the estimated shortfall (Recommendation 17, Action 17.3).¦

Mental Health Australia has advocated adequate funding for psychosocial services needs to be a key component of the National Mental Health and Suicide Prevention Agreement. Our Advice to Governments on this agreement pointed to the acute underfunding of psychosocial services outside the NDIS and advised “Immediate attention must be paid to this need as this support is fundamental to getting the best long-term value out of investment in all other service streams and preventing readmission and recurrent co-morbidity.” §

Recommendation: Australian, State and Territory Governments work together to address the underfunding of the psychosocial supports outside of the NDIS.

Community mental health workforce data

As Mental Health Australia and other representatives have previously raised with this Committee, a further barrier to addressing the gap in psychosocial support services outside the NDIS is the lack of a nationally consistent dataset on the workforce delivering these services.⁅ Despite being a crucial component of the mental health system, without this data,

The psychosocial workforce is often overlooked in national workforce planning and service development.

This data gap was acknowledged by The Productivity Commission Inquiry into Mental Health, which also provided a recommendation to address it. However, it remains unclear whether and how the Australian Government plans to implement this action. Without this data, it will not be possible to monitor, let alone build and develop the necessary workforce to deliver effective psychosocial support.

Recommendation: The Australian Government should implement the Productivity Commission Inquiry into Mental Health Action 24.3: “Australian, State and Territory Governments should ensure a nationally consistent dataset is established in all States and Territories of non-government organisations that deliver mental health services”.

NDIS-funded community supports (ILC & LAC)

The Information, Linkages and Capacity Building (ILC) program and Local Area Coordinators (LACs) were intended to provide broader disability supports for non-NDIS participants, or support for people to access the NDIS. However, as Mental Health Australia and others have previously raised, the amount of ILC funding is nowhere near enough to meet the level of need. Further, the current arrangements for delivering ILC funding through disparate grants does not support the necessary strategic coordination to provide comprehensive support.

In Mental Health Australia’s experience, the way that LACs have been operationalised means they do not have the expertise or capacity to provide the essential psychosocial supports alongside the NDIS. Research examining housing issues for people with a psychosocial disability found that: “Local Area Coordinators (LACs) for the NDIS are supposed to help people navigate and connect with the system. However, LACs have limited capacity to do so and often do not have the skills, expertise or training to address the needs of people with very complex needs, who require an assertive approach to service engagement.“10

Mental Health Australia worked with the NDIA to implement a component of the National Community Connectors Program, funded from August 2020 until June 2021, which focused on engaging people with psychosocial disability with the NDIS. This program particularly focused on people experiencing or at risk of homelessness. In the implementation of the Community Connectors Program, Mental Health Australia and service delivery partners found that despite the program intent being that Community Connectors would engage with people and then refer them to LACs for support, there were many instances where LACs instead referred clients to Community Connectors, as they did not have the expertise or time to support clients with psychosocial disability and complex needs.

Boundary and interface issues between NDIS and other services

As the recent Productivity Commission inquiry into mental health documented, there are ongoing difficulties with the interface between the NDIS and mainstream services for people with psychosocial disability.

The Applied Principles and Tables of Support (APTOS) provides guidance around the respective roles and responsibilities of the NDIS and mainstream services. However these principles were agreed over five years ago and leave significant room for interpretation. As outlined below, there remains ongoing confusion in implementation regarding which service system and level of government is responsible for particular services, and for supporting connection between systems. This has led to gaps in access for people with disability, for example without necessary support to apply for the NDIS or difficulty transitioning between clinical mental health and NDIS supports.

There are ongoing concerns regarding lack of communication and integration of care across NDIS and mainstream supports. Better interfaces are required at both the systemic and individual level, to improve individual outcomes and utilise funding more efficiently and effectively. At the individual level, greater flexibility in how participants can utilise their NDIS funding package may reduce gaps in services that currently fall between mainstream health and NDIS supports. Secondly, service providers have indicated that where Support Coordination is appropriately funded, there has tended to be better integration across service systems and better outcomes. Appropriate ongoing funding of Support Coordinators in NDIS participant plans is critical to maintaining service integration. Coordination between an NDIS participant, informal supports, and formal supports across clinical, housing and the NDIS should happen as a matter of course to best support participants’ wellbeing and goals.

As outlined below, there are also broader systemic changes required to clarify and improve the integration between NDIS and other service systems.

Clinical mental health services

According to the APTOS, the health system is responsible for “treatment of mental illness, including acute inpatient, ambulatory, rehabilitation/recovery and early intervention, including clinical support for child and adolescent developmental needs”.13

However, many people with psychosocial disability are not able to access these services for treatment of mental illness, due to lack of available services or extremely long waitlists and unaffordable co-payments where services do exist. Some service providers have experienced outpatient jurisdictional mental health services moving to exit clients from support once they have an NDIS plan. NDIS participants have reported frustration that they are unable to access clinical services and that their NDIS services are not able to address this, where access to clinical support would really help them make the most of their NDIS supports.14 Lack of access to appropriate clinical mental health supports can severely impact people’s wellbeing, and has potential flow-on effects to their functional capacity and use of NDIS services.

Discharge of people from mental health in-patient care also remains an interface area of significant concern. Mental Health Australia understands that there can be significant delays in discharging people from in-patient acute mental health care, due to NDIS supports not being in place. There are issues both where someone is likely to be eligible for the NDIS but services do not have the capacity to support them to navigate the application process, and where a person has an NDIS plan but their independent living supports haven’t been established. This culminates in significant delays in people being discharged, or people being discharged into inappropriate care – neither of which is in the best interests of the person, nor the NDIS and health systems more broadly.

Mental Health Australia also understands there can be a lack of integration between forensic mental health and NDSI services, for example where a participant may require a particular level of support to transition to the community, but this is not covered in their NDIS plan.

Employment services

People living with severe mental illness and psychosocial disability consistently express the desire to work as a high priority.15 While there has been a slight increase in the proportion of people with psychosocial disability working full-time (from 8.1% in 2015 to 10.9% in 2018), employment rates for people with psychosocial disability in Australia remain very poor.16

Graph 7. All persons (a) aged 15–64 years, labour force status by disability type, 2018

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Key Findings:

• Psychosocial disability: Only one-third of people with psychosocial disability are in the labour force compared to two-thirds of people with other disabilities.
• Unemployment rates:
  • Nearly 8% of people with psychosocial disability are unemployed.
  • 4.5% of people with other disabilities are unemployed.
  • 3.9% of people with no disability are unemployed.

Effective Interventions for Employment Support:

Supported employment programs have been found “to readily assist approximately 50 percent of participants”.‘® These services include an assessment of skills and preferences, supported job-search in the open labour market, and ongoing support from employment specialists to maintain employment. Other programs such as conventional vocational rehabilitation or non-competitive job options have also been found to increase employment for a proportion of people with psychosocial disability, and “job placements can increase by 71% when psychosocial interventions are implemented.”’?

Current Services Available within/Outside NDIS:

There are currently employment services both inside and outside the National Disability Insurance Scheme (NDIS) which aim at supporting individuals living with various types of disabilities so they may participate more fully in work-related activities including but not limited to:

• Disability Employment Services,
• JobAccess,
• jobactive,
• ILC Economic & Community Participation Grants,
• NDIS participant plan supports.

psychosocial disability however show that these systems of employment supports are not as

widely available, nor working as effectively as they should be.

For example, there are known issues in mainstream Disability Employment services which if addressed would improve the quality of these supports and likely employment outcomes for people with psychosocial disability.20 Further, upon reviewing the evidence, the Productivity Commission recommended that governments extend access to Individualised Placement and Support employment services to all non-employed working age people accessing community ambulatory mental health care in Australia (Recommendation 19).21 Improving the employment support services funded outside the NDIS has the potential to improve employment for current NDIS participants accessing these services, and prevent reliance on NDIS-funded employment supports.

As part of the National Mental Health and Suicide Prevention Plan, the Australian Government allocated $5.7m in the 2021-22 Federal Budget to increase Individualised Placement and Support employment programs by piloting the program in Adult Mental Health Centres and further headspace sites. This investment is extremely welcome, but represents only an initial step in the reform that is required.

Secondly, there is significant confusion and complexity in the interface between NDIS and non-NDIS employment services. The experience of a leading jurisdictional peak body is that “Currently, it is difficult for people with psychosocial disability to access and navigate disability employment supports. Many do not pursue employment support because they don’t know where to go or they find the eligibility and assessment processes too difficult (especially in combination with other complicated processes associated with the NDIS and Centrelink). Others who do enter the system often end up with the wrong support or job placement because their needs were not accurately assessed.“22

The APTOS principles leave significant room for interpretation, where they outline that mainstream employment services are responsible for providing advice and support to people with disability to assist with preparing for, finding and maintaining jobs, and to employers to encourage and assist hiring and inclusion of people with disability in the workplace, while the NDIS is responsible for “funding individualised assistance to support a person with disability to take part in work”.23

Through consultation in April-May 2021 on the Australian Government’s National Disability Employment Strategy Consultation Paper, it was found that “the interface between the NDIS and DES was described as disconnected and complex to navigate, with a clear theme coming from feedback that this needs to be addressed.“24 As such, Mental Health Australia

• Cotton, R. (2019). How People with a Mental Illness in Disability Employment Services are Predisposed to Failure: Discussion Paper. Queensland: Worklink.
• Productivity Commission (2020) Mental Health, Report no 95, p827, retrieved 21 October 2021 https://www.pc.gov.au/inquiries/completed/mental-health/report
• Mental Health Victoria (2021) National Disability Employment Strategy: response to consultation paper, p.7, retrieved 26 October 2021 https://engage.dss.gov.au/wp-content/uploads/2021/05/MHV-submission-National-Disability-Employment-Strategy.pdf
• Department of Social Services (2015) Principles to Determine the Responsibilities of the NDIS and Other Service Systems, retrieved 21 October 2021 https://www.dss.gov.au/the-applied-principles-and-tables-of-support-to-determine-responsibilities-ndis-and-other-service
• Australian Government Department of Social Services (2021) National Disability Employment Strategy: Consultation Report, p32 , retrieved 26 October 2021 https://engage.dss.gov.au/wp-content/uploads/2021/10/dss-consultation-report.pdf

Employment Support Services

Recommendation: the Joint Standing Committee on the NDIS closely consider the issues in the performance and interface of NDSI and non-NDIS employment services in this inquiry.

Recommendation:

The Joint Standing Committee on the NDIS include issues and opportunities around employment support services in its consideration of the interface between NDIS and mainstream services.

Housing

Appropriate housing is the critical foundation for people to participate in our society, contribute economically, and recover and maintain mental health. Appropriate housing is also the foundation for engaging with and making the most of NDIS supports.

Provision of appropriate accommodation is mainly the responsibility of service systems outside the NDIS, while the NDIS is responsible for support to assist people to live independently in the community - including capacity to maintain tenancy, and home modifications required due to the functional impact of a participant’s disability.$

The current shortage in affordable housing is affecting access to appropriate accommodation for people with psychosocial disability.$. At least 31,000 people across Australia living with mental ill-health are experiencing or at risk of homelessness, and have an unmet need for long-term housing.$. Many more people with experience of mental illness are living in unsuitable accommodation, and over 2,000 people are stuck in institutional care because other accommodation is not available.$. People with lived experience of mental ill-health often face discrimination in the private rental market, insecure tenure and difficulty accessing housing supports.$.

Inadequate housing has been found to be associated with decreased functioning, while stable housing is associated with decreased service use and costs overtime$. Housing insecurity can then impact effective use of NDIS services, as well as perpetuating high use

$ Department of Social Services (2015) Principles to Determine the Responsibilities of the NDIS and Other Service Systems, retrieved 21 October 2021 https://www.dss.gov.au/the-applied-principles-and-tables-of-support-to-determine-responsibilities-ndis-and-other-service $ Brackertz, N., Borrowman, L., Roggenbuck, C. Pollock, S. and Davis, E. (2020). Trajectories: the interplay between mental health and housing pathways. Final research report, Australian Housing and Urban Research Institute Limited and Mind Australia, Melbourne. Retrieved 13 April 2021 from https://www.ahuri.edu.au/research/trajectories $ Productivity Commission (2020). Mental Health: Productivity Commission Inquiry Report: Volume 3, Canberra, pp.1001-2, Retrieved 13 April 2021 from https://www.pc.gov.au/inquiries/completed/mental-health/report/mental-health-volume3.pdf $ Productivity Commission (2020). Mental Health: Productivity Commission Inquiry Report: Volume 3. Canberra, p.971, Retrieved 13 April 2021 from https://www.pc.gov.au/inquiries/completed/mental-health/report/mental-health-volume3.pdf $ Brackertz, N., Borrowman, L., Roggenbuck, C. Pollock, S. and Davis, E. (2020). Trajectories: the interplay between mental health and housing pathways. Final research report, Australian Housing and Urban Research Institute Limited and Mind Australia, Melbourne. Retrieved 13 April 2021 from https://www.ahuri.edu.au/research/trajectories $ Rog 2004 as cited in The University of Melbourne and Mind Australia (2016), Effective evidence-based psychosocial interventions suitable for early intervention in the National Disability Insurance Scheme (NDIS): promoting psychosocial functioning and recovery, p97, retrieved 26 October 2021 https://www.mindaustralia.org.au/sites/default/files/publications/Effective_evidence_based_psychosocial_interventions_full_report.pdf

of other costly government services including health and hospital care, emergency services,

and interactions with the justice system.31

The Australian Government provided $782.1 million in a Housing Package in the 2021-22 Federal Budget, which will go some way in increasing access to home ownership for first home buyers and single parents with dependent children. However, these investments in and of themselves won’t address the systemic lack of affordable housing, particularly for people already experiencing homelessness or housing insecurity. The Australian Government’s primary mechanism for increasing supply of social and affordable housing is through the National Housing and Homelessness Agreement. This agreement will be reviewed by the Productivity Commission by June 2022,32 and given the level of need Mental Health Australia calls on the Australian Government to increase its funding commitment in renegotiations of this agreement.

There are also issues in the interface between NDIS and housing supports. Service providers working with people experiencing chronic homelessness and complex needs have pointed to a gap in support to access the NDIS. Most services are not able to provide the intensive one-on-one support required for people with complex needs, and particularly homelessness, to navigate the NDIS application process. The component of the National Community Connectors Program demonstrated an effective model for addressing this gap.

Housing and homelessness service providers have also raised concerns regarding:

- extreme difficulty communicating with the NDIA – flowing onto difficulties planning
     participant care
- having ongoing unfilled specialist disability accommodation with disconnection
  between NDIA and service providers
- risk of homelessness for participants where they did not receive housing supports as
     part of their NDIS plan (which they had through programs prior to transition to the
   NDIS), putting their tenancy at risk.

Service providers also reported positive examples of the connection between NDIS and housing, where NDIS funded Support Coordinators were able to support people to find appropriate tenancies, and where people with psychosocial disability were able to access support to maintain their housing and independent living through Supported Independent Living packages.33

Given the current systemic lack of access to appropriate accommodation for people with psychosocial disability, and importance of housing for effective and efficient use of all government services including NDIS supports, Mental Health Australia encourages the Committee to consider opportunities to improve supply of appropriate and affordable housing for people with psychosocial disability, and the interface of housing and NDIS services to support access to and maintenance of tenancies.

31 Parsell, C., Petersen, M. & Culhane, D. (2017). Cost Offsets of Supportive Housing: Evidence for social work. British Journal of Social Work, 47(5), pp.1534-1553 32 Australian Government (2021) National Mental Health and Suicide Prevention Plan, p10, retrieved 28 October 2021 https://www.health.gov.au/sites/default/files/documents/2021/05/the- australian-government-s-national-mental-health-and-suicide-prevention-plan-national-mental- health-and-suicide-prevention-plan.pdf 33 Brackertz, N., Borrowman, L., Roggenbuck, C. Pollock, S. and Davis, E. (2020) Trajectories: the interplay between mental health and housing pathways. Final research report, Australian Housing and Urban Research Institute Limited and Mind Australia, Melbourne, hhttps://www.ahuri.edu.au/research/trajectories .

• Recommendation: the Joint Standing Committee on the NDIS consider opportunities to improve access to appropriate housing for people with psychosocial disability, including housing supply and interface of NDIS and non-NDIS housing services.

Inequity in plan funding

Lack of psychosocial expertise

Service providers have experienced considerable variation in the appropriateness of NDIS plans for people with psychosocial disability.34

Access to planners with psychosocial disability expertise is fundamental in developing appropriate and equitable plans for this cohort. The NDIA previously recognised this and committed to the use of specialised planners through a ‘psychosocial disability stream’.35 Mental Health Australia understands that since this time, the NDIA has undertaken work to identify staff with skills in psychosocial support, established a Complex Support Needs Branch which supports many participants with psychosocial disability and provided training to NDIA planners and LAC staff on psychosocial disability. These changes are very welcome, but have not yet addressed the full extent of the need.

In the recent delivery of the National Community Connector Program, Community Connectors reported experiencing language and information in NDIS planning meetings that was confusing, triggering or overwhelming for participants with psychosocial disability – one service provider alone reported four participants disengaging from the NDIS planning process due to such experiences in planning meetings. Appropriate trauma-informed planners with psychosocial expertise are still required to improve the experience of participants and quality of NDIS plans generated.

Community Connectors also reflected the importance of having a trusted person (either informal or formal supports) with appropriate mental health expertise alongside someone with psychosocial disability during their NDIS plan development and implementation process.

Plan budget reductions related to underutilisation

Mental Health Australia understands that NDIS participants have been having their plan funding reduced upon review, with the justification that the participant was not fully utilising their plan.

While it is appropriate to ensure plans continue to match participants’ needs, underutilisation of plans can occur for many reasons rather than a lack of need for supports. The Tune Review found that the most common reasons participants reported for not using all of the funding in their plans were related to difficulty in finding an available provider in their area to

Ongoing NDIS reforms

Addressing current inadequacies in pricing assumptions

As the sector has continually raised with the NDIA and this Committee, the assumptions underpinning the NDIA pricing model fail to acknowledge the real cost-drivers of psychosocial service delivery. The NDIS Reasonable Cost Model does not account for staff professional supervision and development, makes inaccurate assumptions around face-to-face hours of care, does not allow sufficient provision for investment in quality and improvement, and does not provide an adequate hourly rate to attract and retain people with the necessary skills, experience and qualifications to deliver psychosocial service interventions.

Mental Health Australia continues to call for revision of the NDIS pricing model assumptions so that recovery-oriented psychosocial services can be effectively delivered through the NDIS. A sustainable pricing approach is needed so that regular upskilling, training and professional development is built into organisational systems and processes to support quality service delivery and worker retention and progression.

• Recommendation: the appropriateness of NDIA pricing of supports must be reviewed, with investigation of the accuracy of assumptions underpinning pricing of supports delivered to people with psychosocial disability, including adequate training and professional support.

Embedding recovery-oriented care

Recovery-oriented care is a foundational approach in mental health service delivery. In Australia the psychosocial support sector has a strong emphasis on recovery-oriented care, which “recognises and embraces the possibilities for recovery and wellbeing created by the inherent strength and capacity of all people experiencing mental health issues” and “maximises self-determination and self-management of mental health and wellbeing”. A recovery-oriented approach is fundamental in supporting greater social and economic participation of people with psychosocial disability.

Conclusion

Clarifying the boundaries and improving the integration between NDIS and non-NDIS services is essential to delivering the commitments of the NDIS. Mental Health Australia calls on Australian, State and Territory Governments to address the funding gap for psychosocial services outside of the NDIS, to ensure every person with psychosocial disability can access the supports they need and which are most appropriate for them.

There are strong practice frameworks to guide recovery-oriented care.$^{}$ Further, a comprehensive review of psychosocial recovery-oriented supports confirmed “there is significant evidence that people with psychosocial disability make significant gains in their capacity to engage in social and economic participation if they are offered early intervention”.$^{}$ Interventions that were highly endorsed through this literature review included peer support, cognitive remediation, Cognitive Behavioural Therapy for psychosis, social skills training, outreach treatment and support services, illness self-management, supported education, physical health management and family psycho-education and support. The authors concluded that “Interventions identified in this review have the potential to reduce the experience of impairment and provide early assistance that maximises people with psychosocial disabilities’ potential to work, improve their relationships with their families and others, gain new skills, stabilise their housing and self-manage.”$

There have been concerns that the NDIS service model does not appropriately incorporate or allow for such recovery-oriented psychosocial disability support. For example, service providers have raised ongoing concerns regarding the inability to employ appropriately qualified staff to deliver recovery-oriented care under the current NDIS pricing model, and the imbalance of core, capacity building and support coordination supports in participants’ NDIS plans.

Mental Health Australia has been pleased to work with the NDIA in developing and implementing reforms to improve the sector’s capacity to deliver recovery-oriented psychosocial disability support through the NDIS. This includes the introduction of a new Psychosocial Recovery Coach support item, and the development of the NDIS Psychosocial Recovery Framework. The NDIA’s collaborative engagement with the sector in developing the proposed Recovery Framework was extremely welcome, and has led to a sound and well-supported proposed Framework for embedding recovery-oriented principles in the NDIS. This process offers a model of successful engagement which the NDIA can build on in other areas.$

Mental Health Australia also urges to the Committee to consider issues and opportunities in

the interface of NDIS and non-NDIS services in the areas of clinical mental health care, employment and housing. Ongoing reforms are required to improve the equity of NDIS access and planning processes, and support the delivery of recovery-oriented psychosocial support services. These reforms will deliver the best outcomes both for people with psychosocial disability and the ongoing sustainability of the NDIS.

About Mental Health Australia

Mental Health Australia is the peak, national non-government organisation representing and promoting the interests of the Australian mental health sector and committed to achieving better mental health for all Australians. Mental Health Australia members include national organisations representing consumers, carers, special needs groups, clinical service providers, public and private mental health service providers, researchers and state/territory community mental health peak bodies.

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Mental Health Australia

Mental Health Australia is the peak independent national representative body of the mental health sector in Australia.

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