NDIA Accountability Project

Improve the mental health of communities

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Joint Standing Committee on the National Disability Insurance Scheme (NDIS)

February 2022

Improve the mental health of communities

309 La Trobe Street, Melbourne VIC 3000 Australia T +61 3 9640 0646 F +61 3 9642 5652 ranzcp@ranzcp.org www.ranzcp.org ABN 68 000 439 047

About the Royal Australian and New Zealand College of Psychiatrists

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is a membership organisation that prepares doctors to be medical specialists in the field of psychiatry, supports and enhances clinical practice, advocates for people affected by mental illness and advises governments on mental health care.

The RANZCP is the peak body representing psychiatrists in Australia and New Zealand and, as a bi-national college, has strong ties with associations in the Asia-Pacific region.

The RANZCP has over 7400 members including more than 5400 qualified psychiatrists (consisting of both Fellows and Affiliates of the College) and almost 2000 members who are training to qualify as psychiatrists. Psychiatrists are clinical leaders in the provision of mental health care in the community and use a range of evidence-based treatments to support a person in their journey of recovery.

Introduction

The RANZCP welcomes the opportunity to contribute to the Joint Standing Committee on the National Disability Insurance Scheme (NDIS) Current Scheme Implementation and Forecasting for the NDIS consultation (the consultation). The recommendations contained within this submission are based on extensive consultation with the RANZCP Committees which are made up of psychiatrists with direct experience working with people who have psychosocial disability, and community members with a lived experience. As such, the RANZCP is well positioned to provide assistance and advice about this issue due to the breadth of academic, clinical, service delivery and lived experience expertise it represents.

The RANZCP recognises the commitment demonstrated by the National Disability Insurance Agency (NDIA) to continuous improvement of the NDIS. It has been recognised that the size and scope of the NDIS created a challenging landscape for disability service reform and the intersections and roles of different government sectors require further clarification for some stakeholders. Identifying and addressing the gaps between government agencies which might be impacting on service delivery and implementation is important for delivering holistic care for people with disability.

Executive summary

This submission provides detail on key areas for improvement aimed at strengthening outcomes for people with psychosocial disability, including those who are eligible for the NDIS and for those who are not. Many issues raised in the RANZCP 2020 submission to the Joint Standing Committee are still relevant. These key areas include the need to:

  • Triangulate with healthcare professionals

    • Develop processes to include healthcare professionals in NDIS planning to ensure more holistic care and support is provided to participants. Triangulation between Triangulation between NDIS participants (or prospective participants) and their carers/families/support persons, healthcare professionals, and the NDIA is required.
    • Support healthcare professionals to assist their patient access the NDIS and navigate NDIS processes.
    • Ensure the out-of-pocket cost to see a qualified healthcare professional for the participant or prospective participant does not act as a barrier to gaining access to the NDIS.

  • Integrate systems

    • Acknowledge the overlap between the disability, health, and other social service and welfare sectors. The NDIS needs to be part of an integrated system.
  • Ensure long-term disability support services are available and easily accessible to vulnerable groups and to those who are not eligible for NDIS assistance. - Clarify roles and responsibilities across all governments and NDIS authorities.

Implement best practice processes and care for NDIS participants

  - Ensure NDIS processes best reflect the fluctuating nature of psychosocial disability and support a

    model of recovery. This is essential for providing positive experiences for NDIS participants with
    mental health conditions.
  - Identify and harness opportunities with people living in regional, rural and remote areas to ensure
   NDIS access and processes fit better within the rural and remote health context.
  - Intervene where workforce shortages are most significant and markets are thin to protect the
     wellbeing of people with disability.
  - Include regional, rural and remote participants and prospective participants in reporting about
     performance.

Providing dedicated resources

The RANZCP has previously advocated for providing healthcare professionals with dedicated NDIS resources. This could better assist streamlining access for people with disability especially given the important role of psychiatrists in providing evidence and facilitating access to the NDIS. Psychiatrists have reported considerable variation in NDIA decisions between participants with similar needs, resulting is considerable variation of outcomes for NDIS participants and prospective participants.

The RANZCP highlights the importance of providing clear information and support to prospective participants and those supporting them in the application process. The RANZCP notes the Tune Review Recommendation 8a, p.76: ‘The NDIS Act and Rules are amended to: a. provide clearer guidance for the NDIA in considering whether a psychosocial impairment is permanent, recognising that some conditions may be episodic or fluctuating’. The RANZCP welcomes any opportunity to support the NDIA in providing further clarity to psychosocial eligibility policies and processes.

Developing dedicated resources supporting healthcare professionals to assist their patient access the NDIS and navigate NDIS processes is needed. This may include:

  • A helpline for healthcare professionals who are assisting people to access the NDIS,
  • Services by NDIA staff with a medical background,
  • And a website dedicated to healthcare professionals, which, broken down by profession/specialisation/role, provides information about how that role may best assist people seeking access to the NDIS. This is important to psychiatrists, as it can have negative repercussions on the therapeutic relationship when the patient is found ineligible for the NDIS. For example, the ‘DSP Help’ website provided by Social Security Rights Victoria provides plain-language support to applicants to the Disability Support Pension and healthcare professionals who provide evidence.

Further details on the evidence expectations of the NDIA outlining the exact requirements of assessment should be publicly available to ensure better transparency and accountability. Any tool or resources would need to be widely promoted amongst healthcare professionals to help ensure all healthcare professionals are aware of new resources.

Action: Ensure the out-of-pocket cost to see a qualified healthcare professional for the participant or prospective participant does not act as a barrier to gaining access to the NDIS.

The costs involved in applying to the NDIS may be considerable for people with disability, and prohibitive to accessing the NDIS. The creation of MBS items would create equitable access for people with disability seeking to access the NDIS. Submissions that the Joint Standing Committee received this year were in favour of fully-funded consultations with healthcare professionals for the purposes of evidence for access and planning requests.[1] In particular, some called for a new bulk-billed Medicare Benefits Schedule (MBS) item to address equity issues that may render some prospective participants able to afford medical reports and others unable to afford this.[1]

The RANZCP also highlights that it is important to account for the time spent and unmet costs for healthcare professionals in undertaking the paperwork and supports that a participant or prospective participant requires for meeting NDIS requirements, including evidence provision. Currently the MBS does not cover report writing undertaken by medical professionals on behalf of people looking to access the NDIS including reports or evidence for appeals.[2,3] The documentation processes can be onerous and be a stressor for health care professionals as reported in the 2020 RANZCP Member Wellbeing Survey.[2] Evidence provision by medical professionals of disability and function has an important role in the NDIS, assisting with access and appeals, and should be remunerated as such.

2. Integrate systems

Action: Acknowledge and account for the overlap between the disability, health, and other social service and welfare sectors.

The NDIS needs to be part of an integrated system.

The RANZCP has previously advocated that acknowledging the intersection between health and disability is imperative in improving the experience of people with disability with the NDIS. The Australian Institute of Health and Welfare finds that there is a strong link between mental health and disability, and that disability can be both a cause and effect of mental health conditions.[3] There are many interfaces of NDIS service provision with other non-NDIS services provided by the states, territories and Commonwealth, particularly aged care, health, housing, education and justice services. The RANZCP highlights the specific challenges of people with disability who are in prison putting together a NDIS Plan prior to their release. We have also identified that substance use is a barrier to service provision and that disadvantaged people become further disadvantaged in terms of physical and mental health, social inclusiveness and financial wellbeing. There is a clear need, highlighted by the Productivity Commission, for clearer governance and more seamless connections and care pathways between NDIS and non-NDIS service provision.[4]

Submissions to various NDIS Inquiries have emphasised the need to clarify NDIS access criteria and improve integration between NDIS and non-NDIS services. A service model is needed where all disability needs are met whether this is inside or outside the NDIS. Such a service model must receive adequate funding, be evaluated, and have clear governance. The National Mental Health and Suicide Prevention Agreement is one opportunity to address this. The disability sector continues to be disadvantaged by the siloed nature of these portfolios. Acknowledging the significant crossover between health and disability is key in improving outcomes of NDIS participants.

Action: Australian, state and territory governments collaborate to ensure long-term disability support services are available and easily accessible to vulnerable groups and to those who are not eligible for NDIS assistance.

The RANZCP has previously advocated for ensuring long term disability support services are available and easily accessible to vulnerable groups and to those who are not eligible for NDIS assistance. The Productivity Commission estimated that 154,000 people with severe and persistent mental illness are falling through the gap where the NDIS is not appropriate.[4] Productivity Commission Recommendation 17 is that governments prioritise the availability of psychosocial supports and estimate those falling though the gap at jurisdictional levels.[4]

The two most recent NDIS Quarterly reports (1 July - 30 September and 1 October - 31 December 2021) indicates that access for those with psychosocial disability is down, with both stating that 53% of access decisions determined applicants eligible this quarter compared with 72% in prior quarters.[5] The RANZCP highlights that all people in Australia should have their health and disability needs met.

Action: Clarity of roles and responsibilities across all governments and NDIS authorities.

The RANZCP has previously fed back regarding roles and responsibilities between prescribers of medication and NDIS authorities. NDIS authorities and processes vary between jurisdictions (e.g., the Restrictive Practices Panel in New South Wales), further complicating the issue and exemplifying the need for streamlining NDIS processes and supporting healthcare professionals in navigating them. The RANZCP has welcomed opportunities to support the NDIS Quality and Safeguards Commission in understanding appropriate prescribing, and would welcome further opportunities to support NDIS authorities in the future.

Implement best practice processes and care for NDIS participants

Action: Ensure NDIS processes best reflect the fluctuating nature of psychosocial disability and support a model of recovery.

This is essential for providing positive experiences for NDIS participants with mental health conditions.

The RANZCP submission to the Tune Review noted the need to develop appropriate pathways and processes for people with episodic and fluctuating symptoms of a psychosocial disability. The RANZCP 2020-2021 pre-budget submission recognised that the NDIA is seeking ways to better support people with psychosocial conditions through the NDIS. The RANZCP anticipates that the implementation of the Recovery Framework will be imminent and assist in ensuring NDIS processes best reflect the fluctuating nature of psychosocial disability and support a model of recovery, providing positive experiences for NDIS participants with mental health conditions. The RANZCP highlighted the importance of this is our previous May 2020 submission to the Joint Standing Committee.

Action: Identify and harness opportunities with people living in regional, rural and remote areas to ensure NDIS access and processes fit better within the rural and remote health context.

The RANZCP 2021 submission to the Joint Standing Committee addressed the need to support regional, rural and remote NDIS participants and potential participants. The RANZCP recognises that while the NDIS has proven benefits for many people with disability, there are many challenges faced by those attempting to access, or already accessing the NDIS, including geographical barriers and lack of local resources and supports including service providers.

Health inequity is a significant issue in regional, rural, and remote Australia with people in these areas experiencing poorer health and welfare outcomes than people living in metropolitan areas.[6] In addition, people living with disability in rural, regional and remote areas face further struggles due to health inequity then the general rural population. Often this is due to lack of health services in rural, regional and remote areas generally. However, lack of broader services such as public transport can also significantly impact on healthcare access as people with disability may rely on others for transport. Psychiatrists note that clients are often paying hidden travel costs to receive NDIS support. People with disability in rural and remote Australia may also face stigma and discrimination over their mental health related disability which may negatively impact health care.[7] The NDIA have identified several issues related to supported independent living (SIL) and short-term accommodation services.[8] Psychiatrists report that there are long delays in implementing NDIS services and that SIL houses can take years.

“Comparing by remoteness areas, the percentage of participants who said that the NDIS has helped reduces with increasing remoteness, with those living in the Very Remote areas less likely to say that the NDIS has helped… This trend is linked to the relatively lower utilisation of funded supports in Remote and Very Remote areas and is clearly impacted by more limited access to services and supports.”[9]

The Participants across remoteness classifications report notes that higher proportions of Indigenous NDIS participants live in regional, rural and remote areas.[9] The Queensland Productivity Commission’s NDIS market in Queensland draft report acknowledges that Aboriginal and Torres Strait Islander peoples and culturally and linguistically diverse (CALD) populations also face specific barriers to accessing NDIS services.[10] The RANZCP highlights the fact that these factors which impact on NDIS service access can occur in tandem - e.g. a CALD participant who is a recent migrant living regionally may experience compounding barriers to service access.

Action: Intervene where workforce shortages are most significant and markets are thin to protect

the wellbeing of people with disability.

The success of the NDIS is dependent on a robust and diverse market, allowing participants to self- determine goals and supports.[11] The NDIA is aware of thin markets, which exist where there is a gap between participant needs and their use of funded supports. Thin markets in relation to NDIS services have been raised by the Joint Standing Committee into NDIS Markets, the Productivity Commission and the NDIA.[12] There continues to be ongoing divergence between what is funded by the NDIS and what the market is able to provide. While this has been a prevalent issue for some time, little incentive is provided by the NDIA for services to move into service gaps and the market response to the need is stalled at best, leaving people without access to the support they need. NDIS service providers have raised the low NDIS pricing or price caps to deliver NDIS supports in rural and remote area.[12]

The RANZCP highlights that more needs to be done to protect the wellbeing of people with disability, especially in regional, rural and remote areas where markets are thin. It is the role of the NDIA to intervene and mitigate the impact of thin markets.[12] People in regional rural and remote communities continue to struggle to access the specialist assessments required to gain access to the NDIS, in addition to NDIS services, treatments and supports where access has been permitted.

The RANZCP also highlights dire shortages in the disability workforce with challenges meeting demand being worse in regional, rural and remote areas.[12] In 2018 the Joint Standing Committee on the NDIS conducted an inquiry into the market readiness for provision of services under the NDIS.[12] The final report found significant disability workforce shortages which were compounded in some regional, rural and remote areas.[12] Both the Productivity Commission and the NDIA anticipated higher demand in regional and remote areas.[12] The State of the Disability Sector 2021 report confirms that disability workforce shortages are ongoing and impacting sector performance.[8]

Action: Include regional, rural and remote participants and prospective participants in reporting about performance.

The RANZCP recommends that the NDIS Rural and Remote Strategy 2016-2019 is integrated into the governance framework of the NDIS. In particular, performance indicators for regional, rural and remote service should be monitored and reported by the NDIS. This could occur via the NDIS Quarterly Report to disability ministers and the National Quarterly Performance Dashboard. Access to services is an explicit goal of the NDIS and the NDIS Rural and Remote Strategy 2016-2019.[9, 13] At a minimum, the National Dashboard and annual reports should show a breakdown of per capita NDIS services by remoteness.

References

  1. NDIS Quarterly Report to Disablity Ministers - Q1 2021-2022: National Disability Insurance Agency; 2021

[Available from: https://www.ndis.gov.au/about-us/publications/quarterly-reports.] 6. Rural and remote health: Web report: Australian Institute of Health and Welfare; 2017 7. Accessibility and quality of mental health services in rural and remote Australia: Senate Community Affairs References Committee; 2018 8. State of the Disability Sector Report 2021: National Disability Services; 2021 [Available from: https://www.nds.org.au/images/State_of_the_Disability_Sector_Reports/SoTDS_2021_single.pdf.] 9. Participants across remoteness classifications report: National Disability Insurance Agency; 2020 [Available from: https://data.ndis.gov.au/reports-and-analyses/participant-groups/participants-across-remoteness-classifications. 10. The NDIS Market in Queensland draft report: Queensland Productivity Commission; 2020 [Available from: hhttps://apo.org.au/sites/default/files/resource-files/2020-12/apo-nid309820.pdf.] 11. Reeders D, Carey, G., Malbon, E., Dickinson, H, Gilchrist, D., Duff G., Chand., S., Kavanagh, A. & Alexander, D. . Market Capacity Framework: Centre for Social Impact; 2019 [Available from: https://www.themandarin.com.au/wp- tent/uploads/2019/12/Market-capacity-framework-CSI.pdf.] 12. Final report: Inquiry into the market readiness for provision of services under the NDIS.: Joint Standing Committee on the National Disability Insurance Scheme; 2018 [Available from: hhttps://www.aph.gov.au/Parliamentary_Business/Committees/Joint/National_Disability_Insurance_Scheme/MarketRea diness/Report.] 13. Corporate Plan 2021–25: National Disability Insurance Agency; 2021 [Available from: hhttps://www.ndis.gov.au/about-us/publications/corporate-plan#participant-service-improvement-plan-2020-21.]