NDIA Accountability Project

Addressing underfunding of psychosocial supports outside the NDIS in Western Australia

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Submission to the Joint Standing Committee on the NDIS

Inquiry into Current Scheme Implementation and Forecasting for the NDSI

Introduction

The Western Australian Association for Mental Health (WAAMH) is the peak body for community mental health in Western Australia (WA). WAAMH welcomes the Joint Standing Committee’s invitation to lodge a submission in relation to the inquiry into current scheme implementation and forecasting for the National Disability Insurance Scheme (NDIS).

WAAMH is a member of Mental Health Australia (MHA) and contributed to MHA’s submission to the current inquiry. WAAMH fully supports the recommendations of the MHA submission including:

  • Australian, state and territory governments work together to address the underfunding of psychosocial supports outside of the NDIS as a key component of the National Mental Health and Suicide Prevention Agreement.

WAAMH would like to take this opportunity to provide further detail of ongoing and emerging issues in NDIS implementation in the WA context.

As WA’s peak body for community mental health services, WAAMH is well connected to the NDIS community. We chair an NDIS Reference Group consisting of 21 representatives from other peak bodies, NDIS providers, consumers, carers, NDIS participants, regional, remote, CaLD and Aboriginal perspectives. We also run a psychosocial disability NDIS Quality and Safeguards sector development project funded by the WA Department of Communities engaging with approximately 200 NDIS providers. In addition, WAAMH has representatives on various statewide NDIS Communities of Practice (CoP), including a Quality and Safeguarding CoP, and a Positive Behaviour Support Practitioner/Implementing Providers CoP and regularly engages in consultation opportunities pertaining to the NDSI such as the recent NDIS Annual Pricing Review WA Working Group.

WAAMH’s broader work that informs this submission includes a comprehensive training program, membership engagement and support, systemic advocacy work and various projects in metropolitan and regional/remote areas. The breadth of the activities that WAAMH delivers mean we are well placed to collect and analyse information to identify and respond to emerging NDIS implementation issues in the WA psychosocial disability context.

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The availability of support outside the NDIS for people with psychosocial disability

Adequately funding community-based mental health support is critical to fill the gaps in mental health service delivery because high quality community-based supports can respond to psychosocial disability effectively, keeping people living well in the community and producing better outcomes.

High quality community-based supports are also well placed for prevention and early intervention that contributes to a financially viable mental health system and NDIS sustainability$^1$. High rates of hospital admissions and re-admissions to acute psychiatric services demonstrates a failure to provide timely and quality community-based mental health services$^2$.

In WA the underfunding of community mental health supports outside of the NDIS impacts on the services available to NDIS participants, as well as other people with psychosocial disability and mental health challenges. The underfunding of community mental health services in WA was a concern before the advent of the NDIS and WAAMH has long advocated for increased investment in community mental health supports $^3$.

Community based supports outside the NDIS are critical in supporting the needs of people with persistent mental health challenges that may or may not be NDIS participants. Concerns were raised by the Productivity Commission in 2017 that as federally funded disability support programs (with mental health services of particular concern) were rolled into the NDIS, people using these services, including those not eligible for NDIS, may no longer receive continuity in support$^4$. Community based support is an essential component of an effective and efficient mental health system.

Community based support is also the most under resourced type of mental health service in WA and meets just 22% of the demand for this type of service.$^5$

The Productivity Commission ($^{2017}$) maintained that adequately funded mental health services outside of the NDIS is also critical to the financial sustainability of the NDIS$^6$. Inadequate funding for community-based mental health services outside the NDIS means more people experiencing severe recurring mental health challenges and in need of support are more likely to test their eligibility for the NDIS$^7$. This is illustrated by the latest quarterly (Dec 2021) report data from the NDIA with just $53 ext{ extpercent}$$ of access decisions for psychosocial disability deemed eligible in the second quarter 2021 - 2022$^8$.

Mental health support

In 2020 the Productivity Commission estimated 690,000 people with mental illness are likely to benefit from access to psychosocial support services, with about 290,000 people living with severe mental illness with complex needs.

The Productivity Commission (2020) described a massive gap in community based mental health supports with only around 34,000 people receiving services through the NDIS and only 75,000 receiving psychosocial supports from other Australian, State or Territory government funded programs9. This leaves approximately 181 000 people living with severe mental illness with complex needs and 581 000 people with mental illness that would likely benefit from access to support.

Through the rolling in of existing federally funded community-based support programs, and persistent underfunding of community-based supports, the NDIS and wider mental health system has created further barriers for people living with mental health challenges. Concern and frustration have been expressed by participants, carers and service providers in WA that there are two ‘classes’ of people with psychosocial disability emerging, those on the NDIS and those not on the NDIS, with those not on the NDIS increasingly unable to access community-based supports that aid in recovery and keep people living well in the community10. The Productivity Commission (2020) estimated 154,000 people are not able to access the supports they need under current policy settings11 This is of particular concern in regional and remote areas and is discussed in more detail below.

Funding for community-based support such as the Partners in Recovery (PIR) program and Personal Helpers and Mentors (PHaMS) has been rolled into the NDIS and is now no longer available for people outside of the NDIS. While consumers in WA expressed satisfaction with these programs, their main frustration was the short length of time they could remain in the program. Recovery can be a lifelong journey and longer-term community-based supports outside of the NDIS are needed. The Productivity Commission (2020) describes the folding on of these programs into the NDIS as exacerbating existing challenges for consumers and providers of psychosocial supports12.

The Commonwealth has provided some funding through WAPHA for people with severe mental illness outside of the NDIS. This funding is provided through the National Psychosocial Support Measure (NPSM) and the Continuity of Support (CoS) program. While this funding was available many of these consumers transitioned to the NDIS. The remaining eligible participants can now access the Commonwealth Psychosocial Supports program (CSP). It is understood that this funding will continue until June 2023 after which time the responsibility for psychosocial supports outside the NDIS will lie with the states, with funding to be

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included in the National Mental Health and Suicide Prevention Partnership Agreement (NPA). It is critical that adequate funding for community based mental health services is allocated in the NPA. It is imperative services are provided to a high level, in a timely manner, in the communities in which people live in order to avoid costly and unnecessary hospitalisation and recovery setbacks.

The Productivity Commission (2020) maintains that the delivery of psychosocial supports has been hampered by inefficient funding arrangements and service gaps and recommends as a priority “the shortfall in the provision of psychosocial supports outside the NDIS should be estimated at a regional and State and Territory level (Action 17.3)“13. In WA the Mental Health Commission (2018) identified the shortfall as a need for 5.8 times greater community-based support than was available in 2013 and 5 times increase in the community support hours available in WA 14 In WA the current underfunding of community-based supports results in additional pressure on services that are available. Consumers express despair at multiple barriers to access and lack of capacity in existing services15.

RECOMMENDATION 1.1

WAAMH recommends as a matter of urgency that community based psychosocial support and prevention services be adequately funded outside the NDIS through the National Mental Health and Suicide Prevention Partnership Agreement. The WA Mental Health Commission had identified the level of support increase needed in the WA Mental Health, Alcohol and Other Drug Services Plan 2015 -202516 and WAAMH has conducted rigorous research informed by the lived experience voice, in both metropolitan, regional and remote areas, identifying potential models of effective community-based psychosocial support for implementation with adequate funding17.

  1. The interface of NDIS service provision with non-NDIS clinical community mental health services.

As mentioned in the introduction, WAAMH attends and participates in many forums across both NDIS and other mental health services. We are consistently hearing that the interface between clinical and NDIS services is not working in a way that best supports the participant. Often these services are interacting during the more acute phases of a person’s psychosocial disability which makes it imperative that this interface is seamless to keep people living well in the community and help them transition out of hospital back into their community. Through our NDIS Sector Readiness Project we have had regular contact with clinical mental health services.

The Mirrabooka Community Mental Health Service has drafted a submission to this inquiry that describes the experience at the interface from her perspective as a clinician and community development officer.

13 Productivity Commission, “National Disability Insurance Scheme (NDIS) Costs,” 76. 14 Mental Health Commission, “Western Australian Mental Health, Alcohol and Other Drug Services Plan 2015- 2025 (Plan) Update 2018.”\n15 Kaleveld et al., Increasing & Improving Community Mental Health Supports in WA.\n16 Mental Health Commission, “Western Australian Mental Health, Alcohol and Other Drug Services Plan 2015-\n2025 (Plan) Update 2018.”\n17 Kaleveld et al., Increasing & Improving Community Mental Health Supports in WA.

Western Australian Association for Mental Health

Western Australian Association for Mental Health supports the observations around the need for a more integrated approach to clinical and NDIS services and encourages you to consider the recommendations made in her submission in relation to this.

Drivers of inequity between NDIS participants living in different parts of Australia

Regional and remote Australia faces many unique challenges that are well documented. All of the issues discussed above pertaining to the availability of community based mental health supports outside of the NDIS are exacerbated in regional and remote areas, especially group programs. Communities in the regions advise WAAMH that people living more than 30km from a regional centre do not have access to adequate mental health services and supports, or NDIS services. When people are deemed eligible for the NDIS they may be unable to access services or support due to the limited number of providers available where they live. Additionally, the people providing support and services may lack understanding and the capability to work effectively with people with psychosocial disabilities.

The rolling in of federally funded mental health services into the NDIS has resulted in a complete absence of available services in some regions. Through WAAMH’s regional engagement projects the experiences of people with mental health challenges in the regions has been described as notably worse in terms of accessing needed services. People have lost access to programs such as PIR and PHaMS and accessing the NDIS is a major challenge.

The people WAAMH spoke to in recent consultations in the regional and remote parts of WA were deeply frustrated about the loss of the aforementioned programs as they had been accessed by many people who were considerably marginalized, including Aboriginal people with mental health challenges. In one Wheatbelt town these were the only mental health supports and services accessed by Aboriginal people with mental health issues. Many of these people now have no access to mental health support. Many are deemed ineligible for the NDIS or are still in the process of determining eligibility. The process is described as complex, difficult and time consuming, particularly if they lack support locally.

The National Mental Health Commission points out that non-clinical, individual, and group-based supports for people with severe and complex mental health challenges are underfunded’.Θ The Productivity Commission Mental Health Inquiry (2020) maintains that the roll out of the NDIS has further complicated the funding of these programs’. Service providers in WA have expressed concern over the impact on group services in the regions with programs no longer sustainable because they can only be funded by NDIS plan funding and not all people accessing group programs are NDIS participants. The unintentional reduction in services to rural and remote

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communities is of great concern given the lack of options (and therefore choice and control for consumers) as well as significant unmet need for community-based mental health services20.

In 2017 the Productivity Commission identified that the market needed more support and maintained that if the government failed to intervene, there would be greater shortage, less competition, and ultimately poorer outcomes for participants. Participants in outer regional areas, remote and very remote areas were identified as most at risk 21. In 2020 the Productivity Commission also reiterated the difficulty of accessing quality mental health services in remote areas.

In WA, there were already major staff shortages in the mental health and community services sector in rural and remote areas. There are additional concerns with staffing in rural and remote areas that arise directly from the funding structure of the NDIS. In rural and remote areas. An issue raised consistently in recent consultations undertaken by WAAMH in regional and rural towns and communities in WA was that the level, and structure, of funding available limits the skill level and qualification of staff that can be employed. Similarly, the level of training and supervision that can be provided in relation to psychosocial disability and mental health is inadequate.

Additionally, WA has the unique workforce stressor of competing with the mining industry for staff. There is a need for well-resourced services that are open to NDIS participants and non NDIS participants under a ‘community centered model’ offering a range of services, including culturally appropriate services for Aboriginal people, and providing community connection for people living in isolated areas. This cannot occur under the NDIS and must be funded outside of the NDIS.

RECOMMENDATION 3.1

In addressing the underfunding of community mental health supports through the National Mental Health and Suicide Prevention Partnership Agreement consideration and adequate funding should be allocated to address the additional challenges of regional, remote and very remote communities. Through regional funding models local community-based solutions should be invested in for practical support, skilled locally trained staff, peer workers and opportunities to heal on country for Aboriginal people. Local providers should be supported and enabled to train adequately in mental health and psychosocial disability and retain staff.

RECOMMENDATION 3.2

While local care workforce is always the most desirable model there may be a place in some areas for a fly-in-fly/drive-in-drive out specialist clinical staff such as clinical psychologists and psychiatrists. Travel should be funded off plans and the regional, remote and very remote loading should be increased accordingly to reflect the increase in pricing.

Whether inconsistent decision-making by the NDIA is leading to inequitable variations in plan funding

A key feature of the NDIS is individualised funding. As such variations in plan funding, even for those with similar diagnosis, is not an unexpected outcome. There is a myriad of factors that might influence the nature, frequency and intensity of supports required including life stage, age of disability acquisition, life skills, recovery journey, housing status, history of trauma etcetera. This is particularly the case with psychosocial disability. Variations in funding decision making is necessary to achieve equitable outcomes and should not be expected to be consistent if the goal of the NDIS is to be a person-centred scheme22.

However, inconsistencies in decision making by NDIS planners that results in inequity is of great concern for people living with psychosocial disability. Through WAAMH’s various consultation methods and opportunities outlined in the introduction of this submission, three main areas of concern have been identified. Firstly, procedural inconsistence between planners; secondly, lack of psychosocial expertise amongst planners and LACs; and thirdly, the scheme’s apparent inability to adequately respond to the episodic nature of psychosocial disability including its fluctuating nature, frequency and the intensity of support needs of some participants.

Participants with psychosocial disability, their carers and support providers have shared numerous accounts where the inconsistent procedures undertaken by an NDIA planner have led to inequity in plan funding for participants with psychosocial disability. Examples include, planners failing to meet with a participant before removing funding: or alternatively, due to the presentation of the psychosocial disability, planners have removed funding as they have perceived participants as not being engaged 23. Without expertise in psychosocial disability, it can be difficult for planners to understand the functional impacts for participants.

A recurring example raised in WA by participants, carers and service providers is the refusal of urgent plan reviews requests to include behaviour support. In many cases these reviews are requested following the identification of the use of restrictive practices and the need for inclusion and review of these practices in a behaviour support plan, as required by the NDIS Quality and Safeguarding Commission (The NDIS Commission) and state policy. This is of particular concern because the use of restrictive practice can have human rights implications, and the lack of behaviour support is a participant safety concern. It is unclear why some reviews are granted, and others are not, why time frames for review appear to vary, and why funding decisions are inconsistent and create inequity.

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Under the NDIS Commission, the definition of restrictive practices is much broader than under the National Standards for Mental Health Services (NSMHS). It has become apparent, as mental health services transition to NDIS providers, that the routine use of safeguarding strategies, most notably environmental restraints, are now reportable to the NDIS Commission and must be subject to behaviour support. When plans are in place and the NDIA refuses to engage in plan review, safety is compromised, and the already prodigious administrative burden associated with the use of restrictive practice is exacerbated.

The lack of consistency and transparency in the decision-making process as well as the apparent lack of congruence with the NDIS Commission’s stated requirements, has resulted in apprehension around engaging with the NDIA to request needed supports for the fear that funding will be removed without explanation. Participants, carers, advocates, and service providers are disheartened with the inconsistent decision making that is detrimental to the aspiration of the NDIS.

The issues outlined above are in part caused by a lack of expertise and understanding of psychosocial disability amongst planners and LACs. NDIA staff’s understanding of the functional impacts of psychosocial disability is imperative to addressing inequity in plan funding.

For NDIS participants with psychosocial disability or mental health challenges the episodic nature of their illness may periodically affect their ability to effectively interact with systems. The ability to successfully interact with family, community and social systems (including the NDIA) needs to be supported for the goal of improved quality of life for people with disability to be realised. When someone has little or no expertise in mental health presentations, they are highly unlikely to be able to effectively engage with participants with psychosocial disability.

In this situation it is very difficult for NDIA staff to accurately assess the participants support needs and inconsistent decisions will result in inequitable plan funding. There are many ways in which this might play out; one example is when a participant is coping well, they may assert they have no need for certain supports however, we know from the episodic nature of psychosocial disability that while they may be doing well today and accessing less support, sometime in the future they will be in need of greater support. This support needs to be available when needed if people are to be able to continue to live well in the community, avoid unnecessary hospitalisation and be well supported in their recovery. The experience of participants, families, carers and providers in WA is the significant lack of expertise amongst NDIA staff in psychosocial disability leads to misunderstanding and frustration for all parties and disengagement of people with psychosocial disability from NDIS services.

One aspect of psychosocial disability that is difficult for people with little mental health expertise to reconcile is the episodic nature of psychosocial disability. The recent NDIS amendment (Participant Service Guarantee and other Measures) Bill 2021 recognised the episodic nature of psychosocial disability. When people with

The episodic nature of psychosocial disability

psychosocial disability experience a more acute mental health crisis, theyWAmay needMHhigher intensity and frequency of supports to stay well in the community and avoid unnecessary hospitalisation.

One of the principles of the NDIS Psychosocial Disability Recovery Oriented Framework (NDIS Recovery Framework)24 is “Being responsive to the episodic and fluctuating nature of psychosocial disability”. In order for this aspiration to be realised the episodic nature of psychosocial disability including the fluctuation of the nature and intensity of supports must be reflected in participants plans. For the episodic nature of psychosocial disability to be reflected in plans, planners must have a greater level of understanding of the functional impacts of psychosocial disability and skills in working with complexity.

The Productivity Commission (2017) described real concern around planners’ limited knowledge of particular disabilities and asserted that planners should have a general understanding about different types of disabilities25. In June 2019 the NDIA reported that foundational psychosocial disability training for Planners and LACs was completed26. While this may be considered as going someway to fulfilling the Productivity Commission’s recommendation of ‘general understanding’, the experience on the ground in WA of participants, families, carers and providers is that there is still a profound lack of understanding of the functional impacts of psychosocial disability. In order to make consistent, equitable decisions NDIS staff must be competent in working with people who have a psychosocial disability.

The Productivity Commission (2017) made particular note of the lack of expertise amongst NDIS staff in psychosocial disability and made the following recommendation:

“RECOMMENDATION 4.4

The National Disability Insurance Agency should implement a psychosocial gateway. The gateway should be the primary pathway that people with psychosocial disability enter the National Disability Insurance Scheme.

The gateway should:

  • use specialised staff
  • operate on a face-to-face basis to the greatest extent possible
  • consider models of outreach to engage people with psychosocial disability who are unlikely to approach the scheme
  • provide linkages to both clinical and non-clinical services and supports outside the scheme
  • collect data on both entrants into the scheme and people linked to services and supports outside the scheme“.27

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One of the six principles of the NDIS Recovery Framework is ‘a stronger NDIS recovery oriented and trauma informed workforce’. Improvements in the psychosocial competencies of the NDIA and NDIA partner staff is described as an organisational priority and the NDIA commits to developing and implementing learning and development strategies to this end. WAAMH has been involved in and followed the development of the NDIS Recovery Framework closely and will continue to do so. We are keen to see the aspiration of the NDIS Recovery Framework realised through robust planning, implementation, and evaluation.

RECOMMENDATION 4.1

WAAMH recommends that fair, reasonable, and consistent and transparent procedures for planners and LACs are in place and monitored. People have a right to know how decisions are being made, consistency of process can contribute to equitable decision making.

RECOMMENDATION 4.2

When a plan review is requested due to the identification of the use of restrictive practices, plan reviews are undertaken as a matter of priority and positive behaviour support is provided at a minimum of 60 -70 hours

RECOMMENDATION 4.3

WAAMH strongly recommends the NDIS strengthen mental health and psychosocial disability training for all planners and LACs as well as implementing recommendation 4.4 of the 2017 Productivity Commission inquiry into the NDIS Costs by establishing a psychosocial gateway with specialised staff.

RECOMMENDATION 4.4

WAAMH recommends that one way the NDIA can be responsive to the episodic nature of psychosocial disability is for people with psychosocial disability who experience fluctuation in their symptoms is to have in built crisis funding as a standard part of the planning process so that supports can be stepped up and wound back as needed without the need for review.

References

Kaleveld, Lisette, Catherine Bock, Ami Seivwright, University of Western Australia, and Centre for Social Impact. Increasing & Improving Community Mental Health Supports in WA: The Findings of a Co-Design Process Led by the Western Australian Association for Mental Health in Partnership with the Centre for Social Impact, The University of Western Australia, 2020. Kaleveld, Lisette, Meg McCorry, and Chelsea McKinney. “Better Commissioning Community Mental Health Service.” Unbublished, 2019. Mental Health Commission. “Western Australian Mental Health, Alcohol and Other Drug Services Plan 2015-2025 (Plan) Update 2018.” Government of Western Australia, 2019. https://www.mhc.wa.gov.au/media/3516/plan-update-2018- corrections-29-july-2020.pdf. National Mental Health Commission. “Report of National Review of Mental Health Programmes and Services,” 2014. http://mhaustralia.org/fact-sheets/national- review-mental-health-programmes-and-services-preliminary-analysis. NDIA. “National Disability Insurance Scheme Psychosocial Disability RecoveryOriented Framework,” 2021. ———. “NDIS Quarterly Report to Disability Ministers,” 2021. ———. “People with a Psychosocial Disability in the NDIS Report.” National Disability Insurance Agency, 2019. Productivity Commission. “Mental Health.” Canberra: Productivity Commission, 2020. https://www.pc.gov.au/inquiries/completed/mental-health/report. ———. “National Disability Insurance Scheme (NDIS) Costs.” Canberra: Productivity Commission, 2017. https://www.pc.gov.au/inquiries/completed/ndis- costs/report/ndis-costs.pdf. WAAMH. “WAAMH NDIS Reference Group Minutes.” unpublished, January 2022.