easternhealth
Submission to Joint Standing Committee on the National Disability Insurance Scheme PO Box 6100 Parliament House Canberra ACT 2600 https://www.aph.gov.au/Parliamentary_Business/Committees/Joint/National_Disability_Insurance_Scheme/IndependentAssessments
30th March 2021
Introduction
Eastern Health’s Mental Health Program is a tertiary provider of Mental health treatment and support to the Inner- and Outer- Eastern areas of Melbourne. This program does not provide NDIS supports, but rather interfaces with them as staff work to support and treat people with Mental ill-health and associated psychosocial disabilities.
The following is Eastern Health’s Mental Health Program Submission to the Joint Standing Committee’s inquiry into NDIS Independent Assessments. Our response is aligned to the various elements of the Committee’s Terms of Reference as follows, and pertains to people with a psychosocial disability.
Response aligned to Terms of Reference
- a. the development, modeling, reasons and justifications for the introduction of independent assessments into the NDIS;
The NDIS Act review conducted by David Tune was reported on in November 2019. This report indicated that it would be useful for the NDIS to fund independent assessments for people who could not afford or access them. This report did not recommend that all NDIS applicants should be subject to an Independent Assessment (Tune 2019, p.14).
- b. the impact of similar policies in other jurisdictions and in the provision of other government services;
There is substantial evidence against the implementation of Independent assessments for disability if we are to examine the UK experience. People with disabilities in the UK have been subject to short and independent assessments for several years now. Since the introduction of the independent assessments in 2013 as part of a major reform of the disability sector, many people with disabilities have reported losing benefits that they previously had, many are living below the poverty line, and the suicide rates have been steadily increasing for this population.
https://www.leonardcheshire.org/our-impact/stories/my-experience-applying-pip
The evidence from the UK is that the Personal Independence Payment (PIP) has cost the government considerably more than anticipated, whilst simultaneously depriving people with disabilities of essential funded supports.
https://inews.co.uk/news/pip-reform-george-osborne-disability-benefits-cost-government-money-246403
- c. the human and financial resources needed to effectively implement independent assessments;
Given the current NDIS market failures and concerns about the quality of current NDIS providers, it can be predicted with some certainty that there will be a lack of availability of Independent Assessors if this change becomes mandatory for all NDIS access requests and plan reviews. A lack of suitably qualified assessors with expertise in the participant’s primary disability will lead to significant delays in access to essential disability supports.
https://www.mhvic.org.au/images/PDF/Policy/NDIS/VICSERV_JSC_Market_Readiness_Submission_FINAL.pdf
The costs of employing independent assessors for all NDIS participants is likely to far exceed current costs, as many participants at this time are providing their Government or privately funded professional assessments to the NDIA to support access and planning. Government funded assessments would occur for people accessing tertiary Mental Health services, with or without the NDIS.
For psychosocial disability, it is important that a longitudinal approach to assessment is taken and collateral information gathered from family, carers and current supports. The cost of completing such a comprehensive assessment of a person’s psychosocial disability will be substantially greater than predicted by the NDIA at this time. We recommend that people with mental illness who apply for NDIS and have tertiary or private Mental Health supports in place, be exempted from Independent Assessments, as a cost saving measure and, most importantly, to ensure proper quality of evidence provided.
- d. the independence, qualifications, training, expertise and quality assurance of assessors;
Psychosocial disability is a specialised area of assessment, requiring a longitudinal approach. We estimate a proper assessment should take between 20 and 200 hours in total, over a time period, and include a number of professionals. A good assessment involves collateral information from family, carers, and current supports. Given the predictable market issues, it is unlikely that all people with mental illness will be assessed by someone with suitable expertise in this area.
- e. the appropriateness of the assessment tools selected for use in independent assessments to determine plan funding;
Clinical Mental Health Services take a longitudinal approach to diagnostic assessment of consumers and their needs. A range of tools are applied over time. Mental Health is a complex and non-linear area of treatment and support. When we note the changes over time in an individual’s diagnosis and support needs, it is clear that a single assessment is inadequate to assess their diagnostic picture and the subsequent support needs.
The WHODAS 2.0 is unsuitable as a stand-alone assessment tool for people with significant psychosocial disability. The empirical evidence for its use with this cohort is lacking and the intention of the tool is not as a stand-alone assessment to determine the extent of a person’s disability, as it then translates to funding for supports. The WHODAS 2.0 was designed as a pre and post-test to measure the effectiveness of interventions (Üstün et al 2010, p.5).
Although it is proposed that CHIEF and Vineland will also be applied, these tools do not have sufficient empirical evidence to support their use with people with psychotic disorders either.
The CHIEF is another subjective assessment tool and it has been advised that a home assessment would be a better method of evaluating environmental factors of disability (health.Utah.edu, p. 1). It is considered by some to be most useful to “compare a single client’s changing attitudes towards environmental barriers and support over time” (health.Utah.edu, p.2). This is not how the NDIS Independent Assessor is required to apply the tool.
https://health.utah.edu/sites/g/files/zrelqx131/files/files/migration/image/chief.pdf
The Vineland Adaptive Behaviour Scales are designed to measure adaptive behaviour and support the diagnosis of intellectual and developmental disabilities and delays, and autism. It is not designed to measure with accuracy the support needs of people with psychosocial disabilities related to psychotic disorders.
- f. the implications of independent assessments for access to and eligibility for the NDIS;
Eastern Health Mental Health Services provide support to people with psychosocial and other disabilities along the NDIS pathway to supports. Routine data collected from 13 of Eastern Health’s community based Mental Health teams reveals the following. Of the 1,241 consumers in the data set, 37% have been found by the NDIA to be eligible NDIS participants; and only 3% have been found ineligible. Just 13% of the whole cohort are considered by their case manager to be inappropriate for NDIS. This implies that more than 80% of consumers receiving support from our community teams may be appropriate for NDIS. There are still 46% of the EH community MHP consumer cohort who have either declined to test their eligibility or are ‘just considering’ the NDIS.
Figure 1: Total % NDIS Access status by all programs for 1st September to 31st November 2020, n = 1,241
This large number of consumers who are likely to be found eligible (based on NDIA Act criteria) but have not as yet tested their eligibility, are already facing concerning barriers to NDIS access. Qualitative data reveals that this cohort of Mental Health service consumers with significant psychosocial disabilities decline to test eligibility for the following reasons: Concerns about the access process; mistrust of the scheme; feelings of unworthiness; lack of
insight into their own needs; difficulty engaging with supports. We believe that adding an additional hurdle to the Access process will further alienate this group of likely NDIS participants.
Since the introduction of the NDIS to our region in November 2017, our staff have supported many NDIS applications by providing clinical evidence of permanent functional incapacity and diagnosis. This evidence provision is readily achieved without any additional burden to the consumer. The consumer is known to the service and as such all relevant information to compile the evidence already exists in their file. The evidence is entirely more robust due to its expert and longitudinal nature.
It is our opinion based on evidence, that potential and accepted NDIS participants who are already engaged with tertiary Mental Health (MH) services should be offered the choice of: an independent assessment; or provision of evidence by their treating team in support of their NDIS application; or both. This choice should apply to all plan reviews also. ‘Choice and control’ are key tenets of the NDIS.
- g. the implications of independent assessments for NDIS planning, including decisions related to funding reasonable and necessary supports;
Many people living with more severe psychosocial disabilities are isolated, and no longer connected to families and other supports. This may leave them vulnerable to an assessment process that does not acknowledge the true extent of their disabilities.
In our experience with NDIS participants who have psychosocial disabilities and are engaged with tertiary MH services, it is noted that a professional advocate present in the NDIS planning meeting leads to a more adequate plan being developed. The aforementioned NDIS participant cohort have been known to underestimate their own support needs and their self-reports can be unreliable as indicators of functional incapacity e.g. participant states in planning meeting “I have a lot of friends” when in fact they are completely socially isolated; participant states “I can cook for myself” when in fact they are unable to perform basic cooking tasks safely or adequately.
Without an advocate who has detailed knowledge of the participant being able to provide evidence or attend a planning meeting, the NDIA planner will be unaware of the extent of the person’s disability support needs. Inadequacy of plans will not show up for some time, perhaps not until the plan review. This will lead to increased risk of functional deterioration and safety concerns.
- h. the circumstances in which a person may not be required to complete an independent assessment;
An independent assessment should be optional and available for people who are unable to afford to obtain evidence for themselves and/or who are not already connected to specialist services related to their primary disability. There is no good reason to mandate these likely inadequate independent assessments for people who already have substantial evidence of disability readily available.
- i. opportunities to review or challenge the outcomes of independent assessments;
The results of Independent Assessments won’t be considered a reviewable decision, so participants cannot internally appeal the results of the assessment or challenge what is contained in the report. Participants can only appeal the plan and the budget that is built from the assessment. We believe this to be unfair, particularly given the likelihood that the assessments will not detect the full extent of participants’ disabilities.
The process of appeal regarding inadequate NDIS plans and disputed access decisions is arduous. People with significant psychosocial disabilities are reliant on advocates and professionals to support them through the lengthy processes. This may place them at an unfair disadvantage, and potentially leaves them without vital psychosocial supports whilst they lodge appeals. The NDIA need to set KPIs regarding internal reviews of decisions that take into account the disadvantaged position the person with a disability is likely to be in, whilst they await an outcome.
- j. the appropriateness of independent assessments for particular cohorts of people with disability, including Aboriginal and Torres Strait Islander peoples, people from regional, rural and remote areas, and people from culturally and linguistically diverse backgrounds;
If NDIS were to perform independent assessments for the above cohort, cultural safety would be difficult to achieve. Aboriginal and Torres Strait Islander peoples have experienced significant and generational trauma. This group have found engagement with health professionals to be challenging overall. Historically, health services and government agencies have been instrumental in removing Aboriginal children from their families. Trust is built over time and requires a good level of cultural knowledge. This knowledge is developed through regular engagement with local Community. When a service provider is engaged well with Community, a trusting relationship is developed, enabling assessment and the delivery of appropriate support. Involving an independent assessor for the purposes of NDIS access and later to support plan reviews is very likely to be met with resistance. It is expected that independent assessments may lead to Aboriginal people disengaging with the NDIS processes and subsequently missing out on vital disability supports.
- k. the appropriateness of independent assessments for people with particular disability types, including psychosocial disability; and
Answered above
CONCLUSION
Changes to the NDIS Access and review processes that include the introduction of Independent Assessments, are of significant concern to many staff of Eastern Health Mental Health Program. Our consumer group consists predominantly of people who have psychosocial disabilities. This cohort have demonstrated reluctance to engage in NDIS access processes since the scheme’s roll-out in 2017, and will very likely be further deterred by the introduction of Independent Assessments. The chosen assessment tools appear
grossly inadequate to assess a person’s potential support needs, given the lack of empirical supporting evidence to endorse their use for people who live with chronic psychotic disorders. The stress that is anticipated to be caused by the impost of engaging with yet another practitioner for assessment is deemed unnecessary and unacceptable. Instead, we advise that Independent Assessments be made optional for this cohort, in every case.
References
Price, J, Morris, Z & Costello, S, 2018, The Application of Adaptive Behaviour Models: A Systematic Review, Behavioural Sciences, DOI: https://doi.org/10.3390/bs8010011
Tune, D, 2019, Review of the national disability insurance scheme act 2013, removing red tape and implementing the NDIS participant service guarantee, Australia
Üstün, N Kostanjsek, S Chatterji, J Rehm , 2010, Measuring Health and Disability: Manual for WHO Disability Assessment Schedule (WHODAS 2.0), World Health Organisation