20th February 2018
The Chair Hon Kevin Andrews MP Joint Standing Committee on the National Disability Insurance Scheme PO Box 6100 Parliament House Canberra ACT 2600
Dear Hon Kevin Andrews MP
Re: Market readiness for the provision of services under the NDIS
On behalf of Launch Housing, I welcome the opportunity to respond to the call for submissions regarding the implementation, performance and governance of the National Disability Insurance Scheme (NDIS).
As a provider of homelessness specialist services and housing, and as an advocate for equitable social policy, Launch Housing has an abiding interest to ensure the care outcomes for people experiencing homelessness.
In evidence previously submitted to the Joint Standing Committee on the National Disability Insurance Scheme, we have highlighted concerns about the eligibility criteria of the NDIS (especially for people with a psychosocial disability) and the practical problems for people experiencing homelessness to engage with the scheme.
These issues remain of concern for clients of Launch Housing and we build on this evidence in this submission.
Our main contention is that the ‘market readiness’ for the provision of services under the NDIS is highly reliant on two factors: the ‘individual readiness’ and the practical empowerment of consumers (allowing them to exercise real choice and control) to fully access the NDIS market; and market stewardship by governments to ensure the effective and guided provision of services through the NDIS. This provides the required context to ensure effective supply and to sustain the pre-conditions required for an effective market to emerge.1
It is critical that the NDIS does not reinforce pre-existing inequities and unintentionally exclude people experiencing homelessness from the services and resources available through the NDIS. A failure to do so will only add additional pressures on homelessness specialist services, which have long been a de facto provider of last resort for other service systems and markets.
Launch Housing
Launch Housing is an independent Melbourne based community organisation formed from the merger of Hanover Welfare Services and HomeGround Services on 1 July 2015, which brings a combined 75 years’ experience working with people at risk of or experiencing homelessness.
1 See Warr, D, Dickinson,H, Olney, S, et al (2017) Choice, control and the NDIS, Melbourne: University of Melbourne; p56
We are one of Victoria’s largest providers of housing and homelessness support services. We provide flexible, specialist services that directly assist thousands of individuals, couples and families every year.
Launch Housing is Victoria’s strongest advocate for affordable housing and a leader of research into homelessness. We believe housing is a basic human right that affords people dignity, and this is reflected throughout every aspect of our work. Everyone has a right to a home and it is our job to make this happen. Our mission is to end homelessness.
We operate across 14 local government areas in Melbourne, from Whittlesea in the north to greater Dandenong in the south east. Last year we supported 18,000 people at risk of or experiencing homelessness across Melbourne.
Participant readiness to navigate new markets
The notion of ‘individual readiness’ highlights the role of effective demand and is a necessary pre-condition for the ‘market readiness’ of NDIS providers. The core challenge in implementing the NDIS is to support the capacities of consumers2 and to ensure effective supports are available for all NDIS consumers, including those experiencing homelessness, so that they can exercise choice and control in a meaningful way.
Launch Housing recognises the benefits of a personalised approach, increased access and greater choice and control of services by NDIS participants. This aligns with the person-centric and strength-based approach commonly used by homelessness specialist services. While this logic of choice3 is an important normative principle of the NDIS, the exercise of choice and control is not always straightforward and can potentially compound and widen inequities and inequalities between different groups eligible for the NDIS.4 There is a real risk that those who are most disadvantaged are less likely to access services or supports.
It is readily acknowledged that there are differences in people’s abilities to exercise choice and control, and that the uptake of the NDIS will reflect the “capacity of individuals to engage in personalised care and of professionals and social networks or carers to support people to engage.” 5 In particular a participant’s expectations and experiences of the NDIS are strongly influenced by their circumstances.6
In a submission by Launch Housing to the Productivity Commission7, we outlined and explored concerns regarding access to the NDIS by people with psychosocial disability, more specifically, those at risk of or experiencing homelessness. The NDIS experience to-date suggests a number of potential barriers for participants in accessing the scheme and that pro-active measures are required to empower consumers.
We note that the NDIA is currently developing a new psychosocial pathway that will allow people with a psychosocial disability to better engage with the NDIS. We look forward to the outcomes of the consultations initiated by the NDIA.
We also welcome the announcement by the NDIA to develop a hard-to-reach strategy and that this includes people at risk of, or experiencing, homelessness. However, we are disappointed
2 ibid 3 Malbon, E, Carey, G, & Dickson, H (2017) ‘Accountability in Public Service Quasi-markets: The Case of the Australian National Disability Insurance Scheme’, Australian Journal of Public Administration. 4 See Carey, G, Malbon, E, Reeders, D, Kavanagh, A & Llewellyn, G (2017) ‘Redressing or entrenching social and health inequities through policy implementation? Examining personalised budgets through the Australian National Disability Insurance Scheme’, International Journal for Equity in Health, 16:192 5 Warr, D, Dickson, H, Onley, S, et al. (2017), op. cit; p7 6 Ibid; p 57 7 Launch Housing (2017) Submission to the Productivity Commission: National Disability Insurance Scheme Costs Position Paper, available from: http://www.pc.gov.au/__data/assets/pdf_file/0007/219337/subpp0275-ndis-costs.pdf
that in a scheme which claims to ‘support a better life for hundreds of thousands of Australians with a significant and permanent disability’8, a hard-to-reach strategy was seemingly an afterthought, only developed during the national roll-out of the scheme, and not considered and tested as part of the initial four trial sites.
Based on the experiences of our frontline workers and clients, our concerns remain ongoing, specifically in relation to this group’s ability to access and navigate the complex market.9 The NDIS is a complex scheme which is challenging to negotiate, with many participants relying on the support of family and social networks to assist with access and achieving a level choice and control in the implementation of their plans.10 In a client-driven scheme, it is vital to acknowledge and address the barriers to accessing choice and control for people living with disability11, particularly psychosocial disability. Many Launch Housing clients require significant support to fulfil the necessary requirements which rely on a level of administrative ability to prove eligibility and negotiate the system, and without family supports or networks, this becomes a considerable burden for an already overstretched sector to fulfil.
Evidence highlights concerns about access restrictions and difficulties in negotiating the eligibility system for a range of people including those experiencing homelessness.12 Some individuals may be eligible for the NDIS, but as the individual drives this, it may mean that some do not apply for support from the scheme.13 There are particular challenges for people experiencing homelessness with a mental health issue. Transience, a lack of formal diagnosis, and difficulties navigating the service system have resulted in people experiencing homelessness being excluded from services, particularly in the short to medium term.14
Many clients Launch Housing work with present with complex needs including acute mental health concerns and a substantial, cumulative, experience of rough sleeping. These clients, as outlined in our Frequent Service Users report15, are highly marginalised and present a particular challenge in engaging with and receiving support services and housing. Mental health issues are widespread for this group with nearly all clients having a diagnosed mental health illness. . Whilst such a group would greatly benefit from the NDIS, our experience shows that additional supports are needed to assist a person to navigate the service system and engage with the scheme.
But underpinning these experiences of clients with Launch Housing is a larger issue of housing disadvantage and the risk that the NDIS will inadvertently perpetuate these and related inequities. We agree that “insufficient attention is being paid to promoting equity of outcomes among service users with diverse needs and circumstances. Factors that are well-recognised in driving inequality – household income, education, residential location and household structure – remain critical in filtering opportunities and capacities for service users and their carers to have choice and control in accessing services and resources under the NDIS.”16 This has serious implications, with the NDIS acting to increase existing inequalities, for both the individuals and the demand market. As a result, currently the market does not have effective demand, and the NDIS services and providers that evolve will not adequately meet the needs of many participants.17
8 NDIS 2017 http://www.ndis.gov.au/about-us 9 Rao, M (2017), ‘The NDIS and the Homelessness Sector: When a person is homeless everything else is just harder’, CHP Parity Magazine, Vol 30, issue 10 p22 10 Warr, D, Dickson, H, Onley, S, et al. (2017), op. cit; p.8 11 Ibid 12 VCOSS (2015) 10-year Mental Health Strategy VCOSS Submission; p14 13 Ibid 14 Council to Homeless Persons (2016), Submission to the Ten Year Mental Health Strategy, September 2016; p6 15 Launch Housing (2016) Frequent Service Users Project, First quarterly report, March 2016 16 Warr, D, Dickson, H, Onley, S, et al. (2017), op. cit; p9 17 Ibid; p56
Research shows that Australians with disabilities are likely to be exposed to well-established social determinants of poor health such as social and economic exclusion, as well as poor housing outcomes.18
Housing in Australia is becoming increasingly unaffordable.19 Melbourne’s rental market is increasingly expensive with average rental prices rising by 46% over the past decade.20 Data from Victoria’s Department of Health and Human Services (DHHS) shows that over the past ten years, the proportion of rental properties that are affordable for lower income households has fallen from 27% to just 8.2%.21
Troublingly, the housing trajectories of people living with a disability are more greatly restricted than that of the general population.22 Of particular concern is that people living with a psychiatric disability report the lowest income and the greatest disadvantage of than any group with a disability, including mobility impairment, sensory disability and carers of people with a disability.23 With 34.5 per cent of people with psychiatric disability reporting a household income of less than $12,999, and 90 per cent reporting an income of less than $26,000.24 Additionally, 71 percent of this group were renting their home, most often from a social landlord. Persons with a psychosocial disability are isolated, with 40 per cent residing by themselves, and this is atypical compared to the Australian population overall.25 Of those that do reside in a household with another person(s), 40% reside with another person with a disability.26
This research evidence clearly shows that a large proportion of people with psychosocial disability are economically disadvantaged, socially isolated and excluded from the housing market. The relationship between mental illness and homelessness has long been recognised. Many persons with a disability are estimated to have the highest levels of risk for homelessness in Australia; with the risk of homelessness principally differentiated according to the type of disability.27 The majority of people with mental illness who are homeless experience long-term homelessness and repeated episodes of homelessness. For example, mental health is the second most frequently reported concern (53 per cent) reason people seek assistance from a specialist homelessness service.28
Market readiness
Market readiness refers to the effective supply of services funded by the NDIS and the pre- conditions required for an effective and sustainable market to emerge.
There are a number of factors that may undermine market readiness for the NDIS and these have been well rehearsed in the general literature. These concern, among other factors, the prevalence of ‘thin markets’ especially in rural and regional areas; and the risk of market failure.29 There is also the associated risks about the availability of the NDIS workforce, and the quality and continuity of care provided.
18 Carey, G, Malbon, E, Reeders, D, Kavanagh, A & Llewellyn, G (2017), op.cit 19 Hulse, K., Reynolds, M., Stone, W. and Yates, J. (2015) Supply shortages and affordability outcomes in the private rental sector: short and longer term trends, AHURI Final Report No.241. Melbourne: Australian Housing and Urban Research Institute. Available from: https://www.ahuri.edu.au/research/final-reports/241 20 Department of Health and Human Services (2016) Rental Report, available from: https://dhhs.vic.gov.au/past-rental- reports 21 Ibid 22 Beer, A., Faulkner, D. (2009) The housing careers of people with a disability and carers of people with a disability, AHURI Research Paper, Australian Housing and Urban Research Institute Limited, Melbourne, p8 23 Ibid; p8 24 Ibid; p33 25 Ibid; p33 26 Ibid; p33 27 Beer, A., Baker, E., Lester, L (2014) ‘Non-Psychiatric Disability and Homelessness: Understanding the Risks’, Parity, June, Volume 27, Issue 5 28 See: DHSS (2015) Housing and homelessness - 10-year mental health plan technical paper, Melbourne; p1 29 For example see Carey, G, Malbon, E, Reeders, D, Kavanagh, A & Llewellyn, G (2017), op.cit
Market stewardship
In order to prevent failings of the NDIS market and the consequent increased demand on overburdened services of last resort such as SHSs, good stewardship of the NDIS is required.
A useful distinction is made in the research literature between market regulation and market stewardship.35 Market regulation refers to the minimal regulation interventions such as registering providers and having explicit quality safeguards. From the perspective of Launch Housing market regulation is a necessary but not a sufficient condition for the oversight required for the NDIS. A stewardship role is also required that goes beyond ensuring minimum market protections for citizens to ensure long-term outcomes and public value.36
The need for market stewardship is well described in the following quote37: “to guard against inequities emerging from public sector markets governments must participate in: engaging closely with users, provider organisations and others to understand needs, objectives and enablers of successful delivery; setting the ‘rules of the game’ and allowing providers and users to respond to inventive this creates and constantly monitoring the ways in which the market is developing and how providers are responding to these rules…”
And while the stated long term objective is for the NDIS market to self-manage and regulate, quasi-markets like the NDIS are difficult to create and manage. As Malbon38 has noted “…the potential dilemma of ensuring quality care outcomes in a quasi-market system when markets are new or not fully formed and when the monitoring of quality service provision occurs primarily at the client level.”
In particular, the stewardship role of government is to foster and support the market of providers and oversee the transition from an ‘old’ to ‘new’ approach for both providers and consumers. It has been observed39 that the notion of ‘stewardship’ in the Australian policy context has yet to be fully refined, although the term has come to the forefront in relation to the NDIS, such as the role of NDIA, and the Harper Review into competition policy.
The notion of stewardship is largely based on the UK experience40 whereby “government is committed to opening up public services to greater competition and user choice, the government will need to take an active stewarding role to ensure that markets are vibrant, resilient and deliver high quality services cost-effectively.” 41 Stewardship42 in this context refers to “adjusting…the rules of the game in an attempt to steer the system [and] iteratively engage with providers of public services to steward the market towards producing desired outcomes.”
Provider of last resort arrangements, including for crisis accommodation
As highlighted in this submission a key challenge is to ensure that the NDIS does not reinforce pre-existing inequities and unintentionally exclude people experiencing homelessness from the services and resources available through the NDIS. A failure to do so will only add additional
35 Carey G, Dickson, H., Malbon E., Reeders D. (2018) The vexed Question of Market Stewardship in the Public Sector: Examining Equity and the Social Contract through the Australian National Disability Insurance Scheme 36 Ibid 37 Cited in Carey, G, Malbon, E, Reeders, D, Kavanagh, A & Llewellyn, G (2017), op.cit; p7 38 See Malbon, E, Carey, G, & Dickson, H (2017), op cit; p5 39 See: http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/FlagPost/2016/September /Stewardship_of_human_services_delivery 40 See: ibid 41 See: https://www.instituteforgovernment.org.uk/our-work/new-models-governance-and-public-services/public-service- markets-and-commissioning/learning 42 See: http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/FlagPost/2016/September /Stewardship_of_human_services_delivery
pressures on homelessness specialist services, which have long been a de facto provider of last resort for other service systems and markets.
Services provided by Specialist Homelessness Services (SHS) are symptomatic of inadequacies of the broader service system. These systematic failures of complimentary sectors such as education, out-of-home care and justice contributes to the flow of people to SHSs. This is not a new problem, but it has the unfortunate consequence of spotlighting SHS; despite the existence of collective responsibility in responding to vulnerable peoples housing and support needs.
As demonstrated by the soon to be released Australian Homelessness Monitor (AHM) - sponsored by Launch Housing - this is true of interactions with the justice system and Australia’s rising prison population. The AHM, a Launch Housing initiative aims to raise the profile of homelessness as a critical social problem, and establish links between labour market and housing market trends, and to social security and affordable housing policy developments.43 In the period 2006-2016 the national prison population total rose by over 50% to 38,845.44 All other things being equal, rising prisoner numbers mean rising rates of prisoner discharge. These statistics reveal that 31% of the 51,000 prisoners released in 2014 expected to be homeless on release. While this was a lower percentage than the equivalent figure for 2012, the rising volume of discharges means that the likely number of homeless ex-prisoners was on a rising trend over this period.45
While it is too early for the AHM to make conclusive assessments about the implications of the NDIS for people living with disabilities who are at risk or experiencing homelessness, it is anticipated that inequalities created and exacerbated by the roll out of the NDIS will also result in increased pressures on services of last resort such as Launch Housing.
Summary In summary, Launch Housing welcomes the introduction of the NDIS and notes the challenges facing the implementation of the scheme nationally.
We are supportive of a personalised approach and increased access to appropriate services and supports be it through the NDIS and other services for people with a psychosocial disability. Indeed, the initial experience of the Barwon trial has been positive for those eligible for the NDIS, with a greater choice and varied services available to participants of the scheme.
In summary, the research suggests that individuals with significant supports prior to the personalisation of services are more likely to experience benefits than those who do not.46 For people experiencing homelessness, who do not have these pre-existing supports and networks, there is the ever-present risk that the NDIS will simply compound their current disadvantage.
Effective market stewardship is one way of ensuring this does not occur and that the care outcome of those who experience homelessness are equality met. As outlined in this submission, it is imperative that governments help ensure that the NDIS (and its ‘market readiness’) is properly stewarded.47 It is necessary that the implementation of the NDIS is premised in a way that supports equity of outcomes among service users with diverse needs
43 Launch Housing (2017) Annual Report p11 44 ABS (2016) Prisoners in Australia 2016; Catalogue No. 4517.0, Canberra: ABS 45 Australian Homelessness Monitor Draft Report, unpublished, Launch Housing: Melbourne 46 Carey, G, Malbon, E, Reeders, D, Kavanagh, A & Llewellyn, G (2017), op.cit; p 6 47 Carey G, Dickson, H., Malbon E., Reeders D. (2018), op. cit
and circumstances.48 The fact of experiencing or being at risk of homelessness should not be an impediment to eligibility and access to the NDIS.
Launch Housing looks forward to the outcome of the deliberations of the Joint Standing Committee and can provide further advice if required.
Yours sincerely,
Tony Keenan Chief Executive Officer
48 See Warr, D, Dickson, H, Onley, S, et al. (2017), op. cit; p9
Submission to the Joint Standing Committee on the NDIS
Market Readiness for the National Disability Insurance Scheme
February 2018
Associate Professor Helen Dickinson, Director, Public Service Research Group, UNSW Canberra1 Associate Professor Gemma Carey, Research Director, Centre for Social Impact, UNSW Sydney2 Dr Sue Olney, Research Fellow, Public Service Research Group, UNSW Canberra3
About us
The Public Service Research Group at UNSW Canberra4 and the Centre for Social Impact at UNSW5 have a longstanding commitment to researching public service markets and personalised care systems in Australia and overseas. Associate Professors Dickinson and Carey are Chief Investigators in the Centre of Research Excellence in Disability and Health6 funded by the National Health and Medical Research Council (NHMRC) and our portfolio of work includes a number of research projects investigating various aspects of the NDIS. We welcome the opportunity to contribute to the Committee’s inquiry into market readiness for the scheme.
In 2017 we released a report on the findings of our research into Choice, control and the NDIS.7 A key feature of this project was the participatory and multidisciplinary research method applied to gathering, analysing and presenting data on service users’ perspectives of having choice and control in the NDIS in one of its trial sites.8 This approach gives unique insight into the evolution of the scheme from the perspective of participants, and how policy decisions are translated into practice in different contexts. This evidence, together with findings of other recent research projects, underpin our comments on the following terms of reference for the Committee: participant readiness to navigate new markets; the role of the NDIA as a market steward; and market intervention options to address thin markets.
1 https://research.unsw.edu.au/people/associate-professor-helen-dickinson 2 https://research.unsw.edu.au/people/dr-gemma-carey 3 https://research.unsw.edu.au/people/dr-sue-olney 4 https://www.unsw.adfa.edu.au/public-service-research-group/ 5 http://www.csi.edu.au/ 6 http://credh.org.au/ 7 Warr D, Dickinson H, Olney S, Karanikolas A, Peters D, Katsikis G, Wheeler J, Ozge J, Hargrave J, Wilcox M & Kasidis V (2017) Choice, Control and the NDIS: Service Users’ Perspectives on Having Choice and Control in the New National Disability Insurance Scheme. Melbourne: University of Melbourne http://socialequity.unimelb.edu.au/__data/assets/pdf_file/0010/2364499/Choice-Control-and-the-NDIS- Report-Melbourne-Social-Equity-Institute.pdf 8 http://socialequity.unimelb.edu.au/news/news-archive/NDIS-research-presented-to-MPs
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