Community managed mental health sector pricing, psychosocial disability capacity building and continuity of support | External submission

Submission: Parliamentary Joint Standing Committee: NDIS Market Readiness.

Mental Health Coalition SA (MHCSA)

Contact: Geoff Harris, Executive Director

Introduction

The Mental Health Coalition of SA (MHCSA) values the opportunity to make a submission in relation to Market Readiness for the NDIS.

The MHCSA has over 20 organisational members and provides a unified voice for the Community Managed Mental Health (CMMH) Sector in South Australia. The CMMH Sector comprises non- government organisations that deliver mental health services and work with people with mental illness and their families and carers across the state. The MHCSA work includes a strong focus on supporting and growing the Lived Experience Workforce and promoting positive messages that support people to improve their well-being and reduce stigma and discrimination.

The MHCSA vision is that all people living with mental illness in South Australia and their families will receive the mental health support they need when and where they need it. The MHCSA promotes a recovery approach, meaning the goal of support is to assist people living with a mental illness to build a contributing life in the community including social and economic participation.

Context

The context of this submission is psychosocial disability and market readiness for the segment of the NDIS market that delivers psychosocial disability supports.

The NDIS Act refers to psychosocial disability as “a functional impairment that affects daily living, likely to be lifelong caused by a mental illness”. Based upon original Productivity Commission modeling, 65,000 people in Australia fit that definition, with a further 210,000 with severe and persistent mental illness “with chronic and major limitations on functioning”$^{1}$. Services currently offered to this second group are “in scope” to be rolled into the NDIS, effectively leaving a huge gap in service provision once NDIS is fully rolled out. The NDIS is an important element of a wider mental health system – providing disability supports hitherto largely unavailable to people living with the most severe mental ill health – but it cannot replace the whole system of non-clinical community supports.

$^{1}$ P46, NMHC: National Review of Mental Health Programs and Services, V1

1 MHCSA Submission: JSC- NDIS Market Readiness, February 2018

A key but often overlooked aspect of current mental health services is that most provide short-term support whereas the NDIS will provide lifetime support. Any reduction in mental health service capacity will have a growing impact over time.

The MHCSA has, and will continue to advocate for holistic support for those experiencing mental illness. An effective service system for people with severe mental illness requires three broad service elements - clinical treatment, community psychosocial rehabilitation services and disabilities support. The NDIS meets the third service element while the wider mental health system must offers the first two to be effective.

Summary Recommendations

The mental health sector in South Australia has been working diligently and creatively to prepare their businesses for the NDIS and the opportunities for innovation that it presents. However, no amount of innovation and creativity can overcome the two biggest obstacles that exist and these are well documented$^{2}$.

The two things that emerged most strongly in our provider consultation were pricing and continuity of support.

Pricing – the NDIA must consider a Capacity Building rate that takes into account specialist mental health support skills, based on the SCHADS Award level 4 rate. Qualification level for this support should be Certificate 4 in Mental Health or Certificate 4 in Mental Health Peer Work.
Continuity of Support – It is now public knowledge that the NDIS will not meet the support needs of the majority of people living with mental health community support needs$^{3}$. Commitment to continuity of support beyond full implementation is critical, with adequate funding committed as a matter of urgency.

Key Recommendations:

ToR a. Recommendations

Commonwealth and State Governments must commit to adequately fund Continuity of Support (CoS) for people with severe mental illness in both NDIS and mental health services system.
Commonwealth and State Mental health services should be funded at current levels for at least 12 months after full transition to enable the development of CoS, effective mainstream interface and to allow for current and future delays in achieving full scheme.
NDIS pricing must reflect the true cost to deliver NDIS services of appropriate quality for people living with psychosocial disability.
Ongoing funding is required to engage with people who need extra, targeted support to connect with NDIS (eg homeless).

$^{2}$ NDIS: Productivity Commission Position Paper 2017, NILS Independent Evaluation Intermediate Report 2016 $^{3}$ Senate Community Affairs Committee: Answers to Estimates Questions of Notice – Health Portfolio. Ref SQ17- 001259. 2016-17 Of 800 PHaMS participants, 281 people were found to be eligible for NDIS – 35%

2 MHCSA Submission: JSC- NDIS Market Readiness, February 2018

ToR b. Recommendations

Identify cohorts who will have difficulty engaging with NDIS and develop an integrated response involving NDIA, mental health service providers and mainstream primary and acute care services.
On-going funding of supports to help people who struggle to engage to access NDIS, beyond the work of LACs. This could be through existing service models such as PIR or brokerage to service providers who encounter vulnerable cohorts.
Consider adding case management as a service and allow for support coordination as a longer-term support when indicated.
All NDIA and LAC access and planning staff receive trauma informed care training, together with an understanding of the potential trauma histories of NDIA applicants living with complex trauma.
Training for all NDIA and LAC access and planning staff in Recovery in a psychosocial context - how to work with potential participant and what a recovery-focused NDIS plan should look like.
(With participant permission) bring service providers in to the access and planning process as true partners, especially where a trust relationship exists and other natural supports are not available. The goal of this is to ensure that plans meet the Recovery needs of participants while also addressing disability issues.

ToR c. Recommendations

Add an appropriate code and pricing to the NDIS Price Book for psychosocial and peer supports, using the SCHADS level 4 as the wage rate, adding in reasonable provision for supervision and on-going professional development.
Participant plans for psychosocial disability be focused on capacity building and Recovery, utilising the existing specialist mental health support and peer worker workforce.
Funding and plans for workforce development in the regions to have a reasonable focus on psychosocial disability and the requisite qualifications to provide the right workforce for NDIS participants living with psychosocial disability.

ToR d Recommendations

Review the pricing model to better reflect the need for adequate supervision and professional development.
Add an appropriate code and pricing to the NDIS Price Book for psychosocial and peer supports, using the SCHADS level 4 as the wage rate.
Plans to reflect the need for capacity building for psychosocial disability rather than core supports, making available the use of skilled and qualified psychosocial support and peer workers.

ToR e Recommendations

That the NDIA review sector collaboration arrangements with view to a more transparent exchange, with the common goal of advancing the principles and objectives of the Scheme.
That oversight for pricing be transferred to an independent authority by 1 July 2019, with and interim measure of adding a psychosocial disability/peer work price, per item d above.

3 MHCSA Submission: JSC- NDIS Market Readiness, February 2018

Consult with the mental health sector in relation to psychosocial disability plans and the likely financial impact of higher priced services. We know from experience that over time the need for support diminishes considerably, with the provision of skilled mental health support.

ToR f. Recommendations

Consult with communities and regional service providers where they are covering wide geographical areas, to establish appropriate funding for travel, models to support a geographically diverse community.
In remote communities work directly with Elders and community to establish the best way to support people in their community. Provide adequate training and support resources for them to be work successfully within an appropriate cultural context.
Fund and focus on community development approaches where indicated within individual plans.
Consider “attraction packages” to support providers to locate in regional or remote communities.
Collaborate with local communities, provider and health services to ensure mainstream interfaces can occur.
Transparent reporting from the NDIA that enables the sector to make sound business decisions about whether and how they would like to address service delivery in thin markets – for example becoming a niche provider, partnering with communities to deliver services.

ToR h. Recommendations

Small service providers in particular, are financially supported to comply with the Quality and Safeguarding standards.
Pricing to reflect the cost of the Quality and Safeguarding requirements for staff training and experience.
The Quality and Safeguarding Framework must address psychosocial disability in a mental health context, with appropriate requirements in relation to delivery of Recovery focused psychosocial disability support and the interface between disability and mental health services.

ToR i. Recommendations

Provider of last resort arrangements to be determined between Commonwealth and State Governments and reflected in Full Scheme Bi Lateral agreements.
Published six monthly reporting from LACs about identified need where service providers could not be found, leading to planning around specific issues identified.
Rural and remote – work with communities to identify supports and support providers they want to work with, or training to provide supports themselves.

4 MHCSA Submission: JSC- NDIS Market Readiness, February 2018

Detailed Response

Process

The following submission addresses the Terms of Reference. A consultation process was held with NGO members who deliver mental health services in the community. For each item of the Terms of Reference we asked:

What is working?
What isn’t working (issues)?
What are our recommendations?

Responses were collated for all elements of the Terms of Reference except g. (The provision of housing options for people with disability, with particular reference to the impact of Specialist Disability Accommodation (SDA) supports on the disability housing market) – an area the consultation group felt they were not sufficiently able to comment upon.

ToR a. The transition to a market-based system for service providers.

Given that South Australia (SA) commenced transitioning adults from July 2017 (Commonwealth funded mental health programs), later than many other jurisdictions, SA service providers have been able to observe transition for our interstate counterparts and learn from their successes and challenges. Organisations have subsequently reviewed and changed infrastructure, systems and in some cases built completely new entities to deliver NDIS supports.

Mental Health service providers have spent the past several years preparing for the NDIS with changed service delivery, staffing models and review of corporate systems.

We have also learned that –

It is all but impossible to deliver high quality mental health supports within the pricing envelope (see item d for more detail)
While the sector has mature quality and safety systems in place, the capacity to meet the quality and Code of Conduct requirements of the Quality and Safeguarding Frame work are difficult to achieve without a skilled workforce.
The rollout of NDIS is slower than projected (in SA, DCSI have reported that we have currently transitioned 50% of the target of adults at the last reporting cycle) and business planning is challenging when plan and reality differ markedly.
Uncertainty about Continuity of Supports has meant that business planning can only be based on assumptions. This is especially relevant in the mental health sector where NDIS will support only about 12% of the cohort of people living with severe mental illness.$^4$
Specialists in the community managed mental health sector are particularly skilled in connecting with and supporting people who struggle to connect with mental health services. Future removal of funding (eg PIR) to undertake this work means that we risk losing these services over

$^{4}$ O’Halloran, P. (2014). Psychosocial Disability and the NDIS: An Introduction to the Concept of Holistic Psychosocial Disability Support

5 MHCSA Submission: JSC- NDIS Market Readiness, February 2018

time and with it the capacity to engage people who require more assistance to connect with the services they need.

ToR a. Recommendations

Commonwealth and State Governments must commit to adequately fund Continuity of Support (CoS) for people with severe mental illness in both NDIS and mental health services system.
Commonwealth and State Mental health services should be funded at current levels for at least 12 months after full transition to enable the development of CoS, effective mainstream interface and to allow for current and future delays in achieving full scheme.
NDIS pricing must reflect the true cost to deliver NDIS services of appropriate quality for people living with psychosocial disability.
Ongoing funding is required to engage with people who need extra, targeted support to connect with NDIS (eg homeless).

ToR b. Participant readiness to navigate new markets.

The MHCSA appreciates the work on pathways and the mental health National Access Team, and we look forward to the outcome.

Potential participants in SA living with psychosocial disability commenced testing eligibility for NDIS in July 2017. Given no mental health programs in SA are defined, every potential participant must navigate the eligibility process as well as planning, should they be successful. As already identified in other jurisdictions, people with strong natural supports or community supports with services they trust appear to have a better chance of succeeding in their application.

People living with psychosocial disability are at the most complex end of mental health needs and often have significant health issue and co-morbidities, so the access process remains confusing and confronting for potential participants. The MHCSA chairs an NDIS Interest Group and were able to engage an NDIA speaker who provided expert advice and fielded a range of questions that will make an enormous difference to the way service providers assist their customers. We need much more of this – practical help at a service delivery level that goes beyond fact sheets, that will help us to help our customers.

Insight and capacity to engage in a complex process are the biggest challenges. For people living with psychosocial disability it is important to be able to spend the time to adequately support this cohort. MHCSA believes the best expression of the issues faced by clients/customers is in their stories – the examples below illustrate –

6 MHCSA Submission: JSC- NDIS Market Readiness, February 2018

(client living with intellectual disability and mental health issues) In December 1 client was requested to provide information regarding their intellectual disability diagnosis and other support documentation. The client was upset that this information was sought by an NDIS worker during a phone call. The NDIS worker was not willing to provide the specific requirements in writing so the client could share this with their IPRSS mental health worker who was able to support the process. Consequently there was been a big delay in working through NDIS process as IPRSS staff have had to work hard (found it difficult) to find out what is required and to whom the information should be forwarded.

One client was approved for NDIS and then went to various banks to get a home loan as he thought he could use the money for a home.

In GP Access West (mental health individual support) program – a female who scores highly on LSP-16 assessment, wants social engagement and shopping support, is isolated and says she is lonely. She is avoiding physical and mental health appointments and doesn’t discuss her numerous health issues. It is very difficult to assist her to complete the NDIS application started and she has little insight into the implications of not applying, and doesn’t want to change. She states “I am already registered for the NDIS as I have signed an NDIS disclosure form.”

In GP Access West program - Male client, significant physical and mental health needs. His sister is his only support and she lives in country SA. He refuses to complete government paperwork, is highly suspicious of community services and at best tolerates the support GP Access provides. Support ensures his safety and wellbeing, and is a very significant help/support to his sister. Extremely unlikely to engage with NDIS process.

Client quotes from Metro Options (State Government funded individual support) - “what is this all about?”, “what is all this shit?”, “What’s going on?”, One client who received correspondence from NDIA thought that RDNS was offering them a service - they have no memory of NDIA involvement to date in their life/support.

The following case example provides a more detailed picture -

Case Study – Complex Needs and Access to NDIS

JH is a 55-year-old Returning Home consumer who has been registered with Neami since May 2009. JH has a diagnosis of Schizophrenia, and has a number of physical health issues including, COPD, undiagnosed abdominal growth and end stage lung failure (palliative). JH is also a protected person with a guardian appointed from the Office of the Public Advocate.

JH’s goal has always been to live independently in the community. Due to JH complex and ongoing needs, most recently JH has been supported through community HASP (Housing and Support Program delivering support services in the home in JH’s case). Due to JH’s decline in physical health, a deterioration in JH’s mental state has occurred. Due to end stage lung failure/COPD JH’s CO2 levels are compromised - this results in a state of delirium alongside JH’s ongoing delusions associated with her mental illness.

7 MHCSA Submission: JSC- NDIS Market Readiness, February 2018

Over the last 6 months, an ongoing argument has occurred between medical and psychiatry specialists as to who is responsible for JH’s care. Community living has been deemed as not a viable option for JH due to the high risks associated with this. JH has trailed aged care facilities twice over the last few months, both of which have failed due to JH vulnerability, deteriorating mental state and difficult behaviours. This has resulted in JH spending the majority of the last 6 months in hospital. JH will often abscond from hospital due to feeling that she is unsafe, and regular missing person reports are made. JH has also been referred to Burnside HASP (Housing and Support program in a residential setting); however, her referral has been rejected. Another application is being made to Burnside HASP following a recent vacancy.

Currently JH is in QEH PICU and has been there since 16th December.

Some issues re NDIS:

Would NDIS deem JHs disability to be caused by her mental illness or declining physical health?

Resistance to transition and the NDIS Access process – JH connection and long-term involvement with Neami – she may not have the capacity to understand why changes are happening etc.

Difficult to know JH’s exact needs as she has been in ‘crisis’ (in hospital etc.) more often than not

JH’s willingness to engage with new supports (if she doesn’t engage is this an issue for NDIS provider/billing?)

The need for flexibility in relation to support provided to JH, needs/purpose changes from day to day

Highly skilled staff needed to work with JH, have understanding around complexity, working with difficult behaviours, high-level problem solving.

JH also likely to refuse to work with people/’fire’ them regularly

Will need scope to work between NDIS/mainstream services as they are so embedded and a team approach/collaboration is required

Risk that JH will be deemed ‘too difficult client’ to receive ongoing services.

The capacity for NDIS, within the current pricing structure, to fund the quality and level of skilled support JH requires.

Care leavers have been identified as an especially vulnerable group. For example young people who are leaving the guardianship of the Minister due to their age. Many have significant trauma histories and risk falling through the cracks in the system.

The MHCSA appreciates that support coordination has been added to most psychosocial disability plans. The issues that remain though are that these are time-limited when it is likely that support coordination will be a long-term need. In addition, there is no consideration for the need for case management. The need for case management should be investigated and made available as a specialist support.

8 MHCSA Submission: JSC- NDIS Market Readiness, February 2018

Much of the focus through the transition has been on participants in existing services. We know that 50% of NDIS participants with primary psychosocial disability are previously unknown to services (Eddie Bartnik, 2015). It is imperative that flexible supports are available to assist people in navigating the NDIS access and planning process and access point may not be mental health.

Participant feedback suggests that plans often do not meet the needs of participants – that Core Supports are the main focus without an understanding from planners that to address apparent disability issues (such as meal preparation) through a disability focus keeps the participant disabled. To use capacity building is to build capacity, with the aim that eventually, support is no longer necessary for that issue. If plans meet the needs of participants they are more likely to link with appropriate service providers and fully utilise their plan.

LACs will have high workload initially regarding planning and ongoing with plan review. It is not clear how much capacity LACs will have to address complex issues that will require significant time, a high degree of skill and detailed understanding of the support context. Current services, such as PIR, have this capacity.

ToR b. Recommendations

Identify cohorts who will have difficulty engaging with NDIS and develop an integrated response involving NDIA, mental health service providers and mainstream primary and acute care services.
On-going funding of supports to help people who struggle to engage to access NDIS, beyond the work of LACs. This could be through existing service models such as PIR or brokerage to service providers who encounter vulnerable cohorts.
Consider adding case management as a service and allow for support coordination as a longer-term support when indicated.
All NDIA and LAC access and planning staff receive trauma informed care training, together with an understanding of the potential trauma histories of NDIA applicants living with complex trauma.
Training for all NDIA and LAC access and planning staff in Recovery in a psychosocial context - how to work with potential participant and what a recovery-focused NDIS plan should look like.
(with participant permission) bringing service providers in to the access and planning process as true partners, especially where a trust relationship exists and other natural supports are not available. The goal of this is to ensure that plans meet the Recovery needs of participants while also addressing disability issues.

ToR c. The development of the disability workforce to support emerging markets.

The issues surrounding the workforce for psychosocial disability are well documented. The MHCSA strongly believes that to deliver NDIS supports to participants living with psychosocial disability requires a skilled and trained workforce. In the words of one service provider “The sector has been working for over 15 years to build a strong workforce and the NDIS is driving an old reality, where the least qualified and skilled are being used for the most vulnerable.” The NDIS structure is driving the market down and the sector is forced to hire lower paid staff while our skilled workforce are moving on and often out of

9 MHCSA Submission: JSC- NDIS Market Readiness, February 2018

the sector altogether. This issue is compounded by the lack of certainty regarding CoS so employers cannot offer alternatives through CoS services.

The sector is working hard to drive costs down, but the pricing model simply does not consider wages beyond SCHADS level 2 and at best, 80% face to face time with participants. There is inadequate provision for staff supervision and training – both critical when working with this most vulnerable cohort.

Quote from a carer: “I had a lovely young man come to support my son who has schizophrenia, but he had to keep coming in to me and asking what he had to do next. I want a support worker who knows what they are doing…I’d rather pay for 3 hours of skilled service than 4 hours from someone who doesn’t understand my son’s mental illness and how to support him.”

Funding has been made available in South Australia for workforce development and NDIS Workface Hubs; however, these focus exclusively on disability workforce and supporting prospective work seekers into the Certificate 3 in Community Services, Individual Support qualification, which doesn’t address mental health in any way.

Skilled and experienced mental health support workers with an appropriate Certificate IV in Mental Health or Peer Work qualification in SA are facing an uncertain employment future with NDIS unless Pricing can allow employment of workers at SCHADS Level 4.

Over many years, the MHCSA has championed the development of the mental health workforce and in particular the “lived experience” or peer workforce. Evidence in existing mental health programs and feedback from consumers is that they want to be supported by someone who “gets” their story. NDIS is a tremendous opportunity to utilise the lived experience workforce, however the current pricing structure is too low to employ appropriately qualified and skilled lived experience workers.

Quality and safety in the current mental health service sector is underpinned by relevant quality assurance processes. Important components are training, supervision, professional supervision and ongoing professional development.

ToR c. Recommendations

Add an appropriate code and pricing to the NDIS Price Book for psychosocial and peer supports, using the SCHADS level 4 as the wage rate, adding in reasonable provision for supervision and on-going professional development.
Participant plans for psychosocial disability be focused on capacity building and Recovery, utilising the existing specialist mental health support and peer worker workforce.
Funding and plans for workforce development in the regions to have a reasonable focus on psychosocial disability and the requisite qualifications to provide the right workforce for NDIS participants living with psychosocial disability.

10 MHCSA Submission: JSC- NDIS Market Readiness, February 2018

ToR d. The impact of pricing on the development of the market.

The impact of current pricing for psychosocial disability supports is already well documented and the issues recognised by the Productivity Commission, The Parliamentary Joint Standing Committee and the writers of several reports (eg the NILS evaluation report). The concern is that action on recommendations will come too late. By the time prices are de-regulated the current mental health workforce will be decimated and while participants may seek skilled mental health workers, they won’t be able to find them.

Understanding the issues inherent in a change such as de-regulating pricing, the MHCSA suggests that an interim solution is to introduce a psychosocial supports and peer work price based on the SCHADS level 4 award rate. Participants then have the choice to engage this specialist but more expensive support, or not. This is also relevant for staff delivering group activity. An example from one provider –

Case example – Skylight Mental Health

The core rate and staffing ratios do not allow for staff with the skill set to effectively facilitate some of the emotional and behavioral needs of psychosocial participants. This could be rectified by only delivering “capacity building” groups, however, participants are not coming with this accounted for in their plans. A specific example would include Skylight’s Wayville activity program, which draws on the skill set of 1 SCHADS level 5 facilitator plus some lower level staff. This ensures the facilitation skills required to respond to and facilitate a self-leading group.

The greatest value in the NDIS is that plans and supports can be tailored to the individual participant’s needs and wants. This encourages innovation and a different relationship with the participant where they are the active driver of their supports. It is critical that choice and control includes the ability to choose a level of skilled support, without the price book making this choice increasingly untenable as providers stop absorbing the cost difference in offering supports from skilled and qualified staff. The Queensland Mental Health Commissioner, in his address at the recent National NDIS Conference in Sydney (2017) – said that when he reads the annual reports of service providers he can see their balance sheets continually being eroded and this is not sustainable.

Providers who also use HICAPS for primary care services suggested that NDIA could adopt measures that speed up the payment process. This would be especially helpful for small providers who are struggling to manage while waiting for payment. The case example below illustrates –

Financial systems to support -Quote from Uniting Care Wesley Bowden

“When we looked at the difference between the HICAPs and NDIS billing in our Psychology practice the differences were startling. A HICAPS transition takes on average around 3 minutes and the money is reimbursed in a short time frame, number of issues to follow up is very small. In contrast, the billing for NDIS using the portal was done weekly and took about 10 times longer for each customer. The rate of mistakes and difficulties in being paid is high and this takes additional time to sort out. The administration assistant was spending at least half a day a week to process payments and sort out issues for NDIS customers.”

11 MHCSA Submission: JSC- NDIS Market Readiness, February 2018

ToR d Recommendations

Review the pricing model to better reflect the need for adequate supervision and professional development.
Add an appropriate code and pricing to the NDIS Price Book for psychosocial and peer supports, using the SCHADS level 4 as the wage rate.
Plans to reflect the need for capacity building for psychosocial disability rather than core supports, making available the use of skilled and qualified psychosocial support and peer workers.

ToR e. The role of the NDIA as a market steward.

“The Market Approach outlines how the Agency will work with industry and the wider community, as Scheme stakeholders, to support major growth in the number, range and size of disability support providers and the services they offer. The Agency recognises that for businesses of all sizes and types to confidently and sustainably grow and innovate under the Scheme, they require as much clarity as possible about market development, including what they can expect from the Agency.” (NDIA, 2016)$^5$

The quote above indicates that the NDIA as market steward will work with the disability (including psychosocial disability or mental health) sector to ensure a vibrant market place. The role of the NDIA as market steward would be less problematic if they were not also responsible for pricing – to have responsibility for pricing as well as plan content for individual Participants is a conflict of interest. The MHCSA therefore supports the Productivity Commission recommendation that price regulation be transferred to an independent body by 1 July 2019$^{6}$

NDIA messaging does not always reflect the reality in the field, therefore there is a risk of cynicism in the market. It appears that the paradigm change to an open market is not always reflected in how the NDIA works with providers - – nothing has changed. Providers report receiving bureaucratic responses and political answers to questions. For example the DSS claim that 90% of Personal Helpers and Mentors Service (PHaMS) are likely to be eligible for NDIS supports has now been debunked in Senate Estimates where it had to be reported that approximately 30% is a more accurate percentage.$^7$ In line with this, providers would like to see more comprehensive and timely data – for example the proportion of people who are in DSS programs who test eligibility, who are successful, who are not successful and are subsequently in CoS for the duration of funding, and those who choose to disengage from the process.

$^{5}$ NDIA Annual Report 2016/17 https://annualreport.ndis.gov.au/supporting-a-growing-disability-market/establishing-the-ndia-as-market-steward/ $^{6}$ Productivity Commission (2017) National Disability Insurance Scheme Costs, Productivity Commission Study Report, October 2017. Commonwealth of Australia, Canberra. $^{7}$ Senate Community Affairs Committee: Answers to Estimates Questions of Notice – Health Portfolio. Ref SQ17- 001259. 2016-17 Of 800 PHaMS participants, 281 people were found to be eligible for NDIS – 35%

12 MHCSA Submission: JSC- NDIS Market Readiness, February 2018

The mental health sector has a deep commitment to our client group and would welcome a transparent working relationship with the NDIA and related organisations such as the Quality and Safety Commission when this is established.

ToR e Recommendations

That the NDIA review sector collaboration arrangements with view to a more transparent exchange, with the common goal of advancing the principles and objectives of the Scheme.
That oversight for pricing be transferred to an independent authority by 1 July 2019, with and interim measure of adding a psychosocial disability/peer work price, per item d above.
Consult with the mental health sector in relation to psychosocial disability plans and the likely financial impact of higher priced services. We know from experience that over time the need for support diminishes considerably, with the provision of skilled mental health support.

ToR f. Market intervention options to address thin markets, including in remote indigenous communities.

Obvious thin markets in SA are in regional and remote areas. Less obvious are where service provision has been available under block funding but where providers are seeing that they cannot offer effective service at NDIS prices for certain cohorts such as those with Exceptional Needs or multiple co- morbidities. As funding is transferred from existing services into NDIS, we expect the thin market issues to be exacerbated (see the case example below)

Case example from South East Junction in Mt Gambier

(SE Junction is a peer-led volunteer organisation in regional South Australia) “We are noticing a low number of successful access applications here in Mount Gambier and the Limestone Coast region from our service. Some of our participants diagnosed with schizophrenia and needing medication intake support have been rejected by the NDIS, so we are not sure what will happen now because if they are not taking their medication properly they might relapse and have to be admitted - increasing medical costs instead of decreasing them. For these people, continuity of supports other than NDIS is critical and must be established and funded as a matter of priority.”

We know that the NDIA Engagement Team have been working in remote regions of SA, however the result of that work is not yet apparent. Regional SA providers report that there is a lack of services across the regions and travel is prohibitive, especially given the current pricing structure. NDIS becomes an opportunity for innovation; however, plans will need to reflect a flexible approach to support. For example, peer mentoring and coaching by phone/internet where the peer mentor may or may not be an employee. At present, the Participant would have to self-manage to be able to utilise such a flexible service.

Data about thin markets should be shared across the NDIA, service providers, State Health Departments and Local Government, to enable effective strategies for NDIA and business planning for providers.

13 MHCSA Submission: JSC- NDIS Market Readiness, February 2018

ToR f. Recommendations

Consult with communities and regional service providers where they are covering wide geographical areas, to establish appropriate funding for travel, models to support a geographically diverse community.
In remote communities work directly with Elders and community to establish the best way to support people in their community. Provide adequate training and support resources for them to be work successfully within an appropriate cultural context.
Fund and focus on community development approaches where indicated within individual plans.
Consider “attraction packages” to support providers to locate in regional or remote communities.
Collaborate with local communities, provider and health services to ensure mainstream interfaces can occur.
Transparent reporting from the NDIA that enables the sector to make sound business decisions about whether and how they would like to address service delivery in thin markets – for example becoming a niche provider, partnering with communities to deliver services.

ToR h. The impact of the Quality and Safeguarding Framework on the development of the market.

The MHCSA values a national approach to quality; however, we are concerned that the Quality and Safeguarding Framework is silent on mental health. A review of available documents shows an almost exclusive focus on disability. For example, restrictive practices does not reference restrictive practice in mental health at all.

Current mental health services are provided in context of effective risk management while understanding both mental illness and resulting complexities for people most affected by their mental illness, for example providing peer support, supporting people to identify and address health needs which are so prevalent for people living with psychosocial disabilities. An audit process for the Quality and Safeguarding Framework must address mental health, for example meeting the National Mental Health Standards. The case study above in the ToR b section (page 7) clearly illustrates the skill needed to work with a cohort with complex need and behaviours. By having a specific focus on quality and safety for psychosocial disability, this can help define the boundaries and interface between disability and mental health services.

A review of the Draft Code of Conduct makes it clear that workers on the front line must be trained and qualified to deliver services and that they must comply with the Code of Conduct. This is entirely appropriate; however, remuneration must reflect the expectation placed on workers who are often supporting people with complex needs and behaviours. As mentioned previously, the current mental health workforce is skilled and trained and the MHCSA expects that a Quality and Safeguarding Framework would acknowledge and expect that level if skill for psychosocial disability supports.

14 MHCSA Submission: JSC- NDIS Market Readiness, February 2018

ToR h. Recommendations

Small service providers in particular, are financially supported to comply with the Quality and Safeguarding standards.
Pricing to reflect the cost of the Quality and Safeguarding requirements for staff training and experience.
The Quality and Safeguarding Framework must address psychosocial disability in a mental health context, with appropriate requirements in relation to delivery of Recovery focused psychosocial disability support and the interface between disability and mental health services.

ToR i. Provider of last resort arrangements, including for crisis accommodation

MHCSA supports the CMHA view that provider of last resort arrangements must be determined in consultation between the Commonwealth and State governments as a matter of priority and that these should link to continuity of support arrangements. As block funded services are de-funded and leave the market, the resources for provider of last resort arrangement also diminish.

As stated previously, NDIS should be an important element of the mental health system but it was never intended to replace it. It does present an opportunity to manage a long-term problem of timely, accessible and available services that has been an issue for a long time. For example in remote regions where services have been non-existent, we now have the opportunity to collaborate with communities and fund services appropriate to their needs. Those services could be provided as a Continuity of Support arrangement or through the NDIS depending on whether the service recipient is an NDIS Participant or not.

For CALD and other special needs groups, collaboration with those communities could establish innovative and culturally valid services that could be funded through NDIS or accessed through other elements of the mental health system.

Because LACs have a community engagement role, they are well placed to identify gaps in services that indicate a need for provider of last resort arrangement, perhaps reporting against this on a regular basis. In this way, the NDIA can see market gaps and work towards potential solutions in collaboration with market stakeholders (both provider and Participant).

ToR i. Recommendations

Provider of last resort arrangements to be determined between Commonwealth and State Governments and reflected in Full Scheme Bi Lateral agreements.
Published six monthly reporting from LACs about identified need where service providers could not be found, leading to planning around specific issues identified.
Rural and remote – work with communities to identify supports and support providers they want to work with, or training to provide supports themselves.

15 MHCSA Submission: JSC- NDIS Market Readiness, February 2018