22 February 2018
Joint Standing Committee on the National Disability Insurance Scheme PO Box 6100 Parliament House Canberra ACT 2600
By email to: ndis.sen@aph.gov.au
Dear Committee Secretary
Re: Market readiness of the National Disability Insurance Scheme
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) welcomes the opportunity to provide feedback to the Joint Standing Committee on the National Disability Insurance Scheme (the Committee) regarding the market readiness of the National Disability Insurance Scheme (NDIS). We value the ongoing consultative approach taken by the National Disability Insurance Agency (NDIA) and other stakeholders and we are pleased that concerns voiced by the RANZCP and others in the mental health sector are being increasingly heard.
The RANZCP is the principal organisation representing the medical speciality of psychiatry in Australia and New Zealand and is responsible for training, educating and representing psychiatrists on policy issues. The RANZCP represents more than 6000 members, including more than 4000 qualified psychiatrists, and is guided on policy matters by a range of expert committees and esteemed psychiatrists.
As the peak body representing psychiatrists in Australia, the RANZCP has been closely monitoring the design and implementation of the NDIS and has contributed to numerous consultations, including the Productivity Commission’s study into NDIS Costs (March 2017) as well as the following Committee inquiries:
- Transitional arrangements for the NDIS (August 2017)
- Provision of services under the NDIS Early Childhood Early Intervention approach (August 2017)
- Provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition (February 2017)
The RANZCP supports the principles of the NDIS. We believe that the NDIS has the potential to improve the lives of many people and contribute to the formation of a more inclusive and prosperous society overall. In vesting choice and control in the hands of consumers, the NDIS will help to encourage person-centred and recovery-oriented approaches to care across the sector. These principles are recognised by the RANZCP to be crucial in the provision of best-practice care.
309 La Trobe Street, Melbourne VIC 3000 Australia
T +61 3 9640 0646 F +61 3 9642 5652
ranzcp@ranzcp.org www.ranzcp.org
ABN 68 000 439 047
In order for this potential to be realised, the experiences and support needs of people with psychosocial disability, as well as their families and carers, must be addressed, to ensure that they are appropriately prepared to navigate the new scheme. The RANZCP therefore urges serious consideration of the NDIS’ capacity to support people with psychosocial disability in recognition of the broad concerns of the mental health sector that there is a fundamental disconnect between the approach of the NDIS and the experiences of people with psychosocial disability.
For these reasons, the RANZCP was pleased to note Recommendation 4.4 in the Productivity Commission’s Report which recommends a psychosocial gateway be created as the primary pathway for people with psychosocial disability to enter the NDIS. The RANZCP believes that, if implemented well, the creation of a psychosocial gateway could herald significant benefits for people with psychosocial disability who currently experience a range of challenges in accessing funds under the NDIS. In the RANZCP’s view, it is essential that this gateway be implemented such that it does not become a barrier to access for people with psychosocial disability, or a way of funnelling or restricting access to NDIS funds. The primary function of this gateway should be facilitating access to the NDIS by tailoring processes to the needs of people with psychosocial disability.
Please see the attached submission for our detailed responses to the terms of reference. If you would like to discuss any of the issues raised in the attached submission, please contact Rosie Forster, Senior Department Manager, Practice, Policy and Partnerships via rosie.forster@ranzcp.org or by phone on (03) 9601 4943.
Yours faithfully
Dr Kym Jenkins President
Ref: 1006o
Joint Standing Committee on the National Disability Insurance Scheme’s Inquiry into the market readiness of the National Disability Insurance Scheme
February 2018
improving the mental health of the community
309 La Trobe Street, Melbourne VIC 3000 Australia
T +61 3 9640 0646 F +61 3 9642 5652
ranzcp@ranzcp.org www.ranzcp.org
ABN 68 000 439 047
About the Royal Australian and New Zealand College of Psychiatrists
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is a membership organisation that prepares doctors to be medical specialists in the field of psychiatry, supports and enhances clinical practice, advocates for people affected by mental illness and advises government on mental healthcare. The RANZCP is the peak body representing psychiatrists in Australia and New Zealand and as a binational college has strong ties with associations in the Asia-Pacific region.
The RANZCP has almost 6000 members including more than 4000 fully qualified psychiatrists and over 1500 members who are training to qualify as psychiatrists. Psychiatrists are clinical leaders in the provision of mental healthcare in the community and use a range of evidence-based treatments to support a person in their journey of recovery.
Introduction
The RANZCP is pleased to provide a written submission to the Joint Standing Committee on the National Disability Insurance Scheme (NDIS) regarding the market readiness of the NDIS. We value the ongoing consultative approach taken by the National Disability Insurance Agency (NDIA) and other stakeholders, and commend the government for its continued commitment to implementing the NDIS at a time when the imperative is to reduce national spending.
The RANZCP supports the establishment of the NDIS in principle. We believe that the NDIS has the potential to improve the lives of many people and contribute to the formation of a more inclusive and prosperous society overall. In vesting choice and control in the hands of consumers, the NDIS will help to encourage person-centred and recovery-oriented approaches to care across the sector. These principles are recognised by the RANZCP to be crucial in the provision of best-practice care.
However, in order for this potential to be realised, the experiences and support needs of people with psychosocial disability, as well as of their families and carers, must be addressed. The RANZCP has been concerned for some time regarding the capacity of the NDIS to accommodate people with psychosocial disability in its approach, funding and scope, reflecting broad concerns in the mental health sector that there is a fundamental disconnect between the approach of the NDIS and the experience of mental illness. In particular, the RANZCP believes that people with psychosocial disability require tailored supports to apply for the NDIS, to develop their individually funded packages (IFPs) and to achieve suitable outcomes. As such, while the RANZCP broadly supports the NDIS, we maintain that further work is needed to adequately address the psychosocial needs of Australians with disability.
a. the transition to a market based system for service providers
Connecting participants with providers
While the RANZCP welcomes the potential of the NDIS to improve the capacity of people with disability to choose their own service providers, we also recognise that choosing between different options may not always be straightforward. Once needs have been identified, many individuals and their families and carers expect a list of service provider recommendations. The RANZCP does not believe that one NDIS provider should be recommended over another. However, it would be advantageous for information about services to be available to NDIS participants as well as their families, carers and health professionals, so that they can work together to make appropriate decisions about care. To achieve this, the RANZCP supports the NDIA’s ‘Find a Provider’ project, and suggests that it would be useful to include consumer feedback on service providers on this platform.
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A market-based based system for people with intellectual and developmental disabilities?
While the RANZCP broadly welcomes the transition to a market-based system for service providers, we are concerned about the readiness of such a system to accommodate people with complex needs, particular those with intellectual and/or developmental disabilities (IDD) and comorbid mental health conditions. We believe that, in the case of market failure, the NDIS should fund the development of providers of last resort including for the treatment of people with complex needs associated with IDD.
While the RANZCP appreciates that the NDIS is not intended to provide the full range of services required by this population, we are concerned that the reliance on the disability sector to provide services via a market-based system leads to fragmented service delivery with a lack of governance, accountability and responsibility for ensuring the person’s needs are met. In short, people with complex needs associated with IDD urgently require an integrated service model which a devolving disability sector is unlikely to provide. Relying on the continued cooperation between the disability, mental health and justice sectors is also unlikely to provide the kind of holistic support required.
Approximately 10–15% of people with IDD have frequent and high-risk problem behaviours such as aggression and self-harm. They are often socially isolated, excluded from normal activities, subjected to restrictive practices, provided with inappropriate treatments, all the while being at increased risk of abuse. IDD are out of scope for mental health service providers and justice services are often unwilling to pursue matters. Disability service providers have long struggled to manage this population although they are often not adequately skilled to deal with their complex needs. People with IDD urgently require the development of an integrated service model. In the RANZCP’s view, the transition to the NDIS provides a unique opportunity to get the right policies in place for this group.
Under the NDIS, many people with IDD have been unable to find appropriate service providers. This is no surprise given the systemic difficulties in meeting the needs of this population as highlighted in the media recently with reports of long-term incarceration of people with IDD in both forensic and health settings due to the lack of appropriate placements. In addition to the inappropriate settings which are currently being used to cater for people with IDD, some service providers are not willing to work with many people with concurrent IDD and high-risk problem behaviours due to the risks of harm to staff and the general public. Organisations may also rely on high staff-to-client ratios for safety reasons, but this is costly, ineffective and inefficient as it lacks the capacity to engineer change.
The RANZCP is therefore concerned that the transition to a market-based system is not going to result in the development of specialist services for people with IDD without additional support. What is needed is an integrated service model with a skilled workforce, appropriate facilities and an infrastructure which addresses issues of governance and accountability. The RANZCP would welcome further discussions on how best to manage the complex needs of this population group.
b. participant readiness to navigate new markets
Accessing the scheme
The RANZCP believes that NDIS eligibility criteria present a significant barrier for people with psychosocial disability who would benefit from accessing the scheme. This is because access to supports under the NDIS depends on an applicant’s ability to show that their disability is permanent or likely to be permanent. However, disability permanence is not something that a significant proportion of people with psychosocial disability would want or be able to acknowledge. Eligibility criteria that rely on disability permanence therefore exclude many people with psychosocial disability who refuse to seek, or
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withdraw applications for, NDIS funds which are predicated upon their acceptance of the lifelong nature of their illness.
This is also a problem for mental health professionals who are required to provide evidence of their patient’s disabilities to help them to gain access to the NDIS. Many mental health professionals are not comfortable stating the likelihood of permanency in relation to a psychosocial disability. In addition to being difficult to gauge, the language of ‘permanence’ simply does not fit with the recovery-oriented approach of the mental health sector. This does not necessarily mean that a person’s disability is not enduring enough to merit lifelong care, only that labelling a patient’s disability as ‘permanent’ is often counterproductive to recovery goals and may threaten the therapeutic relationship. In other words, a focus on disability permanence may actually aggravate the underlying condition. The RANZCP would therefore suggest an approach to eligibility that focuses more on enduring functional impairment rather than disability permanence.
In the absence of a change in eligibility criteria, the RANZCP would welcome clarification regarding how the NDIS will accommodate people with psychosocial disability who do not recognise their eligibility for the NDIS. Although not a replacement for appropriate eligibility criteria, consideration should be given to outreach services and improved referral pathways for healthcare providers to refer consumers to the NDIS in instances where this is the most realistic way to link them with supports. Currently, there are limited options for healthcare providers to directly refer eligible participants to the NDIA. In many instances, the first point of contact for people with psychosocial disability is a health service, so optimising access pathways is essential to ensuring that health practitioners can support the application process to be as quick and seamless as possible.
Community awareness
The majority of NDIS communication is online while the proportion of consumers with severe mental illness who have an internet connection at home is thought to be quite low. This might be particularly so in rural and remote regions. Furthermore, people with psychosocial disability generally have much lower than average incomes and lower rates of schooling and employment. People with psychosocial disability may therefore face the double barriers of low literacy and lack of access to information technology. People with prolonged and severe mental illness are also more likely to lack contact with family, carers and other support networks who could assist them.
The RANZCP therefore supports the development of a range of information platforms that are accessible and user-friendly. The Purple Orange project is a good example of how an online platform can be used to empower participants to manage their own care, share information and engage with the NDIS meaningfully. The RANZCP also encourages the trial of ‘expos’, as described in the NDIS Quality and Safeguarding consultation paper, as a way to reach individuals without internet access.
Practitioner awareness
Many mental health professionals are not adequately familiar with NDIS systems and processes, nor the associated resource and eligibility requirements. The RANZCP has therefore welcomed news that Mental Health Australia will be working with the NDIA to develop educational resources for mental health practitioners. The RANZCP will be involved in this process in the understanding that psychiatrists and other practitioners require greater clarity on NDIS processes and requirements, including appropriate terminology and information about how the NDIS interprets psychosocial disability with regard to various mental health conditions.
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The application process
Many people with psychosocial disability are not able to initiate the NDIS application, even if they have access to computers and are computer-literate. The application process is complex and difficult to navigate, particularly for people with cognitive difficulties. This presents a kind of catch-22 scenario whereby people with psychosocial disability require supports to complete their applications, but they cannot access those supports without their applications being approved.
Health professionals face their own barriers in supporting patients to fill out NDIS application forms including a lack of understanding of the process and their role within it, limited familiarity with some patients, and time constraints. Furthermore, although health professionals are required to provide evidence in the application process, the Council of Australian Governments’ Principles to Determine the Responsibilities of the NDIS and Other Service Systems distinguishes between preliminary assessment and disability diagnosis, which is to be funded via the health sector, and ‘further assessment’ which may be funded via the NDIA. This presents an additional obstacle for health professionals in supporting people with psychosocial disability trying to access the NDIS. Completing paperwork requirements may take hours of work and it is unrealistic to expect the mental health sector to absorb these additional resources without additional resources. The mental health sector is already significantly underfunded and patients often do not have funds to pay for additional specialist services. Where health professionals are not remunerated for these additional work requirements, they will do their best, but time constraints mean that some patients will not be adequately supported to complete their applications. As a result, forms may be completed incorrectly, or not all. This not only compromises the effectiveness and efficiency of the system but may actually aggravate underlying psychosocial problems.
Particularly in the private sector, psychiatrists may face even more time pressures and may struggle to obtain and provide all the necessary information to support an application for the NDIS. In the public sector, patients will sometimes have the benefit of case managers, often nurses or allied health practitioners, who have the necessary resourcing to support the application process and liaise with NDIS providers or groups to ensure that all necessary supporting documentation is available. Whether through public sector case managers, support agencies or appropriately funded private practitioners, the provision of human resources to facilitate the application process is essential to ensuring people with psychosocial disability have equitable access to the NDIS, while also supporting the system to function as smoothly as possible.
Needs identification
In order to support people with psychosocial disability to properly identify their own needs and goals, the planning process should be tailored to include multiple sessions with a single planner, and with additional avenues for carer and clinicians to have input into the process.
For people with psychosocial disability, getting the balance right between consumer-driven care and meeting complex needs can be difficult. The NDIS system of service provision is predicated on a rational choice model which is unlikely to work for people with psychosocial disability in the same way that it works for people with physical disability. This is because people with psychosocial disability may have difficulty in identifying their support needs for a number of reasons including a lack of insight into their needs which may be a symptom of the illness itself, the experience of stigmatisation leading to a desire to avoid association with a particular label, or the experience of having a diagnosis change over time which can lead to a lack of faith in the capacity of labels to adequately represent lived experience.
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People with psychosocial disability are also likely to have highly individuated needs. The introduction of the NDIS, as a scheme premised on person-oriented care via self-managed care plans, may therefore be particularly momentous for this group of people. The mental health sector has a deep appreciation that one size does not fit all, and therefore also a recognition of the significant benefits which a focus on maximising choice and control may provide. However, a person’s readiness to articulate their goals and engage with the process of developing an IFP should never be presumed. Expecting this to be achieved by all people with psychosocial disability in a single meeting, at a predetermined time, will, in many cases, not produce good outcomes. In this way, the need for plans to be individualised is even greater for many people with psychosocial disability – so great that it requires this individuation to begin before the planning meeting.
To truly support people with psychosocial disability to actively engage in their care planning requires long-term engagement which is flexible enough to balance the individual’s preferences with proactive outreach when required. This long-term focus will encourage the development of a trusting relationship without which there would be little hope of meaningful engagement. Taking the time to engage with a person in this way allows for needs to be identified organically while the person’s condition is stabilised. Only as this happens will it be possible to build their capacity to identify and articulate treatment preferences and long-term support needs. This is the point at which a planning conversation should be had to match the individual’s goals with the support options available under the NDIS. When it does occur, carer and clinical input will be essential to ensure NDIA staff can come to a well-rounded view of the person’s needs. It is also important that the NDIA staff involved in the process have suitable training to be able to work with people with psychosocial disability.
A worker will not always be required to facilitate this ongoing planning process given the considerable support provided to people with psychosocial disability through the formal and informal sectors. Often, mental health clinicians, carers and family members perform this function. Where this is the case, NDIS funds may still be necessary to support these functions and to ensure that the disability, mental health and/or justice needs of the individual are not unduly aggravated in preparation for the planning process. Where informal carers are not available, additional funds for a support worker will be required. The only alternative is to force people with psychosocial disability to follow the same process as people with physical disability. For many, this will mean planning conversations will occur before they are ready to participate in them, and this runs entirely counter to the purpose of the NDIS to facilitate people’s engagement in decisions regarding their lives.
Support items
Further work is required to ensure that support services provided under the NDIS are adequately tailored to the needs of people with psychosocial disability. A range of additional supports have been suggested by Mental Health Australia in the final report of the Psychosocial Supports Design Project (MHA, 2016), enumerated in ‘2.2.4 Options for additional support items with a plan’. The RANZCP fully supports these suggestions and would welcome further information about the scope of supports provided to NDIS participants with psychosocial disability.
Carers
Often, people with psychosocial disability will be supported by an informal carer or family member fulfilling an unpaid caring role. Given the important contribution carers make to the community, the economy and their families, the RANZCP believes that carers should have the opportunity for a separate
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planning meeting under the NDIS so that their views of their care recipient’s needs, as well as their own, can be factored into the process. The RANZCP maintains that it is essential that carers be more fully integrated into the NDIS model to ensure that they receive targeted supports to meet their and their care recipient’s needs.
c. the development of the disability workforce to support the emerging market
NDIS participants with psychosocial disability are likely to have significant health comorbidities. The development of a suitability skilled disability workforce will therefore need to enhance practitioner knowledge about mental health and disability. Often, staff within the disability system, particularly within nongovernment organisations, lack the necessary skills and expertise to assess and manage complex presentations associated with difficult behaviours in people with psychosocial disability, particularly IDD. They often do not have the time to support their clients with complex application forms nor the knowledge about complex NDIS operations. They are also often unable to access appropriate resources or implement strategies recommended by external service providers. Considerable education initiatives will be required to ensure that disability workers have the appropriate skills and expertise to support clients with complex psychosocial needs.
It is also worth noting the undersupply and geographical maldistribution of psychiatrists across the country. For this reason, many individuals will not have established relationships with psychiatrists, particularly in rural and remote areas. Supporting the development of the psychiatric workforce will ensure that people with psychosocial disability will have access to psychiatric services which may be required to support NDIS processes including the collection of evidence to support applications and the provision of integrated health services.
References
Council of Australian Governments (2015) Principles to Determine the Responsibilities of the NDIS and Other Service Systems. Available at: www.coag.gov.au/sites/default/files/communique/NDIS-Principles-to-Determine-Responsibilities-NDIS-and-Other-Service.pdf (accessed 6 February 2018).
Mental Health Australia (2016) Psychosocial Supports Design Project – Final Report. Available at: https://mhaustralia.org/sites/default/files/docs/psychosocial_supports_design_project_final_-_july_2016.pdf (accessed 30 January 2018).
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