Submission 107 — Suncorp — The provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition

3 March 2017

Joint Standing Committee on the National Disability Insurance Scheme

PO Box 6100

Parliament House

CANBERRA ACT 2600

By email: ndis.sen@aph.gov.au

RE: THE PROVISION OF SERVICES UNDER THE NATIONAL DISABILITY INSURANCE SCHEME FOR

PEOPLE WITH PSYCHOSOCIAL DISABILITIES RELATED TO A MENTAL HEALTH CONDITION

I refer to the Inquiry into the provision of services under the National Disability Insurance Scheme (NDIS) for people with psychosocial disabilities related to a mental health condition (The Inquiry). Suncorp welcomes the opportunity to contribute to the discussion.

Executive Summary

In respect to the NDIS offering services for psychosocial disability, Suncorp offers the following comments:

1. Suncorp has an interest in promoting the success of publically underwritten disability schemes as the success of these schemes, working together with outcome based competitively underwritten personal injury schemes, should form part of a holistic package aimed at fostering social and financial independence early after a medical or injury event;

2. NDIS should be based on insurance principles, with clearly defined entry points into the scheme, acknowledging that psychosocial disability represents a challenging area for eligibility policy settings;

3. To foster a financially sustainable NDIS, the process in establishing psychosocial disability eligibility for individually funded packages (IFP) must be objective, measurable and supported by a cost effective dispute resolution process;

4. To reduce the demand for IFP, it is crucial that health/mental health schemes develop and apply nationally consistent best practice procedures to detect and treat mental illnesses earlier to avoid or reduce ongoing psychosocial disability;

5. In supporting the above point, there should be an active community awareness campaign on the benefits of early detection and treatment of mental health issues – noting the general stigma, mistrust and fear in the community about these conditions;

6. It is in NDIS’ interest to develop deep collaborative ties and data sharing with government departments responsible for the delivery of health/mental health services; income replacement, employment and vocational services; accommodation services and non NDIS disability services (collectively described as front line services) to ensure services are delivered in a timely manner on the basis of trauma informed care,1 noting that recovery cannot realistically commence until the person is in receipt of appropriate

1 Mental Health Australia – Trauma informed practice, 12 June 2014 - https://mhaustralia.org/general/trauma-informed-practice

mental and physical health care, has a stable income, accommodation, and a support person to coordinate the care;

7. For those developing symptoms, if after delivery of front line services for a nominated period, significant ongoing psychosocial disability exists, acceptance for IFP through the early intervention pathway should be considered; and

8. For those with existing psychosocial disability, adopting the interim participant model used by National Injury Insurance Scheme (NIIS) type schemes, might be an effective way to boost social and financial independence without the need of becoming a lifetime participant.

Suncorp

Suncorp offers a range of financial products and services including banking, general insurance, compulsory third party (CTP) insurance, workers’ compensation insurance, life insurance and superannuation across Australia and

New Zealand

Suncorp has about 13,500 employees and relationships with nine million customers. Suncorp is a top 20 ASX listed company with $96 billion in assets.

Suncorp provides a wide range of insurance products to small and medium sized businesses as well as to

corporate  customers.   These  products  are  distributed  nationally,  both  directly and  indirectly,  through

intermediaries.

Suncorp provides workers compensation insurance  in most available jurisdictions around Australia.  CTP

insurance is provided in New South Wales, the Australian Capital Territory, Queensland and South Australia.

The key to Suncorp’s success in insurance is its portfolio of well-known insurance brands - AAMI, GIO, Suncorp, Vero, Apia and Shannons are some of the brands in the Suncorp Group that have built reputations for insurance innovation and customer service.

Suncorp has consistently taken a leadership role within the industry to advocate necessary reform to personal injury statutory schemes. We have published a number of white papers on the issues of competitive underwriting, scheme design and no-fault lifetime care. As Australia’s largest private personal injury insurer, we take this role seriously and will continue to support reform that improves the lives of our customers. Copies of these white papers are available upon request.

This submission is made on behalf of Suncorp’s Personal Injury Portfolio and Products division.

Suncorp in the Community

Suncorp’s community-focused activity is centred on risk management, injury prevention, social participation and quality of care for those who are injured or have a disability. We value the communities in which we live and work, and have entered into partnerships with a range of organisations that are also dedicated to making a difference in the lives of people who have been affected by personal injury.

Our community partners include Youngcare, Adapted Physical Activity Program, James Cook University, Advance

Queensland, Queensland Police, RYDA and Fatality Free Friday. Suncorp also works with youth education initiatives such as the P.A.R.T.Y. Program and has a partnership with the Driver Education Centre of Australia, which aims to address some of the root causes of severe personal injury on Australian roads.

2

Our charity partner is ReachOut.com, Australia’s leading online mental health organisation for young people, providing practical support to help them get through anything from everyday issues to tough times. With most mental health problems emerging before the age of 25 years, and 75 percent of young people who experience issues not receiving help, prevention and early intervention strategies are vital to ensure symptoms do not progress to full blown mental illness and to promote earlier social and financial independence.

The National Disability Insurance Scheme

Suncorp continues to be a keen advocate for the publically underwritten NDIS and NIIS, as recovery based models underpinned by insurance principles. Insurance principles require –

 actuarially estimating the cost of reasonable and necessary supports of the target population;  minimising support costs over a participant’s lifetime - by investing in people early to build their capacity to help them pursue their goals and aspirations resulting in greater outcomes later in life;  investing in research and encourage innovation; and  providing support to the general population ineligible for IFP through its Information Linkages and Capacity Building (ILC) program.

The NDIS (and NIIS) is a social welfare scheme, aimed at maximising social and financial independence early in a person’s lifetime. Suncorp maintains that social welfare schemes such as the NDIS and NIIS are best served in a publically underwritten environment.

This is because of the lifetime nature of the services required. Insurers would be obliged to hold a large amount of capital for a considerable amount of time to pay for these services. This would ultimately make the services unaffordable.

In respect to statutory personal injury schemes, it is Suncorp’s position that non catastrophic type claims are better

served in a competitive underwritten environment.2  Further,  it is Suncorp’s view that statutory scheme design

should be based on a recovery model,3 similar to that used in the NDIS and NIIS.

A recovery model better supports people becoming socially and financially independent earlier after a medical or trauma event. It also better supports the Federal Government’s initiatives to counter the productivity challenges facing Australia due to its ageing workforce moving into retirement.4

Cover Offered by the NDIS

The NDIS offers three levels of cover. It is important to understand the intent of each level of cover, as they have a role to ensure the financial sustainability of the scheme as a whole. The three levels of cover include:

 Tier one - building community awareness of disability issues Intending to cover all Australians with public awareness campaigns and the provision of information to support purposeful integration of mainstream and other services.

 Tier two – ILC - basic information and referral advice

2 Suncorp – Insurance Insights, States in the injury business, November 2014 http://www.suncorpgroup.com.au/sites/default/files/pdf/news/States%20in%20the%20injury%20business%20-%20Suncorp%20white%20paper%20Nov%202014.pdf 3 Suncorp – Insurance Insights, The mechanics of motor injury schemes, October 2013 4 The Australian Government Treasury – 2015 Intergenerational Report, 5 March 2015 http://www.treasury.gov.au/PublicationsAndMedia/Publications/2015/2015-Intergenerational-Report

3

Intending to cover about four million people with a disability and 800,000 of their primary carers by better linking individuals to mainstream supports; assisting services to be more inclusive and responsive to needs and directing investment towards evidence based interventions that improve outcomes for the individual.5

 Tier three - developing and funding a personal support plan for people with a disability. Intending to cover about 430,000 people with the aim of fostering social and financial independence earlier in the participant’s lifetime.6

In providing the three tiers of cover, it is essential that the National Disability Insurance Agency (NDIA) develops deep collaborative ties and data sharing with government departments responsible for front line services. NDIS was never meant to cover the delivery of these services.

However, the financial sustainability of the NDIS relies heavily on the early and effective delivery of appropriate front line services to those living with a mental condition. The aim is to reduce or stop the progression of psychosocial disability in the first place.

Further, for these services to be delivered effectively, there is a good argument that the delivery of front line services should be based on the principles of trauma informed care.7 This requires appropriate policy settings to ensure delivery of front line care and services are individually tailored and outcome based.

Recovery cannot realistically commence until issues of stable health care,8 income replacement and accommodation are resolved. Recovery in the context of mental illness does not equate with cure and the elimination of impairment and disability. Rather, it is about “living a life of optimal wellbeing despite the impact of the illness.”9

In respect to psychosocial disability, the delineation of services offered by NDIS and the health/mental health schemes will not always be clear. For instance, the current differentiation between clinical and social support is coming under pressure, as Australia’s mental health system starts to reorient towards hospital avoidance and community support.10 In reality those living with psychosocial disability require holistic integrated services to maximise social and financial outcomes and the support11 needs to be deployed early.

The Magnitude of Mental Health Issues in Australia

One in five Australians aged 16 to 85 years will experience a mental health disorder each year and almost half will experience a mental health disorder in their lifetime.12 Of concern is that

5The National Disability Insurance Scheme and Mental Health in NSW - Navigating the NDIS: Lessons Learned through the Hunter Trial, July 2016, at page 26 - http://www.mhcc.org.au/media/85852/ndis_lessons_final_301116.pdf 6 Productivity Commission, Disability Care and Support, Report no. 54, Productivity Commission, Canberra, 2011; Mental Health in NSW Navigating the NDIS: Lessons Learned through the Hunter Trial, July 2016, at page 7 http://www.mhcc.org.au/media/85852/ndis_lessons_final_301116.pdf 7 Mental Health Australia – Trauma informed practice, 12 June 2014 - https://mhaustralia.org/general/trauma-informed-practice 8 National Disability Insurance Agency and Mental Health Australia - Psychosocial Supports Design Project – Final report, April 2016, at pages 11 & 77 to 81- https://mhaustralia.org/sites/default/files/docs/psychosocial_supports_design_project_final_-_july_2016.pdf 9 Paul O’Halloran, MHINDS - About Psychosocial Disability and the NDIS, Introduction to the Concept of Holistic Psychosocial Disability Support, at page 15 - https://www.ndis.gov.au/html/sites/default/files/O’Halloran%20paper.pdf 10 National Disability Insurance Agency and Mental Health Australia - Psychosocial Supports Design Project – Final report, April 2016, at pages 11 & 80- https://mhaustralia.org/sites/default/files/docs/psychosocial_supports_design_project_final_-_july_2016.pdf 11 National Disability Insurance Scheme - Tips for Communicating about Psychosocial Disability, August 2016 at page 8 https://www.ndis.gov.au/medias/documents/ha5/h5b/8797799415838/Completing-the-access-process-for-the-NDIS-Tips-for-communicating-about-psychosocial-disability-PDF-KB-.pdf 12 Australian Government, The Department of Health – Draft Fifth Mental Health Plan, at page 12 http://www.health.gov.au/internet/main/publishing.nsf/content/8F54F3C4F313E0B1CA258052000ED5C5/$File/Fifth%20National%20Mental%20Health%20Plan.pdf; Final Report of the Reference Group on Welfare Reform to the Minister for Social Services - A New System for Better Employment and Social Outcomes, February 2015, at page 70 https://www.dss.gov.au/sites/default/files/documents/02_2015/dss001_14_final_report_access_2.pdf

4

 most people will be 25 years of age or younger on the first onset of symptoms with 75 per cent not receiving help;13 and  less than half of people living with mental health issues access treatment each year - with untreated mental illness incurring major personal suffering and economic costs.14

It is reported that mental illness costs Australia around four percent of gross domestic product or about $4000 for every taxpayer and costing the economy more than $60 billion a year.15 In 2009, it was reported that schizophrenia and other psychoses, which only affect one to two percent of the adult population, accounts for about 80 percent of Australia’s spend on mental health care, due to complex service needs over a long period.16

The lack of early detection and treatment possibly adds to the problem. Developing nationally consistent and effective best practice procedures to detect and treat psychotic type conditions earlier is required to address this problem.

Much of the statistics quoted come from the 2007 National Survey of Mental Health and Wellbeing, conducted by the Australian Bureau of Statistics. However, in its 1017-18 pre-budget submission, the Insurance Council of Australia recommended funding for an updated national survey to better understand the prevalence of mental conditions in our community.17

Suncorp supports this recommendation but considers the funding should be expanded to specifically determine the level of psychosocial disability in our community. It is important that policy settings identify those in the community with unmet psychosocial disability support needs. The NDIS trials reveal that up to 58 percent of people found to be eligible for IFP had not been in receipt of government services.18

Further, it is unclear how many people with psychosocial disability applying for IFP were found to be ineligible and/or ‘choosing’ not to apply.19 In any event, from what we do know, there appears to be a level of stigma, mistrust and fear in the community in seeking treatment, which needs addressing.

Not everyone with a mental illness will experience psychosocial disability.20 People living with psychosocial disability must satisfy the eligibility rules to access IFP.21 The eligibility assessment for IFP is not based on a diagnosis but rather on functional capacity.22 However, a psychosocial disability for the purposes of IFP must be related to a psychiatric condition.23

To consider how psychosocial disability should be incorporated into the NDIS, it is important to understand the nature of psychosocial disability. Understanding psychosocial disability will better inform the policy settings required to ensure NDIS access and services are applied appropriately and consistently.

13 ReachOut.dot com 14 Australian Government, The Department of Health – Draft Fifth Mental Health Plan, at page 12 http://www.health.gov.au/internet/main/publishing.nsf/content/8F54F3C4F313E0B1CA258052000ED5C5/$File/Fifth%20National%20Mental%20Health%20Plan.pdf 15 Australian Government, National Mental Health Commission - Economics of Mental Health in Australia, 8 December 2016 http://www.mentalhealthcommission.gov.au/media-centre/news/economics-of-mental-health-in-australia.aspx 16 Australian Government, The Department of Health – The magnitude of the problem https://www.health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-f-plan09-tocmental-pubs-f-plan09-conmental-pubs-f-plan09-con-mag 17 Insurance Council of Australia, Pre-budget submission, 19 January 2017 – at page 4 http://www.treasury.gov.au/~/media/Treasury/Consultations%20and%20Reviews/Consultations/2016/2017%20PreBudget%20submissions/Submissions/PDF/Insurance%20Council%20of%20Australia.ashx 18 The National Disability Insurance Agency Mental Health Sector Reference Group, Sector Communique, October 2016, at Appendix A Key Data on Psychosocial Disability and the NDIS as at 30 June 2016 - https://www.ndis.gov.au/NMHSRG-October-2016.html 19 The National Disability Insurance Scheme and Mental Health in NSW - Navigating the NDIS: Lessons Learned through the Hunter Trial, July 2016, at page 24 - http://mhcc.org.au/media/85852/ndis_lessons_final_200117.pdf 20 The National Mental Health Consumer and Carer Forum - Understanding psychosocial disability, Issue 11, Summer 2014, at page 12 https://nmhccf.org.au/sites/default/files/docs/nmhccf_article-issue_111.pdf 21 National Disability Insurance Agency and Mental Health Australia - Psychosocial Supports Design Project – Final report, April 2016, at page 84 - https://mhaustralia.org/sites/default/files/docs/psychosocial_supports_design_project_final_-_july_2016.pdf 22The National Disability Insurance Scheme and Mental Health in NSW - Navigating the NDIS: Lessons Learned through the Hunter Trial, July 2016, at page 6 - http://www.mhcc.org.au/media/85852/ndis_lessons_final_301116.pdf 23National Disability Insurance Agency and Mental Health Australia - Psychosocial Supports Design Project – Final report, April 2016, at page 84 - https://mhaustralia.org/sites/default/files/docs/psychosocial_supports_design_project_final_-_july_2016.pdf

5

Psychosocial Disability

Psychosocial disability resulting from a mental health condition is not widely understood.24 However, the available literature describes the term ‘psychosocial disability,’25 the impact it has upon people living with this type of disability,26 noting it is complex in nature.

Essentially psychosocial disability impacts a person’s ability to navigate the daily routine of living.27 A key thread is a deficit in working memory due to cognitive impairment. A deficit in working memory makes negotiating even simple daily activities problematic, including:

 daily routines;  personal care;  treatment compliance;  household chores such as shopping, cooking, cleaning and maintenance;  Centrelink obligations to secure steady income replacement;  managing finances;  socialising; and  keeping appointments.28

Without an advocate or support person, a person living with psychosocial disability is at risk of falling through the gaps of well-meaning support initiatives and left in a spiral of poverty and homelessness with a loss of life expectancy of up to 25 years, due to untreated physical conditions.29

A complicating factor is that people living with psychosocial disability may also experience anosognosia.30 Anosognosia is a lack of insight or awareness of their mental illness. It represents the single most common reason why those living with a psychotic disorder do not take their medications, significantly impacting upon recovery and functionality.31

The biggest challenge for the NDIA, apart from the under – developed front lines services32 to detect, treat and support a person through the acute stages of a mental illness early - is to ensure consistent application of the rules in respect to -:

 access to IFP; and  reasonable and necessary support.

24 The National Mental Health Consumer and Carer Forum - Understanding psychosocial disability, Issue 11, Summer 2014, at page 13 https://nmhccf.org.au/sites/default/files/docs/nmhccf_article-issue_111.pdf; National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014, Paragraph 1, Introduction https://www.ndis.gov.au/about-us/governance/IAC/iac-advice-mental-health.html 25The National Disability Insurance Scheme and Mental Health in NSW - Navigating the NDIS: Lessons Learned through the Hunter Trial, July 2016, at page 6 - http://www.mhcc.org.au/media/85852/ndis_lessons_final_301116.pdf; National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014, Paragraph 1, Introduction - https://www.ndis.gov.au/about-us/governance/IAC/iac-advice-mental-health.html 26The National Disability Insurance Scheme and Mental Health in NSW - Navigating the NDIS: Lessons Learned through the Hunter Trial, July 2016, at page 6 - http://www.mhcc.org.au/media/85852/ndis_lessons_final_301116.pdf 27 Paul O’Halloran, MHINDS - About Psychosocial Disability and the NDIS, Introduction to the Concept of Holistic Psychosocial Disability Support, at page 16 - https://www.ndis.gov.au/html/sites/default/files/O’Halloran%20paper.pdf 28 National Mental Health Consumer and Carer Forum - Understanding psychosocial disability, December 2014 at page 12 https://nmhccf.org.au/sites/default/files/docs/nmhccf_article-issue_111.pdf 29 National Mental Health Consumer and Carer Forum - Understanding psychosocial disability, December 2014 at page 13 https://nmhccf.org.au/sites/default/files/docs/nmhccf_article-issue_111.pdf 30The National Disability Insurance Scheme and Mental Health in NSW - Navigating the NDIS: Lessons Learned through the Hunter Trial, July 2016, at page 6 - http://www.mhcc.org.au/media/85852/ndis_lessons_final_301116.pdf 31 National Mental Health Consumer and Carer Forum - Understanding psychosocial disability, December 2014 at page 13 https://nmhccf.org.au/sites/default/files/docs/nmhccf_article-issue_111.pdf 32 National Disability Insurance Agency and Mental Health Australia - Psychosocial Supports Design Project – Final report, April 2016, at page 80 - https://mhaustralia.org/sites/default/files/docs/psychosocial_supports_design_project_final_-_july_2016.pdf

6

The NDIA is challenged because data from the trial sites suggests ineligibility rates for people living with a primary mental condition is significantly higher than other disability types. Further, the number of people accepted into the NDIS is lower than projected by the Productivity Commission.33

It has been estimated that 64,000 Australians (14 per cent of total expected participants)34 with psychosocial disability would be eligible for IFP, but this has been challenged.35 A lack of reliable data in Australia has been argued.36

Current estimates suggest that the projections for IFP eligibility resulting from psychosocial disability is more likely to be 230,000 (of the 690,000 Australians who experience severe mental illness each year).37 This suggests that the application of the eligibility rules or the eligibility rules themselves need enhancing to capture those who should access the scheme.

Hard empirical evidence is crucial to understand the extent of the problem. This would inform policy settings and designate policy responsibility with the appropriate government bodies. As stated previously, funding an updated National Survey of Mental Health and Wellbeing should be seriously considered.

Access to NDIS Tier Three Services

The eligibility rules38 focus on functional impairments as opposed to diagnosis.39 This approach is consistent with eligibility rules in the NIIS.

As stated previously, a psychosocial disability for the purposes of IFP must be related to a psychiatric condition.40 Not everyone living with mental illness will have a psychosocial disability.41 However, psychotic disorders, particularly schizophrenia, are consistently reported as being the cause of the most severe and persistent functional impairment relative to other mental disorders.42

The eligibility rules do raise a number of challenges when assessing psychosocial disability and the problematic ones are discussed below.

 The requirement that impairments must be permanent (or likely to be permanent)

33 National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014 - https://www.ndis.gov.au/about-us/governance/IAC/iac-advice-mental-health.html 34 NDIS – Towards an ordinary life, Annual report 2015-16, at page 26 https://www.ndis.gov.au/medias/documents/ha5/h04/8798853726238/NDI7040-AnnualReport2016-vFaccessible.pdf 35 Further Unravelling Psychosocial Disability - Experiences of the NDIS in the NSW Trial Site: A Mental Health Analysis, August 2015 at page 15 - http://www.mhcc.org.au/media/67408/mhcc-hunter-trial-site-2yr-report-aug2015.pdf 36 National Mental Health Consumer and Carer Forum - Understanding psychosocial disability, December 2014 at page 13 https://nmhccf.org.au/sites/default/files/docs/nmhccf_article-issue_111.pdf 37 Mental Health Australia – CEO Update, Speaking frankly…. here’s hoping for real reform, 19 January 2017 - https://mhaustralia.org/civicrm/mailing/view?reset=1&id=711 38 National Disability Insurance Agency and Mental Health Australia - Psychosocial Supports Design Project – Final report, April 2016, from page 84 - https://mhaustralia.org/sites/default/files/docs/psychosocial_supports_design_project_final_-_july_2016.pdf 39 The National Disability Insurance Scheme and Mental Health in NSW - Navigating the NDIS: Lessons Learned through the Hunter Trial, July 2016, at page 6 - http://www.mhcc.org.au/media/85852/ndis_lessons_final_301116.pdf 40National Disability Insurance Agency and Mental Health Australia - Psychosocial Supports Design Project – Final report, April 2016, at page 84 - https://mhaustralia.org/sites/default/files/docs/psychosocial_supports_design_project_final_-_july_2016.pdf 41 National Disability Insurance Agency and Mental Health Australia - Psychosocial Supports Design Project – Final report, April 2016, at pages 81to 82 - https://mhaustralia.org/sites/default/files/docs/psychosocial_supports_design_project_final_-_july_2016.pdf 42 Centre for Mental Health, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne - Mental health and the NDIS: A literature review, August 2014 at pages 27 to 28 https://www.ndis.gov.au/html/sites/default/files/files/Mental-health-and-the-NDIS-Literature-Review.pdf

7

An important aspect of the eligibility rules43 is the concept of permanent impairment. This sits uncomfortably with the concept of recovery, the language used in respect to mental health services supporting people to live well in the presence or absence of symptoms of mental illness.44

The concept also sits uncomfortably with the episodic nature of mental illness. Complicating the picture in responding to psychosocial disability, is that the disability can present with a vastly differing spectrum of experiences that fluctuate in intensity over time.45

As long as the person’s need for support is likely to be life-long they should be eligible for IFP.46 Practical matters to consider in the assessment stage include the history of hospitalisation or institutionalisation, employment/vocation history, and history of treatment compliance and social isolation.47 Another point to be considered is whether any unmet front line service or support need would improve functional capacity.

Case studies highlighting the issues surrounding permanency of impairment have been reported.48 Others are working on standardising the application of the eligibility rules for these problematic areas.49 However, a summary of mental conditions that are likely to rise to permanent impairment is also a useful guide.50

The interim participation process used in the NIIS may be worth considering when assessing eligibility for IFP for those people with a history of psychosocial disability, especially those not previously known to front line services. In NIIS type schemes (which cover catastrophic physical injuries resulting from an accident), a person may be accepted as an interim participant and re-assessed after two years for lifetime participation.

The aim should be to provide a person living with a mental health condition with holistic, integrated services to maximise social and financial independence early in one’s lifetime. The interim participant model may well assist with this aim. It also satisfies NDIS’s brief to act within the early intervention pathway, described further in this submission.

 Assessment of the degree of functional impairment

This is another important aspect of the eligibility rules,51 that is problematic. Focussing on functional impairment is consistent with the World Health Organisation (WHO) International Classification of Functioning, Disability and

Health (ICF) but  it is acknowledged that  it does not adequately assess psychosocial impairment.52 A reliable

instrument that provides professionals with clear guidelines for the determination of functional impairments is not currently available and its development is a work in progress.53

43 Mental Health Council of Australia – The National Disability Insurance Scheme and Mental Health - Am I eligible for a package of support? – Draft Fact Sheet 2, March 2014 at page 2 - http://www.mhcc.org.au/media/45681/mhca_ndis_fact_sheet_2_draft_march_2014.pdf 44 National Disability Insurance Agency and Mental Health Australia - Psychosocial Supports Design Project – Final report, April 2016, from page 77 - https://mhaustralia.org/sites/default/files/docs/psychosocial_supports_design_project_final_-_july_2016.pdf 45 National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014, 2.1 Interpreting permanency - https://www.ndis.gov.au/about-us/governance/IAC/iac-advice-mental-health.html 46 Mental Health Council of Australia – The National Disability Insurance Scheme and Mental Health - Am I eligible for a package of support? – Draft Fact Sheet 2, March 2014 at page 2 - http://www.mhcc.org.au/media/45681/mhca_ndis_fact_sheet_2_draft_march_2014.pdf 47 Mental Health Australia – Draft Position Paper, December 2016, at page 1 https://mhaustralia.org/sites/default/files/docs/draft_position_paper_on_community_support_during_ndis_transition_and_beyond.pdf 48 Mental Health Council of Australia – The National Disability Insurance Scheme and Mental Health - Am I eligible for a package of support? – Draft Fact Sheet 2, March 2014, from page 5 - http://www.mhcc.org.au/media/45681/mhca_ndis_fact_sheet_2_draft_march_2014.pdf 49 National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014, 2.1 Interpreting permanency - https://www.ndis.gov.au/about-us/governance/IAC/iac-advice-mental-health.html 50 Centre for Mental Health, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne - Mental health and the NDIS: A literature review, August 2014 at pages 27 to 28 https://www.ndis.gov.au/html/sites/default/files/files/Mental-health-and-the-NDIS-Literature-Review.pdf 51 Mental Health Council of Australia – The National Disability Insurance Scheme and Mental Health - Am I eligible for a package of support? – Draft Fact Sheet 2, March 2014 at page 2 - http://www.mhcc.org.au/media/45681/mhca_ndis_fact_sheet_2_draft_march_2014.pdf 52 National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014, 2.2 Assessment of the degree of functional impairment - https://www.ndis.gov.au/about-us/governance/IAC/iac-advice-mental-health.html 53 National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014, 2.2 Assessment of the degree of functional impairment - https://www.ndis.gov.au/about-us/governance/IAC/iac advice-mental-health.html

8

Until a working guide is available, it might be worth considering adopting the interim participation model used by most lifetime care schemes for traumatic injuries (NIIS), in order to maximise earlier beneficial outcomes.

 Defining reasonable and necessary supports

The National Disability Insurance Act 2013 offers aspirational criteria for reasonable and necessary supports. A level of inconsistent assessment of reasonable and necessary support for psychosocial disability across trial sites in Victoria and NSW has been reported.54

The lack of empirical markers for determining ‘reasonable and necessary support’ has not helped the situation and developing those markers would be useful. The Partners in Recovery (PIR) program, a Commonwealth initiative has been put forward as a model to consider for IFP, as it would connect people with psychosocial disability with front line services.55 A PIR type service should be seriously considered as an appropriate support.

For people living with a mental condition, the level of functional impairment can vary between individuals and also within an individual over time, complicating the assessment procedure. Add cognitive impairment, comorbidities, anosognosia, lack of advocate or carer support, the true level of disability may not be realised at assessment and may fluctuate over time. Use of reference packages to assist with assessment is under development for psychosocial disability. Consideration of the National Mental Health Planning Framework once published, might also assist.56

 Other considerations

Other general recommendations have been reported which would provide integrated support services, whilst supporting the financial sustainably of the scheme and includes –

 tracking the use of front line services to ensure a holistic and integrated approach;57  building participant capacity;58  reviewing the operating guidelines to ensure policies and procedures are flexible enough to respond to rapid and significant changes in support needs;59  identifying and funding mental-health specific supports;60  extensively using interim or temporary packages;61 and  incorporating the State and Territory role in providing appropriate services.62

54 National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014, 2.3 Defining reasonable and necessary supports - https://www.ndis.gov.au/about-us/governance/IAC/iac-advice-mental-health.html 55 National Disability Insurance Agency and Mental Health Australia - Psychosocial Supports Design Project – Final report, April 2016, at page 95 - https://mhaustralia.org/sites/default/files/docs/psychosocial_supports_design_project_final_-_july_2016.pdf 56 National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014, 2.3 Defining reasonable and necessary supports - https://www.ndis.gov.au/about-us/governance/IAC/iac-advice-mental-health.html 57 National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014, 2.7 Predicting future demand from people with disabilities related to mental illness and influencing future demand https://www.ndis.gov.au/about-us/governance/IAC/iac-advice-mental-health.html; A NSW NDIS and Mental Health Analysis Partnership Project of the Mental Health Coordinating Council and Mental Health Commission of NSW - Further Unravelling Psychosocial Disability Experiences of the NDIS in the NSW Trial Site: A Mental Health Analysis, August 2015 from pages 53 to 57 http://www.mhcc.org.au/media/67408/mhcc-hunter-trial-site-2yr-report-aug2015.pdf 58 National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014 - 2.8 Building participant capacity - https://www.ndis.gov.au/about-us/governance/IAC/iac-advice-mental-health.html 59 National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014, 2.5 Responding to rapid and significant variations in support needs - https://www.ndis.gov.au/about-us/governance/IAC/iac-advice-mental-health.html 60 National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014, 2.4 Funding of mental-health specific support items - https://www.ndis.gov.au/about-us/governance/IAC/iac-advice mental-health.html 61 National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014, 2.6 Developing, supporting and utilising individual support plans - https://www.ndis.gov.au/about us/governance/IAC/iac-advice-mental-health.html 62 National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014 - 2.9 State and Territory Government’s role in the provision of community rehabilitation and recovery-oriented services - https://www.ndis.gov.au/about-us/governance/IAC/iac-advice-mental-health.html

9

Early Intervention

Access to IFP is also available through the early intervention pathway.63 There is no guidance on how to appropriately and consistently apply these eligibility criteria.

Four requirements must be met to satisfy the early intervention criteria:

 one or more impairments attributable to a psychiatric condition must be identified, which are, or likely to be, permanent;  early intervention support must be provided that is likely to reduce the future needs for support;  early intervention support must be provided that is likely to mitigate or alleviate the impact upon the functional capacity or strengthen the sustainability of informal supports available to the person; and  an early intervention support cannot be funded through some other general system, for instance front line services.64

Literally interpreted, these rules would prevent those developing signs of mental health issues from gaining access to IFP until a formal diagnosis is made and the acute symptoms stabilised through the delivery of appropriate front lines services. However, what also needs to be considered is the contribution of pharmacological treatment upon cognitive functioning, which remains unclear.65

Diagnosis  is made through subjective assessment and observation  of symptoms, having regard to the

classification and diagnostic tool.66 However, there are inherent problems with the diagnostic tool, which can delay formal diagnosis for lengthy periods of time. Accuracy of the diagnostic tool is also challenged.67

Extensive clinical training and judgement is required to make appropriate diagnoses. No objective test is available to confirm the diagnosis.68 What is important to note however, is the longer the period of untreated psychosis before beginning antipsychotic medication relates to poorer symptomatic and functional recovery from the first psychotic episode. However, it is unclear if that initial period of untreated psychosis increases the likelihood of further psychotic episodes.69

As the early intervention pathway represents a gateway to IFP, the NDIA has a vested interest in ensuring front line services identify the early signs of mental health issues; and apply appropriate early intervention to slow or stop the progression of the condition. Deploying front line services with beneficial outcomes would enhance the financial sustainability of the NDIS. Delivering holistic integrated services is also key but there are concerns about this capability.70

If after a nominated period of time, (let’s say two years), the condition progresses or fails to improve despite early intervention, and it results in a level of psychosocial disability, then access to IFP through the early intervention pathway should be considered, to maximise social and financial independence early.

63National Disability Insurance Scheme – Access to the NDIS – Early intervention requirements - https://www.ndis.gov.au/operational-guideline/access/early-intervention-requirements.html 64 National Disability Insurance Scheme - Operational Guideline – Access – Early Intervention Requirements, 2 May 2014, at page 1 https://www.ndis.gov.au/html/sites/default/files/documents/access_early_intervention_requirements3.pdf 65 Centre for Mental Health, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne - Mental health and the NDIS: A literature review, August 2014 at page 39 https://www.ndis.gov.au/html/sites/default/files/files/Mental-health-and-the-NDIS-Literature-Review.pdf 66 American Psychiatric Association - Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), 2013 67 ABC Health & Wellbeing – DSM-5: why all the fuss, 23 May 2013 - http://www.abc.net.au/health/thepulse/stories/2013/05/23/3766048.htm 68 The Conversation - Explainer: what is the DSM and how are mental disorders diagnosed, 22 October 2012 http://theconversation.com/explainer-what-is-the-dsm-and-how-are-mental-disorders-diagnosed-9568 69 Centre for Mental Health, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne - Mental health and the NDIS: A literature review, August 2014 at page 16 https://www.ndis.gov.au/html/sites/default/files/files/Mental-health-and-the-NDIS-Literature-Review.pdf 70 The National Disability Insurance Agency Mental Health Sector Reference Group, Sector Communique, March 2016, at page 5 https://www.ndis.gov.au/html/sites/default/files/NMHSRG-Sector-Communique-March-2016.pdf

10

Tier Two Services

An effective tier two has the important role in ensuring NDIS is financially sustainable by supporting those living with a level of psychosocial disability to live independently.71 Literature suggests that psychoeducation programs have a role in preventing progression or relapse of a mental condition72 and should be considered for tier two services. Engaging with people who live with mental conditions, their family and carers as well as front line services is crucial to enhance the support services offered by tier two, on a continued basis.

Appropriate employment has a  vital role in the recovery process.73    It  is important for the NDIA to work

collaboratively with the Federal Government in reforming the welfare sector by sharing insights and learnings to ensure policy settings are formulated on the principle of trauma informed care to foster recovery and social and financial independence.74

The real challenge here for welfare reform (and indeed for all front line services) is to ensure those living with psychosocial disability do not fall through the gaps in the system due to lack of family and/or carers advocacy. Emotional burnout is common, with those living with severe and persistent psychiatric conditions at risk of losing contact with their families and/or carers entirely and becoming highly isolated.75 Lack of health services; loss of income support and homelessness is not conducive to recovery.

Work has recently commenced on building the ILC capability.76 The work intends to build on the ILC policy framework77 through five streams of activity, with some models tested at the trial sites.78

It is important to build the tier two capability for those people who are considered ineligible for IFP, but nevertheless need support. As stated previously, deep collaboration with government bodies in respect to front line services needs to be developed.

Concerns have been raised in the community that those living with psychosocial disability may completely lose vital support if found ineligible for IFP.79 Current users of Personal Helpers and Mentors (PHaMs) may fall within this category, noting that PHaMs is funded by the Federal Government.

71 KPMG - Interim report: Review of the optimal approach to transition to the full NDIS, 2014 https://www.ndis.gov.au/html/sites/default/files/documents/kpmg_paper.pdf; National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014 - 2.10 Development of Tier 2 services https://www.ndis.gov.au/about-us/governance/IAC/iac-advice-mental-health.html 72 Australian Institute of Professional Counsellors - Psychoeducation: Definition, Goals and Methods, 16 June 2014 https://www.aipc.net.au/articles/psychoeducation-definition-goals-and-methods/; Psychiatric Times - An Evidence-Based Practice of Psychoeducation for Schizophrenia, 7 February 2012 - http://www.psychiatrictimes.com/articles/evidence-based-practice-psychoeducation-schizophrenia/page/0/4 73 Final Report of the Reference Group on Welfare Reform to the Minister for Social Services - A New System for Better Employment and Social Outcomes, February 2015, at pages 60 to 61, 117 & 146 https://www.dss.gov.au/sites/default/files/documents/02_2015/dss001_14_final_report_access_2.pdf 74 Final Report of the Reference Group on Welfare Reform to the Minister for Social Services - A New System for Better Employment and Social Outcomes, February 2015, at page 21 https://www.dss.gov.au/sites/default/files/documents/02_2015/dss001_14_exec_summary_access_2_final_0.pdf 75 National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014 - 2.3 Defining reasonable and necessary supports - https://www.ndis.gov.au/about-us/governance/IAC/iac-advice-mental-health.html 76 National Disability Insurance Scheme - Information, Linkages and Capacity Building (ILC) Toolkit, 31 January 2017 https://ilctoolkit.ndis.gov.au/?utm_source=Information%2C+Linkages+and+Capacity+Building+updates&utm_campaign=9b4e9bbc57 EMAIL_CAMPAIGN_2017_01_31&utm_medium=email&utm_term=0_09639bbccd-9b4e9bbc57-50992905 77 National Disability Insurance Scheme - ILC Policy Framework, August 2015 - https://www.ndis.gov.au/communities/ilc-home/ilc-policy framework.html 78 National Disability Insurance Agency and Mental Health Australia - Psychosocial Supports Design Project – Final report, April 2016, at page 29 - https://mhaustralia.org/sites/default/files/docs/psychosocial_supports_design_project_final_-_july_2016.pdf 79 ABC News - NDIS funding changes lead to mental health case worker job cuts in northern Tasmania, 20 January 2017 http://www.abc.net.au/news/2017-01-20/mental-health-jobs-cut-in-tasmania-after-ndis-changes/8195572

11

As funding for PHaMs is withdrawn, it is up to state and territory governments to provide unmet services.80 It is crucial that support continues in accordance with the Council of Australian Governments (COAG) Agreement,81 to prevent progression of the mental condition to a point that would ultimately require extensive psychosocial support. This unintended consequence would put pressure on the financial sustainability of the NDIS.

Conclusion

Suncorp, as the country’s largest personal injury insurer, considers that the successful implementation of publically underwritten disability schemes is vital in working alongside competitively underwritten personal injury schemes in providing a holistic package with the aim of fostering social and financial independence early after a medical or injury event. Arguably, this approach better supports governments’ initiatives to counter the productivity challenges facing Australia due to its ageing workforce.82

For the NDIS to be financially sustainable, it must be based on insurance principles with clearly defined entry points into the scheme noting that psychosocial disability represents a challenging area for eligibility policy settings. The process of establishing IFP eligibility for psychosocial disability must be objective, measurable and supported by a cost effective dispute resolution process.

Suncorp commends the points raised in the executive summary for consideration and is happy to collaborate with the Committee and relevant stakeholders to develop some of the ideas put forward in this submission. Should you wish to discuss any of the points raised in this submission, please contact me Alternatively, please contact Matt Kayrooz, Head of Accident & Trauma,

Insurance

Regards

Chris McHugh

Executive General Manager

Personal Injury Portfolio & Products

Insurance

80 National Disability Insurance Scheme – Independent Advisory Council advice on implementing the NDIS for people with mental health issues, December 2014 - 2.9 State and Territory Government’s role in the provision of community rehabilitation and recovery-oriented services - https://www.ndis.gov.au/about-us/governance/IAC/iac-advice-mental-health.html 81 Council of Australian Governments – Intergovernmental Agreement for the National Disability Support Scheme Launch, 7 December 2012, Clauses 60-65 http://www.coag.gov.au/sites/default/files/agreements/Intergovernmental%20Agreement%20for%20the%20National%20Disability%20Insurance%20Scheme%20%28NDIS%29%20Launch_signed%20pdf.pdf 82 The Australian Government Treasury – 2015 Intergenerational Report, 5 March 2015 http://www.treasury.gov.au/PublicationsAndMedia/Publications/2015/2015-Intergenerational-Report

12