Submission 109 — Mental Health Coalition of South Australia (MHCSA) — The provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition | External submission

Submission: Parliamentary Joint Standing Committee: The provision of services

under the NDIS for people with psychosocial disabilities related to a mental health condition.

Mental Health Coalition SA (MHCSA)

Introduction

The Mental Health Coalition of SA (MHCSA) values the opportunity to make a submission in relation to NDIS for people living with a psychosocial disability related to a mental illness. We would welcome the opportunity to address the Joint Standing Committee when hearings are held as part of the inquiry process.

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 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

For psychosocial disability, the NDIS Act refers to “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 in to the NDIS effectively leaving a huge gap in service provision once NDIS is fully rolled out.

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 service elements clinical treatment, community psychosocial rehabilitation services and disabilities support.

1 P46, NMHC: National Review of Mental Health Programs and Services, V1 1 MHCSAto a mentalSubmission:health condition,JSC- The Februaryprovision 2017of services under the NDIS for people with psychosocial disabilities related

Over the past 20 years community psychosocial rehabilitation support services delivered by NGOs have matured with a growing evidence base highlighting their effectiveness2 3 4. Mental Health NGOs have developed a skilled and experienced workforce to deliver (non clinical) psychosocial rehabilitation support that has helped many people living with severe mental illness to recover to the point that they are managing contributing lives in the community without continued supports. Major service providers are assessed for quality against the National Standards for Mental Health Services. Community rehabilitation services are relatively short term with the average length of stay in most individual support programs being 12 months or less.

Retaining these programs or something similar as part of the service system is essential to the effectiveness of NDIS and will ensure people have access to the right support for them in a cost-effective and balanced mental health system. This is supported by the National Mental Health Commission Review that recommended a substantial increase in funding into the community sector, aimed at people being able to remain at home rather than needing acute care. The Standing Council on Health “Mental health statement of rights and responsibilities”5 also states that “Australian Governments have the responsibility to support the ongoing development of comprehensive, flexible, integrated community and hospital-based social support, health and mental health services” (p10).

For NDIS to be most effective there must be a strong mental health system to interact with. As well as disability support, people with severe mental illness need access to high quality treatment and community-based psychosocial rehabilitation. Mostly it appears that the treatment services provided by state governments and PHNs (primary health care) will not be impacted by the transition to NDIS in terms of quantum of funding so mainstream services are not the problem. The area that is in danger of shrinking and potentially disappearing is community-based psychosocial rehabilitation services which are in line for defunding to pay for an NDIS. Community based psychosocial rehabilitation services play a vital role in the mental health system by assisting people with severe mental illness to reduce the disabling impacts of their illness and engage effectively with mental health treatment services as well as mainstream health and other services such as housing and employment.

The MHCSA supported the Productivity Commission adding mental illness to the NDIS design because it adds a dimension of long term support that a small proportion of the population living with severe mental illness have not had access to. However in the funding debate for NDIS, the Commonwealth role in funding community-based psychosocial rehabilitation outside of the NDIS appears to have evaporated without any significant justification. This is contrary to over 20 years of national mental health policy, plans and funding. The NDIS is poorly equipped to cover this major gap as evidenced by the legislation which is disability focused (and is silent on mental illness); eligibility criteria for access which excludes the majority of people severely impacted by their mental illness and by the scope of services envisaged. Failure to adequately consider funding for psychosocial rehabilitation services and their roles and

2 http://www.sahealth.sa.gov.au/wps/wcm/connect/d03c5c004c3ed23d9066b4e408a887aa/IPRSS+Final+Report+ +for+distribution.pdf?MOD=AJPERES; 3https://www.sprc.unsw.edu.au/media/SPRCFile/1_SPRC_Report__Evaluation_of_Intensive_Home_Based_Suppor t_Services_v2.pdf 4 http://www.mhcc.org.au/media/3056/cmha-taking-our-place.pdf 5 Standing Council on Health: Mental health statement of rights and responsibilities, 2012 2 MHCSAto a mentalSubmission:health condition,JSC- The Februaryprovision 2017of services under the NDIS for people with psychosocial disabilities related

interactions, risks creating new gaps in services for people with severe mental illness, higher levels of disability and “siloing” of disability support from mental health and other mainstream health, social and welfare services. This is not a good outcome for people with severe mental illness whether they get access to NDIS or not.

The solutions to this must have adequate funding and appropriate governance to maintain high quality community-based psychosocial rehabilitation as part of the mental health system so that people severely impacted by mental illness have the best chance of recovering in the community through access to treatment, community-based rehabilitation and, if eligible, psychosocial disability support through the NDIS. The MHCSA remains deeply committed to the NDIS but it must be part of an integrated system that meets the needs of all people living with severe mental illness to deliver effective outcomes.

Consistently, across the South Australian NGO mental health sector and through the Mental Health Coalition SA (MHCSA) as a coordination and facilitation point, there is a commitment to contribute to both refinement of design of NDIS for people living with psychosocial disability and a wider integrated mental health system that helps people to remain in the community by:

 Participation in a joined up, equal and constructive partnership approach.  Collaboration at strategic and service design levels.  Active and constructive engagement in planning, implementing and reviewing an integrated mental health system that includes NDIS as a critical element.  Contribution of specialist mental health skills, especially in working with people with the most severe levels of mental illness/psychosocial disability.  Participating in data collection and shared care/support planning.  Active involvement in outcomes-based reporting and integrated data collection.

In addition, Mental Health Australia (MHA) and Community Mental Health Australia (CMHA) work with state Peaks to facilitate input across jurisdictions for national projects.

Summary Recommendations

1a. Eligibility criteria for people with psychosocial disability

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 Standard assessment tools based on the 8 domains, that are publicly available.  Partnership with PHNs for GP training and development of a register – to be shared across the mental health sector including NGO services.  Effective interfaces between service providers and mainstream so fluctuations in need are well managed.  Initial offer of a (timely) face to face assessment for people living with psychosocial disability, with involvement of carers or current support organisation to support the applicant.

1b. Transition of Commonwealth Government funded services, including PHaMs, PIR, and in particular – whether these services continue to be provided for people deemed ineligible for NDIS.

 Agreed recognition of an effective mental health system based on 3 parts – treatment services, psychosocial disability support and psychosocial rehabilitation.  Commonwealth to continue to fund psychosocial rehabilitation services such as PHaMs and PIR at same levels, to ensure people living with severe and persistent mental illness but who are not eligible for NDIS have access to an effective mental health system.  Commonwealth and State (South Australia) re-negotiate mental health aspects of the Bi-Lateral agreement to ensure no new gaps are created between the mental health and disability systems, to respond to National Mental Health Standards and to better align psychosocial disability support with other aspects of the mental health system.  Partnership between Governments and NGO sector to design/re-design psychosocial support services to meet the needs to people who require psychosocial rehabilitation support but are not eligible for NDIS. o Foster innovation in rural and remote areas to deliver integrated services, for example taking a community development approach rather than pure health-focus. o Ensure adequate funding to deliver these services, with appropriate outcome measures to ensure the services are meeting the needs of community. o Ensure continuity of support such that consumers are not left with a period of time where supports are not available.

1c. The transition to NDIS of all current long and short-term mental health state and territory funded services and in particular – whether these services will continue to be provided for people deemed ineligible for the NDIS.

 Commonwealth and State (South Australia) re-negotiate mental health aspects of the Bi-Lateral agreement to ensure no new gaps are created between the mental health and disability systems, to respond to National Mental Health Standards and to better align psychosocial disability support with other aspects of the mental health system.  Continue to fund psychosocial rehabilitation services at current levels to ensure consumers have access to effective psychosocial rehabilitation support over the long term. o State Government involve NGO sector and consumers and carers in transition planning and service design for continuity of support for people not eligible for NDIS, but still in need of psychosocial rehabilitation support.

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 Processes are put in place to ensure that when an individual transitions to an NDIS plan, there is continuity of support and payment to service providers during that transition.  Integrated care/support plans that are shared between all service providers with the permission and interests of the consumer at its heart. Software is already available to enable this to happen.

1d. The scope and level of funding for mental health services under the ILC framework.

 Modelling of the real costs to deliver ILC as defined in the ILC Framework and Commissioning Guidelines. Adequate funding to deliver the community-based programs and services that ILC would refer to.  Engage with the mental health NGO sector and consumers and carers to consider how services and supports can be delivered within an integrated mental health system that incorporates NDIS including ILC as an element but not the whole.

1e. The planning process for people with psychosocial disability, and the role of PHNs in that process;

 Integrated planning to develop a 3 part mental health system that incorporates treatment services (hospitals, community mental health teams, mainstream/PHN), disability support (NDIS) and community-based psychosocial rehabilitation (NGO).  Implementation that is funded to provide outcomes-based psychosocial rehabilitation services with appropriate reporting and data collection to measure effectiveness.  Continued funding for PIR support facilitation per the original program guidelines.  PIR to stay with PHNs given that the there is an effective governance mechanism in place.

1f. Whether spending on services for people with a psychosocial disability is in line with projections.

 Effective and transparent modelling of services required for all people living with severe and persistent mental illness who require support, with NDIS as an important element rather than the only community based support service available. The result being an appropriately funded NDIS supporting the right people.  Integrated planning to develop a 3 part mental health system that incorporates clinical services (mainstream/PHN), disability support (NDIS) and psychosocial rehabilitation (NGO). o Implementation that is funded to provide outcomes-based services with appropriate reporting and data collection to measure effectiveness.  Revised data collection for psychosocial disability within NDIS so that effectiveness of the Scheme for different cohorts can be measured, including package costs and outcomes for participants.

1g. The role and extent of outreach services to identify potential NDIS participants with a psychosocial disability

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 Review of design and funding for NDIS/ILC/LAC to incorporate outreach to support people living with psychosocial disabilities to access NDIS. Such review to partner with NGO services and consumers and carers.

1h. The provision and continuation of services for NDIS participants in receipt of forensic disability services.

 For the NDIA and other stakeholders to investigate how psychosocial disability supports could in-reach into the criminal justice system, in particular how mental health lived experience workforce could add value.  To appropriately fund specialist psychosocial disability and peer supports for eligible people in the criminal justice system, especially to support re-entering the community.

1i. Anything else?

 Recognise and remunerate the specialist mental health support workforce, including peer workers and other lived experience workers, at the current levels within the mental health system, including NDIS.  Recognise psychosocial disability support and psychosocial disability peer support as specialisations in the NDIS price guide at the appropriate rate.

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 are our concerns?
What are we asking for?
What do we see as possible solutions?
What are we willing to do to contribute? 1a. Eligibility criteria for people with psychosocial disability

Due to the way funding is being transferred from psychosocial rehabilitation programs to NDIS federally and potentially in South Australia, NDIS may be the only community based individual support available for people living with severe mental illness.

The likely result is that participants in programs will be encouraged to test their eligibility for NDIS when in reality a more time-limited psychosocial rehabilitation support service may be more appropriate. We risk people with severe illness and significant support needs being unable to access NDIS and therefore facing a gap of no access to disability support (via NDIS) and reduced or no availability of psychosocial rehabilitation programs (due to defunding in the transition to NDIS). Another risk is NDIS providing 6 MHCSAto a mentalSubmission:health condition,JSC- The Februaryprovision 2017of services under the NDIS for people with psychosocial disabilities related

services to people whose needs may be better supported with a psychosocial rehabilitation program from which they would emerge self-sufficient and managing their own lives without the need for life long support.

What are our concerns?

 Original scheme design did not include psychosocial disability and this is reflected in the Act – there is no mention of National Mental Health Standards or Acts.  While the Act does not require a mental health diagnosis, but rather a demonstration of functional impairment, NDIA and DSS have both described a formal diagnosis as “helpful” (NDIS Access Workshop, Melbourne 30/11/16). Jurisdictions seem to be consistent in requiring a diagnosis and clinical evaluation that the impairment is likely to be life-long. Some people in the “psychosocial disability” category are not connected with clinical services and are reluctant to engage. They require time to build trust and navigate the process, usually with significant support, to access NDIS. In addition, some health professionals may be reluctant to state in writing that a person may have a life-long disability caused by their mental illness. This is especially problematic when there has been no history of contact with that person.  Each jurisdiction seems to be interpreting guidelines differently, possibly due to a lack of a standard assessment tool for psychosocial disability and varying levels of skill and knowledge of assessors in working with mental illness.  Some consumers tend to minimise their need or level of disability and may present as more functional than they are. Others may present at a time when they are functioning quite well. Without a high level of skill in those conducting assessments, eligibility may be rejected when the consumer actually does need NDIS services.  Lack of GPs with knowledge and interest in NDIS to support consumers to access NDIS.  Phone assessments are problematic – o Consumers may not understand that the phone call is actually an assessment, leading to poor outcomes. o Assessors may not be from the state in which the consumer lives. Feedback that assessors are not seeking clarification about where current support is coming from, eg “I get support from CARA” has been interpreted as receiving informal supports from a person. (CARA is a provider of disability services in South Australia and may be unknown to an assessor from another state.) o Feedback that carers and consumers in some jurisdictions are not able to revise agreed supports from an earlier part of the conversation – “sorry – you’ve already made that decision”. People are being told they will have to seek a plan review. o There is a high degree of social isolation in the cohort eligible due to psychosocial disability (PIR Annual Report, 2016) therefore telephone assessments without significant support is unlikely to result in an effective plan.

What are we asking for?

 Consistent interpretation of psychosocial disability across jurisdictions.  Recognition that there is a difference between disability support (via NDIS) and rehabilitation support (provided by NGOs as part of an effective mental health system) and the need for both for people with severe mental illness. 7 MHCSAto a mentalSubmission:health condition,JSC- The Februaryprovision 2017of services under the NDIS for people with psychosocial disabilities related

 Assessors who are skilled in psychosocial disability and mental health, and be able to interact well with people with psychosocial disability who may become agitated and confused.  Timely face to face assessments for people seeking NDIS support due to psychosocial disability.  Consistent and relevant assessment tools that are known and shared with organisations that may support consumers to access NDIS supports.  Training for and a register of GPs and other mental health professionals who have an interest in supporting people with psychosocial disability to offer considered diagnosis and assessment of support need.

What do we see as possible solutions?

 Recognition of the difference between psychosocial disability support (required life-long and focused on functioning day to day and accessing community) and psychosocial rehabilitation support (goals focused and aimed at self-sufficiency and independence from support services)  Community-based rehabilitation support services remain available for those who do not qualify for NDIS. By doing this we ensure that appropriate people test their eligibility, while others are able to access more suitable psychosocial rehabilitation supports.  Nationally consistent definition of psychosocial disability and eligibility criteria that is publicly available.  Standard assessment tools based on the 8 domains, that are publicly available.  Partnership with PHNs for GP training and development of a register – to be shared across the mental health sector including NGO services.  Effective interfaces between service providers and mainstream so fluctuations in need are well managed.  Initial offer of a (timely) face to face assessment for people living with psychosocial disability, with involvement of carers or current support organisation to support the applicant.

1b. Transition of Commonwealth Government funded services, including PHaMs, PIR, and in particular – whether these services continue to be provided for people deemed ineligible for NDIS.

Losing programs such as PHaMS and PIR is contrary to over 20 years of mental health strategy, planning and service delivery.

Currently almost all psychosocial support program funding will be rolled in to NDIS, despite the fact that the majority of people they support will not be eligible (MHCSA, 2016 – see attachment 1). Transition contracts are focused on transitioning participants to NDIS and contracts state that the NGO may target people likely to be eligible. The result is that already a cohort who would have received support are being locked out, creating an emerging group who will need to be in crisis to receive help through clinical and acute care, with no prospect of psychosocial rehabilitation support.

Based on SA data capture in 2016, we know that there are at least 4,012 SA programs participants in Commonwealth programs, with 967 or 24% estimated to be eligible for NDIS individual support packages. Estimates have varied across states during the trial but around 30% seems to be the average. 8 MHCSAto a mentalSubmission:health condition,JSC- The Februaryprovision 2017of services under the NDIS for people with psychosocial disabilities related

Whilst one program of 50 participants in WA achieved 93% eligibility, the CEO of that organisation has stated that they work with “the sticky end of town” ie people with the highest level of need and so it can be considered abnormally high compared to most other psychosocial rehabilitation programs.

What are our concerns?

 Almost 100% of funding is “in scope for NDIS” despite the criteria for entry to programs being different than NDIS.  De-funding these programs with leave many people without a service (estimated 3,045 in South Australia).  Politicisation of the issues – issues about responsibility, likely eligibility and funding have become the battle ground rather than meeting the health and wellbeing needs of the community. Messages coming from Canberra that there is a blow out in cost for NDIS – concern that NDIS will be capped, with tightened eligibility criteria.  Consumers are being encouraged to test eligibility for NDIS; however they don’t know what will be available to them if they are not eligible.  Risk that people who are outside the eligibility criteria are applying because they don’t see an alternative support – wasting resources and time, and creating unnecessary anxiety.  Timing – DSS have given themselves until the end of 2017 to develop plans for continuity of support and what that might look like. In the mean time consumers are concerned about what will or won’t be available to them in the future. NGOs don’t know what to tell clients and families.

What are we asking for?

 Recognising the need for a 3-part mental system (treatment, psychosocial rehabilitation support and psychosocial disability support). Within this framework NDIS forms a welcome new addition, but maintaining access to psychosocial rehabilitation services for people severely impacted by mental illness who do not meet the eligibility criteria is essential. This will also greatly assist NDIS to target the cohort who genuinely require long term disability support.  In partnership with NGO Mental Health sector, retain or re-design services for people not eligible for NDIS, but who still need psychosocial rehabilitation support services.  Continuity of support defined and planned as a matter of urgency and implemented in such a way that consumers do not experience a period of time when no support is available.

What do we see as possible solutions?

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systems, to respond to National Mental Health Standards and to better align psychosocial disability support with other aspects of the mental health system.  Partnership between Governments and NGO sector to design/re-design psychosocial support services to meet the needs to people who require psychosocial rehabilitation support but are not eligible for NDIS. o Foster innovation in rural and remote areas to deliver integrated services, for example taking a community development approach rather than pure health-focus. o Ensure adequate funding to deliver these services, with appropriate outcome measures to ensure the services are meeting the needs of community. o Ensure continuity of support such that consumers are not left with a period of time where supports are not available.

The South Australian Bi-Lateral agreement6 states that that continuity of support for people in state funded programs will be provided (Schedule D, 4b) however 19b refers to SA administered Disability programs/services – no mention of mental health. Therefore the State will not necessarily provide continued support to this cohort. At the time of writing the SA Government has made no commitment to continue funding psychosocial support services in the community beyond the transition period.

MHCSA data collection in 2016 revealed at least 2,985 people received NGO delivered mental health services in the community with 606 or 20% likely to be eligible for an NDIS individual support package. The main state-funded individual psychosocial rehabilitation support service (IPRSS) had 1,028 participants with 17% or 173 people likely to be eligible, leaving 855 people without a service. SA State funded mental health programs are due to transition from 1 July 2018 with current NGO contracts ending at 30 June 2018.

There has been some discussion about “dollars following people” – ie transitioning a proportion of funding based upon likely percentage eligible for NDIS. This is only relevant in year 1. The reason being, average length of stay in State funded programs is 12 months, with new people entering services. Assuming those who would have re-entered services previously are also likely to be eligible for NDIS, we are left with increasing numbers of people unable to receive a service. Using data gathered by the MHCSA in 2016, for example, if the IPRSS program continues at the current level of funding it will deliver community-based rehabilitation to 10,280 people over 10 years (assuming 12 months average length of service). If IPRSS funding is reduced by 17% (equivalent to estimated access rates to NDIS), this looks like a reasonable approach in the first year. NDIS numbers, however, are not projected to grow except in line with population growth. This means that over every subsequent year there is a gap of 173 people per annum that will no longer have access to the reduced IPRSS service or to NDIS. Reducing total

6 https://www.ndis.gov.au/document/schedule-c-bilateral-agreement-ndi.html 10 MHCSAto a mentalSubmission:health condition,JSC- The Februaryprovision 2017of services under the NDIS for people with psychosocial disabilities related

funding by 17% would result in a gap over 10 years of 1,557 people who will receive neither IPRSS services nor NDIS.

What are our concerns?

 Even if a proportion of funding is retained for State funded psychosocial support programs, over time a significant gap will emerge of people unable to access services.  Service gaps caused by Commonwealth funding transfer to NDIS will put further pressure on the SA mental health system.  The NDIA have stated that about 50% of people with psychosocial disability entering the scheme are currently not known to mental health services (Eddie Bartnik, 2016).  The SA Transition Plan has not been shared with the NGO sector, neither has the NGO sector been invited to participate in planning. The Operational Plan makes very little mention of mental health or psychosocial disability.  There is no information forthcoming about the future of current psychosocial support programs in South Australia or plans to provide services beyond clinical interventions into the future.  Consumers and carers are beginning to express concerns about their future if they are not eligible for NDIS – causing anxiety and distress.  During transition to an NDIS individual plan, service providers report that at times they are not paid for services provided. For example continuing to be paid to deliver services while plan and budget is finalised, to ensure continuity of service for the consumer and avoid the issue of non payment should the plan service differ from that being previously provided.  The NGO psychosocial support sector staff are skilled and experienced in working with people living with mental illness who require psychosocial rehabilitation support. There is a real risk that we will lose these staff given that the pay rate for disability support is lower, as is the qualification required. The mental health lived experience workforce are a critical element of psychosocial support and there is a risk of eroding of losing this workforce.

What are we asking for?

 State Government acknowledges the value of an integrated mental health system that includes clinical services, psychosocial disability support and psychosocial rehabilitation support.  No current service is de-funded without a viable alternative for participants during transition and into the future.  Shared planning for transition involving the NGO sector as a partner in the process, along with PHNs and other stakeholders.  Shared service design involving NGO service providers and consumers and carers in the process and implementation.

What do we see as possible solutions?

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 Continue to fund psychosocial rehabilitation services at current levels to ensure consumers have access to effective psychosocial rehabilitation support over the long term. o State Government involve NGO sector and consumers and carers in transition planning and service design for continuity of support for people not eligible for NDIS, but still in need of psychosocial rehabilitation support.  Processes are put in place to ensure that when an individual transitions to an NDIS plan, there is continuity of support and payment to service providers during that transition.  Integrated care/support plans that are shared between all service providers with the permission and interests of the consumer at its heart. Software is already available to enable this to happen.

1d. The scope and level of funding for mental health services under the ILC framework.

South Australia will transition to ILC from 1 July 2017. Given the final budget for ILC ($132m nationally at full roll-out) the MHCSA cannot see how it can deliver all that is articulated in the Commissioning Framework. ILC specifically excludes provision of 1:1 support as capacity building, and the PHN Flexible Funding Guidelines also specifically exclude psychosocial rehabilitation support. We must therefore conclude that there is no funding within the Scheme or PHNs to provide 1:1 psychosocial support7 – it must be provided either through State Governments or re-allocating some or all of the psychosocial support programs funding currently being rolled in to the NDIS.

Many of the programs and services that ILC would refer to are at risk of ending as funding is transferred to the NDIS – we don’t know what will be left for ILC to refer to, or for consumers and carers to access.

What are our concerns?

 The funding envelope is insufficient to meet the goals of the program.  Services and community based programs currently funded may disappear due to funding transfer to NDIS.  The ILC Framework does not mention psychosocial disability, mental health, Mental Health Standards or Mental Health Acts, despite repeated requests from mental health service providers, consumers and carers during consultations.  ILC is unable to fund time limited 1:1 support for individual capacity building.

What are we asking for?

 Recognition that ILC will not cover the needs of all people living with disabilities including psychosocial disabilities, who are not eligible for an NDIS individual package.

7 P6, DOH PHN Primary Mental Health Care Flexible Funding Pool Implementation Guidance – Stepped Care

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What do we see as possible solutions?

1e. The planning process for people with psychosocial disability and the role of PHNs in that process;

PHNs are an important partner in a balanced and integrated mental health system. The PHN role is to commission services that form part of mainstream services that fall outside the NDIS remit. PHN Flexible Funding Guidelines specifically exclude psychosocial support8, so while PHNs are a significant contributor to primary health services for people living with mental illness, they will not fill the funding gap in rehabilitation support services that will appear and grow as services are defunded to pay for NDIS.

Partners in Recovery (PIR) is now funded through PHNs. This program has been incredibly successful in engaging people with complex needs and it is therefore critical that PIR funding continue into the future, to both support people without adequate natural support to access NDIS, but also to continue the programs original purpose to connect people to other supports if they are not eligible for NDIS.

The success of PIR has been largely due to the focus on addressing immediate need and problem solving with people living with severe mental illness, across clinical health, mental health services, housing, employment etc. Governance of such a program is hard to see fitting well in the rigid disability framework of NDIS, and therefore should be funded separately through the existing mechanisms in place through PHNs.

What are our concerns?

 PIR will not be funded beyond the transition period for NDIS.  PHNs will not fund individual psychosocial rehabilitation support.  Any assumption that PHNs will fill the gap for supports in the community is misguided and is likely to leave people living with severe mental illness relying entirely on clinical services that they may still struggle to access due to cost or availability.  Governance of PIR will not fit within the disability framework of NDIS.

8 P6, DOH PHN Primary Mental Health Care Flexible Funding Pool Implementation Guidance – Stepped

Care

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What are we asking for?

 PIR support facilitation continues to be supported, per the original program intention, with the inclusion of supporting people to access the NDIS.  PHNs form part of the partnership that designs and develops a balanced mental health system that incorporates NDIS as part but not the whole solution for support in the community.  That the NGO sector be involved in joint planning.

What do we see as possible solutions?

1f. Whether spending on services for people with a psychosocial disability is in line with projections.

The key questions for us are how effective will the mental health and disability support system be at full roll-out for people living with severe mental illness? And, will the funding estimate of the Productivity Commission end up being spent on people with psychosocial disability or will under-spends be kept as savings and therefore reducing the funding envelope over time for people with mental illness? Given that the current funding approach will create new gaps in service for people with severe mental illness who can’t access NDIS, a reduction in the funding envelope over time would be an inequitable outcome. The final report from Bruce Bonyhady9 and the NILS review of NDIS10 both acknowledge that there are issues with psychosocial disability – these must be addressed for spending to properly line up with need. Only then will we know how spending aligns with projections.

In the 2016 data gathering exercise undertaken by MHCSA, respondents reported 6,997 people living with severe and persistent mental illness currently accessing services through 11 NGOs over 15 programs. Based on current NDIS projections, approximately 5,120 people in SA will access NDIS with a primary psychosocial disability (8% of 64,000). On that basis we already have a short fall of 1,877 places for some kind of support. Interestingly, the NDIA is finding that 50% of entrants during the trial have been previously unknown “to the system” (Eddie Bartnik, 2016). The eligibility criteria for NDIS have not been publicly released and there is a fair degree of uncertainty regarding what the final numbers of

9 http://www.abc.net.au/news/2016-12-24/outgoing-ndis-chair-sets-out-future-challenges-for-agency/8145852 10

https://www.dss.gov.au/sites/default/files/documents/11_2016/final_intermediate_report_wcag_compliant_24_ nov_2016.pdf 14 MHCSAto a mentalSubmission:health condition,JSC- The Februaryprovision 2017of services under the NDIS for people with psychosocial disabilities related

people in need of NDIS and/or other funded psychosocial rehabilitation support actually are. We don’t know what DSS continuity of support will look like under NDIS nor what funding will be available. There is risk that inappropriate people are trying to access NDIS while people who should receive NDIS support may not have the advocacy and support to enable them to navigate what can be a confronting and frightening process. The MHCSA encourages continued scrutiny – looking broadly at the impacts and benefits of NDIS in the broader context of a three part mental health system, with a key focus on ensuring sufficient funding is available to support people with severe mental illness to recover in the community and improving systems to measure outcomes.

What are our concerns?

 Identified issues within NDIS for people living with psychosocial disabilities. Concern that Productivity Commission estimations won’t be met. Not because of lack of need, but because the scheme design does not adequately meet the needs of people living with psychosocial disabilities.  The potential for the scheme to “blow out” if NDIS is the only community based support available – people who should access a more time limited support such as psychosocial rehabilitation services, attempting to prove eligibility because they don’t know what else to do.  The number of people likely to be left with no support given the program funding that has been rolled in to NDIS.  People’s wellbeing as they undertake the process, especially if they lack support and advocacy to go through process.  Fairness – seems to be inequities in who gets what, despite reference packages. Eg in the Hunter region two sisters with same disability applied for NDIS packages where one got a package and the other didn’t.  Feedback from ineligible people – is this being collected as well as satisfaction for people who have packages? Ie did they feel it was a fair process?  Inadequate data capture – NDIA collects on schizophrenia and “other” for psychosocial disability – should be more specific.  Skill of assessors and planners in working with people living with psychosocial disabilities – are people getting the right plan?

What are we asking for?

 Recognition within the Scheme that there are issues in addressing psychosocial disability, and addressing those issues in a transparent manner.  Appropriate NDIS Individual support packages for people who qualify.  Skilled and knowledgeable assessors and planners who can work effectively with people living with psychosocial disabilities.  Additional services available for people living with severe and persistent mental illness who don’t qualify for NDIS, including 1:1 psychosocial rehabilitation support. This forms part of an integrated mental health system.  Effective data collection that identifies a range of diagnoses, given that the NDIS requires such for access to the Scheme. 15 MHCSAto a mentalSubmission:health condition,JSC- The Februaryprovision 2017of services under the NDIS for people with psychosocial disabilities related

 Mechanisms that ensure that funding for psychosocial disability is spent on packages for people living with psychosocial disability.

What do we see as possible solutions?

1g. The role and extent of outreach services to identify potential NDIS participants with a psychosocial disability

At present currently block funded programs and Partners in Recovery (PIR) are working to assist community members to test their eligibility to access NDIS. PIR reports that they are spending around 20 hours to support people through assessment including engagement in the process. Many people living with psychosocial disabilities have no natural supports or advocacy from family and other carers, therefore reliance on funded support becomes necessary. Within ILC, it has been envisaged that Local Area Coordinators will provide support to access NDIS. In addition, LACs will be expected to develop initial plans and undertake community connection so it is unlikely an LAC will be able to devote 20 hours, sometimes over months, to take on this role. . In South Australia the first organisation contracted to provide LAC services is an aged care provider, which does not engender public confidence in their skill in working with people with complex mental health issues in addition to other disabilities.

What are our concerns?

 There is no funding included in NDIS for outreach support to assist community members to access NDIS.  The assumption that NGOs will take on this role as part of “marketing” as an unfunded activity is unrealistic. Small NGOs in particular are unlikely to be able to support this impost for any extended period of time.  Organisations contracted to deliver LAC services may not have the skill or knowledge to find, engage and work well with people living with psychosocial disabilities.

16 MHCSAto a mentalSubmission:health condition,JSC- The Februaryprovision 2017of services under the NDIS for people with psychosocial disabilities related

What are we asking for?

 Recognition that people living with psychosocial disabilities may not have natural supports to assist them to access NDIS, and that support to access NDIS takes skill and time.  Appropriate funding for specialist skilled resources to engage with and assist people living with psychosocial disabilities to access NDIS.  LACs who have the skills to work with people living with complex mental health issues.

What do we see as possible solutions?

1h. The provision and continuation of services for NDIS participants in receipt of forensic disability services.

For the purposes of this feedback we have used the definition –

“a person nominated as a forensic disability client is a person with a disability for whom a court order under the Criminal Law Consolidation Act 1935 is in place, or a person who has contact with the justice system arising from that person being charged with an offence or the police initiate another similar legal process (that is a summons, court attendance notice or youth court matter).”11

Human rights don’t stop when people are incarcerated. 49% of people entering the prison system have a diagnosed mental illness (AIHW)12. While the prison system has mental health professionals within the system, anecdotal evidence suggests it is under-resourced to meet the needs of the prison population. International evidence shows that specialist psychosocial support in-reach into the criminal justice system offers support that reduces the likelihood of recidivism and helps people to develop life strategies to assist them to make different decisions when they leave the system. Supporting people within the criminal justice system is a specialized skill-set and the MHCSA believes that people who enter the criminal justice system with access to NDIS supports should continue to receive support whilst incarcerated and particularly when preparing to exit to the community. Similarly people within the system who are identified as potentially being eligible should be assisted to test their eligibility for NDIS supports.

In South Australia the NGO mental health service providers have significant experience in supporting people currently in or leaving the criminal justice system, or who have forensic histories.

11 P5, “Forensic Disability: The Tip of Another Iceberg”, SA Exceptional Needs Unit, 2011 http://www.agd.sa.gov.au/sites/agd.sa.gov.au/files/documents/Initiatives%20Announcements%20and%20News/ DJP%20Submissions/Forensic%20Disability%20%20The%20Tip%20of%20Another%20Iceberg.pdf 12 http://www.aihw.gov.au/prisoner-health/mental-health/ 17 MHCSAto a mentalSubmission:health condition,JSC- The Februaryprovision 2017of services under the NDIS for people with psychosocial disabilities related

Skilled support practitioners, especially mental health peer support workers13 may be helpful in assisting individuals experiencing the criminal justice system, to build skills, resilience and capacity to live well in the community and avoid re-offending on exit.

What are our concerns?

 People living with mental illness are over-represented in the criminal justice system.  It is currently difficult to in-reach in to the prison system with psychosocial and disability supports.  There are very few in-reach supports available to assist people with psychosocial disabilities to transition back to the community. This is despite evidence that psychosocial support in-reach works and the skill base is there in mental health NGOs to provide effective support.

What are we asking for?

 In-reach into the criminal justice system through NDIS for people living with psychosocial disability, recognising specialist skills.

What do we see as possible solutions?

1i. Anything else?

The current trajectory of loss of psychosocial rehabilitation services through re-direction of funding will have an impact on the availability of a skilled and qualified mental health support workforce. While this affects individual workers, it must be recognised that losing this skilled workforce has a detrimental impact for people living with psychosocial disability. To ensure we do not lose this workforce we need to do two things –

Recognise and remunerate the specialist mental health support workforce, including peer workers and other lived experience workers, at the current levels within the mental health system, including NDIS.
Recognise psychosocial disability support and psychosocial disability peer support as specialisations in the NDIS price guide at the appropriate rate.

13 Peer Support Workers are people with lived experience of mental illness who are skilled in drawing from their lived experience in ways that model effective recovery and support consumers to take charge of their own recovery journey. 18 MHCSAto a mentalSubmission:health condition,JSC- The Februaryprovision 2017of services under the NDIS for people with psychosocial disabilities related