TheTheTheThe provisionprovisionprovisionprovision ofofofof servicesservicesservicesservices underunderunderunder thethethethe NationalNationalNationalNational DisabilityDisabilityDisabilityDisability InsuranceInsuranceInsuranceInsurance SchemeSchemeSchemeScheme (NDIS(((NDIS)NDISNDIS forforforfor peoplepeoplepeoplepeople withwithwithwith psychosocialpsychosocialpsychosocialpsychosocial disabilitiesdisabilitiesdisabilitiesdisabilities relatedrelatedrelatedrelated totototo aaaa mentalmentalmentalmental healthhealthhealthhealth conditionconditionconditioncondition
Launch Housing Submission
February 2017
Committee Secretariat
Joint Standing Committee on the National Disability Insurance Scheme
PO Box 6100
Parliament House
Canberra ACT 2600
24 February 2017
Launch Housing welcomes the opportunity to provide a written response to inform the deliberations of the Joint Standing Committee on the National Disability Insurance Scheme.
Terms of reference
We note that the Joint Standing Committee is specifically focusing on the provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition. We wish to highlight concerns about the following matters pertinent to the terms of reference for the inquiry:
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1 (a) the eligibility criteria for the NDIS for people with a psychosocial disability;
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1(c) the transition to the NDIS of all current long and short term mental health state and territory government funded services, and
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The continued need for services to be provided for people deemed ineligible for the NDIS.
Launch Housing
Launch Housing is an independent Melbourne based community organisation formed from the merger of Hanover Welfare Services and HomeGround Services on 1 July 2015, which brings a combined 75 years’ experience working with people at risk of or experiencing homelessness. We are one of Victoria’s largest providers of housing and homelessness support services. We provide flexible, specialist services that directly assist thousands of individuals, couples and families every year.
Launch Housing’s mission is to end homelessness. We undertake leading research into homelessness, develops evidence informed policy and are strong advocates for measures to improve affordable housing. . We believe housing is a basic human right that affords people dignity, and this is reflected throughout every aspect of our work. We operate across 14 sites and 13 local government areas from Whittlesea in the north to greater Dandenong in the southeast of Melbourne. Last year we supported 18,000 people at risk of or experiencing homelessness across Melbourne.
Homelessness and Disability
Researchi undertaken by Launch Housing suggests that 28% - 34% of the adult client group may be eligible for the NDIS. While the main category was psychosocial disability some clients also had a physical and/or intellectual disability.
The issue of psychosocial disabilities related to a mental health condition is critical to homelessness specialist agencies such as Launch Housing and the sector generally. Access to appropriate mental health services through the NDIS and other mental health services is essential in ensuring the best service outcomes for people experiencing homelessness. It is critical for a recovery orientated model of care that addresses a person’s mental illness as soon as possible, reduces its impact, and enhances recovery and wellbeingii. This includes access to affordable and appropriate housing.
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Pattern of need
The relationship between mental illness and homelessness has long been recognised. Many persons with a disability are estimated to have the highest levels of risk for homelessness in Australia; with the risk of homelessness principally differentiated according to the type of disabilityiii.
The research evidence clearly shows that people experiencing mental health issues are at greatest risk of homelessness including chronic homelessness. In addition, the majority of people with mental illness who are homeless experience long-term homelessness and repeated episodes of homelessnessiv. For example, mental health issues is the second most frequently reported concern (53 per cent) reason people seek assistance from a specialist homelessness servicev.
Date from specialist clinical mental health service paint a similarly grim picture: “Over a two-year period to July 2014, 2,177 clients of the specialist clinical mental health service system reported their accommodation was highly unacceptable – this is likely to be significantly under-estimated. Of these people, 937 reported a homeless address (that is, no fixed abode) as their address. Mental Health Community Support Service census data reported that 11 per cent of clients in 2010 were homeless or living in insecure housing (an estimated 2,000 people)”.vi
This pattern is consistent with that for Launch Housing - For example, utilising both quantitative and qualitative methods, a 2011 collaborative studyvii that focused primarily on homelessness amongst people with a physical disability, found that around half of the participants had a mental illness in addition to their principal disability. More recently, in-depth analysis of a group of 25 clients experiencing chronic homelessness and with a history of frequent and intensive service use highlighted that mental health support continues to be a significant barrier to their recovery. For some of these clients, there has been a long history of acute clinical support and inpatient hospital admissions. However, accessing community mental health support and developing a clear pathway to recovery appears stalled for a majority of these clients. Further, for a group of 239 Launch Housing clients who had slept rough on the streets of Melbourne and with a support period recorded in 2016, more than a third (36%) had a reported mental health issue, which was more common among the female clients (48%) than male clients (33%).
In particular, people who sleep rough are much more likely to experience mental health issues and psychosocial disability. The characteristics of people sleeping rough have been found to be fairly consistent in both Australian and international research. In the profile of rough sleepers who have accessed support, the AIHW described the group as typically male, aged 35 years or over, unemployed, presenting to services alone, located in major cities and reported that they have a diagnosed mental health issueviii.
Unsurprisingly, mental health issues result in homelessness where they coincide with other vulnerabilities, such as poverty and a lack of family and other social supports. The pathways into and out of homelessness, whilst varied for individuals and households, are defined by a number of key risk and trigger factors including the lack of affordable and appropriate housing. Critically the housing market experiences of persons with a disability are frequently very different to those of the general population. Research shows that people suffering from long-term health conditions such as mental illness are likely to experience multiple disadvantages such as low income and difficulty finding and maintaining employmentix.
Mental illness is exacerbated by the instability of homelessness, and further compounded by the absence of support networks such as family and friends. For this, and many other reasons, people with a mental illness who are homeless often experience homelessness for longer periods, and are at a higher risk of multiple periods of homelessness. Trauma is a further compounding factor. The link between traumas as a contributing or causal factor in developing mental illness has been well established with the majority of people accessing mental health services having experienced some form of trauma.
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Principles of care
Access to appropriate mental health services is essential in ensuring the best service outcomes for people and is critical for a recovery orientated model of care that addresses a person’s mental illness as soon as possible, reduces its impact, and enhances recovery and wellbeingx.
A person-centric and strength-based approach is commonly used by homelessness specialist services and is also a defining feature of good practice in the community mental health sector with its recovery-orientated approach to care for anyone with a psychosocial disability. Recovery is a very individual process and there are some people who continue to need support over many years and others who move in and out of the system as their needs changexi
This notion of a person-centric approach is consistent with the underlying principle of the NDIS and is a positive element of the new scheme. Indeed, the promise of the NDIS is a new approach to providing individualised support for people with a disability (including people with a psychosocial disability). Ideally, the NDIS will provide an opportunity for some people experiencing homelessness and a mental health issue to access more flexible and appropriate care.
Eligibility criteria for the NDIS for people with a psychosocial disability
Mental health (psychosocial disability) was not originally part of the design and was a late addition to the NDIS. The inclusion of mental illness in the NDIS was an important recognition of the human rights of people with psychiatric disability. However, mental health consumers were among the last to phase across to the Scheme in Barwon, and the early stages of transition for this group, and for mental health service providers, has involved a period of confusion and anxietyxii.
Eligibility
Launch Housing is concerned that many people experiencing homelessness and a mental health issue will not meet the threshold requirements for the NDIS. A key stumbling block is the current focus of the NDIS on permanent impairment as an eligibility criteriaxiii. This risks excluding people with serious mental illness whose illness is episodicxiv and ongoing.
The evidence indicates that many individuals with mental health issues will not meet the current eligibility criteria of the NDIS and will therefore be required to rely on other services.xv For example, data from Barwon NDIS trial shows that people who are in unstable housing situations appear to be overrepresented in the group of people with mental illness found ineligible for the NDISxvi.
This is of particular concern in Victoria where all funding for community based mental health support (the current MHCSS) will, over coming years be rolled into the NDIS.
The notions of permanency and a lifetime of care need to be understood differently when referenced against best practice mental health care, which “focuses on recovery and fostering maximum independence for people with disabilities and chronic condition”.xvii For many people with psychosocial disability, their recovery and ability to remain well, depends on ongoing support. Some of the aspects of disability associated with a psychiatric condition are quite different from features of disability associated with physical, sensory and/or learning difficulties, and consequently have not been given the attention they need in the design phase of the schemexviii.
It has been noted in the expert literature that the restricted eligibility criteria for the NDIS also presents issues for health professionals in assisting their mental health clients in accessing services through the NDIS. It is contrary to current evidence-based recovery practice and the episodic nature of mental illness which makes it very difficult for psychiatrists and GPs to formally state that a consumer has a permanent diagnosis/disability and functional impairment.xix
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Other barriers
In addition to the eligibility criteria of the NDIS, other barriers exist for people who experience homelessness with a psychosocial disability. For instance, people often experience episodic disability associated with mental illness.xx Many commentators have noted there is a risk the scheme will work against people with episodic or fluctuating mental illness, and the scheme may also work against a focus on recovery for some participants. Indeed, these access requirements signify a tension between a focus on wellness and recovery models of service provision and raise specific issues for assessing the NDIS for those living with mental illness.
Launch Housing has identified a number of practice issues about the current implementation of the NDIS. For instance, practitioners at Launch Housing have reported lengthy delays in even obtaining the assessment form so that clients can prove their eligibility and get assessed by the NDIA (or Local Area Co-ordinators). At times even being able to speak with a relevant NDIS worker has been problematic and practitioners have also identified a lack of consistency in the provision of advice. Even once the access form has been obtained there is a lengthy and complex process of ‘proving’ eligibility. Many Launch Housing clients will require considerable support to fulfil these requirements. We acknowledge that these are, hopefully, teething problems associated with the roll-out of the scheme but nonetheless effectively pose additional barriers to clients.
The evidence indicates concerns about access restrictions and difficulties in negotiating the eligibility system for a range of people including those experiencing homelessnessxxi. Consumers with mental health issues are far less likely to identify as having a ‘disability’ and therefore may be reluctant to access the NDIS.xxii There are particular challenges for people experiencing homelessness with a mental health issue. Transience, a lack of formal diagnosis and difficulties navigating the service system have resulted in people experiencing homelessness being excluded from these services, particularly in the short to medium termxxiii.
Many clients Launch Housing work with present with complex needs including mental health and a substantial, cumulative, experience of rough sleeping. These clients, as outlined in our Frequent Service Users reportxxiv, are highly marginalised and present a particular challenge in engaging with and receiving support services and housing. Mental illness is widespread for this group with nearly all clients having a diagnosed mental health issue. Whilst such a group would greatly benefit from the NDIS, our experience shows that additional supports are needed to assist a person to navigate the service system and engage with the scheme.
Transition to the NDIS of all current long and short term mental health state government funded services
The NDIS represents a significant shift in focus in the way services are provided to people living with mental illness and to their familiesxxv. Much of this is positive, particularly the ability of consumers to choose the service and provider that best meets their needs. As part of the implementation of this reform, are the changes now underway to programs funded in Victoria through the Mental Health Community Support Services (MHCSS) and the transition of these programs to the NDIS. Current clients of the MHCSS will be transferred to the NDIS between May-June 2017.
The lack of eligibility and access to the NDIS for Launch Housing clients is likely to be compounded by the roll-up of MHCSS services. This risks leaving a significant service gap for people with mental health issues who do not meet the NDIS criteria for service. While there is an expectation, that those who do not qualify for the NDIS, should receive services through mainstream health servicesxxvi; the evidence strongly suggests this is not likely to be the case.
Broadly the evidence suggest there will be a significant service gap for people with mental health issues that do not meet the NDIS criteria for servicexxvii. In particular there is a concern that if people currently using community mental health services are deemed ineligible for NDIS support, they will no longer be able to rely on their current
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support services, putting their recovery and mental wellbeing at risk. Already, transience, a lack of family or friendship supports, a lack of formal diagnosis and difficulties navigating the service system has resulted in people experiencing homelessness being excluded from these services, particularly in the short to medium term.
Continued need for services to be provided for people deemed ineligible for the NDIS
The potential restricted access by people experiencing homelessness to the NDIS, along with the roll-up of MHCSS programs, highlights the need for a specific review within the NDIS roll out to ensure access to appropriate mental health support services for people either experiencing or at risk of homelessness. In particular, additional services are required for individuals who need assistance or and advocacy to navigate the system of care and for those who do not meet the threshold of permanent impairment for mental health support, but for whom without it, the risk of homelessness is highxxviii.
Governments at all levels have a clear role to ensure the provision of targeted, evidence-based community managed mental health services that can help people to better manage their mental distress, assist them in their recovery journey.xxix An integrated partnership approach with specialist homelessness services, such as Launch Housing, is critical to this process. For instance, approaches that draw on the theory and practice experience of Housing First, permanent supportive housing programs, assertive outreach and private rental assistance provide a useful starting point.
Conclusion
In summary, Launch Housing welcomes the introduction of the NDIS. We are supportive of a personalised approached and increased access to appropriate services and supports be it through the NDIS. Indeed, the initial experience of the Barwon trial has been positive for those eligible for the NDIS, with a greater choice and varied services available to participants of the scheme.
However, we remain concerned about those who will not either be eligible for the NDIS, or will have difficulties accessing the scheme. The substantive issue is the need to ensure that perverse incentives are not created that work against the wellness and recovery approach, and that service delivery for NDIS participants is outcome focused.
The design of the NDIS does present significant barriers to entry for our clients and, thus far, the NDIA, and its agents, have not as yet been able to establish means to ensure that people experiencing homelessness will have the access to the scheme that they need.
The consequence of barriers to access to the NDIS are particularly stark in Victoria because community based psychosocial support services will cease to exist. Launch Housing, along with other providers, remain concerned that many people with mental illness will lose the support they need to live in the communityxxx leaving large service gaps for vulnerable peoplexxxi including those experiencing homelessness. In particular, additional services are required for individuals who need assistance to navigate the system of care and those who do not meet the eligibility requirements but for whom without it, the risk of homelessness is highxxxii.
Launch Housing looks forward to the outcome of the deliberations of the Joint Parliamentary Committee and can provide further advice if required.
Further contact:
Nicola Ballenden General Manager Research, Service Development and Advocacy, Launch Housing.
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References
i Launch Husing commissioned research
ii Mind Australia (n.d) Mind’s approach to recovery orientated practice, link: https://www.mindaustralia.org.au/assets/docs/Minds_approach_to_recovery_oriented_practice.pdf
iii Beer, A., Baker, E & Lester, L (2014) ‘Non-Psychiatric Disability and Homelessness: Understanding the Risks’, Parity, June, Volume 27, Issue 5
iv The majority of people with mental illness who are homeless experience long-term homelessness and repeated episodes of homelessness.
v See: DHSS (2015) Housing and homelessness - 10-year mental health plan technical paper, Melbourne; p1
vi Ibid vii Beer, A., E. Baker., S. Mallett., D. Batterham., A. Pate and L. Lester (2011), ‘Addressing homelessness amongst persons with a disability: Identifying and enacting best practice’, FaHCSIA National Homelessness Research Project. viii http://www.aihw.gov.au/homelessness/shsc/profiles-of-homeless-clients/rough-sleepers/
ix See: Baker, E & Lester, L (2016) ‘Multiple housing problems: A view through the housing niche lens’, Cities, October
x Mind Australia (n.d) Mind’s approach to recovery orientated practice, link: https://www.mindaustralia.org.au/assets/docs/Minds_approach_to_recovery_oriented_practice.pdf
xi Papakotsias, A., & Tobias, G (2015) Differentiating holistic mental health care from disability care, new paradigm, Spring 2016; p32
xii VicServ (2015) Learn and Build in Barwon, The impact of the National Disability Insurance Scheme on the provision of Mental Health Services in the Barwon Launch site, June 2015; p7
xiii See Collister, L (2015) Rehabilitation and disability support: are they the same? new paradigm, Spring 2016
xiv Helen Dickinson Gemma Carey , (2017),“ Managing care integration during the implementation of large-scale reforms: the case of the
Australian National Disability Insurance Scheme “, Journal of Integrated Care, Vol. 25 Issue 1
xv Ibid, p7
xvi VCOSS (2015) 10-year Mental Health Strategy VCOSS Submission; p14
xvii See: Deeble Institute, 2014, Implications of the National Disability Insurance Scheme for health service delivery. Deeble Institute, Issues Brief, No.NLCG-5, Australian Healthcare and Hospitals Association, 23 June 2014, Canberra.
xviii See: Mind Australia (2014) Mental health and the NDIS: A literature review, commissioned by Mind Australia for the Independent
Advisory Council to the National Disability Insurance Agency, Melbourne; p1
xix Victorian Health Care Association (2015) Review of the NDIS Act, 13 October 2015
xx Helen Dickinson Gemma Carey , (2017),“ Managing care integration during the implementation of large-scale reforms: the case of the
Australian National Disability Insurance Scheme “, Journal of Integrated Care, Vol. 25 Issue 1
xxi VCOSS (2015) 10-year Mental Health Strategy VCOSS Submission; p14
xxii Helen Dickinson Gemma Carey , (2017),“ op.cit, p6
xxiii Council to Homeless Persons (2016), Submission to the Ten Year Mental Health Strategy, September 2016; p6
xxiv Launch Housing (2016) Frequent Service Users Project, First quarterly report, March 2016
xxv See: VicServ (2015) Learn and Build in Barwon, The impact of the National Disability Insurance Scheme on the provision of Mental Health Services in the Barwon Launch site, June 2015; p 8
xxvi Helen Dickinson Gemma Carey , (2017), op. cit
xxvii See: Council to Homeless Persons (2016), Submission to the Ten Year Mental Health Strategy, September 2016; p6
xxviii Ibid; p4
xxix Naughtin, G., & Grigg, M (2015) Beyond NDIS – Community Managed Mental Health Services, new paradigm, Spring 2016; p17
xxx See McDonald, J (2015) Because mental health and carers STILL matter! new paradigm, Spring 2016
xxxi Naughtin, G., & Grigg, M (2015), op.cit
xxxii Council to Homeless Persons (2016), ibid; p4
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