Navigating the NDIS: Lessons Learned through the Hunter Trial

The National Disability Insurance Scheme (NDIS)

and Mental Health in NSW Navigating the NDIS:

Lessons Learned through

the Hunter Trial

July 2016

MENTAL HEALTH COMMISSION OF NSW AND MENTAL HEALTH COORDINATING COUNCIL

NDIS AND MENTAL HEALTH ANALYSIS PARTNERSHIP PROJECT

Acronyms

For   any        further               information                          please contact:                 ADHC        Ageing, Disability and Homecare (Department of FaCS)Mental       Health             Coordinating                          Council

Building 125, Corner of Church & Glover Streets

Lilyfield NSW 2040                             CANSAS     Camberwell Assessment of Need Short Appraisal Schedule

PO Box 668

Rozelle NSW 2039                          CMO       Community managed organisation

02 9555 8388

info@mhcc.org.au                                DSS         Department of Social Services

www.mhcc.org.au (Commonwealth government department) When referencing this paper please cite as follows:

Mental Health Coordinating Council (2016). The National             FaCS         Family and Community Services

Disability         Insurance               Scheme                         (NDIS)                             and                                    Mental                                            Health                                                              in                     (NSW government department)NSW – Navigating                 the                    NDIS:                          Lessons                                Learned                                        through                                                  the

Hunter Trial. MHCC, Sydney.

Author: Tina Smith                             HNELHD     Hunter New England Local Health District

© Copyright Mental Health Coordinating Council (July 2016).         HNEMHS     Hunter New England Mental Health Service

Disclaimer and limitations of liability

MHCC provides the information contained in this report in          HONOS      Health of the Nation Outcome Scale

good faith. The report derives information from sources

believed         to be accurate and current as at the date of                  IFP            Individual Funded Packagespublication.

Acknowledgments

MHCC respects and promotes people’s fundamental human              ILC           Information, Linkages and Capacity-building

rights. We acknowledge the traditional custodians of the land

and value the lived experience of people recovering from                 IT            Information technology

mental health related conditions – both past and present.

We also acknowledge the contributions of mental health            LAC          Local Area Coordination (an element of ILC; but also

consumers,             their                  families and                               carers, and                                         service                                               providers                                                        to                          Local Area Coordinators, which is an outsourced NDIAthe consultative               processes                       conducted                                   during                                          the                                            course of

the NDIS and Mental Health Analysis Partnership Project. job role in NSW) MHCC developed this guideline, supported by the Mental

Health Commission of NSW.                         LHD          Local Health District

LSP Life Skills Profile

MHCC Mental Health Coordinating Council

NDIA National Disability Insurance Agency

NDIS National Disability Insurance Scheme

NMHCCF National Mental Health Consumer and Carer Forum

NSW New South Wales

PHaMS Personal Helpers and Mentors Service

PIR Partners in Recovery

PHN Primary Health Network

RAS-DS Recovery Assessment Scale (Domains and Stages)

SVDP Saint Vincent de Paul

UNCRPD United Nations Convention on the Rights of Persons

with Disabilities

WHODAS World Health Organisation Disability

Assessment Schedule

Table of Contents

1.    Introduction                                                                4

2.   The National Disability Insurance Scheme (NDIS)                                          7

3.  NSW NDIS trial site mental health experience                                          9

4.   Lessons learned                                                                                   12

Work to engage consumers and carers in the NDIS opportunity 12

Assist consumers to gather evidence of impairment/disability 13

‘Your’ client is now a customer 13

You will need customer service skills 14

Expect innovations in service delivery 15

Documentation of service delivery will be more frequent 16

The NDIS will not solve everything 17

Stay positive about the opportunities presenting 17

Enhanced integration and coordination of services 18

Embrace the learning arising and pursue reflective practice 19

5.   Essential NDIS knowledge                                                      20

Summary of NDIS Support Categories and Outcomes Framework 21

NDIS Individual Funded Packages (IFP) 22

Choice and Control 22

Eligibility 22

Access 23

Access Review 23

Service Planning 24

Service Coordination 24

Service Review 25

Individual Funding Management 26

NDIS Information, Linkages and Capacity-building (ILC) 26

Local Area Coordination 26

Other ILC Activities 26

6.   Next steps & concluding remarks                                                      27

7.    References                                                                                       31

1. Introduction

The Mental Health Commission of New

South Wales (NSW) collaborated with

the Mental Health Coordinating Council NSW HUNTER NDIS TRIAL IN HDELHD

(MHCC) between June 2013 and 2016 to undertake a National Disability Insurance Scheme (NDIS) and Mental Health Analysis Partnership Project. This activity supported directions of

Living Well: A Strategic Plan for Mental

Health in NSW 2014 – 2024, adopted by the Government in December 2014.1

The project focused on the three communities within the Hunter

New England Local Health District

(HNELHD) chosen to trial the NDIS:

Newcastle, Lake Macquarie and

Maitland.

This document shares experiences and some key lessons learned from the NDIS trial. Others in NSW entering the NDIS environment from 1 July 2016 will benefit from the document. MHCC developed this document to give guidance to local communities in NSW where the NDIS implementation will occur over the next two years.

NSW Potential increase in NSW NDIS participants with pyschosocial disability

UP TO 19,000

participants in NSW with a psychosocial disability by the end of June 2019

1022 participants in the Hunter trail site with psychosocial disability at the end of June 2016’

1 NSW Mental Health Commission (2014). Living Well: A

Strategic Plan for Mental Health in NSW 2014-2024. Sydney, NSW Mental Health Commission.

4 NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016]

The Hunter trial site experience has demonstrated a high Why did we develop this document? impact of the NDIS for service providers working with people affected by mental health conditions. It is important that The document supports local communities in NSW in their others have the benefit of understanding, and learning from, readiness to enter the NDIS environment. MHCC developed these experiences. it for organisations that provide services to people affected Another major achievement of the NDIS and Mental Health by mental health conditions, and their carers and families. Analysis Partnership Project was the establishment of the Getting ready will include supporting people with high Hunter NDIS and Mental Health Community of Practice. A levels of psychosocial disability to access the NDIS. complimentary guideline written to support local communities The document describes lessons learned from the to establish a mental health Community of Practice to Hunter trial site in order to maximise NSW readiness for enhance learning arising from NDIS implementation and other opportunities presenting through the NDIS. mental health sector reform accompanies this ‘lessons learned’ report.3

MHCC published a detailed report on the first two years of

the NDIS and Mental Health Analysis Partnership Project from

a community managed mental health sector perspective in August 2015. 2 This brief three-year report summarises experiences and lessons learned from the Hunter trial site for broader dissemination across NSW.

Section 2 provides some basic knowledge about the NDIS. This is provided because mental health sector knowledge of the NDIS, while variable, is mostly still at a relatively low level and this is especially so outside of the trial site.

Section 3 briefly describes NSW NDIS trial site mental health experience of the NDIS and Mental Health Analysis Partnership Project and challenges associated with this.

Section 4 shares some of the lessons learned by people in the NSW NDIS trial site from a community managed mental health sector perspective.

A key lesson learned during the NSW NDIS trial in the Hunter is that knowledge of the NDIS is essential. Section 5 provides additional information briefly describing the basics of what people need to know to navigate the NDIS from a mental health perspective.

The guideline concludes by providing some guidance on next steps for local communities in NSW entering the NDIS environment (Section 6).

2 Mental Health Coordinating Council (2015). Further Unravelling Psychosocial Disability –

Experiences of the National Disability Insurance Scheme in the NSW Trial Site: A Mental Health Analysis. MHCC, Sydney.

3 Mental Health Coordinating Council (2016). The National Disability Insurance Scheme

(NDIS) and Mental Health in NSW: Guideline for Establishing a Local NDIS Community of Practice to Enhance Learning and Sector Reform. MHCC, Sydney.

NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016] 5

NDIS language and psychosocial disability

In entering the NDIS Psychosocial Disability

environment, one Psychosocial disability refers to the disability experienced essential lesson learned by people with mental health conditions due to cognitive is the need to develop and functional difficulties. These difficulties could include both language and the loss of or limitation to physical, social, emotional, practice literacy related cognitive or sensory function, reduced ability to experience to the similarities and full physical health, participation restrictions and many differences between more. mental illness, mental health condition, Psychosocial disability is distinct from psychiatric psychiatric condition, disability in that psychosocial disability refers to the social psychiatric disability and consequences related to mental illness, whereas psychiatric psychosocial disability.4 disability focuses on the impacts of medically defined symptoms. A strong and shared understanding of the While not all persons with mental illness will experience concepts underlying psychosocial disability, those who do are much these words is useful more likely to experience significant disadvantages, to reconcile notions of including unemployment, poor housing, poor health permanent disability and homelessness. Consumers and carers indicate that and recovery and enhance opportunities arising through the appropriate support can significantly reduce the impact of NDIS for people living with mental health conditions. The term psychosocial disability. mental health condition describes the broad range of features that characterise a mental illness whether it is diagnosed or not.

The NDIS Act 2013 does not require a person with a mental health condition to have a diagnosed mental illness. 5 However, a potential NDIS participant must demonstrate impairment/s related to a ‘psychiatric’ (i.e., mental health) condition that result in substantially reduced functional capacity that is – or could be – permanent. While diagnosis by a health professional can be useful evidence to demonstrate disability, neither diagnosis nor disability mean that recovery from a mental health condition is not possible. Promoting a culture and language of hope and optimism that recovery is possible is foundational to recovery-oriented practice.6

The United Nations Convention on the Rights of People with Disabilities (UNCRPD) uses the term psychosocial disability to describe mental health related disability.7 Historically, the term psychiatric disability has been used and this emphasises perceived deficits that a person may experience (i.e., illness and symptoms). Psychosocial disability is about the social and economic participation restrictions that a person with a mental health condition may experience. The NDIS is all about reducing social and economic participation barriers of people with disabilities.

4 National Mental Health Consumer and Carer Forum (2011). Unravelling Psychosocial

Disability: A Position Statement by the National Mental Health Consumer and Carer Forum

on Psychosocial Disability Associated with Mental Health Conditions, NMHCCF, Canberra.

5 Australian Government (2013). National Disability Insurance Scheme Act 2013. 6 Commonwealth of Australia (2013). A National Framework for Recovery-oriented Mental Health Services: Policy and Theory. 7 United Nations General Assembly (2006). Convention on the Rights of Persons with Disabilities. Resolution adopted by the General Assembly, 24 January 2007, A/RES/61/106, United Nations, Geneva.

6 NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016]

2. The National Disability Insurance Scheme (NDIS)

The Australian Government developed a National Disability

Strategy, which includes the NDIS, to help Australia meet Help for all Australians its obligations under the UNCRPD. While psychosocial The NDIS is an insurance scheme disability (i.e., people with impairments related to a mental based on the premise that anyone health condition) is included in the UNCRPD the Australian can develop a disability at any Government did not make a decision to include people with time, and that the likelihood of psychosocial disability until quite late in its planning. this needs to be minimised. The The operational detail of the NDIS has changed as different NDIS is helping to ensure that parts of Australia test the original thinking about it and as the people who need and choose to benefit from disability experience is built through trial. As the NDIS scales up both in related recovery support services can do so. NSW and nationally the learning and refinement will continue. The inclusion of people living with a psychosocial disability The NDIS gives people with a disability greater control due to a mental health condition in the NDIS is important and choice over the services they receive. It fundamentally because it increases the likelihood of them being able to changes the way disability support services are provided in access disability related services and supports. Australia. Substantial growth, restructuring and transformation The NDIS might be called an investment scheme because it in the provision of disability/recovery support services will is investing in the health and wellbeing of Australia through occur through the NDIS. Those eligible under the scheme, as ensuring economic and social participation and inclusion! opposed to disability service providers, receive their funding directly under the NDIS. This will elicit innovation and reform (see more information about individual funding management In 2012, the Commonwealth Government announced plans on p. 25). to establish the NDIS. This is a no-fault insurance scheme The NDIS approach with individualised funding means a shift designed to help people with a disability and their carers away from block funding for organisations providing disability receive access to the support services they need. The National support services. It also means that community managed Disability Insurance Agency (NDIA) was established in 2013 to organisations (CMOs) providing psychosocial disability implement and administer the NDIS. support services must compete with each other to secure The NDIS is part of a larger Australian National Disability work in the disability services ‘market’. Strategy. The NDIS has three main platforms. The NDIS Price Guide describes ‘support categories’ (i.e., „„ Individual Funded Packages (formerly known as Tier 3; service types) that are evolving over time along with an

430,000 people)*                                     accompanying outcomes framework.8, 9   It is not the intent

of this report to describe the history or evolution of these … … need to meet eligibility criteria and develop a plan important frameworks, or to challenge the pricing and costing assumptions underlying them, but it is important to know that … … assist individual’s identify goals and aspirations they exist (see Summary of NDIS Support Categories and … … assist individual’s develop comprehensive plans to Outcomes Framework in ‘Essential NDIS Knowledge; Section achieve their goals 5, p. 21).

… … fund reasonable and necessary supports to enable goals The importance of understanding – and engaging to to be achieved contribute to the development of - the evolving support categories and outcomes framework, and including the „„ Information, Linkages and Capacity-building (formerly emerging Information, Linkages and Capacity-building (ILC) known as Tier 2; 4 million people with a disability and their commissioning framework, is an important continuing element 800,000 primary carers) of lessons learned from the Hunter trial. This engagement will … … better link individuals to mainstream supports help to shape the NDIS for people with psychosocial disability for years to come. … … assist services to be more inclusive and responsive to the needs of people with disability

… … direct investment towards evidence based interventions that improve outcomes for the individual

„„ Help for all Australians (22.5 million people)

… … minimise the impacts of disability through public awareness campaigns

… … provide information to all members of the public

… … assist in reducing social constraints of disability by supporting the purposeful integration of mainstream and other services.

• Recently increased to 460,000 with around 51,000 anticipated to have mental health 8 National Disability Insurance Agency (2016 a). NDIS Price Guide (Vic/NSW/Qld/Tas - Valid conditions. from: 1 July 2016)

9 National Disability Insurance Scheme (2015 b). Outcomes Framework Pilot Study: Summary

Report.

NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016] 7

The Future of the NDIS in NSW

The NDIS will be rolled-out within NSW Local Health District (LHD) catchments between July 2016 and June 2018 according to the timetable summarised below.

From 1 July 2016 From 1 July 2017

„„ the remaining population of the HNELHD (i.e., other „„ Illawarra Shoalhaven than the three trial site LGAs)

„„ Mid North Coast

„„ the remaining population of Nepean-Blue Mountains „„ Murrumbidgee (i.e., other than the early start from 1 July 2015 for young people) „„ Northern NSW

„„ Central Coast „„ South Eastern Sydney

„„ Northern Sydney „„ Sydney

„„ South Western Sydney „„ Western NSW

„„ Southern NSW „„ Far West

„„ Western Sydney

From 1 July 2016, the NDIS will begin to roll out across NSW. In the first year, seven districts will transition to the NDIS

including Central Coast, Northern Sydney, South Western

Sydney, Southern New South Wales, Western Sydney, and the

remaining populations of Hunter New England and Nepean Blue Mountains.

From 1 July 2017, the NDIS will be begin to be available in the districts of Illawarra Shoalhaven, Mid North Coast,

Murrumbidgee, Northern New South Wales, South Eastern

Sydney, Sydney, Western New South Wales, and Far West New

South Wales.

People currently receiving supports through the NSW government Department of Family and Community Services (FaCS) Department of Ageing and Disability (ADHC) specialist disability services program will be moving to the NDIS first. The NDIS will replace existing Commonwealth and state-based disability supports for those eligible.

The NDIS will be operating statewide by July 2018, ultimately providing support to about 140,000 people. This will include up to 19,000 people with psychosocial disability. The NSW government has established a website to provide more information about how and when people will move to the

NDIS.10

During transition there is a ‘guarantee of service’ to ensure that people currently accessing Commonwealth and State funded services will continue to do so through to July 2018 as the NDIS is scaled up.

Continuity of support arrangements

Governments have committed to ensuring people with disability who are currently receiving services are not disadvantaged in the transition to the NDIS. Continuity of support means that people not meeting the NDIS access requirements will continue to receive support consistent with their current arrangements.

10 NSW Government NDIS website: http://www.ndis.gov.au/nsw

8 NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016]

3. NSW NDIS trial site mental health experience

The NDIS and Mental Health Analysis Partnership Project Consumer and carer experience

utilised a Project Officer employed by MHCC to explore the NDIS experiences of people affected by mental health At the end of March 2016, 616 people in the NSW Hunter NDIS conditions, and those providing services and supports to trial site with a primary psychosocial disability had accessed them. Numerous individual, program, organisational and the NDIS. 12 While this number is lower than the anticipated Hunter NDIS and Mental Health Community of Practice 13% of all trial NDIS participants it is clear that more people in contacts contributed to the success of the project. Contacts Newcastle, Lake Macquarie and Maitland with mental health were with people affected by mental health conditions and conditions are receiving funded disability/recovery services those that provide services and supports to them. and supports than previously. There is a need for research to understand people’s health and well-being experiences Through the NDIS and Mental Health Analysis Partnership and outcomes resulting from enhanced access to disability Project, it was evident that the Hunter NDIS and mental support services. health/psychosocial disability experience mostly related to: 1) sector readiness for the NDIS; and, 2) NDIS ‘Individual Funded Many consumers were initially overwhelmed by their lack Packages’ (IFP) access, planning and review. of knowledge about, and experience of, the NDIS and this changed with time as people began sharing their experiences. Given the late inclusion of people with mental health However, there continues to be a need for outreach, advocacy conditions in the NDIS there has been much evidence of the and support services to help people understand and navigate need for a greater emphasis on sector readiness for the NDIS. the NDIS. A full description of this is beyond the remit of the current report and discussions about the matter continue with various As knowledge and experience has built across the three years government departments, Community Mental Health Australia of the trial, it is clear there is a long way to go to facilitate and Mental Health Australia. people’s participation in the NDIS at both an individual and systemic levels. While the NDIS is all about participant choice Much of the experience during the NDIS trial has been on and control, strengthened approaches to supported decision the access of people with mental health conditions to, and making are also required. 13 the management and delivery of, IFPs. People ineligible for, or choosing not to access, IFP may in the future benefit from Strengthened NSW approaches for enhancing local level ILC activities. Ways forward for the ‘commissioning’ of ILC systemic representation and participation by consumers and activities are still under development and more information their families/carers in the co-design of services are required. about this is available on p. 26. 11 That is, people affected by mental health conditions need to be able to have more of a say – both individually and The understanding of the interface of both NDIS IFP and ILC collectively – in what is and is not working so well with the activities with other mainstream services, including health NDIS. and mental health services continues to evolve. As other NSW communities enter the NDIS environment they will be Challenges identified by people affected by contributing to the learning commenced in the Hunter trial site. mental health conditions

• Lack of knowledge and information about what the NDIS Next discussed are the experiences of both people with is and what it means mental health conditions in the NSW NDIS trial site and the government and community sector organisations that provide - Inadequate outreach and engagement by the NDIA to services and supports to them. ‘Lessons learned’ perspectives capture this population of group of representatives from each of these groups are shared in the form of reflections about NDIS challenges. - Insufficient support to access the NDIS

• Barriers to advocacy support in review of access requests

• Workforce quality and availability

• There is a thin market for psychosocial disability/recovery support services (i.e., it is becoming increasingly difficult to find good and relevant services).

NSW NDIS participant feedback to the Mental Health

Australia NDIS Capacity Building Project Consumer and

Carer Working Group (June 2015)

11 National Disability Insurance Agency (2015 b). Commissioning Framework for Information, Linkages and Capacity Building.

12 National Disability Insurance Agency (2016 b). 11th Quarterly Report to the Disability Reform Council.

13 ACT Disability, Aged and Carer Advocacy Service (2016). Supported Decision Making,

Psychosocial Disability and the National Disability Insurance Scheme.

NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016] 9

Sector Panel Discussion at the Getting Ready for the NDIS MHCC Forum in 2015 in Sydney.

Community managed mental health sector Challenges identified by the community experience managed mental health sector In July 2013, there were about 20 CMOs delivering a range of programs for people affected by mental health conditions in - High levels of outreach and engagement are required for the three communities that make up the NSW trial site. CMOs vulnerable and marginalised people with mental health have welcomed opportunities to provide additional services to conditions, and other complex health and social problems, people with psychosocial disability through the NDIS. These to consider accessing the NDIS opportunities are redefining who the sector is and how it - NDIS pricing does not always cover the costs of services delivers services. and, while business efficiencies need to be sought, the Most organisations developed NDIS specific business actual cost of providing psychosocial disability/recovery development, customer service and other strategically placed support services need to be better understood roles as they entered the NDIS environment. Most aspects - Rapidly growing but more casualised CMO workforce of work and service delivery practices required substantial requiring more flexible workforce approaches review.

• Data collection, information technology (IT) and other Most CMOs have grown because of their NDIS experience ‘back of office’ business systems require substantial and benefited from opportunities to improve efficiency and upgrading to meet NDIS requirements effectiveness within their organisations. Many entered the NDIS trial experience with a high degree of confidence, but - An escalation of competitive funding environments and also uncertainty, as to what the organisational and client cultures impacts might be. Both knowledge and experience of the

• Low levels of consumer, carer and community NDIS are required to support organisational and sector representation and participation in NDIS planning, readiness. implementation and evaluation. There is a greater understanding of the challenges associated

Feedback from Hunter NDIS and Mental Health

with NDIS implementation at the end of the trial. The range Community of Practice Forum participants (29 March 2016) of identified organisational and sector readiness challenges include: „„ The cost/price involved in delivering NDIS services and sector/organisational sustainability

„„ Workforce skills and associated service delivery quality and safety considerations

„„ Concerns about the sustainability of the community managed mental health sector ‘market’. 14

Many opportunities present through the UNCRPD principles that underpin the NDIS. As the NDIS is scaled up there is still much work to be undertaken to ensure it achieves optimal outcomes for people affected by mental health conditions.

14 Community Mental Health Australia (2015). Developing the Workforce: Community

Managed Mental Health Sector National Disability Insurance Scheme Workforce

Development Scoping Paper Project. Sydney: Mental Health Coordinating Council.

10 NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016]

Hunter New England Mental Health Service

Challenges identified by the HNEMHS experience

• Clinical governance - health policy, guidelines and

The Hunter New England Mental Health Service (HNEMHS)

procedures to support staff around a range of NDIS and report this to have been a very exciting time for their mental health issues organisation, the people they serve, and their families and carers. HNEMHS has worked closely with the NDIA and, as a - Additional workload for clinical staff in supporting NDIS result, have resolved many issues at a local level. applications and planning processes

The HNEMHS Executive provided direction, and support for - Timeframe of NDIS processes exceeds most inpatient future directions, of the NDIS within mental health. They frameworks around the length of stay implemented a clear governance and internal meeting

• Duality in language experienced between the NDIS and structure. An initiative implemented in early 2014 was the mental health sector (there is a need to reframe the appointment of NDIS ‘champions’ in each mental health team, opportunities associated with the Scheme and develop a who act as a local resource to ensure a seamless transition to shared narrative) the NDIS. HNEMHS ‘Champions’ interface with NDIA planners at the Mental Health and NDIS Subject Group. The purpose - Sophistication and accuracy of data collection methods of this meeting is for collaboration and coordination between government departments. At a district level, mental health - Market shortfall in mental health services to meet the representatives also attend other NDIS Working Groups and number and diversity of NDIS plans Operational Groups and HNEMH Executive attends a HNELHD - There is a need for new services entering the mental transition to NDIS project meeting. health sector for the first time to receive mental health In April 2015, HNEMHS appointed a full-time Senior Project specific education and training Manager position for twelve months (NDIS & Community - Monitoring and safeguard mechanisms for people with Managed Organisation Partnerships Project Manager). complex and vulnerable circumstances Consumers, carers, families and staff were well supported throughout this major reform through this position that helped - There is an increased need for public guardianship for ensure movement through the NDIS transition phase. people with a reduced legal capacity, which significantly delays the discharge process. HNEMHS are extremely happy with the progress to date and many people living with metnal health conditions are Dr Martin Cohen, Director, HNEMHS experiencing an improvement in their health and well-being as NDIA Mental Health Sector Reference Group Meeting a direct result of the funding and support they have received Communique (December 2015) through the NDIS.

Due to the changing mental health landscape, HNEMHS has been engaging heavily with CMOs, including some services that have not traditionally collaborated with health. In addition, because of NDIS, there are many new organisations that are now entering the mental health sector (i.e., that were previously working with other disability types). HNEMHS have been engaged in conversation about how they can assist to enhance their capability to support clients with complex mental health needs (e.g., through shared care arrangements).

NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016] 11

4. Lessons learned
5. Work to engage consumers and carers Building on lessons learned through the NDIS trial in the NDIS opportunity It is important to undertake outreach to engage with people Navigating the opportunities and challenges associated with high levels of psychosocial disability who might be with entering the NDIS environment requires a good eligible for the NDIS and to familiarise them with the Scheme level of knowledge about it. Knowledge of the NDIS and the NDIA who are implementing it. Building your combined with trial site experience obtained through relationships with NDIA staff will be critical to this process. the NDIS and Mental Health Analysis Partnership Project enabled MHCC to support members engaging with the Both service providers and families/carers need to help NDIS and to contribute to the national discourse on NDIS people with mental health conditions to identify their hopes implementation in the context of mental health reform. and dreams for ‘an ordinary life’. Many will have become unaccustomed to making life choices. Work to identify people Not only is good NDIS knowledge needed but also skills that may be able to access an NDIS IFP and/or benefit from are required to ensure the delivery of high quality and other forthcoming ILC activities. Discussions about their hopes customer focused recovery oriented and trauma informed and dreams should begin well in advance of approaching the psychosocial rehabilitation services. The community NDIS and, with the person’s documented agreement, include managed mental health sector’s capacity to deliver friends, family and existing service providers. psychosocial rehabilitation and recovery support services must not be eroded through NDIS implementation. This is equally important for both NDIS participants with psychosocial disability and for other people with Flourish Australia NDIS experience mental health conditions who do not access NDIS funded Peer Work roles in the Hunter trial site have been very services and supports. affective in undertaking outreach and engagement to The lessons learned presented next support NDIS enhance NDIS access. implementation and with particular reference to the Between 2013 and 2015, Flourish Australia (previously knowledge required by frontline workers and team known as RichmondPRA) assisted 29 people with leaders in community managed mental health sector transitioning from ADHC and Commonwealth block funded programs. These lessons are not inclusive of the programs to the NDIS. We now support over 160 people considerable other learning not yet concluded related with NDIS funding who are living with a mental health issue. to a range of organisational and sector readiness issues including tensions related to workforce and NDIS pricing The NDIS offers people the opportunity of choice and and costing. 15 control around the types of services they want. With the assistance of our Senior Peer Worker in the Hunter, more people are empowered to negotiate the services to help Entering the NDIS environment will have a high impact for them reach their goals and aspirations. people affected by mental health conditions with high levels of psychosocial disability and those that provide services Growth under the NDIS means that our workforce has and supports to them. The learning, opportunities and continued to grow. We have been able to increase our peer service delivery reforms resulting from these experiences will workforce in the Hunter to about 50 (there are now 117 peer be considerable. Ten key lessons from the Hunter trial site workers across our entire organisation). follow alongside with some examples of sector responses to them. January 2016

15 Community Mental Health Australia (2015). Op. cit.

12 NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016]

2. Assist consumers to gather evidence 3. ‘Your’ client is now a customer of disability NDIS participants can choose between providers and services based on the goals agreed in their support plan. You will need The NDIA’s Access Request Form does not readily lend to provide a quality and effective service to maintain your itself to the kinds of evidence that demonstrates a high customers in an NDIS world. level of psychosocial disability (i.e., its focus is more on personal care than cognitive-behavioural difficulties). A Many service providers in the Hunter were surprised when range of psychosocial functional information will be required NDIS participants with psychosocial disabilities began ‘firing’ as evidence of disability. It is not sufficient for a GP or organisations that were not providing valued services to them other health professional to provide a letter providing a (ensuring that a Service Agreement including the need to mental health related diagnosis and stating that a person is give notice about a change to service providers will help to permanently disabled. manage this). A large volume of administrative paperwork can be avoided by ensuring organisations are meeting consumer Where an organisation is using routine consumer outcome needs and providing quality care. Workers, both with and measures such as the Camberwell Assessment of Need Short without lived experience of mental health conditions and

Appraisal Schedule (CANSAS), Behaviour and Symptom

recovery, are the most important organisational asset in an Identification Scale (BASIS; 32 item), Recovery Assessment NDIS world. Scale (Domains and Stages: RAS-DS) and World Health

Organisation Disability Assessment Schedule (WHODAS) this

can provide useful information. NDIS participant

The 16 item Life Skills Profile (LSP-16) and Health of the “The main positive change is that I have NDIS support Nation Outcomes Scale (HoNOS) are under discussion for coordination. My coordinator has helped me manage use in development of NDIA psychosocial disability ‘reference countless situations with staff, hospitals, lack of staff etc. packages’. This is of some concern given that these tools have where previously I would have been sucked into another symptoms as their focus and not functioning. complaints system. I have worked with him since February and now have a secure psychologist and mental health dietician as well as my GP regularly supporting me. I am Hunter Partners in Recovery (PIR) evidence also getting through the backlog of fallout from two very example dysfunctional years of inadequate services. I have a cleaner This is a Hunter PIR Access Request Form evidence keeping the chaos at bay and my boys are able to have example related to the life area of ‘learning’. The MHCC more of a parent/child relationship with me. I have just NDIS website has more examples. started self-managing part of my plan as I am still finding staff a major issue. Functional impact The difference this time is that I was not alone on this Mary often states she is interested in participating in journey. My coordinator has helped me stay polite, keep study in her area of interest (Nursing) and eventually everyone informed and make sure that my workers were gaining part-time work in this area. Mary is interested in trained etc.”. volunteering in a nursing home but has been unable to engage in this to date independently due to her high level June 2016 of anxiety. Mary has completed a Certificate III several years ago and feels that with support she can achieve these goals.

Type & frequency of support

A person will assist Mary to engage in study. Purchase of equipment for the purpose on studying online.

NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016] 13

4. You will need customer service skills Organisations will need to market themselves to potential customers and adopt customer service approaches to New Horizons: Just Ask Sandra maintaining customers. All workers providing services should have customer service skills, and organisations providing NDIS IFP services will require strong strategies for ensuring high quality customer services.

Sufficient, and sufficiently skilled staff, are increasingly hard for organisations to find. The relationships required for high quality and timely psychosocial disability/recovery support work can be compromised because of this. Be proactive in thinking about your community’s mental health related NDIS workforce development needs.

As a Lifestyle Planner for New Horizons in the Hunter, Sandra Carle works closely with customers and families to answer all their NDIS questions.

Sandra understands how the NDIS can offer real choice, more options and more individualised supports. The aim of the NDIS is to provide quality of life and build independence.

“I believe that by supporting people to discover their own potential, customers enjoy better outcomes – because they’ve designed their wellbeing goals themselves!” Sandra said.

This was just one of the reasons Sandra was chosen to feature in a New Horizons NDIS advertising campaign.

“I was definitely surprised to be asked – I certainly wasn’t expecting it!” Sandra laughs. “I said ‘are you sure you want me on a billboard?’ And I was assured they did!”

“When people pick up the phone and call New Horizons to ask questions about the NDIS, I’m the one they speak with. Hopefully with the help of this campaign, people will know who they’re talking to in advance. That’s what we’re all about – being personable with customers.”

Got NDIS questions? Just Ask Sandra, your NDIS Guru.

14 NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016]

5. Expect innovations in service delivery Consumer voice: Deb Hamilton speaking at the Getting Ready for the NDIS Forum in 2015.

The NDIS Price Guide describes a range of costs associated with funding for IFP support categories. Fourteen support Further examples of NDIS innovations categories relate to core, capacity building, and capital type funding and eight outcome domains (see p. 21). The 14 An NDIS participant in the Hunter was funded for life support categories break down further to include more than coaching services to help her reflect upon and plan 100 different types of services; each with their own unique strategies to be better able to articulate and strive to identifying code. These support categories help to guide achieve her plan goals (i.e., hopes and dreams). MHCC choice, planning and review. However, It is predicted that in asked this person to present at a NDIS readiness event. the future there will be no Price Guide as services are driven NDIS funding allowed the person to pay for coaching to by participant choice and market response thus resulting in assist in preparation to deliver the speech. This included innovation (e.g., opportunities for consumer cooperatives coaching on her presentation content and timing, as well and more consumer run services). The need for innovations as increasing confidence to contribute to events. in service delivery will continue to increase as organisations Another NSW NDIS participant identified an interest in strive to become more efficient against NDIS pricing and as bridlery (this is an industry involved in leather crafts to NDIS participants become more vocal about the services they make bridles for horses). The NDIS funded this person to want and value. undertake leatherwork and bridlery classes. The person is now earning income from making bridles and selling these at local markets.

NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016] 15

6. More information about service delivery will be documented Organisations chosen by NDIS customers to provide services Individualised funding also means that NDIS participants that and supports will move from block funding paid in advance you provide a service to are able to look at what services you (e.g., PIR, Personal Helpers and Mentors Service/PHaMS) to are billing the NDIA’s information portal (i.e., IT system) against individual payments made in arrears usually within 72 hours. their funding package and check if this is consistent with the In this context, it is critical for organisations to monitor actual services that they have received. and manage activity levels and cash flow. This will require additional documentation and increased use of IT.

Technology and the NDIS

One Hunter organisation provides all NDIS direct care workers with i-pads so that records about service delivery occur in real time. This is resulting in considerable service efficiencies including timelier billing to the NDIA to help manage cash flow.

NDIS participants are also increasingly exploring the use of IT in achieving their plans as illustrated by PIR evidence example provided on p. 13.

Working with the NDIS

Click to play: www.ndis.gov.au/providers

The NDIS Provider and Participant Portal: myplace Aftercare’s NDIS experience In June 2016, the NDIA made changes to their IT portal Aftercare’s services as an NDIS provider in Hunter trial site that will change the process for becoming an NDIS began transitioning from block funding to individualised registered provider and for documentation of service funding in the final year of the trial. Aftercare has worked delivery information and billing. on developing tools to support people to identify their life goals and to understand the supports they might need to The Provider Portal is a secure website for providers of achieve those goals. So far Aftercare has assisted 25 people products and services to NDIA participants where they to transition from ADHC and Commonwealth block funded have access: programs to the NDIS. We are currently providing NDIS

• to browse information regarding registrations, supports to over 40 people, many of whom were receiving documents and payment history little or no supports prior to the NDIS. All have retained at least the same level of funding with most receiving

• to lodge new claims for payment, including reporting significantly higher levels of funding. episodes of in-kind support. January 2016 The Participant Portal is a secure website for participants, nominees and contacts who are approved to view and direct NDIS plans and, where applicable, to make self-managed claims online.

16 NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016]

7. The NDIS will not solve everything 8. Stay positive about the opportunities The NDIS does not duplicate the mainstream services. NDIS presenting implementation creates circumstances where important Just because the trial has concluded this does not mean the discussions about service coordination and closing service 16 learning about the NDIS has finished. The government is both gaps occur: building and delivering the NDIS at the same time. Knowledge „„ Health and experience about how the NDIS best works is shaping development of operational details. The NDIS will take time „„ Mental health to implement as it is the largest human services program „„ Early childhood development introduced since Medicare. „„ Child protection and family support The knowledge required in obtaining an NDIS IFP including access, planning and review processes are now better „„ School education understood (see Section 5, p. 20). However, the NDIS environment continues to be one of uncertainty and change „„ Higher education and Vocational Education and Training and it is important to undertake leadership and become a (VET) champion in embracing the opportunities and challenges that „„ Employment accompany this.

„„ Housing and community infrastructure Most Commonwealth mental health programs are ‘in-scope’ for the NDIS. While our understanding of what this means is „„ Transport still evolving, it has meant a substantial increase in support „„ Justice hours and access to a wider range of types of supports for many people in the Hunter trial site. „„ Aged care.

The health/mental health and NDIS interface is still very much evolving through experience as is the case for all mainstream Service diversification services. Adam is a previous PHaMS client who was receiving about three hours of support a week, Monday through Friday Lack of affordable housing is a major barrier during 9-5 working hours, but wanted and needed a lot to NDIS implementation more help. PHaMS workers supported Adam to access the NDIS and he is now receiving 15 hours of support weekly Many people residing at Morisset Hospital – some for across seven days and including outside of 9-5 working several decades – are eligible to access NDIS IFPs. The hours. main obstacle to their exiting hospital has been the lack of affordable accommodation. Adam is using some of his support hours for study support to help him obtain a driver’s licence as he hopes to gain This situation has prompted some larger CMOs to look PT employment driving a truck or working as a labourer’s for innovations in affordable housing including preparing assistant. Another supporter is paid to assist him to for future opportunities that may present to purpose attend weekly horse racing events where is he is gaining build housing through the NDIA’s Specialist Disability friendships with others who share this interest. Accommodation Support initiative. While initially uninterested in the NDIS as he did not These directions also build on the considerable social understand the need for change Adam is quickly embracing capital that is the relationship between the community the range of new possibilities this might mean for his life. managed mental health and community housing sectors that has developed over decades through the provision of supported accommodation initiatives including the NSW Ministry of Health funded Housing and Accommodation Support Initiative.

16 National Disability Insurance Agency (2015 b). Principles to Determine the Responsibilities of the NDIS and Other Service Systems (2nd edition).

NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016] 17

9. Enhanced integration and coordination of services ‘Coordination of supports’ is one of the most helpful NDIS support types being accessed by people with psychosocial Divergent views about NDIS Coordination of disability (this is similar to what PIR does). Most people Supports with disability and other complex and diverse health and social issues will benefit from this type of support. If an NDIS The introduction of expanded NDIS coordination of planner does not offer coordination of supports then a person supports services in the trial site has elicited some can ask for it. divergent views. NDIA guidance on this change advises that: Three coordination of supports categroes of varying intensity were included in the NDIS Price Guide in late 2015. The “The Support Coordinator should not be the provider of intent here is to build people’s capacity to manage their own any other funded supports in the plan. This is necessary supports over time and to ensure access to care/service to ensure that there is no conflict of interest. In certain coordination at a skill level that best meets a person’s need circumstances, this condition may be waived. Please (i.e., the higher intensity the coordination of supports need is contact the NDIA for further information (p. 6).” 18 the more skilled the worker providing it needs to be). Some MHCC member NDIS providers have expressed The process of applying for NDIS access in itself means that concern about the separation of ‘coordination of supports’ an extensive review of all disability, mainstream and informal from disability/recovery support service provision. There services will occur. Service review, when combined with are concerns about NDIS pricing and the workforce skills coordination of supports, contributes to enhanced integration that can purchased. A concern is that the separation of and coordination of services. The learning about this very support and coordination functions is not inconsistent with important practice must continue and this discourse will recovery-oriented practice. Some other providers support escalate as national mental health reform directions now this separation. MHCC’s position is that this arrangement ask Primary Health Networks (PHNs) to provide clinical care should be individualised to a person’s unique needs and coordination for people with severe mental illness. 17 preferences (i.e., not 100% one-way or the other).

The NDIA CEO, David Bowen, commenting on coordination of supports, said that the same provider can provide coordination of supports but expressed concern about this happening when an organisation is a sole service provider and the person has no natural supports (i.e., family). The arrangement is still possible if a safeguard is put in place to ensure that the person is fully informed of all their choices.

Where an organisation provides both coordination of supports and disability/recovery support to the same person their choice and decision for this to occur, including supported decision-making processes, need to be well documented.

17 Australian Government (Department of Health; 2016). PHN Primary Mental Health Care

Flexible Funding Pool Implementation Guidance: Primary Mental Health Care Services for

People with Severe Mental Illness.

18 National Disability Insurance Agency (2015 c). Coordination of Supports: Information for Providers.

18 NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016]

10. Embrace the learning arising and pursue reflective practice Reflective Practice: Participants at the NDIS Work Force Roundtable in 2016.

The complexities of navigating the NDIS from a mental health perspective must not be underestimated. When the Establish a Community of Practice to enhance NDIS started in the Hunter trial site mental health service learning arising from the NDIS providers (i.e., practitioners) in both the government and A Community of Practice is a group of people who non-government sectors, as well as consumers and their share a concern or interest. A Community of Practice families and carers, began to have a lot of contact with can evolve naturally because of the members’ common the NDIA. However, much of this contact was occurred in knowledge, interest or connections. A goal of gaining isolation for workers, programs, organisations and their knowledge related to a specific field is a reason for clients, families and carers. deliberately creating a Community of Practice. It The NDIA initially prevented community managed service is through the process of sharing information and providers from supporting people in NDIS access due to the experiences with the group that the members learn priority of ‘choice and control’. That is, the NDIA did not want from each other, and have an opportunity to develop service providers making or unduly influencing decisions for themselves. people. The NDIA used collaborative practice approaches Passing knowledge from novice to veteran, and between when the benefits of this, where required and agreed, were peers, helps groups to develop. Members of a Community better understood. of Practice have the opportunity to develop both Coinciding with this change was the establishment of a personally and professionally, while working towards Hunter NDIS and Mental Health Community of Practice. The solving problems facing the group. Community of Practice embraced the learning arising from Establish NDIS and Mental Health Communities of the NDIS and to pursue reflective practice as this relates to Practice, or other approaches to maximising learning both the NDIS and mental health reform environment. arising through NDIS implementation, at the local MHCC has developed a guideline to compliment this report level, as every local community’s experiences will be encouraging the establishment of NDIS and Mental Health different. The NDIS is a national program and each local Communities of Practice across NSW. 19 As the learning community has a unique infrastructure, including choices arising from NDIS implementation continues, you are and preferences, upon which it is being built. encouraged to embrace the learning arising and pursue reflective practice by establishing a Community of Practice in your area.

19 Mental Health Coordinating Council (2016). Op. cit.

NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016] 19

5. Essential NDIS knowledge Navigating the NDIS is challenging and you need to have Navigating the NDIS essential knowledge about it to navigate it. Many people with requires essential mental health conditions and their families/carers have found knowledge it hard to understand, navigate and access the NDIS and require advocacy and support to do so. The key lesson learned is Section 2 provides some basic background information about that knowledge about the the NDIS (p. 7). The information provided in this section seeks National Disability Insurance to build on this knowledge through providing further detail. Scheme (NDIS) is essential for developing organisational Much of the focus of the NDIS trial has been on access to and and workforce capability in management/delivery of ‘Individual Funded Packages’ (IFPs). delivering National Disability Through the NSW Hunter trial site experience we have learned Agency (NDIA) funded that people ineligible for, or choosing not to access, IFP may services. in the future benefit from Information, Linkages and Capacity As the NDIS is expanded - and continues to be delivered Building (ILC) activities. However, we do not yet understand and built –, the experience of local communities will now ways forward for the ‘commissioning’ of the Information be contributing to this state and national knowledge base Linkages and Capacity-building (ILC) framework activities. 20 to improve services for people affected by mental health The NDIS Price Guide describes IFP ‘support categories’ conditions. (i.e., service types) that are evolving over time along with an accompanying outcomes framework. 21, 22 The NDIS Support Categories and Outcomes Framework current as at 1 July 2016 is summarised over page. The framework summary is useful to understand key elements (i.e., steps) in accessing IFP.

Some of the key elements of accessing and negotiating IFPs are then summarised next. Some information about the ILC activities of the NDIS then follows.

Getting ready for the NDIS

Click to play: www.ndis.gov.au/ndis-ready

20 National Disability Insurance Agency (2015 b). Op. cit.

21 National Disability Insurance Agency (2016 a). Op. cit.

22 National Disability Insurance Scheme (2015 a). Op. cit.

20 NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016]

Summary of NDIS Support Categories and Outcomes Framework

NDIS Support Categories (as at 1 July 2016)

The NDIA Price Guide is arranged into 15 categories that align to the purpose of the funded supports and the NDIA Outcomes Framework.

SUPORT PURPOSE SUPPORT CATEGORY

Core 1. Assistance with Daily Living

2. Transport
3. Consumables
4. Assistance with Social & Community Participation

Capital 5. Assistive Technology

6. Home Modifications

Capacity Building 7. Coordination of Supports

8. Improved Living Arrangements
9. Increased Social and Community
10. Finding and Keeping a Job
11. Improved Relationships
12. Improved Health and Wellbeing
13. Improved Learning
14. Improved Life Choices
15. Improved Daily Living Funding has increasingly been made flexible and bundled meaning that resources can be moved around against client’s choices or in relation to variations in the intensity of support needs that may be experienced by people with mental health conditions.

NDIA Outcomes Framework (Adults)

The NDIS Outcomes Framework for adults The adult outcomes framework also has five consists of eight participant domains: family/carer domains:

1. Choice and control 1. Families have the support they need to care

2. Daily activities 2. Families know their rights and advocate

3. Relationships effectively for their family member with disability 4. Home

4. Families are able to gain access to desired 5. Health and wellbeing services, programs, and activities in their

5. Lifelong learning community

6. Work

7. Families have succession plans

8. Social, community and civic participation.

9. Families enjoy health and wellbeing It is likely that the Outcomes Framework will change as our understanding of the NDIS continues to evolve.

   21 NAVIGATINGNAVIGATING THETHE NDIS:NDIS: LESSONSLESSONS LEARNEDLEARNED THROUGHTHROUGH THETHE HUNTERHUNTER TRIALTRIAL [MHCC[MHCC 2016]2016] 21

NDIS Individual Funded Packages (IFP)

The NDIS will fund services and supports that are ‘reasonable and necessary’ for a person with a disability to live an ‘ordinary life’. Our understanding of what this means continues to evolve. NDIS participants’ speak about their experiences of funded services and supports frequently now. The Mental Health Commission of NSW has developed a video describing the experiences of two NDIS participants and one of their carers who are accessing IFPs. You can view the NDIS Mental Health Perspectives video on YouTube.

Choice and Control Eligibility

An important foundation of the NDIS Act 2013 is that people To be eligible for the NDIS you must: with disability are able to exercise choice and control in „„ have a ‘permanent disability’ that significantly affects your pursuing their goals and in the planning and delivery of their ability to take part in everyday activities supports. The type of support, when and how it is provided, and how to measure if it is helping a person to achieve their „„ be aged less than 65 when you first access the scheme goals are all self-directed by the NDIS participant. „„ be an Australian citizen, live in Australia and hold a The concept includes the principle that people with disability permanent visa or hold a Protected Special Category Visa. should be involved in decision-making processes that affect them, and where possible make decisions for themselves. While the NDIS Act 2013 says that a participant’s condition This NDIS concept of ‘self-directed supports’ is the same as must be, or is likely to be, permanent this does not mean that the recovery concept of ‘person-centred and self-directed recovery is not possible. The NDIS trial taught us about ways practice’. of understanding ‘permanency’ in a mental health context. Even though the languages of the mental health and disability sector can vary notions of ‘choice and control’ are entirely compatible with recovery.

The mental health/psychosocial disability early intervention pathway to the NDIS remains to be better understood.

Has the trial determined eligibility benchmarks?

No. Clear benchmarks for NDIS eligibility of people with psychosocial disability are not established (that is, who can get an IFP and who cannot). At the end of March 2016, only 9% of people accessing the NDIS in NSW had primary NDIS - Mental Health Perspectives psychosocial disability. In Victoria, this figure was 14%

Click to play, https://www.youtube.com/watch?v=9X-ea-O50Vg                                                                                              23                                                                       (consistent with Productivity Commission estimates).

The NDIA needs to research access differences as Not all choices are the same psychosocial disability NDIS experience grows.

Simon Duffy from the UK Centre for Welfare Reform

considered a founder of international personalised funding approaches, notes that not all choices are the same, true choice arises from control, or self-management, of personalised funding.

For example, he describes one man with mental health issues related to a brain injury who, instead of being depressed in a day centre, chooses to flourish as he uses his personal budget to make music with his old band mates.

ABC Radio National Life Matters, 20 May 2016

23 National Disability Insurance Agency (2015 b). Op. cit.

22 NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016]

Access Access Review

Supporting people who are in immediate need of assistance, If a person is denied access to the NDIS a reason as to why and do not currently receive support, is important during the must be provided. If the person and/or their supporters rollout. There is some capacity during the rollout for people disagree with this decision, they can request an internal review who have not previously received supports to access the NDIS by the NDIA. when it starts in their local area. Disability Advocacy NSW has had a role to play in the NDIS To access the NDIS you need to contact the NDIA. You can by ensuring that people with a disability receive fair treatment make contact by phone, via the internet or in person. The in their dealings with the NDIA and the range of services and NDIA sends an NDIS Access Request Form to the applicant individuals who provide services with NDIS funds (Ph.1300 to be completed. A family member, friend and/or substitute 365 085). The government funded Disability Advocacy NSW decision maker (for example the Public Guardian) can also in the trial site to support people with External Merits Review complete the form. A health professional is required to processes of an NDIS decision through the Administrative completed part of the form. Appeals Tribunal (Ph. 1800 228 333). It is unclear if this arrangement will continue as the NDIS scales up. A copy of the Access Request Form and a sample letter of support that can be useful for organisations supporting a The Commonwealth Ombudsman’s Office also supports person in their access to the NDIS are available on MHCC’s people who have a concern about their access interactions NDIS website. The sample letter of support includes examples with the NDIA (in addition to the NSW Ombudsman’s Office of how to describe the functional impact and implications who mainly have a role in relation to NDIA funded services specifically in the areas of mobility, communication, social and supports after access has been gained): interaction, learning, self-care and self-management. „„ Commonwealth Ombudsman’s Office: Ph. 1300 362 072 Following return of the Access Request Form to the NDIA, „„ NSW Ombudsman’s Office: Ph. 02 9286 1000 or Toll free along with other evidence of disability/impairment, the NDIA (outside Sydney metro) 1800 451 524. will make an appointment with the person. The appointment can be at the NDIA office or another location, if necessary. The NDIA in NSW is still determining where their offices will be Review decisions outside of the Hunter trial site and early launch in the Nepean Data is not publically reported about how many people Blue Mountains. with psychosocial disability applying were found ineligible The NDIA must provide you with an access determination for the NDIS and/or ‘choosing’ not to apply. Access to this letter explaining the outcomes of the access request in data is important to understand and, where necessary, to case you want to request a review. A sample of an access respond to the experiences people are having. determination letter is also available at the MHCC NDIS In December 2015, the NDIS independent Advisory website. Committee noted that:

Contacting the NDIA “… data from the trial sites indicates that ineligibility rates from access requests from people with primary mental The best way to contact the NDIA is Phone - 1800 800 110 illness are significantly higher than other disability types or Web - www.ndis.gov.au with 1:4 applications requesting access due to primary mental illness being determined as ineligible compared to

NSW NDIA office locations are not yet been made public.                                                                                24                                                                                 1:9 for applicants across the rest of the Scheme”.

This means that access rates for all people of all other disability types are higher than for people with mental Reasons for declining an access request health conditions and public data is needed to have an Hunter service providers have identified that the most inclusive and productive discussion about this. common reason for declining an access request for people with psychosocial disability appears to be lack of sufficient evidence of disability/impairment.

24 Independent Advisory Council (2014). Advice on Implementing the NDIS for People with Mental Health Issues.

NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016] 23

Service Planning Service Review

Review of NDIS participants’ individual plans is required at least annually. However, a person can request a plan review at any time. A plan review can also follow a change to a person’s goals or life circumstances including, but not limited to, hospitalisation.

Plan reviews are linked to measuring whether NDIS participants’ are achieving their goals (p. 22). The NDIS Outcomes Framework supports this outcomes focus.

In early 2016, the NDIA began to review plans over the telephone. Service providers report that some people with mental health conditions who are NDIS participants were My NDIS Pathway confused and unsettled by this process. The NDIA has asked Click to play: www.ndis.gov.au/planning-process organisations to provide the names of people who prefer in person reviews.

The NDIA and others have developed pre-planning guides to help people have conversations about their NDIS eligibility My First Plan and their hopes and dreams (i.e., their NDIS plan goals). These The government advises that ADHC and Commonwealth are available on the NDA website. A recent example of this is funded mental health program clients transitioning to the the NDIS Ready ‘My NDIS Pathway’. NDIS over the next two years will get 12-month initial plans To participate in service planning it is helpful to have called ‘My First Plan’. This means that people phase into the knowledge about NDIS support categories (p. 21). It is a good NDIS at their existing service levels. idea for NDIS service providers to think about how their This is a concern for some people with psychosocial current service offerings align with these support categories. disability funded at low levels against their actual MHCC’s NDIS website provides sample support plans for support needs. They will be disadvantaged despite the people with psychosocial disability. MHCC seeks to identify intergovernmental ‘continuity of service’ arrangements. good practice in NDIS funded psychosocial disability/recovery support and build knowledge of innovation in service delivery. A person’s actual disability/recovery support needs can be reviewed against ‘My First Plan’ arrangements and For people with mental health conditions accessing the NDIS decisions appealed as needed. For more guidance on this, it is useful to ensure that their plan includes arrangements for see ‘Access Review’ on p. 23. when they have both good and not so good mental health (i.e., to accommodate for variations in intensity of disability support needs).

NDIA planners undertook planning during the NDIS trial. Outsourced ‘Local Area Coordinators’ (LACs) will have a greater role in gathering information to assist people with NDIS planning in NSW over the next two years (see more about LACs on p. 26).

NDIS Ready

NDIS Ready is a community awareness-raising project aimed at preparing people with disability, their families and carers, service providers and the community for the roll out of the NDIS from 1 July 2016. It celebrates the successes of the NDIS to date and creates a platform for people to express their support for the NDIS. This new webpage contains information on the simple steps people and providers can take to get ready for the NDIS and a range of new NDIS resources and videos, including the NDIS Ready Communications Toolkit.

NDIS Ready includes a Communications Toolkit and accompanying fact sheet for families and carers to assist people with planning. The toolkit provides individuals and organisations with communication materials that can help spread the word about the NDIS across a range of communications channels, including websites, intranets, social media platforms and electronic and printed newsletters.

24 NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016]

Service Coordination Individual Funds Management

Expanding NDIS coordination of supports items helps to Under the NDIS, funds will go directly to participants rather enhance the integration and coordination of services (p. 18). than block funding to service providers. The key message here is that many people with psychosocial NDIS participants and those that work with them need to be disability that also have complex and diverse health and social aware that are four choices for management of funds. People problems will require some level of coordination of supports can choose between: (i.e., service/care coordination). P. 18 provides a further illustration of good service coordination practice. „„ self-management

If an NDIA planning process does not offer some level of „„ a plan ‘nominee’ ‘coordination of supports’ for a person with psychosocial disability then providers should support people to obtain „„ a registered plan management provider, or information about these services. They will need to ask the „„ the NDIA. NDIA about them. The type of management of the funding for supports The same or different service providers can make coordination that a participant chooses will vary depending on their of supports available to that which provides disability/ circumstances. NDIS plans may have a combination of recovery support services. Where a person has no natural individual funds management options. Combinations of supports (i.e., family and friends) in their life to help guide services and supports can have different funds management their decisions it can be an added safeguard to separate options. coordination of supports from disability/recovery support service provision. Knowing, and having discussions about, the range of individual funds management arrangements is important to increasing NDIS participant’s choice and control.

Individual funds management

Very few NDIS participants are currently managing their own funds. Self-managed funding accounted for only 7% of plans at the end of March 2016. 25

Most plans are solely agency managed (58%) and some are a combination of both self and agency managed (35%).

25 National Disability Insurance Agency (2016 b). Op. cit.

NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016] 25

Information, Linkages and Capacity Other ILC Activities

Building (ILC) The ILC Policy Framework states that other suggested activity streams of ILC are: There are approximately 800,000 Australians who need assistance with activities of daily living at least weekly, but „„ Information, linkages and referrals - to make sure people only 460,000 are likely to access the NDIS as individually with disability and their families have access to reliable and funded participants. About 61,000 of these will be people with relevant information psychosocial disability. ILC activities and other mainstream „„ Capacity building for mainstream services - to make and community based services - where these are available services more accessible for people with disability will support people who are not eligible for IFP. „„ Community awareness and capacity building - to make it ILC (formerly known as ‘Tier 2’) is a key component of the easier for people with disability to fully participate socially, NDIS insurance model. It will contribute to the sustainability economically and in their communities, and of the NDIS by building the capacity of the community, people with disability, their families and carers, and potentially „„ Individual capacity building - to help people with disability achieve greater community inclusion. ILC developments develop the skills and confidence to achieve their goals. will over time reduce the demand for, and level of specialist LAC will incorporate every other ILC activity stream and disability support required, by many people with disability support ILC initiatives within local communities. (i.e., IFPs).

The Disability Reform Council released the ILC Policy

26                                  ILC Consulations - Summary Report (June 2016)   Framework in August 2015.   Consultation and trialling to

develop the ILC is continuing. ILC activities will likely look Between February and April 2016 the NDIA talked further different in local communities while also having state and with people about ideas related to the ILC. The NDIA is national similarities. For this reason, it is important to engage now developing a second version of the ILC Comissioning with consultation and other co-design opportunities to help Framework. shape local community ILC activities and opportunities. Innovative regionally based reforms require consumer, carer and community co-design strategies (the importance of this is further discussed in MHCC’s NDIS and Mental Health Community of Practice guideline). 27

Local Area Coordination (LAC)

LAC is to be the backbone of the ILC. Different states and territories are trying alternate approaches to LAC roles and functions.

NDIS LAC roles and functions in NSW are an outsourced arrangement until June 2018. The two organisations providing LAC services are:

„„ Saint Vincent de Paul (SVDP)

South Western Sydney, Central Coast and Hunter New

England in 2016 and the Sydney and South Eastern Sydney districts that will commence in 2017.

„„ Uniting

Nepean Blue Mountains, Northern Sydney, Western Sydney

and Southern NSW in 2016 and Illawarra Shoalhaven district which will commence in 2017.

Not yet announced are LAC arrangements for the Mid North

Coast, Murrumbidgee, Northern NSW, Western NSW and Far

West districts.

In the first instance, the LAC arrangements in NSW will focus on the planning required to support the transition of ADHC funded clients to the NDIS. This is because the NSW government plans to stop delivering services through ADHC by July 2018. The role of SVDP and Uniting LAC workers (i.e., Local Area Coordinators) in supporting Commonwealth funded mental health programs clients in their NDIS access and/or planning processes is unclear.

26 Disability Reform Council (2015). National Disability Insurance Scheme: A Framework for

Information, Linkages and Capacity Building.

27 Mental Health Coordinating Council (2016). Op. cit.

26 NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016]

6. Next steps & concluding remarks Next Steps People with primary psychosocial disability currently accessing specialist disability supports The NDIS in NSW will be rolled-out between July 2016 and June 2018 according to the LHD timetable described on p. 8. ADHC funded clients typically do not have primary mental health conditions/ psychosocial disability. ADHC fund some The NSW focus is on transition of 78,000 ADHC clients people with psychosocial disability in some parts of NSW. For receiving disability support services. As previously noted, example: this is because the NSW government plans to stop delivering ADHC funded services by July 2018 and following this will „„ Central Coast (mostly participants at an ADHC funded withdraw from the delivery of specialist disability support centre based activity program) services in NSW (i.e., and close ADHC). According to the NSW Bilateral Agreement people residing in ADHC’s Large „„ Blue Mountains (mostly ex-boarding house residents) Residential Centres and group homes will be a first priority to „„ Inner-west of Sydney (mostly current and ex-boarding transition. 28 house residents). The NSW Government has established the following priorities for NDIS access: New participants

7. People currently receiving ADHC funded specialist disability There is scope for a further 57,621 people of all disability types supports, including: in NSW to be new participants over the next three years and access NDIS IFP as indicated in the table below. „„ people living in supported accommodation

   „„ accessing a community access service such as a day Q1 Q2 Q3 Q4

program, or

2016/17   1,563      1,526     1,634      1,755     6,567

„„ a case management service.

2017/18   6,107     6,138     6,405    5,999    24,650

The majority will be able to access the NDIS in the first six

months of each of the two-year rollout periods. They will not      Subtotal                                           31,217

need to apply for access to the NDIS, but will go through a

simplified access process.                                     2018/19  N/A     N/A     N/A     N/A     N/A

2. People who access specialist disability supports from time-      Total                                             57,621

to-time, or for a short amount of time each week including people who access respite or a community care program (Adapted from the NSW NDIS Bilateral Agreement) will be able to access the NDIS throughout each of the two- Furthermore, there is likely to be additional places available year rollout periods. People receiving respite services will because of a predicted shortage in meeting the NSW trial site go through a simplified access process. People receiving target of 10,000 people accessing the NDIS (this shortage is community care services will be supported to apply for thought to be about another 2,000 places). access to the NDIS. The NSW mental health sector will need to test the

3. New participants (people who do not currently receive requirement for people with high levels of psychosocial ADHC funded specialist disability supports from the disability that are new participants to have no support and be NSW Government) will have the opportunity to access in immediate need of assistance. The NSW Ministry of Health the scheme when it starts in their local area, if they are in will support some vulnerable and marginalised people living immediate need of assistance, and do not currently have with a mental health condition through funded mental health support. 29 programs that continue to be block funded, or by their family and friends. However, the level of support they access is not always adequate to ensure their participation in the economic and social lives of our community.

28 Commonwealth and NSW Governments (2015). Bilateral Agreement between the Commonwealth and New South Wales: Transition to the NDIS.

29 National Disability Insurance Agency, Commonwealth Government and NSW Government

(2015). Operational Plan Commitment between the National Disability Insurance Agency

(NDIA), New South Wales Government and Commonwealth Government for Transition to Full Implementation of the NDIS.

NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016] 27

Consumer and carer participation at the Hunter NDIS and Mental Health Community of Practice Forum in June 2016

New participants include NDIS eligible Commonwealth funded New NDIS participants with mental health conditions can be mental health program clients: supported in their access by their families and friends, and workers from across a range of government and community „„ PIR sector service providers. Estimates are that it takes 20 to 60 „„ PHaMHS, and hours of work to gather evidence to support a person’s access to an NDIS IFP. Hunter service provider’s report that this time „„ Day to Day Living. includes: Exploring the numbers and experiences of people in „„ activity to identify potentially eligible people Commonwealth funded mental health programs in NSW that access NDIS IFPs will be important over the next two to three „„ outreach to engage people in taking forward an access years. Neither NSW nor national data about Commonwealth request, and funded mental health program client access across the 2013 to „„ working with the person, and their family and carers where 2016 NDIS trial is yet available. required and agreed, to gather sufficient documentation of The total number of Commonwealth funded mental health evidence of disability/impairment program clients in NSW is also unknown. However, both „„ attending and/or supporting a person to attend access and PIR and PHaMS capacity are around 7,000 people in each planning meetings. program in NSW. Assessments of NDIS IFP eligibility of more than 14,000 Commonwealth mental health program clients in NSW will happen over the next two to three years. The Supporting people with high levels of timeframe and processes for this to occur is not fully known psychosocial disability to access the NDIS with some 2016/17 contracts and transition planning still to be For the period July 2019 to June 2018, you are encouraged finalised. to identify people with high levels of psychosocial disability MHCC has estimated that about 19,000 people with due to a mental health condition and support their access psychosocial disability should access NDIS IFP in NSW. This as new participants to the NDIS. Ideally, these will be figure is 13% of the 140,000 people that will access the NDIS in people with no or very few supports in place. Such people NSW. Thirteen percent is the total burden of disability due to may or may not have current or past relationships with mental ill health in Australia. mental health treatment services or have a diagnosed mental illness. However, where public and private health The Hunter trial site was not successful in achieving this 13% and mental health practitioners, including GPs, have been benchmark (i.e., it achieved only 9% while access rates in involved in a person’s treatment this has facilitated NDIS Victoria were in-line with Productivity Commission estimates). access. At the end of March 2016 only 616 people in NSW with a primary psychosocial disability, and 1,492 nationally, had Some people with mental health conditions in the Hunter accessed an NDIS IFP and had a plan. The learning arising trial site have had request reviews of decisions made and/ from this access experience will contribute to the considerable or reapproached the NDIS for access up to four times learning that has occurred through the experiences of the first before accessing funded services and supports. people with psychosocial disability to access the NDIS in NSW. It is through the process of exploring people’s NDIS access that the body of knowledge about the NDIS and mental health will continue to grow both in NSW and nationally.

28 NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016]

Getting ready for the full roll-out of the NDIS 30

The full rollout of the NDIS in NSW will occur between July 2016 and June 2018. Some things to consider in getting ready if you are not in a trial site:

„„ familiarise yourself with what NDIS is and stay „„ convene or participate in a local community informed about what we are learning about meeting to discuss what your mental health how it works sector can be doing to get ready for NDIS

„„ understand the language of NDIS and learn „„ encourage the local public mental health how to reconcile this with recovery oriented service to conduct an audit of clients known to language them that might be eligible for NDIS

„„ begin to identify people with high levels of „„ encourage your local Partners in Recovery psychosocial disability that might be eligible for program, where these have been established, individually funded services and supports to develop a list of people known to them that may be eligible for the NDIS „„ engage in pre-planning with these people to: „„ ensure that the information about any current … …help potentially eligible people put together clients is up-to-date and comprehensive. This written information about how their disability is especially true for people receiving PHaMS affects their life and Day-to-Day Living Program services, and … …assist potentially eligible people to think for NSW, people with primary mental health about their hopes and dreams for their lives conditions in receipt of ADHC funded disability support services (e.g. former boarding house „„ become aware of and meet with the various residents). support providers in your local area that might support people in aspiring to their hopes and „„ where accessible use the National Disability dreams Service NDIS capacity building resources, including the Organisational Toolkit, to assess „„ discuss with people their four options for and build the readiness of your community personalised funding money management sector organisation for the NDIS arrangements and what is required for self management: „„ ensure that your organisation’s policies, procedures and practices are NDIS ready … …self-managed … …NDIA managed „„ create a new role within your organization for an NDIS Liaison Officer or similar who … …other managed can assist frontline workers, people with … …a combination of the above psychosocial disability and their families and carers. Help people to prepare for the NDIS and understand funded services and supports.

30 Adapted from Mental Health Coordinating Council (2015).Op cit. p. 89

29                                   NAVIGATINGNAVIGATING THETHE NDIS:NDIS: LESSONSLESSONS LEARNEDLEARNED THROUGHTHROUGH THETHE HUNTERHUNTER TRIALTRIAL [MHCC[MHCC 2016]2016]                                        29

Concluding Remarks

Contribute to the NDIS learning about Full implementation of the NDIS is a major undertaking that psychosocial disability! will likely require generational change. Although national and NSW implementation is planned to conclude by July 2019, The NDIS is a very large reform to the disability sector that learning about the NDIS from a mental health perspective is will be continuously improving in its approach for years to likely to continue for many years. come. As planned, it has relied heavily on the experiences of the trial sites between July 2013 and June 2016. Learning The NDIS will profoundly change how people with continues as the NDIS scales up nationally from July 2016. psychosocial disability undertake activities of daily living, participate in the community and contribute to the social Your support of people in both their access to and and economic life of Australia. National NDIS implementation experience of the NDIS is an important part of that will now see trial learning consolidated, scaled up and built continuing learning. The planning, provision and review of upon. More people with psychosocial disability will access NDIS funded services and design/implementation of the NDIS IFP. As the ILC builds through co-design approaches, the ILC will create many forward opportunities for us all to lived experience of the NDIS and mental health will grow. The learn together. interface of the NDIS with mainstream health/mental health and other services also continues to develop.

Our understanding of what is known evidence-based practice in mental health (e.g., employment/education, skills development, family and carer support, accommodation support, early intervention and promotion, psychological therapies, peer support, consumer operated services, cognitive remediation, etc.) will need to be reconciled with notions of choice and control.

This must include consideration of the capacity of the community managed mental health sector in entering the NDIS environment along with other health/mental health reform directions including, but not limited to, the emerging role of PHNs.

Other NSW communities will benefit from the experiences and lessons learned in the Hunter trial site. MHCC’s experiences can help other NSW communities to explore the opportunities and challenges presenting through the NDIS.

30                                      NAVIGATINGNAVIGATING THETHE NDIS:NDIS: LESSONSLESSONS LEARNEDLEARNED THROUGHTHROUGH THETHE HUNTERHUNTER TRIALTRIAL [MHCC[MHCC 2016]2016]                                      30

6. References

ACT Disability, Aged and Carer Advocacy Service (2016). NSW Mental Health Commission (2014). Living Well: A

Supported Decision Making, Psychosocial Disability and the Strategic Plan for Mental Health in NSW 2014-2024. Sydney, National Disability Insurance Scheme. NSW Mental Health Commission.

Australian Government (Department of Health; 2016). National Disability Insurance Agency (2016 a). NDIS Price

PHN Primary Mental Health Care Flexible Funding Pool Guide (Vic/NSW/Qld/Tas - Valid from: 1 July 2016)

Implementation Guidance: Primary Mental Health Care

National Disability Insurance Agency (2016 b). Quarterly Services for People with Severe Mental Illness. Report to COAG Disability Reform Council 31 March 2016.

Australian Government (2013). National Disability Insurance

National Disability Insurance Scheme (2015 a). Outcomes Scheme Act 2013. Framework Pilot Study: Summary Report. Commonwealth of Australia (2013). A National Framework for National Disability Insurance Agency (2015 b). Principles to Recovery-oriented Mental Health Services: Policy and Theory. Determine the Responsibilities of the NDIS and Other Service Commonwealth and NSW Governments (2015). Bilateral Systems (2nd edition). Agreement between the Commonwealth and New South National Disability Insurance Agency (2015 c). Coordination of Wales: Transition to the NDIS. Supports: Information for Providers.

Community Mental Health Australia (2015). Developing

National Disability Insurance Agency, Commonwealth

the Workforce: Community Managed Mental Health Sector

Government and NSW Government (2015). Operational National Disability Insurance Scheme Workforce Development

Plan Commitment between the National Disability Scoping Paper Project. Sydney: Mental Health Coordinating

Insurance Agency (NDIA), New South Wales Government Council. and Commonwealth Government for Transition to Full Disability Reform Council (2015). National Disability Insurance Implementation of the NDIS. Scheme: A Framework for Information, Linkages and Capacity National Mental Health Consumer and Carer Forum (2011). Building.

Unravelling Psychosocial Disability: A Position Statement

Independent Advisory Council (2014). Advice on Implementing by the National Mental Health Consumer and Carer Forum

the NDIS for People with Mental Health Issues. on Psychosocial Disability Associated with Mental Health

Conditions, NMHCCF, Canberra.

Mental Health Coordinating Council (2016). The National

Disability Insurance Scheme (NDIS) and Mental Health in NSW: United Nations General Assembly (2006). Convention on the Guideline for Establishing a Local NDIS Community of Practice Rights of Persons with Disabilities. Resolution adopted by the to Enhance Learning and Sector Reform. MHCC, Sydney. General Assembly, 24 January 2007, A/RES/61/106, United Nations, Geneva.

Mental Health Coordinating Council (2015). Further Unravelling

Psychosocial Disability – Experiences of the National Disability National Disability Insurance Agency (2015). Commissioning Insurance Scheme in the NSW Trial Site: A Mental Health Framework for Information, Linkages and Capacity Building. Analysis. MHCC, Sydney. NSW Government NDIS website: http://www.ndis.gov.au/nsw

31 GUIDELINE FOR ESTABLISHING A LOCAL NDIS COMMUNITY OF PRACTICE TO ENHANCE LEARNING AND SECTOR REFORM [MHCC 2016]

NAVIGATING THE NDIS: LESSONS LEARNED THROUGH THE HUNTER TRIAL [MHCC 2016] 31