27 February 2017
Joint Standing Committee on the National Disability Insurance Scheme
PO Box 6100
Parliament House
Canberra ACT 2600
Phone: +61 2 6277 3083 ndis.sen@aph.gov.au
RE: Inner South Community Health Submission to the Joint Standing Committee on
the NDIS on the provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition
Thank you for providing the opportunity to contribute to the Joint Standing Committee on the NDIS inquiry into the provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition. This work is essential to help understand the impact of the NDIS to those accessing community services for support, recovery and rehabilitation from psychosocial disability due to mental ill health.
Inner South Community Health (ISCH) strongly supports increased user choice and control in the human service sector, recognising the significant body of evidence that shows that greater consumer involvement and choice in their health provides better health outcomes1. However we have grave concerns regarding gaps in service for people living with mental illness requiring psychosocial supports for recovery and rehabilitation.
ISCH is a major provider of health and community services across the inner southern region of Melbourne and beyond. ISCH is a not-for-profit organisation located at four dedicated centres within the St Kilda, Prahran, Cheltenham and South/Port Melbourne areas and 6 auxiliary centres. We have a strong track record of engaging with some of the most marginalised people in the community. These include those who are homeless and / or people who have complex psychosocial needs.
Our submission will address the following Terms of Reference;
a. the eligibility criteria for the NDIS for people with a psychosocial disability;
b. the transition to the NDIS of all current long and short term mental health Commonwealth Government funded services, including the Personal Helpers and Mentors services (PHaMs) and Partners in Recovery (PIR) programs, and in particular;
i. whether these services will continue to be provided for people deemed ineligible for the NDIS;
1 Australian Commission on Safety and Quality in Health Care (ACSQHC). Australian Charter for Health care rights. Sydney :ACSQHC, 2008
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c. the transition to the NDIS of all current long and short term mental health state and territory government funded services, and in particular;
i. whether these services will continue to be provided for people deemed ineligible for the NDIS;
e. the planning process for people with a psychosocial disability, and the role of primary health networks in that process;
f. whether spending on services for people with a psychosocial disability is in line with projections;
g. the role and extent of outreach services to identify potential NDIS participants with a psychosocial disability;
In preparing this submission ISCH worked closely with one of our peak bodies the Victorian Commission on Social Services (VCOSS). ISCH supports the recommendations from the Australian Commission on Social Services (ACOSS) provided to this inquiry and offer our detailed submission below.
If any aspect of this response requires clarification please contact Damian Ferrie by email or by phoning the Inner South Community Health Office on
Yours sincerely,
Damian Ferrie
CHIEF EXECUTIVE OFFICER
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Inner South Community Health Submission to the Joint
Standing Committee on the NDIS on the provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition
About Inner South Community Health and the Community Health
Sector
A key component of Victoria’s health system is a funded sector called Community
Health. Community Health Services are registered under the Victorian Health Act2, The
Victorian Government funds 100 community health services. Some community health services are integrated with acute hospital services or smaller rural health services. Other community health services like Inner South Community Health are not-for-profit proprietary limited (Pty Ltd) companies. Community health provides integrated medical, social and community services in local communities.
Community health services work extensively with governments and other local partners to provide coordinated primary healthcare and social services to meet local needs. Community health can play a critical role in keeping residents well, building community and providing essential care when people become unwell. Community health services work within the social determinants of health model, recognising that real gains in health status can only be achieved when social, environmental, political, cultural and economic factors that contribute to poor health are addressed. This focus on addressing health inequity means that community health services generate significant social, economic and health benefits that flow to both the individual and the broader community3,4,5.
ISCH is a major provider of health and community services across the inner southern region of Melbourne and beyond. We deliver more than 150,000 services each year, spanning pregnancy, childhood, adulthood and seniors. ISCH provides a range of primary health care services including, general practice, oral health, mental health, homelessness and alcohol and drug services. As well as direct service delivery, we engage in community building and health promotion activities to build the health and wellbeing of the local community. We have specialist expertise in engaging high risk and hard to reach groups. ISCH offers health services to all, regardless of a person’s ability to pay.
2 Victorian Health Services Act (1988)
3 Lomas, Jonathan. “Social capital and health: implications for public health and epidemiology.” Social science & medicine 47.9 (1998): 1181-1188. 4 Frieden, Thomas R. “A framework for public health action: the health impact pyramid.” American journal of public health 100.4 (2010): 590-595. 5 Marmot, Michael, and Commission on Social Determinants of Health. “Achieving health equity: from root causes to fair outcomes.” The Lancet 370.9593 (2007): 1153-1163.
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Response to Terms of Reference
a. the eligibility criteria for the NDIS for people with a psychosocial disability;
a.1. Recovery Based Practice
The current NDIS eligibility criterion creates a significant barrier for people with psychosocial disability. Many service providers including ISCH operate recovery orientated mental health practices, in accordance with the National Standards for Mental Health Services6. The model emphasises and supports a person’s potential for recovery7.
The population eligible for psychosocial support through the NDIS must have a severe mental illness and a significant functional impairment that is likely to be permanent8. This creates two significant issues;
-
Mental health professionals are reluctant to assess a person’s condition as permanent or likely to be permanent as this may impede recovery for some people. Participants are also reluctant to engage as they do no relate to the term ‘permanent disability’.
-
There are approximately 229,000 persons each year with severe mental illness that require some form of community support (individual support, group support or non-acute residential care)9,10. These individuals are not considered eligible for the NDIS.
Without adequate consideration of the importance of community support for people with mental illnesses, there will be detrimental effects to people and the health system11. The Federal Government must commit to support citizens with mental health conditions to ensure access to services that will not be replaced by the NDIS.
6 Commonwealth of Australia. National Standards for Mental Health Services 2010. Canberra,
Commonwealth of Australia (2010) 7 Commonwealth of Australia. National Standards for Mental Health Services 2010. Principles of recovery oriented mental health practice Canberra, Commonwealth of Australia (2010) 8 National Disability Insurance Agency. Completing the access process for the NDIS Tips for Communicating about Psychosocial Disability p. 4 ( August 2016) Canberra, Commonwealth of
Australia
9 Mental Health Australia (2017) Submission 1- Attachment 1 Mental Health Australia The
implementation and operation of the psychiatric disability elements of the National Disability Insurance Scheme: A recommended set of approaches, Technical Paper Prepared by David
McGrath Consulting. p.6 Canberra
10 This excluding the 57,000 individuals that will be eligible for NDIS due to psychiatric disability.
Mental Health Australia (2017) Submission 1- Attachment 1 Mental Health Australia The
implementation and operation of the psychiatric disability elements of the National Disability Insurance Scheme: A recommended set of approaches, Technical Paper Prepared by David
McGrath Consulting. p.5 Canberra
11 Hoult, J., Reynolds, I., Charbonneau-Powis, M., Weekes, P., & Briggs, J. (1983). Psychiatric hospital versus community treatment: the results of a randomised trial. Australian and New Zealand Journal of Psychiatry, 17(2), 160-167.
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b. the transition to the NDIS of all current long and short term mental health Commonwealth Government funded services, including the Personal Helpers and Mentors services (PHaMs) and Partners in Recovery (PIR) programs, and in particular;
i. whether these services will continue to be provided for people deemed ineligible for the NDIS;
b.1. PHaMs ISCH is aware that current PHaMs clients who are eligible for the NDIS will be transitioned to the NDIS or continuity of support arrangements by 2019
- Future clients who are currently not receiving services, are on waitlist, or those who are ineligible for the NDIS, will not be able to access equivalent services to PHaMs or PIR. It is unclear how these future clients will receive the necessary psychosocial supports to remain well and within the community.
ISCH uses a social model of health to provide services that address social, environmental, political, cultural and economic factors that contribute to poor health. This is central to service provision under the current ISCH PHaMs program, much of which is considered psychosocial support as seen in Figure One.
It is unlikely that any of these services will continue as the NDIS is implemented, noting that several of the activities will not be funded by either the NDIA or PHNs, leaving substantial gaps in service as the Victorian State Government withdraws funding from mental health services. ISCH contends that PHaMs and PIR needs to remain funded. These programs provide support to people who will not be eligible for services within NDIS.
12 Australian Government Department of Social Services Information for Providers: Personal
Helpers and Mentors Services (July 2016) Commonwealth of Australia, Canberra.
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•Development of care plans Care planning with •Review of care plans multidisciplinary teams •Support identification of goals •Use of multidisciplinary team in case reviews •Community group programs Acess to meaningful activities •Vocational activities •Working with consumers and carers Therapeutic relationships and •Understanding trauma informed care motivational counselling •Assertive outreach •Modelling healthy and productive relationships •Access to GPs, allied health, dentists, smoking cessation programs, Working to improve physical health wellbeing groups and exercise groups •Relapse prevention •Supporting client symptom self management Managing ongoing mental health •Psychosocial education –promoting insight and understanding of own mental health •Developing plans to manage current levels of distress •Encourage and assist skill development Independence and skill building •Group programs to build skills •Support access to housing •Carer support referrals Working with carers/natural •Family sessions to help provide support supports/dependants/family •Liaising with carer support services
•Provide harm-minimisation information and techniques Dual Diagnosis with Drug and •Working with AOD programs Alcohol addiction •relationship between mental health and substance use/misuse
•Assertive outreach Community capacity building •Health promotion
Figure 1: ISCH Current PHaMs service provision
These services allow people to remain in the community and can prevent, or reduce need for acute services13.
b.2. Continuity of Support As a provider of PHaMs services in Victoria, ISCH has been informed that the Victorian Government will provide in-kind support to people not eligible to the NDIS accessing PHaMs for at least a period of 12 months. This is likely to be in individual funding packages. Details of these funding packages are unknown including;
Funding amount Services funded Ongoing sustainable models funding and care.
ISCH is concerned that the lack of clarity around continuity of support funding will mean that clients are at risk of falling through a significant gap in service provision.
The most significant issue is that future clients will not have access to these services as no long-term replacement for these supports has been proposed.
13 Armijo, J., Méndez, E., Morales, R., Schilling, S., Castro, A., Alvarado, R., & Rojas, G. (2013). Efficacy of community treatments for schizophrenia and other psychotic disorders: a literature review. Frontiers in psychiatry, 4, 116.
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c. the transition to the NDIS of all current long and short term mental health state and territory government funded services, and in particular;
i. whether these services will continue to be provided for people deemed ineligible for the NDIS; Recovery and rehabilitation services for mental illness are not supported in the new models of funding and service provision. Psychosocial rehabilitation and recovery remains a large gap in services it has been stated this is not the purpose of NDIS funding, and is not in scope of Primary Health Network Stepped Care models14.
In the draft South Eastern Melbourne Region Primary Health Network Stepped
Care Model shows explicitly that psychosocial disability is out of scope15.
Figure 2: Draft South Eastern Melbourne Region Primary Health Network
Stepped Care Model16
Looking at the above figure, community rehabilitation and recovery is not supported.
It is uncertain what support is available to existing or future clients that do not need, or are not eligible for basic living support through the NDIS, or more intensive clinical care provided by the Victorian Health system.
14 Australian Government Department of Health ( July 2016) PHN Primary Mental Health Care
Flexible Funding Pool Implementation Guidance Stepped Care Canberra, Australia
15 South Eastern Melbourne Primary Health Network (SEMPHN) (December2016) Mental Health
Stepped Care Model p.6, Melbourne, Victoria
16 South Eastern Melbourne Primary Health Network (SEMPHN) (December2016) Mental Health
Stepped Care Model,p.6 Melbourne, Victoria
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Without community recovery and rehabilitation, there will be undue pressure on the health system to provide this support in a more acute setting as peoples mental health deteriorates17,18.
ISCH questions the effectiveness of imposing a national system like the NDIS onto mental health services previously managed at a state and territory level, given the exceptionally different mental health care models currently being utilised to meet local need.
Though some psychosocial disability falls under the NDIS, there is still a need for a separate state mental health community rehabilitation service in Victoria, as these services are limited.
e. the planning process for people with a psychosocial disability, and the role of primary health networks in that process;
e.1. Individual Planning
Psychosocial support is currently not likely to be funded in the Southern Metro Region through PHNs and is currently considered out-of-scope of the Stepped Care Plan (Figure 2). This means that planning for people with psychosocial disability will be managed at an individual level by the NDIA and Local Area Coordination providers.
There is concern from the community sector that many Local Area Coordinators do not have experience or resources to work with people with mental illness and psychosocial disability as models of care differ significantly to disability services.
As members of VCOSS, we support the suggested solution of the management of assessment and planning to occur through a specialised mental health LAC who can work closely with the local PHN and other services.
e.2. Population Health Planning
As the Victorian government roles funding from Mental Health Community Support Services (MHCSS), into NDIS, this funding must be based on accurate projections. This raises two issues for the inquiry: It is not clear how these projections will be used by PHNs to commission services appropriate to each PHN area while providing consistent services across Victoria. The current projections used may not provide viable planning information given that service demand will change as organisations
17 Hoult, J., Reynolds, I., Charbonneau-Powis, M., Weekes, P., & Briggs, J. (1983). Psychiatric hospital versus community treatment: the results of a randomised trial. Australian and New Zealand Journal of Psychiatry, 17(2), 160-167. 18 Torrey, W. C., & Wyzik, P. (2000). Recovery vision as a service improvement guide for community mental health center providers. Community Mental Health Journal, 36(2), 209-216.
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change their services and models of care in response to the NDIS and consumer choice.
f. whether spending on services for people with a psychosocial disability is in line with projections;
The projections used for spending for people psychosocial disability in the NDIS are inaccurate, with significantly more people currently using psychosocial supports19.
The April 2016 NDIA Victorian Market Position Statement states the number of NDIS participants projected in the Southern Melbourne area by June 2019 will be 10,20020. This figure includes all likely to be eligible for the NDIS.
In a recent report from South Eastern Melbourne Primary Health Network, 36,000 people living in the catchment were reported to have a ‘severe, disabling mental health condition, of which 12,000 are estimated to be living with a psychotic condition21.
With only 10,200 NDIS places allocated, many of the 36,000 living with severe mental illness will be reliant on clinical mental health services, and will not have access to crucial community support and rehabilitation services.
Projections for psychosocial disability will be difficult to use effectively as this is modelled on current service provision, not redesigned systems responding to the roll-out of the NDIS. As the scheme is built to be reactive to individual need, the Barwon area trial does not provide insight into the projected need of the individuals in the Southern Melbourne area.
It is unlikely that the projections used by the NDIA estimated using population projections and phasing as per the bilateral agreement between the Commonwealth and Victoria, is accurate.
Accurate projects are crucial to ensure current and future demand for psychosocial support is met.
g. the role and extent of outreach services to identify potential NDIS participants with a psychosocial disability;
Current projections suggest that supported positions in the NDIS for people with psychosocial disability are at capacity. This suggests that outreach to identify further participants would not be feasible.
19 Mental Health Australia (2017) Submission 1- Attachment 1 Mental Health Australia The
implementation and operation of the psychiatric disability elements of the National Disability Insurance Scheme: A recommended set of approaches, Technical Paper Prepared by David
McGrath Consulting. p.6 Canberra
20 National Disability Insurance Agency. Market Position Statement Victoria p. 10( April 2016)
Geelong, Commonwealth of Australia
21 South East Melbourne Primary Health Network, Integrated Atlas of Mental Health, Alcohol
and Other Drugs and Homelessness – Draft 2.2 (February 2017),p.52, Victoria, Australia
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Outreach and pre-planning activity is currently not funded by the NDIA. Given the effectiveness of once-off preplanning funding as provided in the ACT NDIS trial, we support the introduction for this funding in Victoria22 . Assertive community outreach will be critical to ensure the most vulnerable NDIS consumers can access needed services.
g.1. The importance of assertive community outreach Those with psychosocial disability who are vulnerable, for example, those who are rough sleeping are not provided with adequate community support, they are more likely to disengage from all support systems. This includes housing, case management, and any dual diagnosis with alcohol and other drug use. As a result, their condition becomes more acute, requiring significant acute treatment and care23,24,25.
A significant barrier for consumers with psychosocial disability who are homeless or lack a permanent address is the need to complete access request forms from the NDIA to determine eligibility, usually posted or through a MyGov account.
There are also reports of the NDIA refusing to give paperwork to access the NDIS to caseworkers or outreach workers if no address is provided.26 This will grossly limit access to those in need of NDIS services with no permanent address.
Our experience is that disadvantaged clients find it difficult to independently seek services without the support of trained outreach clinicians and staff. Building relationships is at the core of working with these clients and is essential in the delivery of high quality, integrated services. The concern is a highly competitive and contestable environment where pre-planning activity is not funded can mitigate against this joined-up and integrated service, and jeopardise continuity of care for vulnerable consumers.
Conclusion
ISCH is well positioned to continue to provide high quality mental health services to our community , and will be seeking opportunities to continue this delivery in the future through a variety of avenues including the NDIS, State Government funding and PHN funding.
22 Victorian Council on Social Services,(VCOSS) VCOSS Member consultation, Level 8, 128
Exhibition St, Melbourne, 9 February 2017
23 Drake, R. E., Essock, S. M., Shaner, A., Carey, K. B., Minkoff, K., Kola, L., … & Rickards, L. (2001). Implementing dual diagnosis services for clients with severe mental illness. Psychiatric services, 52(4), 469-476. 24 Killaspy, H., Bebbington, P., Blizard, R., Johnson, S., Nolan, F., Pilling, S., & King, M. (2006). The REACT study: randomised evaluation of assertive community treatment in north London. Bmj, 332(7545), 815-820. 25 Phillips, S. D., Burns, B. J., Edgar, E. R., Mueser, K. T., Linkins, K. W., Rosenheck, R. A., … & McDonel Herr, E. C. (2001). Moving assertive community treatment into standard practice. Psychiatric services, 52(6), 771-779. 26 Victorian Council on Social Services,(VCOSS) VCOSS Member consultation, Level 8, 128
Exhibition St, Melbourne, 9 February 2017
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However, we remain concerned there are significant gaps in service for people with psychosocial disability. The most significant of these gaps is the lack of rehabilitation and recovery services under the NDIS, and the lack of other suitable rehabilitation alternatives for consumers not eligible for the NDIS. These gaps could lead to poor health outcomes for people and greater inefficiencies in community, health and human service delivery.
Inner South Community Health looks forward to see the outcomes of this inquiry and would be more than happy to discuss our submission further.
Inner South Community Health Service
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References
Australian Government Department of Health ( July 2016) PHN Primary Mental
Health Care Flexible Funding Pool Implementation Guidance Stepped Care
Canberra, Australia
Australian Commission on Safety and Quality in Health Care (ACSQHC). Australian Charter for Health care rights. Sydney :ACSQHC, 2008
Australian Government Department of Social Services Information for
Providers: Personal Helpers and Mentors Services (July 2016) Commonwealth
of Australia, Canberra. Armijo, J., Méndez, E., Morales, R., Schilling, S., Castro, A., Alvarado, R., & Rojas, G. (2013). Efficacy of community treatments for schizophrenia and other psychotic disorders: a literature review. Frontiers in psychiatry, 4, 116.
Commonwealth of Australia. National Standards for Mental Health Services
- Canberra, Commonwealth of Australia (2010)
Commonwealth of Australia. National Standards for Mental Health Services
- Additional Paper: Principles of recovery oriented mental health practice Canberra, Commonwealth of Australia (2010) Drake, R. E., Essock, S. M., Shaner, A., Carey, K. B., Minkoff, K., Kola, L., … & Rickards, L. (2001). Implementing dual diagnosis services for clients with severe mental illness. Psychiatric services, 52(4), 469-476. Frieden, T R. A framework for public health action: the health impact pyramid. American journal of public health 100.4 (2010): 590-595. Hoult, J., Reynolds, I., Charbonneau-Powis, M., Weekes, P., & Briggs, J. (1983). Psychiatric hospital versus community treatment: the results of a randomised trial. Australian and New Zealand Journal of Psychiatry, 17(2), 160-167. Killaspy, H., Bebbington, P., Blizard, R., Johnson, S., Nolan, F., Pilling, S., & King,
M. (2006). The REACT study: randomised evaluation of assertive community treatment in north London. Bmj, 332(7545), 815-820. Lomas, J. Social capital and health: implications for public health and epidemiology. Social science & medicine 47.9 (1998): 1181-1188. Marmot, Michael, and Commission on Social Determinants of Health. Achieving health equity: from root causes to fair outcomes. The Lancet 370.9593 (2007): 1153-1163. Mental Health Australia (2017) Submission 1- Attachment 1 Mental Health Australia The implementation and operation of the psychiatric disability elements of the National Disability Insurance Scheme: A recommended set of
approaches, Technical Paper Prepared by David McGrath Consulting. p.6
Canberra
National Disability Insurance Agency. Market Position Statement Victoria p. 10( April 2016) Geelong, Commonwealth of Australia National Disability Insurance Agency. Completing the access process for the NDIS Tips for Communicating about Psychosocial Disability p. 4 ( August 2016)
Canberra, Commonwealth of Australia
Phillips, S. D., Burns, B. J., Edgar, E. R., Mueser, K. T., Linkins, K. W., Rosenheck,
R. A & McDonel Herr, E. C. (2001). Moving assertive community treatment into standard practice. Psychiatric services, 52(6), 771-779.
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South East Melbourne Primary Health Network, Integrated Atlas of Mental
Health, Alcohol and Other Drugs and Homelessness – Draft 2.2 (February
2017),p.52, Victoria, Australia
South Eastern Melbourne Primary Health Network (SEMPHN) (December2016)
Mental Health Stepped Care Model, Melbourne, Victoria
Torrey, W. C., & Wyzik, P. (2000). Recovery vision as a service improvement guide for community mental health center providers. Community Mental Health Journal, 36(2), 209-216.
Victorian Council on Social Services,(VCOSS) VCOSS Member consultation,
Level 8, 128 Exhibition St, Melbourne, 9 February 2017
Victorian Health Services Act (1988)
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