Provision of NDIS services for people with psychosocial disabilities related to mental health

PARLIAMENT OF AUSTRALIA

JOINT STANDING COMMITTEE ON THE

NATIONAL DISABILITY INSURANCE SCHEME

THE PROVISION OF SERVICES UNDER THE NDIS

FOR PEOPLE WITH PSYCHOSOCIAL DISABILITIES

OCCUPATIONAL THERAPY AUSTRALIA (OTA)

SUBMISSION

FEBRUARY 2017

Occupational Therapy Australia Limited ABN 27 025 075 008   | ACN 127 396 945

6 / 340 Gore St. Fitzroy VIC 3065

Ph +61 3 9415 2900   | Fax +61 3 9416 1421   |  Email policy@otaus.com.au   |  Website www.otaus.com.au

Introduction

Occupational Therapy Australia (OTA) welcomes the opportunity to make a submission to the Joint Standing Committee on the National Disability Insurance Scheme as part of its inquiry into the provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition.

Occupational Therapy Australia is the professional association and peak representative body for occupational therapists in Australia. As of September 2016 there were more than 18,000 nationally registered occupational therapists working across the government, non-government, private and community sectors in Australia. Occupational therapists are allied health professionals whose role is to enable their clients to participate in meaningful and productive activities.

Occupational therapists provide services such as physical and mental health therapy, vocational rehabilitation, assistive equipment prescription, home modifications and chronic disease management, as well as key disability supports and services.

Occupational Therapy Australia is a strong supporter of the NDIS and the scheme’s focus on providing individualised support for participants with informed choice and control over their plans. Occupational therapists work across all NDIS launch sites and contributed to the design and implementation of the scheme during its trial period.

Occupational Therapy Australia strongly believes that people with psychosocial disabilities arising from a mental health condition should be able to access supports and services through the NDIS, as those with severe and complex forms of mental illness can experience similar barriers to participating fully in everyday life as those with physical disabilities. Following its reforms to mental health services announced in November 2015, the Federal Government committed to a ‘stepped care’ model reflecting the different levels of care required by consumers. Occupational Therapy Australia believes that the provision of NDIS services for people with psychosocial disabilities should reflect this needs-based approach, allowing this cohort to access the services they need when they need them.

However, despite the scheme’s potential to transform the lives of people with mental illness and facilitate greater social inclusion, there are a number of ongoing issues that need to be addressed as a matter of urgency. These are outlined in more detail throughout this submission.

Summary of recommendations  Measures to reduce uncertainty around the NDIS eligibility criteria for people with mental health conditions should include: developing a comprehensive definition of psychosocial disability, including case studies of participants with psychosocial disabilities on the NDIS website, developing consumer-friendly marketing material, and refining the NDIS access requirements to provide greater clarity for prospective participants and their families.  Funding should be provided to increase the number of NDIS Local Area Coordinators (LACs) and therefore reduce the number of people assigned to one LAC. Additionally, there should be a greater focus on recruiting people who have experience working with clients with a dual diagnosis or co-occurring disorders to fill LAC positions.  Principles of recovery oriented mental health practice should be used to guide the delivery of the NDIS for people with psychosocial disabilities.

 The Department of Social Services should commission another review of the legislation underpinning the NDIS (the NDIS Act), and particular attention should be paid to the concept of permanency.  The training provided to NDIS Planners should be revised to provide for more comprehensive participant plans and reduce the frequency of plan reviews. NDIS providers, including occupational therapists, should be consulted throughout the process of developing or refining training material.  Consideration should be given to increasing the number of assessment and treatment services available through programmes such as Helping Children with Autism (HCWA) and Better Access to Mental Health (BAMH), as well as the number of claimable allied health services available through the Medicare Benefits Schedule (MBS), to ensure adequate support for people who are not eligible for the NDIS.  GPs should be provided with comprehensive information on the various services funded through Medicare to ensure that referrals are consistent with a client’s therapy needs.  The Department of Social Services should provide funding to increase support for mental health carers. This should involve raising awareness of carers’ needs, developing programmes and initiatives to facilitate carer engagement in a range of activities, improving the accessibility of information about support services, and commissioning research into evidence based support models.

Context: The role of occupational therapists in mental health

Occupational therapists are key providers of mental health services to people of all ages. Mental health occupational therapists use a person centred approach to supporting optimal engagement for people with mental illness. Some examples of their work include:

 Designing a range of individual and group programmes and activities that are tailored to specific cultural, developmental and social needs;  Developing coping strategies to assist clients to better manage or overcome their mental health issues;  Improving clients’ confidence and self-esteem in social situations;  Establishing preventative measures to address occupational deprivation and facilitate occupational engagement;  Exploring clients’ occupational histories and life roles;  Working in a holistic manner to address co-occurring conditions so that optimal levels of engagement and performance are achieved

Despite the breadth of roles and interventions performed by occupational therapists working in mental health, there remains a general lack of awareness and recognition of these. This is due in large part to the tendency to automatically associate mental health care with certain disciplines, such as psychology and psychiatry.

Problem 1: Unclear eligibility criteria

The subject of support for people with mental health issues under the NDIS has received significant media coverage since the scheme’s trial period began in July 2013, and it appears that many of the potential issues raised by mental health advocates remain unresolved. In June 2014, Frank Quinlan, CEO of the then Mental Health Council of Australia, wrote a piece entitled ‘Getting the NDIS right for

people with psychosocial disability’.1 In it he argued that there were substantial but not insurmountable challenges associated with making the NDIS work for people with mental illness. Quinlan noted that there was a very real risk of people with mental illness missing out on key supports and services because of the rushed roll out of the scheme, however with the proper solutions in place this risk could be significantly reduced. More than two and a half years on, people with mental health conditions remain confused about whether they even qualify for the scheme as a result of unclear eligibility criteria.

An independent evaluation of the NDIS, released in January 2017, found that NDIS participants with mental health conditions were experiencing poorer outcomes than those with physical disabilities.2 People with psychosocial disabilities were also more likely to report that they now had less choice and control over their supports, which is in direct contrast with the objectives of the NDIS.

Perhaps the most pressing issue is the fact that there remains a lack of clarity around what is meant by the term ‘psychosocial disability’. A survey conducted last year by the ACT Mental Health Consumer Network revealed that most respondents did not know what a psychosocial disability was.3 A factsheet developed for prospective NDIS participants with a mental health condition states that psychosocial disability is ‘the term used to describe disabilities that may arise from mental health issues’.4 Occupational Therapy Australia believes that any promotional material needs to provide more detail about the types of disabilities resulting from a mental health condition that would render a person eligible for the NDIS.

The issue of dual diagnosis (when a person is experiencing both mental health and substance abuse issues) requires particular attention. These people require integrated access to services, rather than having to apply for and access several pockets/agencies for funding. They should have access to an NDIS Local Area Coordinator (LAC) who can assist them to access information about supports that are available in their community.

Recommendation 1: The Department of Social Services, in partnership with the National Disability Insurance Agency, should take steps to reduce uncertainty around when people with mental health conditions are eligible for the NDIS. These should include:  Developing a comprehensive definition of psychosocial disability that draws on evidence based research;  Including case studies on the NDIS website that provide examples of situations when an individual would or would not be eligible for the NDIS;  Developing consumer friendly marketing material for health professionals to distribute to clients with mental health conditions;  Refining the NDIS access requirements to allow mental health consumers to make an informed decision about whether they will be eligible for the NDIS. A specific checklist for people with psychosocial disabilities may be a useful tool.

Recommendation 2: Funding should be provided to increase the number of NDIS Local Area Coordinators (LACs) and therefore reduce the number of people assigned to one LAC. There should also be a greater focus on recruiting people who have experience working with clients with a dual

1 https://mhaustralia.org/general/getting-ndis-right-people-psychosocial-disability 2 https://www.dss.gov.au/disability-and-carers/programs-services/for-people-with-disability/national disability-insurance-scheme/ndis-evaluation-intermediate-report 3 http://www.abc.net.au/news/2016-04-18/ndis-confuses-applicants-with-psychosocial-definition/7334114 4 https://www.ndis.gov.au/medias/documents/heb/h21/8799160959006/Fact-Sheet-Psychosocial-disability recovery-and-the-NDIS-PDF-774KB-.pdf

diagnosis or co-occurring disorders to fill LAC positions, thus providing more integrated support for those who may have to apply to different agencies for funding.

Problem 2: Episodic nature of mental illness

Concerns have been raised by a number of mental health stakeholders that the NDIS does not take into account the relapsing/remitting nature of mental illness. The access requirements for becoming an NDIS participant stipulate that an individual may meet the disability requirements if they ‘have an impairment or condition that is likely to be permanent’, and the impairment ‘substantially reduces [their] ability to participate effectively in activities, or perform tasks or actions’ without assistance.5 The access requirements do specify that an impairment that ‘varies in intensity’ may still be considered a permanent impairment. It is clear that some degree of flexibility is required to support those whose condition does not overtly manifest itself into visible signs and symptoms of mental illness.

The need for a condition to be permanent seems to conflict with principles of recovery oriented mental health practice, which underpin the provision of mental health services by clinicians such as occupational therapists. These principles have been adopted by numerous federal and state government departments and agencies, and are used to guide the implementation of the National

Standards for Mental Health Services.6

Although the NDIS is aimed at people with psychosocial disabilities stemming from severe and complex mental illness, it is still possible for an individual’s condition to fluctuate greatly over the course of their lifetime. Occupational Therapy Australia has previously called for clarification to be provided around the access criteria for those with mental health conditions and the scheme’s capacity to provide ongoing support for those who fall within this category.

This issue was also raised by numerous other stakeholders in submissions to the independent review of the NDIS Act undertaken by EY in late 2015. Although the final report from this review recommended that the NDIS Act not be amended to address concerns about the concept of permanency in the context of mental illness, it did state that ‘there would be value in revisiting the appropriateness and effectiveness of the permanency provisions as part of the next review of the NDIS Act’.7 Occupational Therapy Australia calls on the Department of Social Services to adopt the recommendation that a further review of the NDIS be conducted (Recommendation 31), and ensure that this review gives due consideration to the concept of permanency and the impact of this on NDIS participants with psychosocial disabilities.

Recommendation 3: Principles of recovery oriented mental health practice should be used to guide the delivery of the NDIS for people with psychosocial disabilities arising from a mental health condition.

Recommendation 4: The Department of Social Services should commission another review of the legislation underpinning the NDIS (the NDIS Act), and particular attention should be paid to the concept of permanency and whether or not this limits the recovery efforts of participants with psychosocial disabilities. This is in line with Recommendation 31 of EY’s final report from the review of the NDIS Act that was undertaken in 2015.

5 https://www.ndis.gov.au/people-disability/access-requirements 6 http://www.health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-i-nongov-toc~mental pubs-i-nongov-pri 7 https://www.dss.gov.au/sites/default/files/documents/04_2016/independent_review_of_the_ndis_act.pdf

Problem 3: Lack of recognition of the role of occupational therapists as NDIS providers

As mentioned above, the role of occupational therapists in providing mental health services is often poorly understood.

We believe that occupational therapists should play a key role in working alongside NDIS Planners to assess the functional needs of prospective NDIS participants, including those with a mental health condition. Following extensive consultation with Occupational Therapy Australia members, it is apparent that Planner inconsistency is a significant issue nationwide. The quality of NDIS plans varies considerably from person to person, and depends on the Planner’s level of experience and understanding of the different services available to participants.

Occupational therapists working in mental health have reported that NDIS Planners frequently underestimate the hours of therapy required for a participant to achieve their goals. Additionally, many Planners fail to recognise that NDIS participants with psychosocial disabilities may be better supported by an occupational therapist rather than other mental health professionals. We acknowledge that some Planners do have an allied health background and have developed plans that adequately reflect the complexities of a participant’s needs.

Recommendation 5: The training provided to NDIS Planners should be revised to provide for more comprehensive participant plans and reduce the frequency of plan reviews. Planners should be required to have a minimum understanding of therapeutic supports and their value in helping participants to develop key skills and enhance their independence. Occupational Therapy Australia recommends that consideration be given to how the skill level of Planners can be increased with respect to occupational therapy practice. We also call for the training of NDIS Local Area Coordinators (LACs) and Support Coordinators to be enhanced to allow for greater understanding of the roles of different health professionals. NDIS providers should be consulted throughout the process of developing or refining training material.

Problem 4: Lack of clarity around support for people with disability who are not eligible for the NDIS

Given the lack of clarity around the access criteria for the NDIS for people with mental illness, it is clear that a significant number of people will be deemed ineligible. It was recently reported that more than 100,000 people with severe mental illness who are currently receiving services will not be eligible for the NDIS.8 There will only be 64,000 NDIS places allocated for people with psychosocial disabilities once full roll out of the scheme is complete, meaning that many people could miss out. It is feared that the transition of funding for federal programmes and services to the NDIS will increase pressure on state-funded services and leave many worse off. This is despite the Federal Government’s commitment to ensuring continuity of care for those who are ineligible.

Although Occupational Therapy Australia is supportive of the NDIS, it is critical that funding for the scheme does not come at the expense of existing programmes and services for people with mental health conditions. The growing focus on the NDIS has meant that other federally funded initiatives have become something of an afterthought, despite the fact that people with mental health conditions who are not eligible for the scheme are likely to significantly outnumber those who are. Following the release of the NDIS Quality and Safeguarding Framework in early February, industry

8 http://www.theaustralian.com.au/national-affairs/health/100000-mentally-ill-lose-ndis-cover/news story/3f2363653fc5e86044f4ae2116395273

stakeholders immediately raised concerns that the rights of people with disability who are not NDIS participants would not be protected.9

Occupational Therapy Australia joins with Mental Health Australia in calling on the Federal Government to provide separate funding for Personal Helpers and Mentors (PHaMs) services, rather than draw on funds from the NDIA budget. This will ensure that funding that has been set aside for the NDIS can be directed towards those with severe and complex mental illness. Additionally, we endorse Mental Health Australia’s recommendation that $150 million be provided for the Partners in Recovery (PIR) initiative once it transitions to the NDIS, in line with the estimated cost of PIR when it was announced in 2011.10

Occupational Therapy Australia believes that one area that should be given particular consideration within the scope of this inquiry is early intervention. While the NDIS has the potential to benefit a great many people with disability, the scheme’s focus on investing in people early on to improve their outcomes later in life opens up significant opportunities for children with disability.

Occupational therapists are key providers of early intervention services to children through the Helping Children with Autism (HCWA) and Better Start for Children with Disability (Better Start) initiatives. It is understood that children receiving services through these initiatives will transition to the NDIS if they are deemed eligible, while those who are not eligible will continue to receive support through these existing programmes.

Occupational therapists are well placed to provide practical, thoughtful and functional support to children and parents with mental health concerns. Our members who provide services to children through government programmes such as HCWA and Better Access to Mental Health (BAMH) have found that the number of focused psychological strategies and/or interventions approved through these initiatives is very limited. Additionally, strategies and interventions that are funded do not always take into account the skills that occupational therapists can offer children and their families.

Occupational therapists are further hampered by the fact that GPs and paediatricians often overlook the services that occupational therapists provide, resulting in limited referrals for their services.

Recommendation 6: Consideration should be given to increasing the number of assessment and treatment services available through programmes such as Helping Children with Autism (HCWA) and Better Access to Mental Health (BAMH). This will ensure adequate support for people who are not eligible for the NDIS. We also recommend that the number of claimable allied health services available through the Medicare Benefits Schedule (MBS) be increased to allow for follow-up and other evidence based best practice interventions that are currently excluded.

Recommendation 7: GPs should be provided with comprehensive information on the various services funded through Medicare to ensure that referrals are consistent with a client’s therapy needs – for example, referring a client with mental health concerns who requires a functional needs assessment to an occupational therapist rather than a counsellor.

9 https://probonoaustralia.com.au/news/2017/02/concerns-ndis-quality-safety-framework-forgets-majority people-disability/ 10 Mental Health Australia, Key actions to ensure continued access to community support for people affected by severe mental illness during NDIS transition and beyond

Problem 5: Inadequate support for mental health carers

Concerns have been raised by our members that the individualised nature of the NDIS may lead to inadequate support for carers and family members of people with mental illness. Occupational Therapy Australia is a strong advocate of the rights of mental health carers, and we call on the Federal Government to prioritise initiatives aimed at increasing support for carers of all ages. A recent report released by Anglicare highlights the fact that carers’ needs are not currently being met under the NDIS.11 Concerns have been raised that respite programmes will be discontinued, while carers have reported finding it difficult to locate information about available services.

We strongly urge the Federal Government to increase support for carers, including spouses, partners, children and siblings. Carers tend to have limited capacity to engage in meaningful occupations, particularly if they are caring for someone with a severe illness or disability.

Many carers find that they are forced to give up full time employment and move to a part time or casual role, while others stop working altogether. This can have a significant impact on household finances and a carer’s personal relationships.

Occupational Therapy Australia recommends that the Department of Social Services review the functionality of the National Carer Gateway to improve its accessibility for carers. Additionally, funding should be provided to raise awareness of carers’ needs and to develop programmes and initiatives to facilitate carer engagement in paid work and other activities. There is also a need for the Federal Government to commission research into best practice, evidence based support models for carers of all descriptions.

Recommendation 8: The Department of Social Services should provide funding to increase support for mental health carers. This should involve raising awareness of carers’ needs, developing programmes and initiatives to facilitate carer engagement in a range of activities, improving the accessibility of information about support services, and commissioning research into evidence based support models.

11 https://www.anglicare.org.au/sites/default/files/Carers_Report_Digital.pdf

including occupational therapists, should be consulted throughout the process of developing or refining training material.  Consideration should be given to increasing the number of assessment and treatment services available through programmes such as Helping Children with Autism (HCWA) and Better Access to Mental Health (BAMH), as well as the number of claimable allied health services available through the Medicare Benefits Schedule (MBS), to ensure adequate support for people who are not eligible for the NDIS.  GPs should be provided with comprehensive information on the various services funded through Medicare to ensure that referrals are consistent with a client’s therapy needs.  The Department of Social Services should provide funding to increase support for mental health carers. This should involve raising awareness of carers’ needs, developing programmes and initiatives to facilitate carer engagement in a range of activities, improving the accessibility of information about support services, and commissioning research into evidence based support models.

Conclusion

Thank you for the opportunity to submit to this inquiry. The investigation of these issues by the Joint Standing Committee on the NDIS is a positive step towards resolving many of the issues facing current and future NDIS participants with psychosocial disabilities and their families.

We would be more than happy to provide further clarification on any of the matters raised in this submission should this be required.