Submission 68 — Mission Australia — The provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition

Submission to the Joint

Standing Committee

on the NDIS: The provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition

About Mission Australia

Mission Australia is a national non-denominational Christian organisation that delivers evidence-based, consumer-centred community services. In the 2015-16 financial year we supported over 131,000 Australians through 452 programs and services. We work with individuals, families and children, young people and people experiencing homelessness and also provide specialist services for mental health, disability and alcohol and drug issues.

We deliver community mental health services in most States and Territories, including the Commonwealth-funded Personal Helpers and Mentors (PHaMs), Partners in Recovery (PIR) and Family Mental Health Support Services (FMHSS), and State-funded services such as the Housing and

Accommodation Support Initiative (HASI) and Enhanced Adult Community Living Support (EACLS) in

NSW. In 2015-16 we assisted 7,657 consumers through our 43 specific mental health services and 22,566 people with mental health issues across all of our 452 services nationwide.

In collaboration with clinical care, Mission Australia provides psychosocial support that assists people to achieve their desired goals and aspirations along their recovery journeys, improving wellbeing, building individual and sector capacity, and strengthening communities.

We are also a provider of Local Area Coordination (LAC) services in Tasmania, and a registered provider of Tier 2 NDIS supports in other regions.

Executive summary Mission Australia welcomes the opportunity to make a submission on the provision of services to people with a psychosocial disability under the NDIS. We have a number of concerns about the exclusion of some people from support through the NDIS, and also the implementation of supports for those who are eligible for Individual Funded Packages (IFPs).

We acknowledge the work of the NDIA in improving its understanding of psychosocial disability, including the formation of the Mental Health Sector Reference Group, the introduction of the NDIS Transition Support Program and the Psychosocial Supports Design Project undertaken jointly by the NDIA and Mental Health Australia. However, we still have significant concerns on the basis of our experience as a national provider of community mental health services, including:

• Many consumers of existing mental health programs will not be eligible for NDIS support or are discouraged from applying;

• Resources must be distributed appropriately and proportionately between the NDIS and the non-NDIS mental health system, and adequate supports must remain in place outside of the NDIS structure;

• People with either low-moderate or episodic mental illnesses are in danger of becoming increasingly under-served, as many policy and service delivery frameworks currently focus on people with severe and complex mental illnesses;

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• Failure to adequately invest in earlier intervention services risks poorer outcomes for individuals and higher costs to government over the longer term.

• There is a lack of clear accountability for the interaction between the NDIS and the non-NDIS mental health system.

These concerns are detailed throughout our submission.

Summary of recommendations

Eligibility Criteria

1. That the Productivity Commission’s 2017 review include a rigorous re-appraisal of the likely size of the cohort of people with a psychosocial disability who will be eligible for IFPs, the likely cost of their packages and how best to distribute resources across the NDIS and the mental health system to make sure that everyone who needs it can access services.

2. That the Commonwealth and State/Territory Governments, non-government sector and consumers and carers engage in co-design processes to ensure

a. that a new set of eligibility criteria are put in place for people with a psychosocial disability; and

b. that adequate services are provided outside the NDIS for people living with a mental illness who are ineligible for NDIS funding.

3. That NDIS adopts a recovery-oriented practice approach and that assessments used and questions asked by the NDIS are designed for individuals with psychosocial disability to maximise wellness.

4. That, as a matter of priority, the Commonwealth and State/Territory Governments resolve issues around future funding, program and governance arrangements to enable people to continue to receive vital support services.

Transition to NDIS of Commonwealth-funded mental health programs

5. That the transition of the PhaMs program into the NDIS should be put on immediate hold, so that an assessment can be made of the demand and resources available for people both within and outside the NDIS.

6. That, over the longer-term, community mental health programs such as PhaMs and PIR are retained outside of the NDIS, or replaced with other community mental health programs, in order to meet the needs of people who do not meet the NDIS eligibility criteria.

7. That consideration be given to future entry points into the NDIS once PIR has been fully transitioned.

8. That staff of existing mental health services, including peer support workers, are appropriately supported to assist consumers to apply for IFPs.

9. That NDIS assessment requirements are made flexible and streamlined so as not to exclude mental health consumers or overly burden carers.

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Transition to NDIS of state/territory-funded mental health programs

10. That State-funded mental health programs continue to be operated outside of the NDIS, including HASI, HASI Plus and EACLS.

Funding under the ILC

11. That the ILC budget be increased with an adequate proportion of dedicated funds remaining outside the LACs.

12. That the ILC include specialist psychosocial disability supports and projects targeting people who are homeless as a result of their psychosocial disability.

Planning Processes

13. That training in mental health and the specific needs of people living with mental illness be offered to Planners and LACs working with the NDIS.

14. That the Commonwealth and State/Territory Governments, non-government sector and consumers and carers engage in co-design processes to ensure that people are able to easily access services both inside the NDIS and in the wider mental health system.

Projected and actual spending

15. That the Productivity Commission’s 2017 review of the NDIS include consideration of whether an independent pricing authority should be established to provide independent advice to government on pricing for NDIS services and the efficiency of the NDIS payments system.

16. That the efficiency of enacting NDIS service agreements be reviewed by the Productivity Commission in 2017 with a view to improving the time taken to sign agreements.

Outreach services

17. That, over the longer-term, community mental health programs such as PhaMs and PIR are retained outside of the NDIS, or replaced with other community mental health programs, in order to meet the needs of people who do not meet the NDIS eligibility criteria and provide outreach to people with new or recurring mental illness.

18. Failing this, that the NDIA provides funding either to LACs or to other support organisations to provide outreach to people with new or recurring mental illnesses.

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1 Eligibility criteria TOR 1a. The eligibility criteria for the NDIS for people with a psychosocial disability.

Assumptions underpinning the eligibility criteria

In 2011 the Productivity Commission found that people with enduring and significant psychiatric disabilities were likely to meet the criteria for inclusion in the NDIS, estimating the size of this cohort at 57,000.i Subsequently, the Australian Government Actuary estimated that there are 56,000 people with ‘complex needs requiring co-ordinated services from multiple agencies’ – those expected to be broadly eligible for NDIS funding. Outside of this group, there are 103,000 people with severe and persistent mental illness who are likely to need psychosocial support, and 321,000 with an episodic mental illness, neither of which the Productivity Commission reported would be likely to be eligible for NDIS funding.ii The Australian Government Actuary noted that at least the 103,000 with a severe and persistent mental illness appear to meet the eligibility criteria for IFPs, and that it appeared at least on the surface that excluding them would be inconsistent with the Productivity Commission’s proposed eligibility criteria.iii

The Productivity Commission estimated that the funding required for the presumed 57,000 eligible people would be $1.8 billion per annum, based on an average package cost of approximately $32,000. However, it appears that the actual packages for people with a psychosocial disability in trial sites are fairly consistently around $21,000.iv If this trend continues over the long-term, this will contribute to a potential overabundance of resources within the NDIS at the cost of mental health services outside the NDIS, leaving the 103,000 people with a severe and persistent mental illness without adequate supports outside of the NDIS.

This is compounded by paying for much of the estimated $1.8 billion by transitioning programs into the NDIS, on the assumption that consumers of those programs will largely be eligible for IFPs. As outlined in Section 2, this assumption is proving to be incorrect, with consumers of some PhaMs and PIR programs seeing a very low success rate in applying for IFPs, and a cap put on the number of clients that PIR services can assist to transition into the NDIS.

Recent reports based on the unpublished findings of the National Mental Health Service Planning Framework, estimate that 100,000 people experiencing mental illness and requiring community mental health supports will lose all or part of their support as programs shift focus and are phased out.v Further data reports on NDIS access show 78% of participants with a psychosocial disability submitting an access request have been found eligible for the scheme (noting that a further 3% are in the process of having their eligibility assessed).vi

We recommend that the Productivity Commission’s intended 2017 review of the NDIS include a rigorous re-appraisal of the likely size of the cohort of people with a psychosocial disability who will be eligible for NDIS IFPs, and an associated review of the amount of funding required for NDIS consumers as well as for those who need to access supports from the mental health system outside of the NDIS.

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Eligibility criteria and continuity of service

The eligibility criteria for the NDIS are not appropriate for people with a psychosocial disability, for two principle reasons:

1. The eligibility criteria discourage people who may be eligible for applying. The language of the eligibility criteria around ‘permanent disability’ discourages people with mental health issues who do not consider themselves to have a disability. People need to be able to identify with the eligibility criteria and feel as though it describes them and their condition. The ‘choice and control’ element of the NDIS is inaccessible to them because they do not see themselves reflected in the language of the NDIS. While our program staff work very hard to explain the NDIS language to consumers and help them to see the benefits that receiving funding through the NDIS could bring them, some consumers refuse to engage.

Accessing services such as PHaMs is a different experience because a) the services use recovery-oriented language and b) they are voluntary and do not insist that people seek or receive a formal diagnosis. In the experience of our PHaMS services, many people react strongly against the suggestion that they have a disability and refuse to apply for NDIS funding. Similarly, due to the nature of their illness, some consumers of our services lack insight or are too unwell to make an informed decision about their service and support needs. Further previous trauma may mean consumers are service averse and reluctant to engage. Understanding the potential benefits of IFPs and being able to negotiate the choice based environment of the NDIS would be even more difficult for some.

2. They exclude many people who need support. Mission Australia is concerned that these issues in the transition to the NDIS may have unplanned impacts on people with mental health issues who are likely to ‘fall through the gaps’. Some consumers of community mental health programs which are transitioning into the NDIS including participants in PHaMs will be ineligible for assistance through the NDIS as they hope to (and in many cases will) recover from their mental health condition. Indeed, the effectiveness of these programs comes from their explicit recovery focus, which contrasts with the NDIS’ explicit focus on permanent disability.

Ensuring service continuity for those ineligible for the NDIS

Sufficient support needs to be provided outside the NDIS for those who are ineligible to receive support within it. If the eligibility criteria are altered to encourage or allow more people with a psychosocial disability into the NDIS, this will affect the proportion of funding that should be allocated for individual packages within the NDIS as opposed to block funding for programs outside it.

Crucially, people with a psychosocial disability need to be supported whether they are eligible for support within the NDIS or need to seek assistance outside it. This means that resources must be distributed appropriately and proportionately between NDIS and non-NDIS supports, and that adequate supports must remain in place outside of the NDIS structure to care for people with a psychosocial disability who do not meet the eligibility criteria or who are not applying for funding within the NDIS.

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Funding flows (including funding drawn from the integration of mental health programs into the NDIS) must be adjusted to reflect this. It is imperative that there are sufficient mainstream services available to meet the needs of consumers.

Continuity of support arrangements, as required under the NDIS bilateral agreements, should ensure this. However, at the same time, we know that people with either low-moderate or episodic mental illnesses are in danger of becoming increasingly under-served, as many policy and service delivery frameworks currently focus on people with severe and complex mental illnesses. This trend can be seen in the draft Fifth National Mental Health Plan, as well as in the funding directions being pursued by the States, the NDIS’ eligibility requirements for permanency of condition, and restrictions on Primary Health Networks to funding clinical mental health services. We note that psychosocial mental health supports need to be funded and integrated with clinical supports, to fill in the emerging gaps for people living with low-moderate or episodic mental illnesses. We believe that this is the way forward in mental health service provision, with collaborative arrangements between housing and health departments and NGOs, as evaluations of HASI have demonstrated now over many yearsvii.

We are also concerned about people aged 65 years and over, none of whom are eligible to access the NDIS. Although the NDIA has given assurances of continuity of support for this groupviii, we remain concerned that if community mental health programs become scarcer, this group will be unable to access needed supports.

We also note the difficulty that people in rural, regional and remote areas will face in accessing a range of supports, including diagnoses to support applications for NDIS funding, and adequate services to meet their needs both within the NDIS and in the mental health system outside of the NDIS.

To address these issues, we recommend that the Commonwealth and State/Territory Governments, non-government sector and consumers and carers engage in two co-design processes:

1. To ensure that a new set of eligibility criteria are put in place for people with a psychosocial disability; and

2. To ensure that adequate services are provided outside the NDIS for people living with a mental illness who are ineligible for NDIS funding. Such programs will be particularly important for under-served regions such as remote Aboriginal and Torres Strait Islander communities. It is important that consumers are involved in design, implementation and evaluation of the NDIS.

Lack of accountability

Mission Australia is concerned that there is a lack of a clear ‘owner’ within and between governments for these issues. The confusion around accountability for this issue is, from our experience, preventing the size and seriousness of this issue being identified and resolved. Like Mental Health Australia, we are:

… agnostic about which system, and which level of government should be responsible for providing services to this group of people. However, we are deeply concerned that it is currently

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unclear who, if anyone, has policy responsibility for this cohort and how these issues are going to be resolved.ix

This situation, if not speedily resolved, will cause a rise in the number of people with mental illness in the community with no support. This will have flow-on impacts for other government-funded service systems including homelessness, health (particularly hospital Emergency Departments), education and criminal justice. Failure to provide early intervention services in the community will worsen long term outcomes for people experiencing mental illness and increase costs to government through crisis supports, Accordingly, the Commonwealth has an important role to play to resolve issues around the NDIS transition and ensure that people with a moderate or episodic mental illness do not fall through the gaps of service provision.

We recommend that, as a matter of priority, the Commonwealth and State/Territory Governments act to resolve issues around future funding, program and governance arrangements to enable people to continue to receive vital support services.

Case study: Gus

Gus* is a consumer of one of Mission Australia’s PHaMs programs, who is suffering from obsessive compulsive disorder (OCD) and anxiety, which forced him into a vicious cycle of physical and emotional stress and homelessness. After his second visit to the mental health ward, he knew it was time to make a change so he connected with Mission Australia’s PHaMs program.

Due to escalating tension as a result of his mental state, Gus was forced to move out of his home. The period afterwards was difficult and the added stress of regularly having to access emergency accommodation only made his condition worse and resulted in several visits to the hospital emergency ward.

Gus’s case worker helped him develop a plan of action to address this but it proved to be a difficult task due to his obsessive-compulsive neurosis and the remote community in which he lived. With a combination of a mental health management plan and support from his case worker, Gus was finally able to find permanent housing. He is passing all his inspections and has been able to maintain his tenancy for a year now. Gus’s case manager often encouraged him to attend social gatherings in order to help him gain confidence and build his social skills. He uses his newfound confidence to raise awareness of mental illness and advocate for programs such as PHaMs in the hope that his journey can help someone that may be experiencing similar issues. This is essential in a remote location where services may be hard to find.

Gus is now taking control of his life; however, like many consumers suffering from mental illness, the episodic nature of Gus’s condition may mean that he won’t be able to produce sufficient evidence to be deemed eligible for the NDIS. PHaMs are working with Gus to get a formal diagnosis for his illness which will allow him to apply for the NDIS, however, there is no guarantee that he will be successful.

• Name has been changed to protect privacy. 7

Recommendations:

1. That the Productivity Commission’s 2017 review include a rigorous re-appraisal of the likely size of the cohort of people with a psychosocial disability who will be eligible for IFPs, the likely cost of their packages and how best to distribute resources across the NDIS and the mental health system to make sure that everyone who needs it can access services.

2. That the Commonwealth and State/Territory Governments, non-government sector and consumers and carers engage in co-design processes to ensure

a. that a new set of eligibility criteria are put in place for people with a psychosocial disability; and

b. that adequate services are provided outside the NDIS for people living with a mental illness who are ineligible for NDIS funding.

3. That NDIS adopts a recovery-oriented practice approach and that assessments used and questions asked by the NDIS are designed for individuals with psychosocial disability to maximise wellness.

4. That, as a matter of priority, the Commonwealth and State/Territory Governments resolve issues around future funding, program and governance arrangements to enable people to continue to receive vital support services.

2 Transition to NDIS of Commonwealth-funded mental health programs TOR 1b. 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; whether these services will continue to be provided for people deemed ineligible for the NDIS.

Rates of transition to NDIS

Mission Australia is concerned that some consumers of the Personal Helpers and Mentors (PHaMs) program will be ineligible for assistance through the NDIS as a result of the episodic nature of their mental illness and the requirement for a formal clinical diagnosis of a mental health condition for the NDIS where none has been in place for PHaMs. This has implications for consumers who we are concerned will start to fall through gaps in service provision, partly because PHaMs services themselves will become decreasingly viable as the program transitions to the NDIS. The ramp-down of block funding from DSS for PHaMs is based on the assumption that an increasing proportion of PHaMs consumers will be fee-paying through the NDIS, which will ensure their viability. However, we are becoming increasingly concerned that the number of PHaMs consumers (either current or new) who will become fee-paying NDIS consumers of PHaMs has been overestimated, although this varies widely by region.

For example, in Tasmania, DSS figures show that 57 per cent of all PHaMs consumers are not transitioning to NDIS, and our own service experience suggests even less comprehensive transition with only 10 out of 150 PHaMs consumers in our Tasmanian sites having been assessed as eligible for an IFP. In one of our NSW PHaMs sites, however, approximately 90 per cent of clients have been assessed as

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eligible, although more recently applications have been knocked back at higher rates. Nonetheless, given the regional variation and the very low rates of successful applications in some areas, like Mental Health Australia we remain concerned about the proportion of community mental health consumers transitioning into the NDIS, including PHaMs and PIR participants.x

A related concern is around the time taken to prove eligibility for the NDIS for people with a psychosocial disability and to be assessed for eligibility for a plan. In our experience, the assessment process can take up to six months, depending on the time taken to obtain a diagnosis, be assessed for a plan, make changes to that plan and then have it finally accepted. Obtaining a diagnosis – which is not usually a requirement of being a consumer of a community mental health service can be difficult and time consuming. In some cases it is an insurmountable barrier where people do not want to identify as having a mental illness or disability and therefore will not seek a formal diagnosis. We recognise that the processes for determining eligibility will require some form of proof of need: however, we also note that this may be difficult to acquire for many people living with a mental illness and alternatives such as functional assessments could be used.

There is a need for greater consistency in evidence required as some applications have only required a single supporting report from a GP or Psychiatrist as evidence of the consumer’s disability, while others have required up to five or more reports from different services. It is important that this process is streamlined as much as possible. Third parties (e.g. service providers) should be able to provide information about eligibility. Burdensome and inflexible evidence requirements may result in consumers being excluded from the NDIS because they do not have the support and assistance required to complete the exhaustive assessment process. It may also place an excessive burden on carers.

We recommend that the transition of the PhaMs program into the NDIS be put on immediate hold, so that an assessment can be made of the demand and resources available for people both within and outside the NDIS, including:

• A re-assessment of the number of people with a psychosocial disability likely to be eligible for the NDIS (particularly if the eligibility criteria will be re-designed for people with a psychosocial disability); and

• The amount typically expended per person per annum by people with a psychosocial disability in the NDIS.

We also believe that there is a need over the longer-term to maintain programs such as PhaMs and PIR outside of the NDIS, or replace them with other community mental health programs, in order to meet the needs of people who do not meet the NDIS eligibility criteria.

Future entry points into the NDIS

We welcome the recent announcement that PIR funding will be extended for two years until June 2019, but remain concerned about the longer-term impacts of transitioning PIR to the NDIS. One of the potential risks once PIR (and PhaMs) come to an end is that people who then become unwell, or have not previously been involved with the mental health system, have no natural entry point into the NDIS.

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At the moment, PIR provides support for people living with a mental illness in the community to access the NDIS, and is able to help people who need lots of coordination and communication support to navigate the complex systems. Our understanding is that LACs may be expected to take on this function once the PIR program is no longer funded, but our experience in some areas is that LACs are not mental health specialists and do not have sufficient expertise to perform this function well.

Ensuring skilled staff are supporting consumers

The skill of service staff in assisting consumers to acquire the necessary documentation to support their application is a key issue. Where staff are not sufficiently qualified, equipped with the skills or experience to adequately perform this function, consideration should be given to either providing them with training or setting up formal arrangements to refer consumers to other programs with skilled staff who have experience in supporting such documentation processes. The Transition Support Project for the PIR and Day to Day Living (D2DL) services may be a good model for supporting staff of other mental health services that are assisting consumers to access the NDIS (for example, PHaMs, and State-funded services such as HASI).

We believe that being able to draw on a peer support workforce is a huge benefit for mental health service and support provision. Mission Australia’s National Recovery Framework has principles which include enhancing a peer workforce to enable us to better understand the value of lived experience, and realise the many benefits peer workers can bring to recovery focused practice. We actively engage the expertise of people with lived experience in policy development, planning, evaluation, education and training, advocacy and service delivery that is more inclusive to the range and needs of people with lived experience. We support the conclusion of the Psychosocial Supports Design Project that one of the goals of the NDIS ‘…could be to ensure that all peer workers are appropriately skilled and experienced professionals who possess a comprehensive knowledge and understanding of the local service system (including health and welfare sectors) and both clinical and non-clinical support services.’xi

Recommendations:

5. That the transition of the PhaMs program into the NDIS should be put on immediate hold, so that an assessment can be made of the demand and resources available for people both within and outside the NDIS.

6. That, over the longer-term, community mental health programs such as PhaMs and PIR are retained outside of the NDIS, or replaced with other community mental health programs, in order to meet the needs of people who do not meet the NDIS eligibility criteria.

7. That consideration be given to future entry points into the NDIS once PIR has been fully transitioned.

8. That staff of existing mental health services, including peer support workers, are appropriately supported to assist consumers to apply for IFPs.

9. That NDIS assessment requirements are made flexible and streamlined so as not to exclude mental health consumers or overly burden carers.

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3 Transition to NDIS of state/territory-funded mental health programs TOR 1c. The transition to the NDIS of all current long and short term mental health state and territory government funded services, and in particular; whether these services will continue to be provided for people deemed ineligible for the NDIS.

Some State-funded services provide crucial supports to people living with a mental illness that they may not be able to access within the NDIS, and we therefore recommend the continuation of programs such as the HASI, HASI Plus and EACLS outside of the NDIS. This is particularly necessary for people who lack insight or are too unwell to make an informed decision about their service/support needs. This especially includes those who have been living in institutional care for a long time. For example, HASI Plus and EACLS programs work with people who are exiting long time psychiatric care and prisons. After such long stays in these institutions – sometimes 20 years or more – they often need a significant amount of intensive support to live in the community and have frequently lost the decision-making skills that would allow them to operate within the ‘choice and control’ environment of the NDIS. This intensive support (sometimes required 24/7) is needed by some consumers for many years.

Recommendation:

10. That State-funded mental health programs continue to be operated outside of the NDIS, including HASI, HASI Plus and EACLS.

4 Funding under ILC TOR 1d. The scope and level of funding for mental health services under the Information, Linkages and Capacity building framework.

We note the high level of concern in the sector that funding for the Information, Linkages and Capacity building framework (ILC) is inadequate for the task it is required to do. With the majority of ILC funding already allocated to LACs ($550 million of less than $700 million), leaving approximately $132 million, the concern is that the remaining four streams of the ILC will be severely under-funded.

Mission Australia currently runs one LAC, in Tasmania. Our experience there suggests that in smaller jurisdictions the objectives of the ILC may be able to be met under the expected funding arrangements. A Community Engagement Facilitator employed by our LAC is well-embedded in the local community and is able to perform a range of information and capacity-building tasks that fit well within the ILC Policy Framework, directed towards improving the access of all people with a disability to mainstream services.

However, we are particularly concerned that in larger jurisdictions such as NSW this will not be the case, and that there will not be enough remaining money within the ILC to fund its intended objectives. With only $132 million available out of the total NDIS budget of around $22 billion, we lack confidence that the ILC is sufficiently well-funded to meet the ILC outcomes.

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LACs are also now required to take up planning functions which will skew their workload away from community programs towards more individualised work, further diminishing the amount of resources dedicated towards the ILC objectives.

Further it would be useful for ILC to include specialist psychosocial disability supports and projects targeting people who are homeless as a result of their psychosocial disability.

Recommendations:

11. That the ILC budget be increased with an adequate proportion of dedicated funds remaining outside the LACs.

12. That ILC include specialist psychosocial disability supports and projects targeting people who are homeless as a result of their psychosocial disability.

5 Planning processes TOR 1e. The planning process for people with a psychosocial disability, and the role of primary health networks in that process.

Mission Australia is concerned that, in some regions, the Planners who are allocating IFPs are insufficiently trained in mental health issues and are applying guidelines inconsistently. The experience of our staff is that some seem to be unaware that mental health issues may satisfy the criteria for NDIS funding, indicating that their work is focused exclusively on people with physical disabilities. In our experience in some regions, neither Planners nor LACs understand psychosocial disability and how mental health affects functioning, as indicated in the examples below.

This affects whether those who are eligible for IFPs are getting the right items in their plan. For example, the experience of one of our PIR services is that planners are not familiar with the need for people living with a mental illness to have adequate coordination and communication support. That service calculated that the supports they provide through PIR would require approximately $7,500 in annual funding under the NDIS to provide equivalent coordination and communication support, but have found that most of their consumers who are eligible for an IFP are receiving much less than required in that kind of support. In such cases, there is not adequate continuity of service provision during the transition to NDIS and consumers are worse off (at least in terms of the services provided by PIR) under the NDIS than they were beforehand, contrary to the undertakings given by governments around continuity of support and no disadvantage in the transition to the NDIS. We recommend that training in mental health, impacts on functioning and required supports be offered to Planners and LACs working with the NDIS as a matter of priority.

Mission Australia is also concerned about the lack of transparency for consumers who are eligible for NDIS funding and their interaction with the rest of the mental health system. It is not clear whether or how people living with a mental illness who are eligible for the NDIS will be able to access services that sit outside the NDIS. We strongly advocate that people be able to access services both within and outside the NDIS where eligible, with proportional funding arrangements to be made so that there are

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no artificial restrictions on the services that they can access. This could be addressed as part of the co design process recommended in Section 1.

At this stage, the relationship between the NDIS infrastructure and Primary Health Networks (PHNs) seems to vary widely between regions. Our staff report that in some regions there is limited interaction between the two, while in others the relationship appears to be very healthy and the PHN has undertaken a regional consultation and developed a plan that involves a number of different mental health responses, both community based and clinical. Service coordination under the NDIS The following is a report from a Mission Australia Program Manager in a PIR service about meetings held to discuss the Individual Funded Plan of two consumers with the NDIS LAC:

Example 1: We attended the Planning Meeting with the LAC and the consumer. We felt the meeting went well and they were very clear that they would be looking at ensuring the supports that the consumer had were maintained and any gaps identified that could support working towards his personal goals would be included in his first plan. We were very clear about the role of PIR in the consumer’s coordination of services and the consumer was clear in his views that he wanted this to continue. When the plan was finalised, it had no Support Coordination and limited amounts in other areas. We requested a review and were advised by the NDIA Planner that the original plan was done by a LAC staff member and clearly did not take into account all the consumer’s needs. She advised this was a problem occurring ‘across the board’. The consumer subsequently received increases in all areas of support and $5000 for Support Coordination. Although this was a high amount, given that the average support time PIR consumers receive is 80 hours annually, it is still below what is considered to ‘maintain existing supports’.

Example 2: The planning meeting included attendance of the consumer, PIR Support Facilitator and LAC staff. Again the meeting was considered to go well. When the plan was received, the amount of Support Coordination was low at $2,400. This translates to less than 30 minutes per week. The consumer had a variety of NDIS services, as well as non-NDIS organisations and services that related to his goals that would necessitate far more than 30 mins/week support coordination. We contacted the NDIS about reviewing the plan and were advised that the consumer would need to utilise the funds allocated before they would review. We are already up to $900 and will be submitting a request for review soon. The request for a review will come out of the Support Coordination budget which would not be necessary had a more realistic amount been allocated in the first place.

Recommendations:

13. That training in mental health and the specific needs of people living with mental illness be offered to Planners and LACs working with the NDIS.

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14. That the Commonwealth and State/Territory Governments, non-government sector and consumers and carers engage in co-design processes to ensure that people are able to easily access services both inside the NDIS and in the wider mental health system.

6 Projected and actual spending TOR 1f. Whether spending on services for people with a psychosocial disability is in line with projections.

Funding NDIS psychosocial supports

We acknowledge that the cost projections for people with a psychosocial disability are very difficult, as the unpredictable recovery patterns anticipated by a recovery-oriented approach are inconsistent with assumptions of reduced spending over time that inform NDIS modelling.

However, there also appears to be a considerable discrepancy between the projected and actual spending on people with a psychosocial disability in the NDIS. As noted in Section 1, the estimated funding required for the 57,000 eligible people was $1.8 billion per annum, based on an average package cost of approximately $32,000, which is far exceeding the actual take-up amount which is averaging close to $21,000.

As outlined in Section 1, our recommended solution for this is for the Productivity Commission to review the size of the cohort who are eligible for IFPs, their likely average cost, and how to best distribute resources across the NDIS and the remaining mental health system to make sure that everyone who needs services can access them.

NDIS pricing

We note that the pricing regime under the NDIS has caused consternation across the sector, with Mental Health Australia writing that:

Since rollout of the NDIS commenced in launch sites, mental health providers have consistently raised concerns about the match between the hourly prices paid by the NDIA for psychosocial support work and the reality of delivering that work by suitably qualified personnel … This means service providers are currently cross-subsidising suboptimal transition arrangements. Mental Health Australia’s consultations suggest that the scale of cross-subsidisation is alarming and unsustainable.xii

Mission Australia’s own experience is similar. The fee rates determined by the NDIS to be paid for PHaMs services by NDIS participants are insufficient to cover delivery costs, especially for consumers who need mentoring, coordinating and family support services as opposed to more intensive services. Funding is often sufficient only to cover staff salaries at a comparatively junior level (CSW 3 and below). This makes it difficult for the sector to retain staff with degree qualifications who are required to effectively deliver programs for consumers with complex needs. The amounts set out in the NDIS Price Guidexiii are not enough to fund complex case coordination or skilled staff particularly once expenses

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such as developing individual case plans and group programs, travelling time, making and following up referrals and so on have been removed.

We support Mental Health Australiaxiv in calling for consideration of an independent pricing authority to provide expert advice to governments on pricing for NDIS services, and recommend that such an authority also be given the power to investigate the efficiency of the NDIS payments system to ensure that service agreements are being signed and funded efficiently. We note that the experience of hospitals in moving to Activity-Based Funding (ABF) has not been successful in terms of mental health treatments. We acknowledge that ABF is a more useful way of providing incentives for greater efficiencies than block funding, and that it may be fit-for-purpose for physical health treatments. However, given the diversity and unpredictability of the needs of mental health consumers, ABF for treatments in acute mental health has not been successful.

Efficiency of NDIS service agreement processing

Another potential issue is the lack of efficiency in enacting NDIS service agreements, which may have implications for consumers. For example, a consumer of one of our PIR services was receiving support from the part-subsidised NSW-funded service Home Care. The consumer was assessed as eligible for an IFP in October 2016 and elected to stay with the same Home Care provider. However, the service agreement was not signed until January 2017. The consumer received a bill from the provider for that three-month period prior to the agreement being signed.

This presents a further risk for small services who may be unable to sustain involvement in a system of slow payments. This will ultimately lead to fewer services for consumers.

Recommendations:

15. That the Productivity Commission’s 2017 review of the NDIS include consideration of whether an independent pricing authority should be established to provide independent advice to government on pricing for NDIS services and the efficiency of the NDIS payments system.

16. That the efficiency of enacting NDIS service agreements be reviewed by the Productivity Commission in 2017 with a view to improving the time taken to sign agreements.

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

For people who are already ‘in the system’, broadly speaking the issue is not with identifying people with a psychosocial disability to apply for NDIS funding – in many cases, our mental health services are confident that they are reaching those who need to be reached. The problem is with encouraging them to apply for NDIS funding and/or establishing their eligibility for NDIS support.

However, in the future, if PIR and PhaMs are completely transitioned, there does not appear to be a natural mechanism for providing outreach to people with new or recurring mental health issues and

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drawing them into the NDIS. As noted in Section 2, it is not clear whether LACs are expected to take on this function, but Mission Australia’s current observation is that they do not have the appropriate skills in either mental health or outreach service provision to undertake this role well.

Our strong recommendation is for a range of community mental health programs to be retained in order to engage in needed outreach to people with newly-developing or recurring mental illnesses. If this recommendation is not taken up, the NDIA will need to provide funding to provide outreach to people with new or recurring mental illnesses, either to LACs or to other support organisations or suffer the consequences of an already overstretched public health system (especially hospital emergency departments) getting worse.

Recommendations:

17. That, over the longer-term, community mental health programs such as PhaMs and PIR are retained outside of the NDIS, or replaced with other community mental health programs, in order to meet the needs of people who do not meet the NDIS eligibility criteria and provide outreach to people with new or recurring mental illness.

18. Failing this, that the NDIA provides funding either to LACs or to other support organisations to provide outreach to people with new or recurring mental illnesses.

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

We believe that people in receipt of forensic disability services should be subject to the same recommendations as discussed throughout this paper.

Conclusion

We hope that the Committee carefully considers the significant concerns raised above regarding both the people who may miss out on much needed mental health supports in the transition to the NDIS and the adequacy and timeliness of supports provided to those who are eligible for IFPs on the basis of their psychosocial disability.

Resources must be distributed appropriately and proportionately between the NDIS and the non-NDIS mental health system and accountability between the systems clarified. Ultimately adequate community-based mental health supports must remain in place outside of the NDIS structure to provide earlier intervention that improves the wellbeing of mental health consumers and reduces long-term costs to government.

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Endnotes

i Productivity Commission. 2011. Disability Care and Support: Productivity Commission Inquiry Report Overview

and Recommendations, No. 54, 31 July 2011. ii Australian Government Actuary. 2012. NDIS costings – Review by the Australian Government Actuary. Accessed online December 2016 at http://www.treasury.gov.au/~/media/Treasury/Access%20to%20Information/Disclosure%20Log/2012/National%2 0Disability%20Insurance%20Scheme%20Costings%20Review%20by%20the%20Australian%20Government%20Actu ary/Downloads/PDF/doc1.ashx iii Mental Health Australia. Letter to Minister Christian Porter. 19 May 2016. iv Mental Health Australia. 2016. Incoming Government Brief. Accessed online December 2016 at https://mhaustralia.org/publication/2016-incoming-government-brief v Moreton R (19 December 2016) ‘100,000 mentally ill lose NDIS cover’, The Australian. Accessed online at http://www.theaustralian.com.au/national-affairs/health/100000-mentally-ill-lose-ndis-cover/news story/3f2363653fc5e86044f4ae2116395273

vi National Mental Health Sector Reference Group Sector Communiqué – October 2016 – Attachment A Key Data on

psychosocial disability and the NDIS as at 30th June2016, accessed at: https://www.ndis.gov.au/NMHSRG-October 2016.html vii Bruce, J., McDermott, S., Ramia, I., Bullen, J. and Fisher, K.R. (2012), Evaluation of the Housing and

Accommodation Support Initiative (HASI) Final Report, for NSW Health and Housing NSW, Social Policy Research

Centre Report, Sydney. viii NDIA. 2016. Fact sheet: The National Disability Insurance Scheme and people aged 65 and over (updated August 2016). Accessed online January 2017 at http://ndis.nsw.gov.au/wp-content/uploads/2015/08/Factsheet-The NDIS-for-people-aged-65-and-over-August-2016_updated.pdf

ix Mental Health Australia. 2016. Policy submission: Draft ILC Commissioning Framework. Accessed online

November 2016 at https://mhaustralia.org/sites/default/files/docs/mental_health_australia_submission_to_ilc_commissioning_fram ework_april_.pdf x Mental Health Australia. 2016. Incoming Government Brief. Accessed online December 2016 at https://mhaustralia.org/publication/2016-incoming-government-brief xi Roberts, D. and Fear, J. 2016. Psychosocial Supports Design Project – Final Report (NDIA and Mental Health Australia), April 2016. Accessed online December 2016 at https://mhaustralia.org/sites/default/files/docs/psychosocial_supports_design_project_final_-_july_2016.pdf xii Mental Health Australia. 2016. Incoming Government Brief. Accessed online December 2016 at https://mhaustralia.org/publication/2016-incoming-government-brief, p.13. xiii NDIS. 2016. NDIS Price Guide Vic/NSW/QLD/Tas, valid from 1 July 2016. Accessed online November 2016 at https://www.ndis.gov.au/html/sites/default/files/documents/Provider/201617-vic-nsw-qld-tas-price-guide.pdf xiv Mental Health Australia. 2016. Incoming Government Brief. Accessed online December 2016 at https://mhaustralia.org/publication/2016-incoming-government-brief, p.13.

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