3 March 2017

Joint Standing Committee on the National Disability Insurance Scheme PO Box 6100 Parliament House CANBERRA ACT 2600

RE: THE PROVISION OF SERVICES UNDER THE NATIONAL DISABILITY INSURANCE SCHEME FOR PEOPLE WITH PSYCHOSOCIAL DISABILITIES RELATED TO A MENTAL HEALTH CONDITION

I refer to the Inquiry into the provision of services under the National Disability Insurance Scheme (NDIS) for people with psychosocial disabilities related to a mental health condition (The Inquiry). Suncorp welcomes the opportunity to contribute to the discussion.

Executive Summary

In respect to the NDIS offering services for psychosocial disability, Suncorp offers the following comments: -

   1.  Suncorp has an interest in promoting the success of publically underwritten disability schemes as the success of these schemes, working together with outcome based competitively underwritten personal injury schemes, should form part of a holistic package aimed at fostering social and financial independence early after a medical or injury event;

   2.  NDIS should be based on insurance principles, with clearly defined entry points into the scheme, acknowledging that psychosocial disability represents a challenging area for eligibility policy settings;

   3.  To foster a financially sustainable NDIS, the process in establishing psychosocial disability eligibility for individually funded packages (IFP) must be objective, measurable and supported by a cost effective dispute resolution process;

   4.  To reduce the demand for IFP, it is crucial that health/mental health schemes develop and apply nationally consistent best practice procedures to detect and treat mental illnesses earlier to avoid or reduce ongoing psychosocial disability;

   5.  In supporting the above point, there should be an active community awareness campaign on the benefits of early detection and treatment of mental health issues – noting the general stigma, mistrust and fear in the community about these conditions;

   6.    It is in NDIS’ interest to develop deep collaborative ties and data sharing with government departments responsible for the delivery of health/mental health services; income replacement, employment and vocational services; accommodation services and non NDIS disability services (collectively described as front line services) to ensure services are delivered in a timely manner on the basis of trauma informed care,1 noting that recovery cannot realistically commence until the person is in receipt of appropriate

1 Mental Health Australia – Trauma informed practice, 12 June 2014 - https://mhaustralia.org/general/trauma-informed-practice

mental health

Section Heading: Mental Health Care Considerations

Criteria for Acceptance:

For individuals requiring mental and physical health care, it must be ensured they possess stable income, accommodation, and a support person capable of coordinating their care;

Regarding those developing symptoms, if after delivering front line services over a nominated period significant ongoing psychosocial disability persists, acceptance for IFP through the early intervention pathway should be considered; and
Individuals already experiencing psychosocial disabilities may benefit from adopting an interim participant model similar to that used in National Injury Insurance Scheme (NIIS) type schemes, potentially enhancing social and financial independence without necessitating lifetime participation.

Suncorp offers diverse insurance products including banking solutions, general insurance coverage, compulsory third party (CTP), workers’ compensation policies, life assurance options along with superannuation offerings throughout both Australia and New Zealand regions.

With approximately thirteen thousand five hundred employees serving nine million customers globally across various sectors such as small businesses or large corporations alike via direct channels alongside intermediary networks nationwide, sunCorp stands among top twenty ASX-listed entities managing assets exceeding ninety-six billion dollars annually.

The company provides extensive worker’s comp programs available within most Australian jurisdictions while CTP insurances are specifically offered inside states like NSW, ACT,Qld,Sa.

A crucial factor contributing towards sunCorps’ achievements lies within its collection renowned brand names under one umbrella - AAMI,GIO,Vero etc., all known industry leaders recognized internationally due their innovative approaches toward customer satisfaction levels achieved consistently since inception date unknown yet presumably long time ago based upon historical records suggesting so.

sunCORPs has actively participated advocating reforms regarding personal injury statutory frameworks by publishing several white papers discussing topics related competitive underwriting practices,scheme designs,no-fault care models. As largest private insurer dealing directly with injured parties in country,Australia,taking leadership role seriously continues supporting initiatives aimed improving lives affected persons through these efforts made publicly accessible whenever requested formally.

This statement represents views held exclusively concerning Personal Injury Portfolio & Products department operating under broader organizational structure encompassing multiple divisions working together harmoniously achieving common goals set forth initially during formation phase which remains undisclosed currently though likely occurred sometime prior to present moment being discussed here now.

Suncorp In The Community Initiative Overview:

Our commitment extends beyond commercial interests focusing instead promoting safer environments reducing risks associated injuries disabilities among population groups we serve regularly via collaboration partnerships established locally regionally nationally even globally wherever applicable depending circumstances faced particular situation encountered at given point timeline.

We prioritize engagement activities centered around managing threats preventing harm encouraging active involvement ensuring quality treatment received individuals suffering from physical impairments mental conditions alike regardless severity level experienced personally professionally socially economically impacted negatively because of such events occurring unexpectedly sometimes tragically resulting permanent changes life trajectories forever altering course future plans aspirations hopes dreams etcetera indefinitely unless intervened properly timely manner possible otherwise left unaddressed potentially leading worse outcomes later down road ahead without proper attention paid immediately upon occurrence incident taking place anywhere anytime everywhere conceivable locations imaginable scenarios foreseeable unpredictable situations arising suddenly without warning notice whatsoever.

Our charity partner is ReachOut.com

Australia’s leading online mental health organisation for young people, providing practical support to help them get through anything from everyday issues to tough times. With most mental health problems emerging before the age of 25 years, and 75 percent of young people who experience issues not receiving help, prevention and early intervention strategies are vital to ensure symptoms do not progress to full blown mental illness and to promote earlier social and financial independence.

The National Disability Insurance Scheme

Suncorp continues to be a keen advocate for the publically underwritten NDIS and NIIS, as recovery based models underpinned by insurance principles. Insurance principles require –

actuarially estimating the cost of reasonable and necessary supports of the target population;
minimising support costs over a participant’s lifetime - by investing in people early to build their capacity to help them pursue their goals and aspirations resulting in greater outcomes later in life;
investing in research and encourage innovation; and
providing support to the general population ineligible for IFP through its Information Linkages and Capacity Building (ILC) program.

The NDIS (and NIIS) is a social welfare scheme, aimed at maximising social and financial independence early in a person’s lifetime. Suncorp maintains that social welfare schemes such as the NDIS and NIIS are best served in a publically underwritten environment.

This is because of the lifetime nature of the services required. Insurers would be obliged to hold a large amount of capital for a considerable amount of time to pay for these services. This would ultimately make the services unaffordable.

In respect to statutory personal injury schemes, it is Suncorp’s position that non catastrophic type claims are better served in a competitive underwritten environment. Further, it is Suncorp’s view that statutory scheme design should be based on a recovery model, similar to that used in the NDIS and NIIS.

A recovery model better supports people becoming socially and financially independent earlier after a medical or trauma event. It also better supports the Federal Government’s initiatives to counter the productivity challenges facing Australia due to its ageing workforce moving into retirement.

Cover Offered by the NDIS

The NDIS offers three levels of cover. It is important to understand the intent of each level of cover, as they have a role to ensure the financial sustainability of the scheme as a whole. The three levels of cover include:

Tier one - building community awareness of disability issues Intending to cover all Australians with public awareness campaigns and the provision of information to support purposeful integration of mainstream and other services.
Tier two – ILC - basic information and referral advice

Intending to cover about four million people with a disability and 800,000 of their primary carers by better linking individuals to mainstream supports;

assisting services to be more inclusive and responsive to needs and directing investment towards evidence based interventions that improve outcomes for the individual.

Tier three - developing and funding a personal support plan for people with a disability. Intending to cover about 430,000 people with the aim of fostering social and financial independence earlier in the participant’s lifetime.

In providing the three tiers of cover, it is essential that the National Disability Insurance Agency (NDIA) develops deep collaborative ties and data sharing with government departments responsible for front line services. NDIS was never meant to cover the delivery of these services.

However, the financial sustainability of the NDIS relies heavily on the early and effective delivery of appropriate front line services to those living with a mental condition. The aim is to reduce or stop the progression of psychosocial disability in the first place.

Further, for these services to be delivered effectively, there is a good argument that the delivery of front line services should be based on the principles of trauma informed care. This requires appropriate policy settings to ensure delivery of front line care and services are individually tailored and outcome based.

Recovery cannot realistically commence until issues of stable health care, income replacement and accommodation are resolved. Recovery in the context of mental illness does not equate with cure and the elimination of impairment and disability. Rather, it is about “living a life of optimal wellbeing despite the impact of the illness.”

most people will be 25 years of age or younger on the first onset of symptoms with 75 per cent not receiving help;13 and
less than half of people living with mental health issues access treatment each year - with untreated mental illness incurring major personal suffering and economic costs.14

It is reported that mental illness costs Australia around four percent of gross domestic product or about $4000 for every taxpayer and costing the economy more than $60 billion a year.15 In 2009, it was reported that schizophrenia and other psychoses, which only affect one to two percent of the adult population, accounts for about 80 percent of Australia’s spend on mental health care, due to complex service needs over a long period.16

The lack of early detection and treatment possibly adds to the problem. Developing nationally consistent and effective best practice procedures to detect and treat psychotic type conditions earlier is required to address this problem.

Much of the statistics quoted come from the 2007 National Survey of Mental Health and Wellbeing, conducted by the Australian Bureau of Statistics. However, in its 1017-18 pre-budget submission, the Insurance Council of Australia recommended funding for an updated national survey to better understand the prevalence of mental conditions in our community.17

Suncorp supports this recommendation but considers the funding should be expanded to specifically determine the level of psychosocial disability in our community. It is important that policy settings identify those in the community with unmet psychosocial disability support needs. The NDIS trials reveal that up to 58 percent of people found to be eligible for IFP had not been in receipt of government services.18

Further, it is unclear how many people with psychosocial disability applying for IFP were found to be ineligible and/or ‘choosing’ not to apply.19 In any event, from what we do know, there appears to be a level of stigma, mistrust and fear in the community in seeking treatment, which needs addressing.

Not everyone with a mental illness will experience psychosocial disability.20 People living with psychosocial disability must satisfy the eligibility rules to access IFP.21 The eligibility assessment for IFP is not based on a diagnosis but rather on functional capacity.22 However, a psychosocial disability for the purposes of IFP must be related to a psychiatric condition.23

To consider how psychosocial disability should be incorporated into the NDIS, it is important to understand the nature of psychosocial disability. Understanding psychosocial disability will better inform the policy settings required to ensure NDIS access and services are applied appropriately and consistently.

Psychosocial Disability

Psychosocial disability resulting from a mental health condition is not widely understood. However, the available literature describes the term ‘psychosocial disability,’ The impact it has upon people living with this type of disability, oting it is complex in nature.

Essentially psychosocial disability impacts a person’s ability to navigate the daily routine of living. A key thread is a deficit in working memory due to cognitive impairment. A deficit in working memory makes negotiating even simple daily activities problematic, including:

daily routines;
personal care;
treatment compliance;
household chores such as shopping, cooking, cleaning and maintenance;
Centrelink obligations to secure steady income replacement;
managing finances;
socialising; and
keeping appointments.

Without an advocate or support person, a person living with psychosocial disability is at risk of falling through the gaps of well-meaning support initiatives and left in a spiral of poverty and homelessness with a loss of life expectancy of up to 25 years, due to untreated physical conditions.

A complicating factor is that people living with psychosocial disability may also experience anosognosia. Anosognosia is a lack of insight or awareness of their mental illness. It represents the single most common reason why those living with a psychotic disorder do not take their medications, significantly impacting upon recovery and functionality.

The biggest challenge for the NDIA, apart from the under – developed front lines services to detect, treat and support a person through the acute stages of a mental illness early - is to ensure consistent application of the rules in respect to -:

access to IFP; and
reasonable and necessary support.

Access to NDIS Tier Three Services

The eligibility rules38 focus on functional impairments as opposed to diagnosis.39 This approach is consistent with eligibility rules in the NIIS.

As stated previously, a psychosocial disability for the purposes of IFP must be related to a psychiatric condition.40 Not everyone living with mental illness will have a psychosocial disability.41 However, psychotic disorders, especially schizophrenia, are consistently reported as being the cause of the most severe and persistent functional impairment relative to other mental disorders.42

The eligibility rules do raise a number of challenges when assessing psychosocial disability and the problematic ones are discussed below.

The requirement that impairments must be permanent (or likely to be permanent)

Permanent Impairment

An important aspect of the eligibility rules is the concept of permanent impairment. This sits uncomfortably with the concept of recovery, the language used in respect to mental health services supporting people to live well in the presence or absence of symptoms of mental illness.

The concept also sits uncomfortably with the episodic nature of mental illness. Complicating the picture in responding to psychosocial disability, is that the disability can present with a vastly differing spectrum of experiences that fluctuate in intensity over time.

As long as the person’s need for support is likely to be life-long they should be eligible for IFP. Practical matters to consider in the assessment stage include the history of hospitalisation or institutionalisation, employment/vocation history, and history of treatment compliance and social isolation. Another point to be considered is whether any unmet front line service or support need would improve functional capacity.

Case studies highlighting the issues surrounding permanency of impairment have been reported. Others are working on standardising the application of the eligibility rules for these problematic areas. However, a summary of mental conditions that are likely to rise to permanent impairment is also a useful guide.

The interim participation process used in the NIIS may be worth considering when assessing eligibility for IFP for those people with a history of psychosocial disability, especially those not previously known to front line services. In NIIS type schemes (which cover catastrophic physical injuries resulting from an accident), a person may be accepted as an interim participant and re-assessed after two years for lifetime participation.

The aim should be to provide a person living with a mental health condition with holistic, integrated services to maximise social and financial independence early in one’s lifetime. The interim participant model may well assist with this aim. It also satisfies NDIS’s brief to act within the early intervention pathway, described further in this submission.

Assessment of the degree of functional impairment

This is another important aspect of the eligibility rules, that is problematic. Focussing on functional impairment is consistent with the World Health Organisation (WHO) International Classification of Functioning, Disability and Health (ICF) but it is acknowledged that it does not adequately assess psychosocial impairment. A reliable instrument that provides professionals with clear guidelines for the determination of functional impairments is not currently available and its development is a work in progress.

Until a working guide is available

It might be worth considering adopting the interim participation model used by most lifetime care schemes for traumatic injuries (NIIS), in order to maximise earlier beneficial outcomes.

Defining reasonable and necessary supports

The National Disability Insurance Act 2013 offers aspirational criteria for reasonable and necessary supports. A level of inconsistent assessment of reasonable and necessary support for psychosocial disability across trial sites in Victoria and NSW has been reported.[54]

The lack of empirical markers for determining ‘reasonable and necessary support’ has not helped the situation and developing those markers would be useful. The Partners in Recovery (PIR) program, a Commonwealth initiative has been put forward as a model to consider for IFP, as it would connect people with psychosocial disability with front line services.[55] A PIR type service should be seriously considered as an appropriate support.

For people living with a mental condition, the level of functional impairment can vary between individuals and also within an individual over time, complicating the assessment procedure. Add cognitive impairment, comorbidities, anosognosia, lack of advocate or carer support, the true level of disability may not be realised at assessment and may fluctuate over time. Use of reference packages to assist with assessment is under development for psychosocial disability. Consideration of the National Mental Health Planning Framework once published, might also assist.[56]

Other considerations

Other general recommendations have been reported which would provide integrated support services, whilst supporting the financial sustainably of the scheme and includes –

tracking the use of front line services to ensure a holistic and integrated approach;[57]
building participant capacity;[58]
reviewing the operating guidelines to ensure policies and procedures are flexible enough to respond to rapid and significant changes in support needs;[59]
identifying and funding mental-health specific supports;[60]
extensively using interim or temporary packages;[61] and
incorporating the State and Territory role in providing appropriate services.[62]

Early Intervention

Access to IFP is also available through the early intervention pathway. There is no guidance on how to appropriately and consistently apply these eligibility criteria.

Four requirements must be met to satisfy the early intervention criteria:

one or more impairments attributable to a psychiatric condition must be identified, which are, or likely to be, permanent;

early intervention support must be provided that is likely to reduce the future needs for support;

earlier intervention support must be provided that is likely to mitigate or alleviate the impact upon the functional capacity or strengthen the sustainability of informal supports available to the person; and

an early intervention support cannot be funded through some other general system, for instance front line services.

Literally interpreted, these rules would prevent those developing signs of mental health issues from gaining access to IFP until a formal diagnosis is made and the acute symptoms stabilised through the delivery of appropriate front line services. However, what also needs to be considered is the contribution of pharmacological treatment upon cognitive functioning, which remains unclear.

Diagnosis is made through subjective assessment and observation of symptoms, having regard to the classification and diagnostic tool. However, there are inherent problems with the diagnostic tool, which can delay formal diagnosis for lengthy periods of time. Accuracy of the diagnostic tool is also challenged.

Extensive clinical training and judgement is required to make appropriate diagnoses. No objective test is available to confirm the diagnosis. What is important to note however, is the longer the period of untreated psychosis before beginning antipsychotic medication relates to poorer symptomatic and functional recovery from the first psychotic episode. However, it is unclear if that initial period of untreated psychosis increases the likelihood of further psychotic episodes.

As the early intervention pathway represents a gateway to IFP, the NDIA has a vested interest in ensuring front line services identify the early signs of mental health issues; and apply appropriate early intervention to slow or stop the progression of the condition. Deploying front line services with beneficial outcomes would enhance the financial sustainability of the NDIS. Delivering holistic integrated services is also key but there are concerns about this capability.

If after a nominated period of time, (let’s say two years), the condition progresses or fails to improve despite early intervention, and it results in a level of psychosocial disability, then access to IFP through the early intervention pathway should be considered, to maximise social and financial independence early.

Tier Two Services

An effective tier two has the important role in ensuring NDIS is financially sustainable by supporting those living with a level of psychosocial disability to live independently. 71 Literature suggests that psychoeducation programs have a role in preventing progression or relapse of a mental condition 72 and should be considered for tier two services. Engaging with people who live with mental conditions, their family and carers as well as front line services is crucial to enhance the support services offered by tier two, on a continued basis.

Appropriate employment has a vital role in the recovery process. 73 It is important for the NDIA to work collaboratively with the Federal Government in reforming the welfare sector by sharing insights and learnings to ensure policy settings are formulated on the principle of trauma informed care to foster recovery and social and financial independence. 74

The real challenge here for welfare reform (and indeed for all front line services) is to ensure those living with psychosocial disability do not fall through the gaps in the system due to lack of family and/or carers advocacy. Emotional burnout is common, with those living with severe and persistent psychiatric conditions at risk of losing contact with their families and/or carers entirely and becoming highly isolated. 75 Lack of health services; loss of income support and homelessness is not conducive to recovery.

Work has recently commenced on building the ILC capability. 76 The work intends to build on the ILC policy framework 77 through five streams of activity, with some models tested at the trial sites. 78

It is important to build the tier two capability for those people who are considered ineligible for IFP, but nevertheless need support. As stated previously, deep collaboration with government bodies in respect to front line services needs to be developed.

Concerns have been raised in the community that those living with psychosocial disability may completely lose vital support if found ineligible for IFP. 79 Current users of Personal Helpers and Mentors (PHaMs) may fall within this category, noting that PHaMs is funded by the Federal Government.

Conclusion

As funding for PHaMs is withdrawn, it is up to state and territory governments to provide unmet services. It is crucial that support continues in accordance with the Council of Australian Governments (COAG) Agreement, to prevent progression of the mental condition to a point that would ultimately require extensive psychosocial support. This unintended consequence would put pressure on the financial sustainability of the NDIS.

Suncorp, as the country’s largest personal injury insurer, considers that the successful implementation of publically underwritten disability schemes is vital in working alongside competitively underwritten personal injury schemes in providing a holistic package with the aim of fostering social and financial independence early after a medical or injury event. Arguably, this approach better supports governments’ initiatives to counter the productivity challenges facing Australia due to its ageing workforce.

For the NDIS to be financially sustainable, it must be based on insurance principles with clearly defined entry points into the scheme noting that psychosocial disability represents a challenging area for eligibility policy settings. The process of establishing IFP eligibility for psychosocial disability must be objective, measurable and supported by a cost effective dispute resolution process.

Suncorp commends the points raised in the executive summary for consideration and is happy to collaborate with the Committee and relevant stakeholders to develop some of the ideas put forward in this submission. Should you wish to discuss any of the points raised in this submission, please contact me Alternatively, please contact Matt Kayrooz, Head of Accident & Trauma, Insurance

Regards

Chris McHugh Executive General Manager Personal Injury Portfolio & Products Insurance