NDIA Accountability Project

Issues in transitioning community-managed mental health services to the NDIS

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Submission to the Joint Senate

Standing Committee:

Inquiry on transitional arrangements

for the National Disability Insurance Scheme (NDIS)

Suite 5 Mayfair Plaza 236 Sandy Bay Road Sandy Bay TAS 7005

Phone: (03) 6224 9222 Mob:

Email:

Contact: Connie Digolis Chief Executive Officer

Prepared by: Elida Meadows Policy Lead Date: August 2017

Preface

The Mental Health Council of Tasmania (MHCT) is a member based peak body. We represent and promote the interests of community managed mental health services and have a strong commitment to enabling better mental health and wellbeing outcomes for every Tasmanian.

MHCT welcomes the opportunity to respond to the Joint Senate Standing Committee Inquiry on transitional arrangements for the National Disability Insurance Scheme (NDIS).

Organisational members of MHCT have been in discussion with the Council regarding the transition of programs - Personal Helpers and Mentors (PHaMs), Partners in Recovery (PIR), Day to Day Living Program (D2D Living) and Mental Health Respite: Carer Support (MHR:CS). to the NDIS and the transitional arrangements of the scheme. These programs represent, in fact, the majority of services delivered in the community managed mental health sector.

Issues raised in this discussion can be summarised as:

  • The importance of not separating transitional issues for ineligible clients from Scheme issues facing eligible clients. Both can lead to less than optimal outcomes for consumers and require urgent consideration. For those found ineligible for the Scheme, there is a lack of a clear safety net to support ineligible consumers as identified under the bilateral agreement. Eligibility issues are interwoven with the lack of appropriately designed and priced supports within the NDIS.
  • The issue with current NDIS plans is not their value but their lack of flexibility – if the degree of flexibility that was introduced for core supports was also introduced for capacity building supports client outcomes would be significantly improved.
  • The issue of ongoing service provider viability – given the disconnect between the unit price for the delivery of NDIS supports and the Award rate of pay for qualified mental health workers it is not possible for organisations to operate without a loss (estimated at 50% per episode of care). The lack of an appropriate market assessment to ensure the viability of the market post transition is compromising the integrity of the planning process and the quality of participant plans.

MHCT would like to stress at this point that, as far as the community-managed mental health sector is concerned, there are two overarching objectives related to transitioning to the NDIS:

  • Effective transitioning of people into a person-centred NDIS system which provides adequate supports driven by the person requiring services, rather than the service provider.
  • Ensuring the suitability of the scheme to meet the needs of people with psychosocial disability in its current configuration and the potential need for alternatives.

Regarding the transitioning of Commonwealth funded programs (as listed above), primary data from organisational members of the MHCT and other state providers of Commonwealth mental health programs has been collated to produce the ‘Snapshot of Mental Health Programs Transitioning to the NDIS in Tasmania’ (Snapshot) attached with this paper. The Snapshot gives a current overview of the emerging gaps in existing services and supports for those who will not transition to the NDIS in Tasmania. These gaps are likely to increase as further age cohorts roll into the NDIS.

A. Boundaries and interface of NDIS service provision, and other non-NDIS service

provision, with particular reference to health, education and transport services

In its submission to the Joint Standing Committee on the NDIS, Community Mental Health Australia (CMHA) made the point that “effective mental health support must address three core areas - clinical treatment, community based rehabilitation and disability support - and that these areas must be linked to the mainstream health, mental health, housing and other social health services people need.”

People with psychosocial disability rely on a wide range of services — including mainstream services, specialist services and community supports. For the NDIS to work efficiently and effectively, the interface of the scheme with these other services on which people rely must be as seamless as possible. In particular, determining the appropriate interfaces between the NDIS and mainstream services has not been resolved. Greater clarity is required for interfaces with health, education, transport, child protection, and justice. It is widely accepted that systems working collaboratively and cooperatively will deliver the best outcomes for people with psychosocial disability.

MHCT notes the clear need for a nationally consistent approach to the supports funded by the NDIS and the basis on which the NDIS engages with other systems, with flexibility and innovation built into in the way NDIS funds deliver these activities. In the COAG paper, Principles to determine the responsibilities of the NDIS and other service systems3, there is a clear commitment to the coordination of NDIS supports with supports offered by the health system and other relevant service systems (including employment, mental health, housing and community infrastructure, early childhood development, transport, child protection and family, justice, school education, aged care, higher education and vocational education and training). The interactions of people with psychosocial disability with the NDIS and other service systems should be as seamless as possible, which requires integrated planning and coordinated supports between NDIS service providers and providers of other non-NDIS service provision. However, the division of responsibilities may not be as straightforward or well understood in practice as intended, especially by people with psychosocial disability and at the individual level there can be confusion around boundaries.

The interface between the NDIS and mainstream services and the gaps that will be created for mental health in the transition to the NDIS are some of the most significant and concerning issues for the community-managed mental health sector. The community-managed mental health sector is concerned that there is already an emerging decline in access to community based psychosocial rehabilitation support as part of the transition to the NDIS. This will result in increasing episodes of crisis and the likelihood of an increase in complex presentations in other community services such as housing, employment and education.

Feedback from MHCT members is that, until the interface issues and associated boundaries are settled, it is important that governments do no withdraw from services too quickly. There needs to be more security that the range of psychosocial supports across sectors is available and within the scope of NDIS supports for people with psychosocial disability. There is a strong argument for the development of partnerships between State government, community-managed service providers and the NDIA, particularly in the area of appropriately

Accountable Services and Models of Care

Accountable services and models of care for clients with complex needs. This must be considered by State government agencies as a critical part of the NDIS implementation work.

A clear understanding of boundaries in service provision will also help governments and the NDIS to address needs and gaps in the evolution of the Scheme. As noted by Mental Health Australia (MHA) a well-designed and appropriately funded system of Information, Linkages and Capacity (ILC) services, including Local Area Coordinators (LACs): …can make a vital contribution to improve the interface between the NDIS and mainstream services, help to alleviate some of the fragmentation within the disability system and assist mainstream services to be inclusive of people with disability. However, these objectives will be hampered by the loss of Commonwealth programs for people who are ineligible for NDIS Individually Funded Packages. A sudden and significant decrease in services available to this cohort would undermine ILC’s effectiveness. For example, LACs and PHNs will be unable to refer people with psychosocial disability to appropriate services.

Chronic health issues

In their submission to the Joint Standing Committee on the National Disability Insurance Scheme Inquiry into tansitional arrangements for the NDIS, CMHA noted that, ‘a further interface issue is the crossover between disability and chronic health issues, which people with a mental illness are over-represented when it comes to such co-morbidities.’

B. Consistency of NDIS plans and delivery of NDIS and other services for people with

disabilities across Australia

1. NDIS workforce

As mental health is a specialist area of disability, it requires an NDIS workforce which understands the particular issues related to psychosocial disability from assessment through to service delivery and specifically designed operational frameworks. Planning processes for people who are eligible for the NDIS are yet to mature to reflect best practice in mental health. Because of this general lack of knowledge and understanding towards psychosocial disability, our members report that there are people receiving NDIS plans that are not fit for purpose or tailored for their individual needs. This situation is also reflective of a disconnect between the NDIS process and the people who can provide the specialist knowledge, for example, the PIR staff who are supporting individuals to transition to the NDIS. There is also the question of how the LACs and planners are engaging with the community-managed mental health sector in general.

2. Assessment and planning

Furthermore, our members tell us that assessment against the eligibility criteria appears to arrive at inconsistent and unexpected outcomes with some people receiving very generous packages and others, who are clearly in need of higher levels of support receiving minimal packages. Transitioning to the NDIS can be a confusing and challenging process for many people. The NDIA has funded a website, Reimagine Today as a

Clear and Reasonable Supports

Mechanism for Supporting People with Psychosocial Disability

mechanism to support people with psychosocial disability to test their eligibility and prepare for planning meetings. This is a welcome initiative but it does not take the place of person-to-person support, without which inequality of access to NDIS is likely to be exacerbated. Even the Workbook7 which is available on the website may not be useful to some people with psychosocial disability if they do have personal support and guidance to work through it.

Assessment Process Transparency

MHCT members have expressed that the assessment process is not transparent and the current review process is not the appropriate vehicle to identify and resolve any inconsistency in the way eligibility is assessed. Anglicare Tasmania has noted that NDIS participants who have been confirmed as having both a severe and permanent psychosocial disability need more responsive support. Their symptoms may fluctuate and change rapidly and often, or may be episodic. This means that their support needs may change equally rapidly and often and their package of support needs to be flexible to adapt with a participant’s changing needs. The rigidity of the NDIS planning and review process, as well as long delays in accessing reviews, do not lend themselves to responsive plans and support to be put in place for participants. This means that when crises occur, participants and their families cannot get additional support in an effective timeframe, leaving them to deal with changing circumstances and crises largely alone, which can have catastrophic outcomes.

Specialist Knowledge in Planning

In Tasmania, NDIS planning is often conducted by LACs who, up to now, have not had specialist knowledge or understanding of mental health issues. MHCT member Anglicare Tasmania has made the point that, “the assessment and planning tools are not specific enough to capture the needs of Tasmanians living with psychosocial disability and consequently, where eligibility for NDSupport on the basis of psychosocial disability is confirmed, this compressed planning process is often leading to inadequate plans and goals for participants. This then has a knock-on effect on the relevance and types of support participants might access. NDIS eligibility guidelines should be reviewed to provide a clearer framework for NDIS Planners and LACs to make more consistent and informed decisions regarding psychosocial disability.”8

Another of the challenges within the NDIS planning and engagement process specific to new participants with psychosocial disabilities is the arrangement for one-off, and largely (up to now) phone-based planning meetings, often without the opportunity to bring a support worker with them. Although there is now a commitment to cease the telephone interviews, due to the nature of their condition, participants with mental health conditions find it difficult to divulge the full impact that the condition has on their day-to-day lives to someone they have just met. Furthermore, asking participants to articulate the finer details of a plan that is intended to provide adequate support over 12 months is a daunting and anxiety-inducing task. A related issue is the difference between the language of mental health and that of the NDIS which is not simply about semantics. An understanding of key concepts and language of the mental health sector will go far in promoting more understanding within the planning and assessment process of the NDIS.

Clear and Reasonable Supports

MHCT has noted that consumers and carers need to be fully aware of their rights in terms of support and what the parameters of support may be, especially in the use of the term “clear and reasonable”. Based on consultations, MHCT is not convinced that consumers and their carers find this criterion sufficiently clear and

C. Rollout of the Information, Linkages and Capacity Building Program

At this stage, it is unclear how the Information, Linkages and Capacity Building Framework will cover gaps which are emerging as the NDIS is implemented. MHCT highlighted in our submission to the Joint Standing Committee on the NDIS, that there was an expectation in the mental health sector that this funding would meet some of the needs of people with mental health conditions who are not eligible for Tier 3 supports. The key issue will be the level of funding for the ILC. It is unclear to the sector what the long-term vision for ILC funds will be and on what basis the allocation of funds has been made, given the clear evidence that there would be a significant number of people who would be ineligible for the level 3 packages.

In its response to the Joint Standing Committee on the National Disability Insurance Scheme into the provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition, CMHA made the point that: Given the limited amount of funding available under the Information, Linkages and Capacity (ILC) building framework, and the fact that there is no quarantining for psychosocial disability and/or mental health, access to this funding will be highly competitive. Overall, ILC doesn’t have the capacity to provide for the scope of what existing services deliver, and respond to the needs of people who won’t be eligible for the NDIS.9

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individuals deemed ineligible for the NDIS and individuals deemed eligible. Eligibility issues are manifestly interwoven with the lack of appropriately designed and priced supports within the NDS.

  • Service providers in Tasmania have encountered a general unwillingness within the NDIA to acknowledge that transitional issues in relation to participant access and planning may be systemic rather than organisational, despite the emergence of identical issues in virtually all states and jurisdictions (with some foreseeable variation in relation to the states and territories’ individual bilateral arrangements).
  • Many of the identified transition issues for the mental health cohort have been borne out in the preliminary findings of NDIS reviews and inquiries (for example, the June release of the Productivity Commission’s Position Paper on NDIS Costs). The anticipated August release of the Joint Standing Committee report into the provision of services under the NDIS for people with psychosocial disabilities is expected to provide a greater depth of recognition and scrutiny in relation to these issues.

Finally, it should be noted that tangible solutions to many of the transitional issues have already been identified by the community-managed mental health sector in Tasmania. There is a strong feeling that what is needed now is for individuals, with decision-making power, endorse these recommendations before outcomes for Tasmanians with a chronic or severe mental illness worsen considerably.

In various submissions and platforms, MHCT members have said that:

  • ‘Commonwealth and State and Territory Governments need to ensure there is co-ordinated national, as well as regional oversight of planning and outcomes for mental health services to ensure there are no gaps in clinical and community services for consumers with complex and severe mental health conditions, their carers and their families. This national and regional oversight needs to consider both those who are NDS eligible and those who are not.’10
  • A further failure of the transition process is that the NDIA entry and planning processes take months. Assuming eligibility, this means a gap of three months or more without support for participants who have been exited from other programs. This level of delay is untenable.
  • Provide a dedicated mental health entry point within the NDIS which would be in the form of a portal that employs recovery language and philosophy.

Outreach is another area requiring due consideration as noted by CMHA: The NDIA must identify tailored ways in which to support the transition of the NDIS utilising an outreach model, in particular for Aboriginal and Torres Strait Islander and CALD communities. Identifying activities appropriate to the community, ensuring appropriate methods for measuring outcomes are employed, appropriately resourcing and acknowledging the importance of family are all important aspects of outreach that should be considered for many communities.11

In this transitional period, it is important that no person with mental health conditions, both within and outside of the NDIS, do not lose necessary supports. Of critical concern is that no one should be disadvantaged by this transition with the result that they may receive less quality support than they had before the changes to the mental health system in general, and the NDS in particular, come into effect

10 Partners in Recovery Tasmania Consortium (2017), Submission to the Joint Standing Committee on the National Disability Insurance Scheme: the provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition, p. 29, hhttp://www.aph.gov.au/Parliamentary_Business/Committees/Joint/National_Disability_Insurance_Scheme/MentalHealth 11 CMHA (2017b), op. cit, p. 18.

MHCT Submission to the Joint Standing Committee on NDIS transitional arrangements | 7

NDIS

Percentage

INELIGIBLE

NO. TRANSITION TO 207 242 53 30 N/A ESTIMATED Number

TO

NDIS 62% 85% 90% N/A ELIGIBLE TO Percentage 59%** NO. DATA 336 297 270 N/A ESTIMATED TO 349** Number CLIENT SIXTH A OF INCLUSION 543 591* 350 300 N/A NO. The TASMANIAN PARTICIPANTS with still in in NDIS a NDIS- a NDIS- thecarewithwith25-28 29-34 35-49 50-64 higher with with be TIMELINE exit exit 15-24 12-14 4-11 their theyNDIS carers clients reduction line reduction line phase phase become 2017: 2018: 0-3, 2019: to as supporting becoming supporting becoming would as NDIS of of to 2019: to 2019: in theto to 2016 on 2016 on 2013: 2016: 2017: 2018: supports. for June July January July January July figures July 19 July carer TRANSITION Staggered funding number expected program become participants Staggered funding number expected program recipients participants 1 30 Transition focus clients ready 1 30 Transition focus clients ready 1 1 1 1 1 1 1 of total Tas: that in provisionarrangements Submission scheme:

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