ndis transitional arrangements

summary

cohealth welcomes the opportunity to respond to the Joint Standing Committee on the National Disability Insurance Scheme inquiry into Transitional arrangements for the NDIS.

cohealth is one of Australia’s largest not-for-profit community health services, operating across 14 local government areas in Victoria. Our mission is to improve health and wellbeing for all, and to tackle inequality and inequity in partnership with people and their communities.   cohealth provides integrated medical, dental, allied health, mental health and community support services, and delivers programs to promote community health and wellbeing. Our service delivery model prioritises people who experience social disadvantage and are consequently marginalised from many mainstream health and other services.

cohealth provides a range of services for people experiencing mental illness, from residential accommodation to community outreach and mentoring to interagency planning coordination.  Our mental health consumers in the North East Melbourne area have recently transitioned to the NDIS, and our comments in this submission reflect their experiences, along with those of workers and the service system involved.

cohealth fully supports the NDIS as an important system to provide much needed supports to people with disabilities. The fundamental NDIS philosophy of client choice and control aligns with cohealth values and approaches, and we acknowledge the potential opportunities for NDIS participants to identify and structure their supports in the ways that best suit them.

Nonetheless, we hold serious concerns about the ability of the NDIS to effectively respond to the needs of people with psychosocial disability, and for the overall provision of mental health supports to those not eligible for the NDIS.  Victoria is unique among the states in having transferred all funding for community mental health services to the NDIS, and we are already seeing a significant loss in community based mental health services and support for consumers in transitioning areas.  The potential consequences of this reduction of supports are significant, particularly for people with complex and/or specialised needs.  Our concerns are further elaborated in response to the terms of reference, below.

Terms of Reference

a. the boundaries and interface of NDIS service provision, and other non-NDIS service provision, with particular reference to health, education and transport services.

In Victoria a range of vital and complementary services respond to and support the needs of people with a severe mental illness:

• Clinical mental health, providing acute, community and specialist services. These services focus on treatment, medication and stabilising a person’s condition.
• Mental Health Community Support Services (MHCSS), provided by non-government organisations. These complement clinical services by providing specialised recovery-based psychosocial rehabilitation to help people with severe and enduring mental illness live successfully in the community. MHCSS are a vital complement to the clinical mental health system. However, MHCSS will cease in Victoria as funding moves to the NDIS, leaving a significant deficit in services and care for people with a mental illness.
• NDIS services, providing practical disability support services. These supports are quite different in nature from the support provided by psychosocial rehabilitation services (i.e. MHCSS).  As an example, a consumer may state they need assistance with shopping. Practical disability support, of the kind provided by the NDIS, would involve physical assistance, such as taking the person to the shops.  For someone with a psychosocial disability this may require significantly more skilled rehabilitation work, for example, addressing significant anxiety associated with leaving the house and social interactions.

cohealth is becoming increasingly concerned about the emerging gaps in service provision for people with a serious mental illness in Victoria, both for those eligible for the NDIS and those who aren’t.

i) Provision of rehabilitation support for people who experience mental illness.

In Victoria, existing community managed psychosocial rehabilitation funding (MHCSS) has been rolled into the NDIS.   We are seriously concerned about how people with a serious mental illness will have their psychosocial rehabilitation needs met, due to:

• • A lack of services for people not eligible for the NDIS
  • NDIS disability support services providing services that are qualitatively different to the psychosocial rehabilitation previously provided by MHCSS
  • Difficulties eligible consumers experience in accessing NDIS supports as a result of shortcomings in engagement and planning processes. This is particularly marked for those with multiple and complex needs.

We are very aware that it is not the intention of the NDIS to support all people with a psychosocial disability. As the Productivity Commission Position Paper on NDIS Costs^[1] states:

“Clearly, there needs to be support for people with mental health illnesses outside of the scheme — a responsibility that remains (largely) with State and Territory Governments… At this stage, it is unclear what supports will be available for people with a mental illness who do not meet the NDIS eligibility criteria and this should be clarified as a matter of urgency.”

Nonetheless, there is a significant need for specialist rehabilitation support to be provided, and we support the Productivity Commission’s call for greater clarity about the supports that are available for people with a mental illness.  While we acknowledge that this is a Victorian issue, due to the transfer of funding to the NDIS, it has created a significant service gap for some of the most vulnerable members of the community. This anomaly needs to be recognised as a matter of urgency to ensure that emerging service gaps are identified and addressed prior to the further implementation of the NDIS.  The ongoing provision of appropriate supports is essential for the health and wellbeing of all people with psychosocial disabilities, regardless of NDIS eligibility.

ii) Rehabilitation support for NDIS participants.

As described earlier, the disability support available through the NDIS is very different to the specialised psychosocial rehabilitation support provided to date through community managed services.

Unfortunately, the current NDIS price structure means that services are unable to provide this recovery-based rehabilitation so essential in supporting people to live successfully in the community.    Providing effective rehabilitation for people with psychosocial disabilities requires a workforce that has specialised knowledge and skills about the complexities of working with people with a mental illness. This is quite different work to the generic disability support work on which the pricing structure is based. This difference is not reflected in the NDIS pricing structure.  Services are already finding it difficult to employ appropriately qualified and experienced staff to provide the necessary level of support.  Clearly, if providers are not remunerated for the cost of providing appropriate support the risk is that these services will not be provided.   There is a risk that participant choice will be constrained, over time jeopardising the scheme aims.

iii) Interface with other services

People with a psychosocial disability and a chronic health condition have, to date, often received assistance from their mental health supports to manage their health condition.  We hold concerns that this support will be considered a health matter, and not funded through NDIS plans, despite this support being essential in managing the condition and preventing further involvement with the primary or acute health systems.  An example of how this has played out for a NDIS participant with a psychosocial disability and diabetes is described in the submission to this inquiry by Community Mental Health Australia (CMHA).    In such situations the psychosocial disability and chronic condition are inextricably linked, and both the NDIS and state systems must be able to account for this interaction, to ensure that holistic services are provided for consumers.

cohealth recommendations:

1. Review the pricing structure to ensure it allows sufficient resources to effectively meet the needs of people with psychosocial disability. Specifically, a separate cost line for specialised recovery-based psychosocial rehabilitation should be included, with a higher hourly rate, enabling the employment of a specialised workforce.  Provision for payment for features essential to the work, such as active outreach work, two worker visits, ‘no-shows’, case conferences and extended travel provisions should be included.
2. That the State and Territory governments meet their obligations to ensure that psychosocial rehabilitation is adequately funded, to ensure that psychosocial rehabilitation supports are available for people with a mental illness, regardless of their NDIS eligibility.   This is a key concern and risk in Victoria, and needs to be addressed as a matter of urgency.

b. the consistency of NDIS plans and delivery of NDIS and other services for people with disabilities across Australia.

The individual planning process is critical in ensuring that the supports a participant receives are appropriate to their circumstances and respond to their individual needs.  To date, the experience of our consumers has highlighted the limitations of the current approach.  cohealth shares the concerns of the National Institute of Labour Studies 2016 Evaluation of the NDIS Intermediate Report:

“… qualitative reports indicate that some people with disability were experiencing poorer outcomes under the NDIS and were receiving a lower level of services than previously. These were particularly people with disability who were unable to effectively advocate for services on their own behalf, including some people with psychosocial disability and/or those people who struggled to manage the new and sometimes complex NDIS processes”^[2]

Likewise, the Productivity Commission’s recent Position Paper on NDIS costs outlined a range of limitations with the current planning process for people with psychosocial disabilities, and recommended a range of changes to improve outcomes for people with a psychosocial disability^[3]. cohealth fully supports these recommendations.

cohealth consumers and the staff working with them have identified a number of areas where improvements to the planning processes must be made if the NDIS is to meet its stated aims of choice and control, reflecting the Productivity Commission recommendations:

• Support for consumers to prepare for planning would assist them to develop the most appropriate plan – to be able to articulate the nature of their condition, their support needs, and to be informed of the types of supports they can include in their plan.
  • Consumers have emphasised the importance of this being done face to face (rather than over the phone), and that there be capacity for multiple meetings if required.
  • Recent changes that have enabled existing support workers to be more involved in planning process are an important improvement. Continued work on improving access to the NDIS is essential to ensure those eligible for supports are able to obtain them.
  • In Victoria, existing MHCSS have developed their understanding of how to best support consumers transitioning to the NDIS. We are very worried about how this support for engagement and pre-planning with the NDIS will be provided to future participants once MHCSS have ceased.
• At planning meetings it is important that planners have a sound understanding of psychosocial disability, the types of supports and services available, and, critically, an awareness of the episodic nature of these conditions.  An effective plan needs to anticipate the supports a consumer may need when they are most unwell – even if the person is not in need of such services at the time of developing the plan.  In addition, if a consumer is unwell at the time of planning their insight into their needs may be constrained, along with their ability to articulate in detail the support they need.
• This is quite different to those with other disabilities.  For example, a consumer may state they need assistance with shopping.  For someone with a psychosocial disability this may mean significantly more than physical assistance.  It may involve assistance with planning meals, dealing with anxiety about leaving the house, budgeting, etc.  Planners need to have the skill to ask appropriate questions, with sensitivity and utilising a strength based approach.
• Face to face planning meetings, potentially multiple, are essential to ensure proper consideration of complex consumer needs.
• cohealth has observed that the composition of plans is inconsistent, even for people with similar conditions and in similar circumstances.  For example, two consumers of cohealth mental health community support services, with very similar conditions and circumstances received very different plans.  The main difference appeared to be that one had an advocate/support accompany them to the planning meeting.  This consumer had a plan developed that was more comprehensive and provided for more effective and appropriate supports. In other situations we’ve heard of planners acting as ‘gatekeepers’ for the scheme – focusing on limiting plan (and NDIS) expenditure, rather than the most appropriate supports for participants.
• Reviewing and changing plans is proving to be a lengthy and difficult process due to the pressures currently on the system. However, to provide effective support if a person’s condition changes, as is common with psychosocial disability, plans must either be able to be altered quickly to respond to these needs or have flexibility built into them from the outset.  Our experience has been that early plan reviews have been extremely difficult to obtain if a participant’s needs change.  While we understand that this is due to the pressure to complete as many plans as possible, it is essential that plans are responsive to the changing needs of participants. This is particularly critical if the limitations of the planning processes have resulted in inadequate plans being developed at the outset.
• Plans need to recognise that the relationship between the support worker and the person with a psychosocial disability is of critical importance in recovery, and also allows for ongoing oversight of a person’s condition.  We are concerned that the current pricing structure will prevent services from being able to provide worker consistency and skill.

Good preparation for participants, their supports and the service system prior to planning processes being undertaken is essential.  To this end Information, Linkage and Capacity Building Program (ILC) activities, and other pre-planning work, should commence well before the NDIS is rolled out in a particular area.

Our experience, however, during the recent transition process for mental health consumers in the North East Metropolitan Area of Melbourne was that the timelines were brought forward with little notice.  The focus was on Local Area Coordinators (LACs) achieving targets in short time lines, so planning processes occurred first, with ILC type work happening after.  As a result services had insufficient time to assist participants prepare for the planning process, too often resulting in inadequate plans being prepared. cohealth strongly cautions about rushing the planning process in the future.   Investing in improving the information and preparation prior to the planning process commencing, and a clear schedule that is adhered to, will result in more appropriate plans, greater certainty for participants, carers and support services, and ensure the NDIS can deliver the fundamental outcomes of greater choice and control.

cohealth recommendations:

1. LACs recognise that greater support and advocacy for consumers for pre-planning and at planning meetings is required, and ensure that existing support people are involved in these processes. This could be done by ensuring continued block funding to services that currently support the most vulnerable consumers until the person is fully transferred to NDIS supports.  This is currently not happening and many people are left without supports between the two systems.
2. Require planners to have a sound knowledge of mental illness and associated psychosocial disability and related supports. Alternatively consideration should be given to having specialised planners for people with psychosocial disability.
3. Incorporate flexibility into plans to respond to the episodic nature of mental health conditions and/or improve the ease of adjusting plans to respond to changes in condition.

c. the rollout of the Information, Linkages and Capacity Building Program.

cohealth is concerned that insufficient funding has been allocated to the Information, Linkages and Capacity Building (ILC) program to effectively meet the aims of this framework, or to meet the support needs of consumers ineligible for funded packages.  Of the $682m allocated annually to ILC (at full roll out), $550m is allocated to Local Area Coordination (LAC), leaving $132m nationally for other ILC work.  The first funding round, of $13m, is a very limited amount for national programs.

The focus of ILC grants to date is providing modest grants to develop small scale, replicable projects to assist consumers to access services, or to build the capacity of mainstream services. While these projects are important, there will be diminished scope for services to provide effective, targeted activities for particular communities or meet the needs of consumers who require ‘lower level’, yet still ongoing, specialised support.

To date only a couple of mental health specific services have been funded through the ILC program.  Existing services are providing NDIS information to consumers, carers and other supports without receiving funding to do this.  In the long term services will not be able to sustain this.  Greater investment in ILC is required to ensure that information can be provided to consumers, and to enhance the capacity of mainstream services to respond to the needs of people ineligible for the NDIS.

cohealth recommendations:

6. Broaden ILC grants guidelines to allow for targeted projects aimed at specific communities, particularly those most vulnerable and in need to specialised responses eg CALD, Aboriginal and Torres Strait Islanders communities and people experiencing homelessness.
7. Increase funding to the ILC framework to ensure it is able to effectively meet its functions.

d. any other related matters.

i) Responding to complex needs

The Productivity Commission has identified that thin markets will persist for some participants, including those “with complex, specialised or high intensity needs, or very challenging behaviours”, and that “in the absence of effective government intervention, such market failure is likely to result in greater shortages, less competition and poorer participant outcomes”^[4].

cohealth agrees with these concerns, and anticipates that a number of participants with psychosocial disabilities will fall into this category, due to their complex needs.  Some of the most disadvantaged consumers – people with complex mental health issues who also experience homelessness, Aboriginal and Torres Strait Islanders, people from CALD backgrounds or those involved with the criminal justice system – require a more intensive level of support.

We fear that services may find it unsustainable to provide supports to these consumers, due to the additional costs associated with providing the appropriate level of support combined with the current price structure, resulting in a lack of services. It is critically important that these people continue to receive appropriate supports, including the vital rehabilitation supports to which they are entitled.

The risks associated with people with psychosocial disabilities not receiving appropriate support services are real and significant – to the individuals, their families and the community, and run counter to the aims of the NDIS.  Potential consequences include: a decline in individual wellbeing, greater responsibility placed on families and informal supports, and increased pressure on the acute mental health, health, alcohol and other drugs and justice systems.

In this context cohealth argues that block funding should be provided to existing providers, to ensure the continuity of support for particularly disadvantaged groups, such as refugees, people experiencing homelessness, CALD communities, Aboriginal and Torres Strait Islander groups, people involved in the criminal justice system and those with complex support needs.

ii) Market readiness

The market has not yet developed sufficiently to provide the supply of services required.  We are aware of participants, with approved plans, who have been placed on a waiting list due to a lack of services available to meet their needs.  In addition to the impact on the individual participant, responsibility for providing support in the interim often falls to an already overloaded informal support network (if one exists).  cohealth remains concerned about the potential consequences, including:

• Deterioration in health and wellbeing, including increased risks of self-harm, for the individual.
• Negative impacts on individual’s participation in family and community activities, and an increased burden on family and friends to provide informal supports.
• Increased presentation by individuals at acute services, such as emergency departments, increased interactions with police and justice system, and increased risks of becoming homeless – placing additional demand on already strained services.

cohealth recommendations:

8. That block funding should be maintained to existing providers, to ensure the continuity of support for particularly disadvantaged groups, such as refugees, people experiencing homelessness, CALD communities, Aboriginal and Torres Strait Islander groups, people involved in the criminal justice system and those with complex support needs.

For further information about this submission please contact:

Aram Hosie
Director: Public Affairs
aram.hosie@cohealth.org.au

Footnotes

[1] Overview and Recommendations (2017) p23

[2] Mavromaras, K, Moskos, M, Mahuteau, S (2016) Evaluation of the NDIS Intermediate Report, National Institute of Labour Studies, Flinders University pxi

[3]  Productivity Commission, Position Paper on NDIS costs. Section 4.3: How is the planning process tracking? and Draft Recommendations 4.1 and 4.2 http://www.pc.gov.au/inquiries/current/ndis-costs/position/ndis-costs-position.pdf

[4] Ibid p232