Case study: mental health services still struggling in the NDIS era

By Stephen Easton

Tuesday February 26, 2019

There is ongoing concern that certain mental health services are struggling to survive after their funding was shifted to the National Disability Insurance Scheme, despite being designed to serve a wider group than the 64,000 people with psychosocial disabilities thought to be eligible.

A recent case study produced by Canberra’s Woden Community Service shows the issue is far from resolved after years of discussion, debate, analysis and official advice. The article, published by the Sax Institute’s online journal, argues non-clinical mental health services sit awkwardly within the NDIS, due to their focus on recovery and rehabilitation, and have a bleak future if nothing changes.

It warns such programs are financially unsustainable under the current NDIS model, because many of their clients are not eligible for the scheme, and those that are typically only get a small amount for psychosocial support.

Releasing the latest NDIS quarterly report this month, Social Services Minister Paul Fletcher focused on a contrasting but equally valid narrative, of people receiving services for the first time in their lives through the scheme: 73,956 or 32% of current participants (not counting kids in the Early Childhood Early Intervention stream).

It’s fair to say the landmark scheme has “made great strides” in terms of access to services and support in general, according to Dr Sue Olney, a research fellow at UNSW Canberra’s Public Service Research Group whose work has covered access and equity in disability services, as well as other public services delivered in competitive market.

“But despite principles to determine the responsibilities of the NDIS and other service systems having been agreed by COAG, who should be funding and delivering what to whom is still a minefield of governance and jurisdictional ambiguities across federal, state, territory and local government,” she told The Mandarin by email.

“Legal challenges to assessment of eligibility for the scheme or assessment of reasonable and necessary supports are mounting, and common themes are emerging in government inquiries into various aspects of the NDIS around competing priorities and lack of equity of access to information, services and support, particularly for people in remote locations or those with complex needs (see for example reports from the Joint Standing Committee on the NDIS and the ACT Legislative Assembly in 2018).”

Part of the issue is the blurred line between mental healthcare and disability support as indicated by the crossover between the key terms, mental illness and psychosocial disability, according to the case study’s lead author Dr Sebastian Rosenberg, a WCS board member and mental health policy researcher, attached to programs at the University of Sydney and the Australian National University.

“The junction between when health stops and the NDIS starts is really unclear and very unhelpful,” he told The Mandarin.

It seems unlikely that more fact finding exercises are going to add much at this point. There have been over 30 separate inquiries into relevant issues between 2006 and 2012, by Rosenberg’s count. “It’s a joke. We know everything we need to know. What is important at the moment is not what works, it is who pays.”

 ‘An already-fragile sector in danger of collapse’

Woden Community Service has operated under the NDIS longer than most, as the entire ACT has been covered since trials began in mid-2014. As such, its experience offers “salutary lessons about how to convert the opportunity of the NDIS into new ways of supporting durable psychosocial recovery” in Rosenberg’s view.

He argues the NDIS is “hindering, not helping” psychosocial support programs because it is “geared towards services that perpetuate client maintenance and dependence rather than recovery and independence” – a common view that was recognised in a bipartisan recommendation of a 2017 Senate inquiry, but rejected by the federal government.

Two programs run by WCS – Partners in Recovery (PIR) and Personal Helpers and Mentors (PHaMs) – illustrate a common complaint.

They received federal grants until that funding was shifted to the NDIS on the basis that most clients would be eligible, but WCS has found many are not, raising the question of where they can go, and whether the programs are sustainable on NDIS funding alone.

The issue was also “concerning” to the Senate committee and it recommended users of the programs like PIR and PHaMs “should not have to apply for the NDIS to have guarantee of continuity of supports and access services” – but the Commonwealth government also rejected this as unnecessary.

It is difficult to know precisely how many people who would have previously used such programs are also NDIS participants; the question has been a matter of conjecture and contention, as the case study article notes.

“The real issue for me here is that the psychosocial rehabilitation sector in Australia is emblematic of Australia’s approach to providing community mental health services,” said Rosenberg, who has considerable experience studying mental health policy in academia, the public service, for government advisory bodies and not-for-profits.

“These psychosocial rehabilitation services, often provided by NGOs like Woden, were always a peripheral element of the mental health service landscape, and shifting money which used to get block-funded to these organisation has meant an already-fragile sector is in danger of collapse.”

He contends the psychosocial rehabilitation sub-sector has “always been stunted” but has fostered a small workforce with specialist skills, and now this “valuable, rare psychosocial expertise is disappearing and going to work in other places” as employment opportunities in the small field dry up.

Much of this was covered in the Senate inquiry; the committee found it “concerning” to hear that programs like PIR and PHaMs funding had transferred to the NDIS but many of their clients would not be eligible, for example, and that “services previously delivered by states and territories were being withdrawn before recipients of those services are properly transitioned into the NDIS.”

In its official response, the government defended the funding transitions for services like PIR and PHaMs on the basis of “close program alignment with the NDIS” and because it expected the majority of clients would be eligible.

Continuity with change

The senators noted the “commitment made by all governments to provide continuity of support for people with psychosocial disabilities who are not eligible for the NDIS” but said at the time there was “a need to clarify and make public how they intend to provide these services and address the emerging gaps created by the transition of existing services into the NDIS.”

It’s still not entirely clear. In response to the inquiry, however, the Commonwealth argued “timely testing” of the actual NDIS eligibility of all clients of the relevant programs would help with accurately estimating the resources needed to maintain continuity of service for those who don’t meet the criteria.

The National Disability Insurance Agency also felt the need to assert it was “supportive of continuity of support arrangements and an appropriate level of mainstream services for those people not eligible for the NDIS” last year, while accusing a group from the University of Sydney of misunderstanding the scheme, failing to engage with the agency or acknowledge its work, and misrepresenting the situation for people with psychosocial disability.

Rosenberg cites the report that offended the NDIA as a indication of the “fundamental misalignment” that he sees between recovery-focused mental health support and the NDIS, as well as the agency’s surprisingly strong rebuttal (which we’ve uploaded as it was no longer online).

“These tensions are the subject of ongoing developmental work involving the NDIS and the mental health sector,” he observes in the paper.

Asked for his view on the overall institutional responses to the vexed issues around mental health services and the NDIS from governments, their agencies and independent advisory bodies like the PC, he is less diplomatic.

“It’s a dog’s breakfast. It really is, you’ve got a variety of different jigsaw pieces and I’m not even sure they’re even pieces of the same jigsaw puzzle, let alone how they fit together.”

Non-core support

According to the case study, several WCS psychosocial programs don’t count as “core support” in the NDIS, but this is where 76% of the funding goes. It reports they now get by on “increasingly tiny amounts of ‘support coordination’ funding provided to clients in their NDIS packages” through the peripheral capacity-building stream, which has attracted about a fifth of total support.

“These are the kind of specialist support services that can help a person maintain a life of stability and dignity in the community,” said Rosenberg. He contends they struggle in the NDIS era partly because they don’t fit the scheme’s primary purpose of providing ongoing support for permanent disability.

“Most mental illnesses are episodic, not permanent, that’s the first thing, and the second thing is most people aspire to recovery.”

The article notes the inclusion of some people with psychosocial disabilities in the NDIS has always been controversial. Various stakeholders and experts, notably the celebrated psychiatrist Patrick McGorry, said it was a mistake to include mental health; some suggest governments must have misunderstood its limited inclusion in the disability scheme, or used it as cover to cut funding for mental health support that isn’t fully covered by the NDIS.

The current estimate based on the Productivity Commission’s modelling is that 64,000 people will be eligible for NDIS support for their psychosocial disability. Health bureaucrats think there are over 10 times as many people living with a severe mental illness, and about 230,000 who receive ongoing support for it. The scheme was never supposed to cover all of them.

While the Commonwealth has been clear about this, Olney says “there’s still confusion and uncertainty about how this works in practice when responsibility to provide a service remains without dedicated funding” – as described in the WCS case study.

“It’s being addressed in a piecemeal way, with money to bolster community mental health services coming from various sources – $1.45 billion from the federal health minister (with a promise to change the funding model for future security); $70 million from the Victorian Government; an $82.4 million increase in funding in NSW – and a promise of continuity of support,” she adds.

“All this will ultimately be backed up by local service coordination on the part of the NDIS.”

Nobody wants to take anything away from the 64,000-odd people expected to qualify for some psychosocial support under the NDIS, of course, but Rosenberg and many others fear they will mostly get the bare minimum while many more miss out altogether.

He thinks the mental health sector in general is contracting as a result of the NDIS when it should be expanding, if anything; McGorry says it is in crisis. Rosenberg suggests hundreds of thousands of Australians with serious mental health conditions like bipolar or schizophrenia could benefit from support services that help them build life skills, reduce relapses and cut hospital admissions, but don’t access them for various reasons – including lack of awareness.

“The NDIS, in my understanding was not to interfere in any markets unless there were elements of market failure. And I would say that’s what we’ve got here.”

In Olney’s view, the shift from block funding to a consumer-directed model “adds complexity for mental health service providers around strategic planning, workforce retention and sustainability” but she points out there are lessons for governments in previous attempts to harness market forces in public service delivery, notably in employment services, and education and training.

“The same arguments put forward by Dr Rosenberg against it were made in the lead-up to skills reform, and in every review of employment services,” she observed.

“I hope governments heed the lessons of previous reforms that opened public services to the market here, because there is clear evidence that approach exposes people with complex needs to exploitation and neglect.”

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