Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697636209784.pdf (Australia)
Submission to the Joint Standing Committee on the National Disability Insurance Scheme Inquiry into Capability and Culture of the National Disability Insurance Agency 12 October 2022 Capability and Culture of the NDIASubmission 18 Contents Introduction Issue: lack of psychosocial disability specific skills, knowledge, and experience Issue: lack of assertive outreach Issue: inconsistent NDIS access assessment outcomes Issue: NDIS plans do not support recovery Issue: NDIS does not support a recovery focussed psychosocial workforce 5 Issue: psychosocial services outside the NDIS Conclusion 7 8 Capability and Culture of the NDIASubmission 18 Introduction Since inception of the National Disability Insurance Scheme (NDIS), Mental Health Australia, Community Mental Health Australia (CMHA) and the Mental Illness Fellowship of Australia (MIFA) have been working collaboratively with the Australian Government and its agencies to continuously improve the responsiveness of the NDIS to the needs of people with psychosocial disability.1 Despite implementation of some recommendations of the 2019 review of the NDIS Act, the NDIA’s organisational culture (including its policies and practices), still does not allow for appropriate consideration of the episodic impacts of disabilities, including psychosocial disabilities, particularly at the level of face-to-face interaction with participants and prospective participants.
NDIA staff still focus administration of the NDIS on a narrow interpretation of permanent disability, which does not account for episodic impacts and recovery journeys for participants with psychosocial disability.

This lack of flexibility to accommodate episodic conditions fundamentally impacts on all aspects of the NDIS journey for people with psychosocial disability.
For example, people with psychosocial disability have reported difficulty providing evidence for the permanent nature of their disability to access the scheme, as psychosocial disability is approached through a strengths-based, recovery-framework by health professionals.

NDIS participants with psychosocial disability have also reported receiving plans which focus largely on core supports, which act to maintain dependency rather than capacity building supports, which act to enhance personal recovery.
However, significant progress has been made improving the scheme’s responsiveness to people with psychosocial disability and Mental Health Australia, CMHA and MIFA are keen to see this continue.

In particular, the work to develop the NDIS Psychosocial Disability Recovery-Oriented Framework and the development of the Psychosocial Recovery Coaches support item are important steps forward.
The implementation of the Framework will require ongoing work with the mental health sector that Mental Health Australia, CMHA and MIFA are committed to supporting.

In this context, this submission outlines issues relating to the capability and culture of the NDIA, with reference to operational processes and procedures.
It also outlines the impact of these operational processes and procedures on the experiences of people with disability and NDIS participants, focussing on people with lived experience of psychosocial disability and carers/families.

In addition, this submission provides recommendations to address the issues it raises and improve the responsiveness of the NDIS toward people with psychosocial disability.
1 The National Mental Health Consumer and Carer Forum (NMHCCF) describes psychosocial disability as the “disability experience, impairments and participation restrictions related to mental health conditions…” (see the NMHCCF position statement ‘Unravelling Psychosocial Disability’).

Psychosocial support helps people with psychosocial disability to develop skills, capacity and connections to improve their wellbeing and live a meaningful and contributing life.
Psychosocial support is available to some extent both within and outside the NDIS.
1 | Submission to the Joint Standing Committee on the National Disability Insurance Scheme, 12 October 2022 5 Capability and Culture of the NDIASubmission 18 Issue: lack of psychosocial disability specific skills, knowledge, and experience Issue description NDIA staff, Local Area Coordinators and other partners do not have adequate psychosocial disability specific skills, knowledge and experience.2,3 This hampers their ability to effectively support people with psychosocial disability to undertake NDIS access, planning and review processes.
The NDIA has committed to: “develop and implement learning and development strategies to deliver psychosocial disability competencies and skills required for NDIA and partner staff”4 and to “embed lived experience positions in both policy and operational areas of the NDIA”5.

These are good steps in the right direction but should be expedited.
Mental Health Australia, CMHA and MIFA also welcome the Australian Government’s commitment to “put people with disability back at the centre of the NDIS” through “ensuring solutions are evidence based and codesigned with people with disability, their families and carers, and service providers and workers.”6 Impact The lack of psychosocial disability specific skills, knowledge and experience has resulted in: • difficulty in navigating NDIS process • plans that do not meet the participant’s needs inappropriate decision making at plan review • • deterioration of a participant’s disability either through poorly managed interactions with the participant or the removal of critical services • challenges in providing guidance and working with providers to achieve recovery outcomes • poor outcomes for people who are unable to exercise choice and control at important junctures in the process (such as during planning) and do not have adequate support to do so 2 Mental Health Australia, National Disability Insurance Scheme: Psychosocial Disability Pathway (2018), https://mhaustralia.org/report/ndis-psychosocial-pathway-project-final-report 3 David Tune, Review of the National Disability Insurance Scheme Act 2013: Removing Red Tape and Implementing the NDIS Participant Service Guarantee (2019), 205, https://www.dss.gov.au/disability-and-carers-programs-services-for-people-with- disability-national-disability-insurance-scheme/review-of-the-ndis-act-report 4 National Disability Insurance Agency, National Disability Insurance
 Scheme: Psychosocial Disability Recovery-Oriented Framework (2021), 13, https://www.ndis.gov.au/understanding/how-ndis-works/mental-health-and-ndis 5 National Disability Insurance Agency, National Disability Insurance Scheme: Psychosocial Disability Recovery-Oriented Framework (2021), 9 6 Labor, “A Better Future for the NDIS”, accessed September 29, 2022, https://www.alp.org.au/policies/a-better-future-for-the- ndis 2 | Submission to the Joint Standing Committee on the National Disability Insurance Scheme, 12 October 2022 5 Capability and Culture of the NDIASubmission 18 Recommendation 1 The NDIA should expedite implementation of delivery of psychosocial disability competencies and skills for NDIA and partner staff and embedding lived experience positions in both policy and operational areas of the NDIA.
Issue: lack of assertive outreach Issue description Some of the most vulnerable people with psychosocial disability require assertive outreach and support to apply for the NDIS.7,8,9,10 The 2019 review of the NDIS Act found “There is a clear need for assertive outreach strategies to support people with psychosocial disability to access the NDIS.”11 In 2020, the NDIA funded Mental Health Australia to manage a NDIS Community Connectors program to deliver this support to people with psychosocial disability who were homeless or at risk of homelessness.
The evaluation of this program identified common barriers for people with psychosocial disability in accessing NDIS to include the appropriateness of NDIS policies and processes for people with mental illness, previous trauma and negative experiences of services or NDIS leading to mistrust and disengagement and homelessness itself further amplifying barriers with little flexibility from the NDIA to adapt to this.12 Unfortunately, despite the program supporting 366 people to submit an access request, funding was not continued beyond its first year of operation.
Mental Health Australia welcomes the NDIA’s intention to “review the procedures for access and change of circumstances so they are more timely”.13 However, this review should also consider whether the access and change of circumstances processes are appropriate for people with psychosocial disability.
7 Nicola Hancock, Justin Newton Scanlan, Damian Mellifont, Debra Hamilton, & Jennifer Smith-Merry, Breaking down Barriers: Co-designed recommendations to reduce stakeholder identified NDIS access barriers for people with psychosocial disability (2022), https://hdl.handle.net/2123/29557 8 Mental Health Australia, National Disability Insurance Scheme: Psychosocial Disability Pathway (2018) 9 David Tune, Review of the National Disability Insurance Scheme Act 2013: Removing Red Tape and Implementing the NDIS Participant Service Guarantee 10 Dr Karen Jordan and Dr Emma Tseris, Engage-In Research Project: Access to the NDIS for people with psychosocial disability living in institutional settings: Exploring the details of effective advocacy (2022), https://pwd.org.au/engage-in-final- research-report/ 11 David Tune, Review of the National Disability Insurance Scheme Act 2013: Removing Red Tape and Implementing the NDIS Participant Service Guarantee, 88 12 Mental Health Australia, Outreach and connection: NDIS National Community Connectors Program for people with psychosocial disability: Final Report (2021), https://mhaustralia.org/ndis-psychosocial-community-connectors-program 13 National Disability Insurance Agency, National Disability Insurance Scheme: Psychosocial Disability Recovery-Oriented Framework (2021), 12 3 | Submission to the Joint Standing Committee on the National Disability Insurance Scheme, 12 October 2022 5 Capability and Culture of the NDIASubmission 18 Impact The lack of assertive outreach to support people with psychosocial disability to access the NDIS means that vulnerable people who would qualify for a NDIS individualised support package are missing out on vital supports.
Recommendation 2 The Australian Government should fund assertive outreach and support for people with psychosocial disability to access the NDIS.
Issue: inconsistent NDIS access assessment outcomes Issue description The 2019 Review of the NDIS Act identified that “health professionals who assist prospective participants to make an access application have found the assessment processes inconsistent, with people with similar clinical and psychosocial disability needs and circumstances receiving different outcomes.
It appears that in some cases, this inconsistency is a result of insufficient guidance being provided to health professionals about the form of evidence needed to support a decision.”14 Health professionals have also reported a lack of respect from NDIA staff about their professional expertise, when submitting evidence to support a NDIS application.
15 Mental Health Australia, CMHA and MIFA welcome the NDIA’s intention to review procedures for access.16 This review should include consideration of appropriate assessment tools and procedures for people with psychosocial disability.
Impact The impact of inconsistent assessment outcomes is threefold: - “The therapeutic relationship between the person with psychosocial disability and their health professional can be damaged particularly when a health professional recommends a person with psychosocial disability apply to the NDIS and they are subsequently determined by the NDIA to be ineligible after undertaking a lengthy and taxing access application process.
- There is a reduction in health professionals’ confidence in their own ability to identify suitable candidates to apply for Scheme access.

- Potential NDIS participants are discouraged from applying after stories spread about the difficulty of the application process and inconsistency in access determinations.
14 David Tune, Review of the National Disability Insurance Scheme Act 2013: Removing Red Tape and Implementing the NDIS Participant Service Guarantee, 73 15 Mental Health Australia, Health professionals, psychosocial disability and NDIS access: Final Report (2019) 16 National Disability Insurance Agency, National Disability Insurance Scheme: Psychosocial Disability Recovery-Oriented Framework (2021), 12 4 | Submission to the Joint Standing Committee on the National Disability Insurance Scheme, 12 October 2022 5 Capability and Culture of the NDIASubmission 18 This means they may not be accessing optimal care even though they may be eligible to receive it.”17 From a whole of system perspective, the impact of inconsistent assessment outcomes is that there is not equitable distribution of public funds.
Recommendation 3 As a part of its planned review of procedures for access, the NDIA should consider appropriate assessment tools and procedures for people with psychosocial disability.

Issue: NDIS plans do not support recovery Issue description NDIS plans for people with psychosocial disability are too focussed on the provision of core supports and not focussed enough on capacity building.
Mental Health Australia’s Optimizing Psychosocial Supports Report outlined an alternative approach to psychosocial packages.

The NDIA has since implemented the Recovery Coaches support item.

Some have raised concerns about this item’s pricing and implementation.
In this context, Mental Health Australia, CMHA and MIFA welcome the NDIA’s intention to “update the current psychosocial recovery coach support item”.18 Impact The focus on core supports as opposed to capacity building acts to maintain dependency rather than capacity building towards meaningful personal recovery.

Recommendation 4 The NDIA should expedite its review of the recovery coach support item.
Issue: NDIS does not support a recovery focussed psychosocial workforce Issue description Pricing for NDIS supports designed to assist people with psychosocial disability fail to acknowledge the cost drivers of psychosocial service delivery.
It is unclear how an organisation could maintain a sustainable, skilled and supported workforce operating purely 17 Mental Health Australia, Health professionals, psychosocial disability and NDIS access: Final Report (2019), 12 18 National Disability Insurance Agency, National Disability Insurance Scheme: Psychosocial Disability Recovery-Oriented Framework (2021), 8 5 | Submission to the Joint Standing Committee on the National Disability Insurance Scheme, 12 October 2022 5 Capability and Culture of the NDIASubmission 18 within NDIS pricing structures.
It would be difficult for any organisation to meet essential requirements such as one-on-one professional supervision and development, investment in quality and improvement and an adequate hourly rate to attract and retain people with required skills, experience and qualifications.
In this context Mental Health Australia, CMHA and MIFA welcome the NDIA’s intentions to “update the current psychosocial recovery coach support item”.19 This review should consider the impact of pricing on the above-mentioned key components across the range of support items designed to assist people with psychosocial disability.
In addition, Mental Health Australia, CMHA and MIFA welcome the NDIA’s intention to “work with DSS in the roll out of the NDIS National Workforce Plan on workforce and learning and development strategies for psychosocial disability services”20 and have noted in particular the Plan’s Initiative 11 to continue to improve NDIS pricing.
This also appears to be aligned with the Australian Government’s commitment to review NDIS pricing, markets and compliance and development of a comprehensive NDIS Workforce Strategy,21 another very welcome initiative.
Mental Health Australia, CMHA and MIFA also welcome the NDIA’s intention to “Work with the NDIS Quality and Safeguards Commission to share relevant learning and development resources on psychosocial disability and recovery-oriented, trauma-informed practice”.22 This should be accompanied by adequate resourcing to ensure psychosocial service providers have adequate capacity to take advantage of learning and development opportunities.
Impact The inadequacy of the NDIS pricing structure has seen at least one major national provider discontinue providing psychosocial services through the NDIS all together and several others scale down and reduce their service offering.

The impact for consumers and carers is to limit choice around which providers they can access NDIS services through.
Other providers have reported needing to casualise workforces and reduce workforce supports to enable a viable business model under the current pricing structure.

Providers have reported that this casualisation and reduction in workforce supports has led to higher staff turnover and reduced availability of experienced and appropriately qualified staff.
Ultimately it is consumers and carers that will miss out on the benefits of a skilled workforce and the NDIS will incur costs for services that deliver on poorer outcomes for participants.
Recommendation 5 In undertaking its update of the current psychosocial recovery coach support item and future pricing reviews the NDIA should consider whether the cost model underpinning this support 19 National Disability Insurance Agency, National Disability Insurance Scheme: Psychosocial Disability Recovery-Oriented Framework, 8 20 National Disability Insurance Agency, National Disability Insurance Scheme: Psychosocial Disability Recovery-Oriented Framework, 13 21 Labor, “A Better Future for the NDIS”, accessed September 29, 2022, https://www.alp.org.au/policies/a-better-future-for-the- ndis 22 National Disability Insurance Agency, National Disability Insurance Scheme: Psychosocial Disability Recovery-Oriented Framework, 13 6 | Submission to the Joint Standing Committee on the National Disability Insurance Scheme, 12 October 2022 5 Capability and Culture of the NDIASubmission 18 item and other support items designed to support people with psychosocial disability are sufficient to ensure a sustainable, skilled and experienced workforce.
That a review of the current NDIS funding model be undertaken to explore possible alternative arrangements such as a combination of conditional block funding with the fee for service model.
Issue: psychosocial services outside the NDIS Issue description The Productivity Commission Inquiry into Mental Health recommended that Governments ensure all people who have psychosocial needs receive adequate psychosocial support, however under current policy settings an estimated 154,000 people would not be able to access the psychosocial support services they require.23 It recommended that “the shortfall in the provision of psychosocial supports outside of the NDIS should be estimated and published at both State and Territory and regional levels”24 and that “state and territory governments, with support from the Australian Government, should increase the quantum of funding allocated to psychosocial supports to meet the estimated shortfall.”25 The National Mental Health and Suicide Prevention Agreement acknowledges psychosocial support as “an important part of a well-equipped mental health service system”26, commits to agree upon a common definition for psychosocial support and estimate demand for these services and to maintaining current investments in psychosocial support services, while this work is undertaken.27 Impact If people with psychosocial disability who are ineligible for the NDIS do not have access to appropriate psychosocial support outside the NDIS, their disability may deteriorate to a level where NDIS supports are required.
Mental Health Australia, CMHA and MIFA have long advocated that lack of a well-functioning and effective mainstream system for providing psychosocial supports for people not eligible for the NDIS is a key risk in containing the long-term costs of the NDIS.
With this in mind, Mental Health Australia, CMHA and MIFA welcome the current Minister for the NDIS, the Hon Bill Shorten MP’s acknowledgement of the importance of ensuring a strong community mental health sector exists outside the NDIS.28 23 Productivity Commission, Mental Health (2020), 827, https://www.pc.gov.au/inquiries/completed/mental-health#report 24 Productivity Commission, Mental Health (2020), 866 25 Productivity Commission, Mental Health (2020), 866 26 Australian Governments, National Mental Health and Suicide Prevention Agreement (2022), https://federalfinancialrelations.gov.au/agreements/mental-healthsuicide-prevention-agreement 27 Australian Governments, National Mental Health and Suicide Prevention Agreement (2022), 29 28 Shorten, Bill, “5AA Radio Interview,” Interview by Leon Byner.
5AA Radio, June 28, 2022 7 | Submission to the Joint Standing Committee on the National Disability Insurance Scheme, 12 October 2022 5 Capability and Culture of the NDIASubmission 18 Recommendation 6 The Australian Government should expedite the analysis (required under the National Mental Health and Suicide Prevention Agreement) to estimate the shortfall in psychosocial support outside the NDIS and fund psychosocial supports to address the shortfall.
Conclusion The NDIA has made significant progress in recent years in relation to the responsiveness of the NDIS to people with psychosocial disability, particularly through development of the NDIS Psychosocial Disability Recovery-Oriented Framework.

It is now imperative that the practical implementation of this framework, co-designed with key stakeholders, including people with lived experience of psychosocial disability and carers, is expedited.
Ideally this would ensure swift improvement to the psychosocial disability specific skills, knowledge and experience of NDIA and partner staff, implementation of assertive outreach and support for people with psychosocial disability to access the scheme, improved consistency of NDIS access assessments, plans that support recovery and pricing which acknowledges the cost drivers of psychosocial support delivery.
In addition, it is equally important that psychosocial support outside the NDIS is expanded to meet demand as this will act to contain NDIS costs.

Mental Health Australia, CMHA and MIFA are ready to assist the NDIA to reform the NDIS, to a scheme which supports people with psychosocial disability in meaningful personal recovery.
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