The National Disability Insurance Scheme (NDIS) began its national rollout on July 1, after being trialled at various sites across the country over the past three years. While there is much to rejoice about with this landmark change, it is posing particular issues in mental health.
Simon Viereck, Executive Officer of the Mental Health Community Coalition ACT, has a unique perspective on those issues, with the Australian Capital Terrritory being the only whole-of-jurisdiction, whole-of-population trial.
In the following article, written for the upcoming edition of VICSERV's newparadigm journal, he outlines four main lessons from the experience:
- the pace and scope of change is "astounding, ambitious and completely inadequately planned for"
- strong local relationships and communication are critical
- the NDIS was not designed for psychosocial disability, and
- the NDIS 'market' is not a market!
Simon Viereck writes:
The National Disability Insurance Scheme (NDIS) Trial commenced in the Australian Capital Territory (ACT) on 1 July 2014, one year after the commencement of the first trial sites. The ACT Trial Site is the only whole-of-jurisdiction, whole-of-population trial. This means the ACT has a unique perspective on the likely impact of the implementation of the NDIS. As the peak body for the community managed mental health sector in the ACT, Mental Health Community Coalition ACT (MHCC ACT) is well placed to monitor this impact. So what has our experience been?
Our starting point
The ACT has seen steady and significant growth in government funding for mental health services for a decade. The range of services provided by the community-managed mental health sector has expanded to include sub-acute services, an outreach service for people exiting detention, specialist education and mental health promotion services, and other new initiatives. Commonwealth investment saw the introduction of the Personal Helpers and Mentors (PHaMs) program and Partners In Recovery. Funding for community managed mental health services as a proportion of the total mental health services budget has been one of the highest in the country.
The ACT Government also supported quality improvement and workforce development initiatives. Through this support MHCC ACT was able to implement a program of subsidised training in Certificate IV in Mental Health and Certificate IV in Mental Health Peer Work. By 2014 we estimated that at least 75 per cent of the community managed mental health sector workforce was qualified at a Cert IV level or higher.
The sector also reported being able to increasingly attract people with higher qualifications and more experience – despite the competition posed by higher wages in the government sector. MHCC ACT also supported organisations to pursue accreditation against the National Standards for Mental Health Services and to foster a culture of collaboration, cooperation and continuous improvement.
Preparation for NDIS
Eighteen months out from the commencement of the ACT NDIS Trial the ACT Government formed an NDIS Taskforce, which was charged with using NDIS Sector Development funds and ACT Government funding to undertake a range of activities to help the disability and mental health sectors prepare for and implement the NDIS. Importantly the Taskforce included a Mental Health Specialist Officer. The Taskforce quickly began to work collaboratively with the ACT office of the National Disability Insurance Agency (NDIA) and the relevant peak bodies: National Disability Services ACT (NDS ACT), MHCC ACT, Carers ACT, and the ACT Mental Health Consumer Network.
Prior to commencement of the NDIS Trial the Taskforce oversaw implementation of several preparatory initiatives, including:
- a trial of small self-directed funding grants to individuals to purchase services and supports
- Community Conversation sessions with groups of potential NDIS recipients
- workshops on business essentials, international experience of implementing personalised funding, and other topics.
Once the NDIS Trial commenced additional support was funded, including:
- business investment packages up to $50,000 and other programs for organisations to implement strategic business change
- small grants for individuals to prepare and plan for NDIS
- a workforce awareness tool with NDIS factsheets and information
- NDIS engagement and planning support for harder to reach groups
- dedicated programs for Aboriginal and Torres Strait Islander people
- planning and wellness support for carers of NDIS participants
- Ready4 portal and program of business support tools and resources.
Communication and collaboration
When implementing comprehensive social policy change such as the NDIS, good communication is critical. Forums were created for this purpose, including a CEO Forum with NDIA established by NDS ACT and co-hosted by MHCC ACT, a meeting of executives of government and community managed mental health services, and a whole-of-mental health sector forum organised collaboratively by MHCC ACT, the NDIS Taskforce and NDIA.
These forums were instrumental in identifying and jointly problem-solving practical challenges during the transition to NDIS. Challenges addressed include a process to cover funding shortfalls for participants whose NDIS transition is delayed, development of a simpler Evidence of Disability Form for people with psychosocial disability, ensuring timely completion of NDIS forms by clinical managers and psychiatrists, working groups on key issues such as transport, and simply ensuring communication flows between NDIA, ACT Health and the community managed mental health and disability sectors.
MHCC ACT also set up a group of frontline workers and team leaders as a community of practice in managing practical aspects of NDIS implementation in provider organisations.
A culture of cooperative relationships between individuals in government and community-managed sectors was also crucial in ensuring providers and peaks could get timely access to key policy and operational officials in government to raise and address issues as they arose.
Local versus national issues
Despite the best efforts, cooperative attitudes and hard work of all involved at the local level, those forums and mechanisms were not able to address key areas of concern, including in areas like:
1. The funding and pricing model.
2. Barriers to access and support for people with psychosocial disability.
3. Lack of critical information.
4. Support for people who are not eligible for NDIS.
5. Safety and risk management for staff and participants.
Our experience is also that the NDIA national office continues to feel remote and unresponsive. Information, concerns and questions have been regularly fed back to the national office from ACT forums and stakeholders with little response received. Major changes were made to the Scheme, but local NDIA officials were given inadequate information and too little time to effectively communicate even that to stakeholders. Despite requests, NDIA has refused to develop more effective mechanisms for information sharing.
The lack of timely information is an example of the apparent attitude towards service providers at the national level of NDIA. David Bowen, the NDIA CEO, has suggested community managed organisations are top-heavy, inefficient and resistant to change. In our experience this is not only incorrect, especially when compared to government organisations, but also not a very constructive way to approach your critical partner in major reform.
The consumer and provider experience
Mental health sector advocates have long been concerned about the deficit based language of the NDIS and the concept of ’permanent disability’. It was therefore no surprise that ‘permanent disability’ presented a barrier for individuals seeking access to the Scheme and for workers supporting them. After decades of recovery-oriented and strength based service, it is not simply a question of getting used to new language!
Providers find that it has generally taken 2–10 sessions and sometimes much more to engage existing participants in conversation about the Scheme and preparing for a planning conversation with NDIS. This period of engagement is not funded by the NDIS and will not generally be possible once the gradual withdrawal of existing funding is completed.
Other access barriers have included GPs lacking understanding of the Scheme or being unwilling to term mental illness a ‘permanent disability’, clinical managers not prioritising completion of evidence of disability forms, and inadequate understanding of and information about NDIS across the mental health sector.
While initial satisfaction with NDIS plans for individual participants reportedly remains high, multiple plan revisions have often been required as participants did not appreciate the need to include all existing supports or because planners with inadequate understanding of mental health prepared inadequate plans. MHCC ACT members also observe that many people with psychosocial disability have found the NDIS planning process highly stressful, and some simply can’t and won’t engage in the process. While individuals within the NDIA are willing to respond creatively to this, it too often fails on a systemic level resulting in distress and serious risks for those participants.
Attempting to implement plans also often leads to disappointment when seemingly large dollar figures translate into limited support hours or providers are unable to provide supports in a particular way.
An inability to deliver supports is related to the inadequate NDIS pricing framework. Mental health providers across the trial sites report hourly funding rates effectively being halved compared to block funding. It is telling that general disability providers in the ACT also report being unable to viably deliver services at the rates on offer.
The impact on organisations of business change also cannot be overstated. Organisations have had to dedicate vast amounts of financial and human resources to developing new business processes and ICT systems in a very uncertain and continually changing environment.
What happens next?
The sector’s concerns about workforce issues are becoming reality. MHCC ACT and our fellow peaks have highlighted the potential loss of existing skilled and qualified staff and a de-skilling of the workforce. Our members are already seeing staff leave for more secure and better paid jobs and are unable to recruit suitably skilled new staff at the pay rates they are able to offer. The consequence is that they are unable to offer services to people with NDIS Plans. In turn NDIA officials are growing increasingly concerned and frustrated at the low rates of plan implementation.
Some service providers are attempting to manage viability issues by only providing low-priced supports if the NDIS participant also purchases higher-priced supports from them, effectively aiming to at least somewhat offset losses on support with profits on another. This limits choice and control and undermines the objectives of the NDIS. More often however, providers cross-subsidise from non-NDIS sources of funding.
In time providers will likely opt to hire the lower-skilled staff they can afford and offer NDIS services. This picture is one of change from recovery-focused psychosocial rehabilitation supports to generalist disability supports.
The withdrawal of block-funding will result in little capacity in community-managed organisations to support people with psychosocial disability to engage with and access the NDIS. This puts the responsibility back on the NDIA and Local Area Coordinators to take up this engagement work. It is unclear what this means for the many people with psychosocial disability who are expected to access the NDIS, but are not yet engaged.
Lastly the Information, Linkages and Capacity Building (ILC) framework which was reportedly designed to minimise the need for individual funding packages, has not materialised yet, and the allocated funding will not enable it to fill this role.
Firstly, the pace and scope of change associated with NDIS implementation is astounding, exceedingly ambitious, and completely inadequately planned for. Engaging in highly complex, system-wide and organisation-wide change in a highly uncertain and continuingly changing environment is incredibly difficult. Bigger organisations are more likely to have the necessary resources to manage this, which points to greater risks for smaller organisations.
We have learnt that strong local relationships and communication are critical to managing the combination of rapid change, lack of information, and the host of practical issues and problems arising. Being able to call on contacts in the ACT Government and NDIA for information or to discuss issues has been invaluable for community-managed organisations.
Thirdly the NDIS was not designed for psychosocial disability. The Scheme design lacks understanding of the particular flavour of complexity associated with supporting a person with psychosocial disability. The practical consequences are evident on a daily basis and unfortunately too often result in distress for participants. The psychosocial disability sector needs to continue to advocate loudly and concertedly for changes to better meet the needs of people with psychosocial disability.
Lastly the NDIS 'market' is not a market! Prices are fixed, supports are strictly defined, administrative burdens have increased, information gaps abound, changes are constantly being made, and critical information is not available in a timely manner.
To the extent it is a market, this is reflected in service closures, workers leaving, business mergers, and less choice and control. Unless service providers are given the freedom to decide which services they want to offer, to price those services, and to test whether they can sell their product in the market at the price they ask, the NDIS won’t produce efficient market-based outcomes and won’t work for provider organisations.
Power to Persuade thanks VICSERV and Simon Viereck for permission to publish this preview article from newparadigm.