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02 Mar 2018

Introduction

The NDIS will be increasingly important in the lives of people with mental illness, especially severe mental illness. The National Disability Insurance Agency (NDIA) is an independent statutory agency whose role is to implement the NDIS. The Board of the NDIA is responsible for managing the strategic direction of the Agency.  The Government has also appointed an Independent Advisory Council (IAC), which brings together participants, carers and sector experts to advise the NDIA Board on the delivery of the NDIS.

Many mental health programmes including Partners in Recovery (PiR), Day to Day Living (D2DL) and Personal Helpers and Mentors (PhaMs) are being rolled into the NDIS. This means funding that was in the 'community' for day-to-day supports and psychosocial services is now with the NDIS.  The transition had been problematic,  the  Joint  Standing  Committee  on  the   National   Disability   Insurance  Scheme receiving  evidence indicating that  the transition of PiR, PHaMs and D2DL into  the  NDIS "will  result  in a significant  number  of  current  clients  of those  services not   accessing the  [NDIS] Scheme."  

As a result, the Government allocated a further $80 million in the 2017-18 Budget for psychosocial services for those with mental illness who did not qualify for the NDIS. This funding is conditional on it being matched by States and Territories. Negotiations are still underway about the allocation of this funding to States and Territories.  In the meantime, workforce insecurity and uncertainty remain with a paucity  of information about what future funding  guarantees are in place, and  widely   voiced  concerns  about  Primary  Health  Networks   (PHNs) not  being  able  to commission   psychosocial   services.  As mental health funding is transferring to the PHNs, it is reasonable to expect that, at a minimum, PHNs provide both clinical and psychosocial care, as needed

AMA concerns

The AMA has made submissions to parliamentary inquiries and engaged with its members and stakeholders on NDIS issues. The NDIS affects three sections of the AMA: Public Health (including Indigenous Health), General Practice and Workplace Policy and Medical Practice. The AMA's concerns can be broadly categorised into the following issues:

  1. The role of medical practitioners (especially GPs and psychiatrists) in providing NDIS assessments; the recognition of medical diagnoses, and the time  needed by practitioners to provide these assessments.
  2. Access to appropriate medical and psychosocial supports for people with mental illness, including for those deemed ineligible for NDIS packages.
  3. Aboriginal and Torres Strait Islander people and those from culturally and linguistically diverse (CALD) communities and their specific problems with assessments and access.

A concern recently brought to our group’s attention is the practice of psychiatrists and GPs being approached by so-called ‘NDIS-registered plan managers’.  These are private companies that have established themselves in the wake of the NDIS to act on patients’ behalf to broker applications with the NDIS for remuneration packages and then coordinate distribution of payment to any authorised providers for psychosocial services, for a fixed cost or commission. 

One concern is that if the NDIS classifies, and then approves clinical treatment by clinicians such as medical practitioners, nursing practitioners or allied health clinicians, then this will blur the boundary between psychosocial support by unqualified non-clinical support workers and clinical healthcare by qualified clinicians.

That will lead to confusing consumers, administrators, and clinicians about the difference between the type of ‘care’ they are being funded for or are receiving, which will:

  • increase the risk of bureaucratic processes deciding the ingredients of care packages instead of the determination being based on medical assessment and management plans, reducing essential and quality care being received;
  • increase the risk of non-evidence based treatments being received if psychosocial support and medical care are not distinguished;
  • distort the statistics of what specific typesof ‘mental health care’ patients are actually getting, either overstating their level of bona fide treatment or understating it;
  • pave the way for cost reduction being the primary motivator of care decisions;
  • lead to the slippery slope of arguments being made to remove Medicare being the source of subsidised medical treatment so that NDIS clerks make the funding decisions as a form of managed care model;
  • lead to state governments downgrading their mental health services, removing access to medical care to the community for large numbers of people with severe mental disorders who are unable to access adequate specialist care within the private sector, NGOs or the NDIS;
  • lead to rural psychiatric units (who are particularly vulnerable due to likely workforce gaps) substituting clinical staff with non-clinical support workers such as peer workers based on this blurring between who is a provider of psychosocial care versus clinical care; and
  • lead to increased mental health system inefficiencies due to scarce mental health dollars being wasted on bureaucratic processes and therefore less being available for essential quality clinical healthcare.

We would discourage members from signing up with NDIS-registered plan managers until the remuneration model is made clearer and in particular there is a guarantee that the NDIS will continue to provide psychosocial support and not medical treatment for select patients with chronic mental disorder causing chronic disability.

The current situation

The NDIS is an insurance-based scheme that replaces block funding previously used to support NGOs looking after people with mental illness. It is therefore person based although it is recognised that contract funding may eventually be required for some services for people with psychosocial disability.

The NDIS provides funding packages for people with permanent impairment that substantially reduces their physical, intellectual, cognitive, neurological, sensory, psychological and social functioning.   There are an estimated 4.3 million Australians (aged 16 to 65) with disability, however the majority of people with disability will not meet the eligibility criteria for NDIS funded packages. People with disability use an eligibility checklist to see if they meet the criteria, and if so, they apply to receive funded support through the NDIS. The NDIS assigns funding to individuals, and service providers/agencies compete in a market environment to attract NDIS customers.

Funding is available for "reasonable and necessary supports" for people with disability to live a life as "ordinary" as possible. The funding covers:

  • aids and equipment such as wheelchairs and hearing aids;
  • helping people with personal care (e.g. showering);
  • managing finances;
  • house cleaning and domestic activities;
  • psychological, social and speech therapy and physiotherapy;
  • social participation activities such as in clubs; and
  • transport to connect with friends and community.

It is designed to be front-loaded to save money on an actuarial basis. Psychosocial disability is widely defined and comorbid alcohol or substance use are not exclusions. The NDIA recognise that people with mental illness have special requirements and they therefore have a psychosocial assessment team. It is also recognised that psychosocial disability may fluctuate and therefore effect on function should be assessed over 12 months. Since assessment is based on functional ability, the specific diagnosis less important than the functional impairment. The NDIS have issued a brief guide for doctors, which although it is targeted at GPs does provide some useful general information. It’s available at:

https://ndis.gov.au/medias/documents/hb6/h13/8803902619678/GP-Factsheet-web.pdf

The RACP has issued a somewhat longer guide that’s available from this web site:

https://www.racp.edu.au/docs/default-source/default-document-library/racp-ndis-qa-guide-for-physicians.pdf?sfvrsn=4

And also RANZCP:

https://www.ranzcp.org/Publications/Guidelines-and-resources-for-practice/NDIS-for-psychiatrists.aspx

In relation to people from culturally and linguistically diverse (CALD) communities, translator and interpreter services are supposed to be available and the costs of these do not come out of a person’s care package.

NDIA at November 2017 Federal Council

At the November 2017 Federal Council meeting, a Policy Session was devoted to the National Disability Insurance Scheme (NDIS). The AMA invited Mr Scott McNaughton, General Manager Participant Pathway Design for the NDIA, to address the Council and engage in a Q & A with members. Scott’s role is to design and manage the planning pathway for participants entering the NDIS, as well as associated service delivery policy issues. Scott also has responsibility for the Mental Health portfolio within the NDIA.

The AMA’s Senior Executive Assistant, Lauren McDougall, took the minutes, which have been used here to provide a summary of the NDIS Policy Session.

Dr Kisely chaired the Policy Session. He began by noting that the Public Health Secretariat has identified several specific areas of concern with the NDIS.  One is the role of medical practitioners, particularly GPs and psychiatrists, in providing NDIS assessments. Another is access to appropriate medical and psychosocial support for people with mental illness.  Currently those patients treated in the public system are heavily reliant on NGOs for a lot of their psychosocial care.  In the past, NGOs were funded by the Government, however funding is now directed through the NDIS.  It has become crucial that patients be accepted by the NDIS in order to gain access to ongoing care. There are also issues with access for Aboriginal and Torres Strait Islander people and from other cultural backgrounds. As such, in terms of people with mental illness gaining access to the NDIS, Prof Kisely commented that the NDIS is not working as well as it was intended to, with ongoing questions being raised about funding and problems with assessments.

Mr McNaughton then provided the Federal Council with a high level overview of the NDIS.

  • There are currently approximately 120,000 participants in the scheme, which did not exist three years ago. The Productivity Commission estimates that by 2020 there will be 460,000 participants in the NDIS, which means that the scheme is not even a third of the way through. 25,000 people will enter into the scheme between 2020 and 2022, primarily newborn children with disabilities, people with acquired disabilities, or people who suffer some other sort of accident or illness that creates a disability.  Approximately 20,000 people will exit the scheme during this period through natural attrition.
  • One of the tasks for the NDIS is to create much better social and economic participation for people with disabilities in Australia. NDIA teams hear stories of people whose pathway and transition into the scheme has not been to the level that they would have liked. The NDIA acknowledges this and is undertaking a significant review of the planning pathway for people to try and meet the ambitious targets set by Government of trying to bring so many people into the scheme quickly.
  • The NDIA trialled ‘phone based planning’, but it was not well received and the NDIA is now converting back to a quality relationship based face-to-face planning approaches, delivered through the NDIS staff and also partner network coordinators.
  • A number of people who have entered the NDIS were already in State/Territory disability systems. In Victoria, 70% of people entering the NDIS were already receiving some form of support by the Victorian Government. In Queensland, it was less than 50%; and in NSW it was approximately 75%. Once all existing people from State and Territory disability schemes are transitioned into the NDIS, the NDIA proposes that everyone entering the NDIS will be treated as if they are receiving disability support for the first time in their lives.
  • The NDIA recognises that for this reason, it is important to work closely with the GP sector, as quite often doctors will form the gateway into the NDIS. GPs are becoming part of the first point of call for people to be referred and assessed under the NDIS. The NDIS needs to work to ensure GPs have the right information, products and tools needed to assist people to find out about the NDIS, help them navigate their way into the NDIS, and provide the best information that the NDIS needs to make an assessment.
  • The modelling shows that to support the NDIS, the service provider market needs to grow by at least 80,000 to 90,000 employees over the next two years, noting that this is in a market that competes with aged care and a range of other similar industries. If, for example, the NDIS could give every single participant a plan tomorrow, there would not be enough service providers to facilitate or implement those plans which would create inflationary impacts on the market. The NDIA is already seeing thin markets emerging in rural and remote communities, and thinking about how to deal with these markets innovatively. The market challenge cannot be underestimated as it is one of the biggest risks to the Scheme.  Having a good market for some of the most complex and vulnerable of participants – those in complex family situations, in and out of the justice system, with psychosocial conditions – and to have the ability to find the right behavioural supports, the right support coordinators, and the right providers who can support those people to stay connected is proving a challenge, even in quite mature regions
  • The NDIS has recently published a number of guidelines, specifically, a guide for GPs navigating the NDIS. The guides refer to the types of information the NDIS needs from GPs to make an assessment and how that information is presented. The NDIA has a dedicated national eligibility access team, with a mental health unit, including clinical psychologists and people trained in psychosocial disability who are making the assessments.
  • The NDIA recently signed an agreement with the national telephone interpreter services to improve the capacity for GPs and service providers to connect with participants from non or poor English speaking backgrounds. This agreement is not funded out of individual plans, unlike Auslan or other disability related services which are funded out of the individual’s plan, but is funded by the NDIA.
  • The NDIA does not want fly in/fly out approaches in remote communities and has begun recruiting ‘Community Connectors’, who are local Aboriginal or Torres Strait Islander people from the communities to help promote the NDIS to the community and also assist people to enter and understand the scheme. The Community Connectors are in the community all the time, and they translate for the NDIA teams into the local dialect.
  • The Commonwealth Government is establishing the National Quality Safeguards Commission (NQSC), which will oversee the quality of services providers within the NDIS. Currently, this is a loose federation of State-based quality safeguards, but by the end of 2018, all State safeguards will be rolled up into the national model.  The NQSC will have investigative, registration, and deregistration powers and the NDIA expects that the NQSC will create a strong quality and safeguard mechanism.

Published: 02 Mar 2018