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Recovery-focused psychosocial supports in the NDIS and the broader mental health system

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Supporting people with the most significant psychosocial disabilities is core business for the NDIS

The NDIS has delivered a significant increase in funding for disability supports for people with severe mental ill-health. There are 62,000 participants (10 per cent of all participants) with a primary psychosocial disability, such as schizophrenia, post-traumatic stress disorder or borderline personality disorder, and an additional 37,000 participants (6 per cent of all participants) with a secondary psychosocial disability, such as anxiety or depression, in the scheme as of June 2023.137

The NDIS has made a positive difference for many people. In the June 2023 National Disability Insurance Agency (NDIA) dashboard, 77 per cent of participants with primary psychosocial disability said the NDIS has helped them have more choice and control over their life.138

The importance of choice and control, a recovery orientation, life-long support and the successes that can be achieved through a well-functioning NDIS cannot be under-estimated for people with psychosocial disability.

- National Mental Health Consumer and Carer Forum 139

While the NDIS has improved the lives of many, participants with psychosocial disability continue to experience lower community participation, employment and carer employment than other participants in the scheme.140 We have heard that approaches to eligibility, planning and plan reviews are traumatising,and that the NDIA and partners do not have a good understanding of psychosocial disability.141

Mental health still feels like an afterthought of the NDIS.

- Participant 142

Attempting to access NDIS supports and services often re-traumatises those with psychosocial disability due to a lack of psychosocial-specific training for frontline staff and assessors, and without having lived experience embedded in the agency to help people navigate the system.

- National Mental Health Consumer and Carer Forum 143
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The NDIS has not structured its processes or stewarded the provider market to support independence and personal recovery

We have also heard from many people with psychosocial disability, family and carers, providers, advocates and researchers that the NDIS is not investing in the right supports to get the best outcomes for participants with psychosocial disability.144 In particular, the NDIS does not respond sufficiently to the often episodic nature of psychosocial disability and the potential for recovery.

Personal recovery is not primarily about the medical basis of symptoms and cure. Rather, as the World Health Organisation describes: “For many people recovery is about regaining control of their identity and life, having hope for their life, and living a life that has meaning for them whether that be through work, relationships, spirituality, community engagement or some or all of these”.145

With a lack of diversified services in the market and poor understanding of the need for recovery-focused supports, planning has drifted towards mainly funding ongoing daily living and social and community access supports, similar to the support mix for participants with physical and intellectual disability, rather than focusing on personal recovery and long-term outcomes.146 Daily living supports remain essential, during an acute mental health episode or on an ongoing basis for participants with ongoing needs. However, best practice psychosocial programs invest in evidence-based supports that rebuild engagement and skills, self-management and optimal independence.

The effectiveness of services like navigation, capacity-building and housing depends on providers who are trauma-informed and have a good understanding of psychosocial supports. However, there are currently too few providers with psychosocial competencies. The NDIS is not stewarding the market to deliver a recovery-focused approach.

In my experience, good support workers are few and far between, especially within the psychosocial space. Support work needs to be regulated. Anyone can be a support worker and that’s dropping the standard. To work within mental health, you should have to have qualifications, experience and supervision.

-Participant 147

The under-emphasis on early intervention supports across the Scheme for adults likely to benefit, for example for people with neurological conditions, to improve outcomes and reduce the long-term impacts of disability, also affects people with psychosocial disability. An early intervention approach for psychosocial disability under section 25 of the National Disability Insurance Scheme Act 2013 has not been developed, despite strong evidence about the effectiveness of early intervention supports. A 2016 literature review by the University of Melbourne found “significant evidence that people with psychosocial disability make significant gains in their capacity to engage in social and economic participation if they are offered early intervention”.148 The lack of an early intervention approach is a missed opportunity to help participants maximise their quality of life.

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For participants with highly complex needs, the NDIS is not providing intensive, coordinated assistance

A smaller number of participants with psychosocial disability have particularly complex support needs. They may be long-stay patients in hospital or have co-occurring conditions or complex behaviour management issues. Some may cycle through hospital, homelessness services or correctional or forensic services.

The NDIS does not have an integrated complex care approach with the public mental health system. This means participants are more likely to experience unnecessarily long stays in hospital, have inadequate supports to transition and live in the community, and are therefore at greater risk of returning to hospital or correctional facilities.

People with severe mental health issues should never be released from a psychiatric ward without wrap around supports (supported independent living with decreasing intensity over time according to improvement/needs).

- Participant and carer 149
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The NDIS does not operate effectively with the broader mental health system and there are major gaps in psychosocial supports outside the NDIS

Despite the connection between mental health and disability services, governments have not taken a holistic approach to supports for people with severe mental ill-health. Gaps in mental health services prevent people from being as well as they can be and maximising life outcomes. Gaps also place additional pressure on the NDIS. It is important to acknowledge that while Australia's mental health system is currently being reformed, the NDIS remains disconnected from broader mental health policy reform development.

NDIS expenditure on primary psychosocial disability was approximately $4.3 billion in 2022-23.150 In comparison, total funding for mental health, excluding the NDIS, was $11.6 billion in 2020-21.151 The significance of the interdependencies between these two large national service systems is not reflected in national policy frameworks or intergovernmental agreements.

A key example of this is the use of acute mental health beds by long stay patients in public hospitals. As at June 2023, there were approximately 443 NDIS participants with psychosocial disability who have been resident in public hospitals for more than twelve months, using an estimated 160,000 bed days (at a cost of $211 million to the public hospital system).152 The lack of a joined-up approach across policy and practice results in poorer participant outcomes and reduced productivity in the public hospital system.

There is also a major shortage of psychosocial supports outside the NDIS. In 2020, the Productivity Commission estimated that 154,000 non-participants with severe and persistent mental illness were missing out on the supports they need. This includes services such as assistance participating in the community, finding accommodation, managing daily tasks, and improving connections with family and friends. Other key services include help with financial management and budgeting, help to find and maintain a home, assistance with maintaining physical wellbeing and support accessing alcohol and drug addiction programs. The Productivity Commission estimated that the funding shortfall was approximately $610 million per annum in 2020.153

Psychosocial supports are very challenging to get assistance with. This should not be such a challenge for those with these needs to access the support they need.

– Carer154

While participants with psychosocial disability are among those with the greatest need for mental health services, many participants have difficulty accessing treatment. Availability and affordability are significant barriers to accessing mental health treatments.

There is a shortage of community mental health services and too few clinicians and waitlists in some areas.155 In addition, rehabilitation for mental illness prior to hospital discharge is not consistently available.

In the world of psychosocial disability, psychiatry isn’t bulk billed and despite Government saying that it’s readily available through the state health care system, it’s simply not.

– Participant 156

The result is some participants finding themselves in a situation where they can access NDIS funding but cannot afford psychology, psychiatry and some general practice services.157 These barriers particularly affect people with severe psychosocial disability. A particular gap is care for young people with more complex, severe mental illness, and who are at risk of recurring psychosis.158This means some young people do not get access to early intervention within the mental health system and as a result may be more likely to require NDIS supports in the future.

Collectively, these issues mean some people applying for the NDIS have not and will not receive timely mental healthcare.

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