Clearer, fairer pathways are needed for people seeking psychosocial care, writes Dr Sebastian Rosenberg, Senior Lecturer, Brain and Mind Centre, University of Sydney.
Sebastian Rosenberg writes:
At the 4th NDIS and Mental Health Conference, hosted recently by Community Mental Health Australia in Sydney, Minister Bill Shorten reminded attendees that the NDIS was established as a new public insurance scheme for people with a disability, designed to operate AS PART of an overall ecosystem of care and services.
He noted that for many people, accessing these services, mostly from the health system, remained very difficult, particularly in mental health. He described this situation as leaving the NDIS as an oasis in a desert.
In the absence of other services, gaining entry to the NDIS has become vital for those seeking psychosocial care.
NDIS spending
Minister Shorten then explained that almost $4 billion is now being spent each year on the 60,000 Australians who qualify for the NDIS with psychosocial disability as their primary disability.
Just under $1 billion was spent in the first quarter of 2022-23, a 35 percent increase from the same time in the previous year. This equates to annual per capita spending of nearly $67,000 across these NDIS recipients.
By contrast, about 3.3 million Australians receive mental healthcare under Medicare or through services run by the states and territories, mostly hospital-based care. The governments together spend about $11 billion each year providing this care.
On this basis, annual per capita spending would be $3,333 for those in receipt of federal or state mental healthcare.
By these calculations, NDIS recipients receive 20 times as much funding to respond to their mental illness than those who do not qualify for the NDIS. This will be an underestimate, because while non-NDIS recipients cannot receive NDIS-funded services, NDIS recipients are entitled to use hospital and Medicare services. In other words, NDIS recipients receive part of the $11 billion government mental health budget.
We know that mental health has been underfunded. The NDIS would be even more of an oasis if its more generous levels of financial support clearly led to better outcomes.
The most recent NDIS data indicate fairly small increases in social and community participation, as well as in education outcomes, and no change in employment status for either clients or their families/carers.
It would be useful to know more about the access of NDIS clients to mainstream healthcare services, to build a fuller picture, both of costs and of need.
For example, has NDIS funding reduced emergency department (ED) or inpatient admissions by NDIS recipients? Sixty-one percent of psychosocial NDIS clients are deemed to have ‘medium’ functioning, with 31 percent reporting low level functioning. Given these assessments, it is likely that many NDIS clients may well have frequently required the acute mental healthcare support currently only available in hospitals.
The NDIS publishes data on the value of average support packages across all recipients. In the 12 months to 30 September 2022, Â $61,700 was the average payment for a participant with a psychosocial disability, an 11 percent increase compared to the previous year. This averaging masks likely significant disparities between smaller and larger NDIS support packages.
Psychosocial sector
Presentations to the Sydney conference indicated that while spending on NDIS clients is already considerable and rising rapidly, it does not seem as if this funding, or much of it, is finding its way to the typically community-managed organisations who had been providing psychosocial care.
Despite good evidence to justify expenditure on psychosocial support to be a partner to clinical care, these organisations (like NEAMI, the Mental Illness Fellowship of Australia, Mission Australia) were never funded to be more than a peripheral element of Australia’s mental health service mix (receiving less than seven percent of state and territory spending on mental health services).
It does not appear that the advent of the NDIS has changed this situation, with new evidence demonstrating in some jurisdictions either a reduction in overall access to these psychosocial supports or a reduction in the diversity of services available.
Show me the money!
This raises a fundamental question.
If $4 billion of NDIS spending on psychosocial care is not going to the community sector organisations with decades of (underfunded) experience in providing this kind of housing, employment, education and social support to people with psychosocial needs, where exactly is this money going?
People receiving an NDIS package can either manage their own package (themselves or through a plan managers) or they can have an agency manage their package for them. In September 2022, the split was around 60/40 in favour of self-managed packages.
For people self-managing their plans or using a plan manager, payments were made to 46,514 providers for NDIS-funded services, of which 82 percent were unregistered providers.
For agency-managed participants with a psychosocial disability, 4,979 providers received a payment, with 100 percent registered.
A registered provider is an approved person or provider of supports who is registered with the NDIS Quality and Safeguard Commission. While a registered provider can provide supports to all participants, an unregistered provider can only provide supports to participants who use a plan manager or who are self-managed.
Where agencies manage plans on behalf of individuals, as opposed to the individuals themselves, there is a clear preference to pay for services provided by registered providers.
NDIS data reveal that of 48,106 total providers of psychosocial services, 57 percent of these operate as individuals or sole traders. Given the severity or complexity of NDIS clients, it is likely they need support from a team of people. However, as is the case with fee-for-service healthcare in Medicare, it is not likely these funding arrangements encourage multidisciplinary, team-based care.
Allied health providers, psychology services and professional bodies have understood the opportunity associated with the advent of the NDIS. They refer to ‘improved daily living’ and ‘functional’ rather than ‘clinical’ improvement, as goals to emphasise for clients wishing to include psychological care as part of their NDIS funded packages, and to avoid confusion with Medicare-funded services.
It is worth noting here that for 50 minute appointments, a Medicare rebate of $89.65 applies for people with a Mental Health Care Plan referral from a doctor, with sessions capped (now) at 10 per calendar year.
The national peak bodies, the Australian Association of Psychologists Inc. (AAPi) and the Australian Psychological Society (APS) recommend a fee of $280 for a 50 minute session of psychology care under the NDIS, and there are no caps. There are strong incentives for psychologists to prioritise NDIS work over Medicare work.
In July 2018 Senator Rachel Siewert asked the NDIS (Question 884) if it knew how much it spent specifically on psychology. It did not.
Making the most of the NDIS opportunity
Minister Shorten also described the NDIS as the only lifeboat in the ocean.
There are 60,000 psychosocial clients in the Scheme now. It has been estimated that 64,000 Australians with severe and persistent mental illness would be eligible for the Scheme.
This suggests there are almost no places left on the lifeboat. Each year, around 700,000 Australians living with complex mental health conditions require psychosocial supports to live well and connect as contributing members of their community.
The fabled Tier 2 support services, designed to provide support to people outside the NDIS, have failed to emerge. This means the circumstances separating the 64,000th NDIS client from the 64,001st are massive and growing, raising issues of equity and fairness. This inequity is testament to the poverty of Australia’s mental health ‘ecosystem’, particularly its undeveloped psychosocial service sector.
The psychosocial sector provides opportunities where people can experience, develop and sustain their autonomy, adaptability and personal agency. This includes provision of useful tools and strategies helping people to connect to community and live contributing lives.
As it stands, the evolution of the NDIS as a funder of psychosocial services in Australia is hampered by a lack of accountability, standards and definition. Rare and precious psychosocial services, always peripheral, now face existential threats.
While significant new NDIS spending may have benefited some providers, it has not resulted in people being able to easily contact a vibrant and healthy psychosocial service sector.
An NDIS package should not preclude aspirations for recovery and opportunities to flourish. It should be the core focus and measuring outcomes along these lines should be a fundamental requirement. From this standpoint, ‘choice and control’ looks a mirage.
The Federal Government has instituted a review into the NDIS. As a priority, it should consider how to better understand and respond to the psychosocial needs of Australians. This would fit with recommendations made by the Productivity Commission in 2020.
There is still the potential for the NDIS to be the motor for the clear articulation of the role and potential for psychosocial services, driving their development to become fully fledged partners to clinical care, in prevention and across primary, secondary and tertiary mental health settings.
This work should be undertaken as part of an overall process of mental health service design, taking into account urgent re-design of corollary services in the health system, especially Better Access, so that we can capitalise on our valuable, finite human resources and create clearer, fairer pathways for people seeking psychosocial care.
Oasis, lifeboat, mirage. Each of these metaphors indicate that for all the potential and excitement surrounding the NDIS and psychosocial support, it is in danger of becoming just another disconnected piece in Australia’s already fragmented response to mental illness.
• Dr Sebastian Rosenberg is Senior Lecturer, Brain and Mind Centre, University of Sydney
Note: Croakey asked Minister Shorten’s office for a copy of his speech to the conference, but this was not forthcoming. We had hoped to be able to provide a link for readers.
See Croakey’s archive of articles on the NDIS
Bill Shorten has elsewhere pointed to the cost shifting that has occurred with the states and territories vacating their own disability and psychosocial programs and pushing people into NDIS funded services with the strong inference that this is now primarily a Commonwealth responsibility.
State Governments need to be brought to account on this virtual rorting of the purpose of the NDIS.
(Note from Croakey editor: minor edit made for our editorial style).