Amid questions and concerns about some of the recommendations focused on psychosocial disability in the National Disability Insurance Scheme (NDIS) Review Report, the authors below urge reforms that enable self-determination for people with disabilities.
“Engaging the sector in creative ways and recognising lived experience expertise, occupational therapy expertise, and the enormous and unrecognised micro-success of pockets of NDIS innovation will contribute to innovative solutions,” they state.
Muriel Cummins and Neil Turton-Lane write:
As 2024 begins, we take a deep dive into the National Disability Insurance Scheme (NDIS) Review Report, and the recommendations focused on psychosocial disability. The Review panel, which aimed to improve the Scheme and ensure cost-effectiveness, released its final report on 7 December 2023, and governments must now consider the recommendations in detail.
Australia can and should aspire to be a world leader in the provision of equitable disability support. The current NDIS legislation grants all people living with permanent and substantial disability the right to reasonable and necessary support to live an ‘ordinary’ life, for their lifetime.
The Review includes some strong recommendations that have potential to improve the lives of people living with psychosocial disability, both inside and outside the NDIS.
Importantly, the Review took a strong stance on in-principal reduction and elimination of restrictive practice. The Review also calls for building NDIA capacity to work with people with psychosocial disability, and brings a renewed focus on trauma-informed care.
Equitable access to disability support for psychosocial disability?
To address current support gaps, the Review highlights the need to build a psychosocial disability ‘ecosystem’ by building low-intensity foundational supports for the 154,000 people with psychosocial disability who were identified by the Productivity Commission as requiring disability support outside the NDIS.
The future of equitable access to support for people with psychosocial disability within the NDIS is less clear.
The Review report recommends that in future, most people with psychosocial disability who meet eligibility criteria, enter the NDIS under Section 25 of the NDIS Act 2013 (the Act), the ‘early intervention pathway’. This pathway was previously typically not utilised for people with psychosocial disability, and the Review recommends legislation change to enable.
Over 80 percent of current psychosocial participants are aged over 35, have typically experienced years or decades of mental health treatment, and enter the Scheme under Section 24 of the Act by demonstrating permanent disability and substantially reduced functional capacity.
The Review report recommends a timeframe of three years for the early intervention pathway, with assessments to occur frequently. Following this, the Review report indicates that many people may no longer need the NDIS and can be exited back to foundational supports.
The Review does not provide solid evidence to demonstrate that the proposed early intervention approach will attain the outcomes indicated in the Review report, that functional impairment will be recovered to the degree that psychosocial participants will experience a reduction in support needs and no longer need the NDIS. This is an unproven assumption based on a yet-to-be developed ‘theory of change’.
There is also a need to further clarify the constructs described in the Review, with blurring between personal recovery, recovery from symptoms, and the recovery of function – each discrete constructs requiring discrete interventions.
According to the NDIS Review Report (page 232): “To be eligible under section 25 [of the NDIS Act], there should be a clear theory of change that a period of early intervention funded by the NDIS would significantly improve outcomes and be cost effective.”
Unlike NDIS participants broadly, these changes would mean the NDIS no longer provides certainty of support for the lifetime for most people with substantial psychosocial disability, and would instead predominantly become a three-year program for this cohort. While the Minister for the NDIS has stated no current participants will lose access to support, the potential implications of the proposed legislation change for the 63,000 current participants with psychosocial disability remain unclear.
The early intervention pathway encompasses a shift away from the current provision of goal-based, personalised supports. Home and Living supports, such as Supported Independent Living and Specialist Disability Accommodation are not specified within the prescribed list of supports, raising questions around access to these supports for a cohort at high risk of disability-related poor housing outcomes, institutionalisation, and homelessness.
Access to disability-focused allied health services is also not specified, an omission that appears at odds with the stated intensive capacity-building focus of the early intervention pathway.
Concerningly, the proposed introduction of the early intervention pathway raises potential questions around equality and Australia’s obligations under the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), such as: is this segregation by policy targeting a particular group of disabled people?
While the Review broadly recommends moving away from a diagnostic focus, the psychosocial disability cohort are defined by the diagnostic origins of the disability and the early intervention pathway is proposed within the Review report, in detail and at scale, singling out this adult group only.
Challenges ahead in building the psychosocial disability ecosystem
The Review vision for the psychosocial disability support ecosystem indicates a step-up, step-down approach where people would shift between support levels of varying intensity, including foundational supports, targeted foundational supports, early intervention, and the NDIS.
Under this vision, support levels would likely be governed by funding and governance structures across multiple federal, state and potentially, local government jurisdictions.
This is a shift in thinking, as a key driver for an insurance scheme was to move from… “a ‘welfare approach’ to disability services, according to which Governments plan for expenditures over a [defined] time frame [and] [a]s a consequence, the funds available for disability can change – depending on the economy, tax revenues and the requirements of other portfolios.“ (Bruce Bonyhady, March 2017).
In this context, the proposed complex psychosocial ecosystem risks resembling a bureaucratic house of cards.
Further, the step-up, step down model poses risks to continuity of support, and re-creating the notorious ‘revolving door’ phenomenon, (a yo-yo cycle of decline following stepped-down care leading to increased support needs), frequently a feature of mental health clinical settings, for the NDIS.
The economic modelling underpinning the NDIS Review has not been publicly disclosed; nor has the proportion of NDIS cost-containment falling at the feet of psychosocial disability. Without access to this critical information, uncertainty remains regarding the cost-justification underpinning changes.
A further, monumental challenge that lies ahead for governments is to strike a balance between upholding choice and control for participants, while ensuring the safe-guarding frameworks are robust enough to prevent abuse, neglect and exploitation.
What needs to occur to ensure psychosocial disability needs can be met?
A deeper, evidence-informed understanding of the nature and ramifications of psychosocial disability and evidence-based interventions is required, which examines NDIS learnings over the past ten years and international research developments during that time.
Reverting to retrograde programs of support or a one-size-fits-all implemented in a hurry to satisfy budget bottom lines are likely to be counterproductive. Engaging the sector in creative ways and recognising lived experience expertise, occupational therapy expertise, and the enormous and unrecognised micro-success of pockets of NDIS innovation will contribute to innovative solutions.
Clearly, the ‘early intervention pathway’ would need to be rigorously co-designed, piloted and proven prior to limiting support options, changing the legislation and introducing the pathway at scale.
The assessments recommended by the NDIS Review must be co-designed and capable of capturing the broad range of psychosocial disability needs.
The NDIS requires a workforce capable of understanding the what, when and why of supports intending to remediate an aspect of psychosocial disability (targeted capacity building), and when to offer disability-focused accomodation strategies (support work, environmental modification, assistive technology), to ensure better outcomes.
The disability sector is advocating for a Disability Reform Implementation Council, engaging directly with National Cabinet, to drive reforms.
Community expectations include commitment to NDIS delivery that is person-led, not system-led. Self-determination is a priority for people with disabilities and a hallmark of a rights-based system.
Author details
Muriel Cummins is an occupational therapist and holds a Master of Public Health. She was awarded the Australian Allied Health Awards Occupational Therapist of the Year Award in 2022. She graduated in Dublin 2001 and has worked in mental health and disability in Australia since 2005. She is passionate about working in close partnership with those with lived experience, and promoting co-design in service development.
Neil Turton-Lane has worked in lived experience roles in mental health for over 20 years. He has an enduring interest in the NDIS and its potential to improve the lives of people of people with a psychosocial disability. Since the NDIS’s implementation, Neil has provided individual and systemic advocacy on issues of concern for NDIS participants. A Community Development practitioner by training he has worked closely with grassroots NDIS participant-led groups to ensure that the voices of NDIS participants with a psychosocial disability continue to be heard.
• Note from Croakey: This article was edited on 29 January at the authors’ request to amend this paragraph from “most people will no longer need the NDIS” to:
“Following this, the Review report indicates that many people may no longer need the NDIS and can be exited back to foundational supports.”
• Note from Croakey: This article was edited on 16 February at the authors’ request to amend this sentence from “with assessments to occur six-monthly” to:
“The Review report recommends a timeframe of three years for the early intervention pathway, with assessments to occur frequently”.
See Croakey’s extensive archive of articles on the NDIS
