Level 2, 22 Horne Street
Elsternwick Victoria 3185
T 03 9519 7000 F 03 9519 7022
www.vicserv.org.au

Submission

Productivity Commission Inquiry into Disability Care and Support - Draft Report  

Contact details:

Kim Koop, Chief Executive Officer
Psychiatric Disability Services of Victoria (VICSERV)
Level 2, 22 Horne Street, Elsternwick Victoria 3185, Australia
T 03 9519 7000  F 03 9519 7022
W www.vicserv.org.au  

Written by Anthea Tsismetsi, Policy and Research Officer 
Psychiatric Disability Services of Victoria (VICSERV) 
Level 2, 22 Horne Street, Elsternwick Victoria 3185, Australia
T 03 9519 7000  F 03 9519 7022
W www.vicserv.org.au  

Psychiatric Disability Services of Victoria’s (VICSERV) role 

VICSERV is a membership-based organisation and the peak body representing community managed mental health services in Victoria.  These services include housing support, home-based outreach, psychosocial and pre-vocational day programs, residential rehabilitation, mutual support and self-help, respite care and Prevention and Recovery Care (PARC) services.  

Many VICSERV members also provide Commonwealth funded mental health programs. 

VICSERV welcomes the opportunity to provide an additional submission to the Productivity Commission’s (the Commission) inquiry into establishing a national disability insurance scheme (NDIS).  This submission builds upon VICSERV’s previous submission in August 2010 in relation to the eligibility of people with a psycho-social disability and implications on the community-managed mental health sector.

1)	Psycho-social disability 

The Commission has specifically requested feedback on whether all people with a mental health condition should be included within the NDIS.   However before considering this, the Commission needs to be fully informed about what it means to have a psycho-social disability (used by some interchangeably with “psychiatric disability”); a term indicating a severity of mental illness which profoundly affects psycho-social functions.  The draft report indicates that there is a mixed understanding about this term and is heavily influenced by the medical model of disability.  

As indicated in VICSERV’s original submission, a universal definition of disability needs to be determined and adopted.  A good starting point is the International Classification of Functioning, Disability and Health (ICF) as endorsed by the World Health Organisation.  The ICF takes into account social factors of disability, such as environmental factors, impaired relational skills, capacity to perform general tasks or to participate in society through work or otherwise.  The ICF however will need to be applied in comprehensive way to ensure it reflects the realities of persons with a psychosocial disability.

The reality for many is unstable housing, interrupted educational trajectories, isolation from family and/or community or poor physical health.   The stressors of these factors contribute to disability.  Further, living with the episodic nature of mental illness can in itself be disabling for some.  There are times where due to episodes of illness, people, for example, cannot attend to their day to day tasks or participate in work or have a capacity for self-care.  

2)	Eligibility criteria 

Eligibility should be considered within the framework of the social model of disability with a greater emphasis on activities related to relationships, communication and social inclusion.  

As the eligibility criteria for the NDIS currently stand, only a small proportion of clients of community-managed mental health services would be eligible for the proposed Tier 3 individualised packages.   The Commission proposes that assessment be based on the following core areas of significant limitation: 

•	Communication;
•	Mobility; or 
•	Self-care. 

VICSERV reiterates its previous submission that consideration should be given to additional significant areas where people face limitations to a disabling effect.  The World Health Organisation Psychiatric Disability Schedule II (WHODAS II) to the International Classification of Functioning, Disability and Health suggests that the following additional assessment areas to those proposed by the Commission would give a better indication of areas of need: 

•	Getting along with others 
•	Household and work activities 
•	Participation in society.

VICSERV supports Mind Australia’s submission that the additional assessment areas are particularly applicable to those with a psycho-social disability.  Expanding the eligibility criteria to look at disability in terms of participating in society, household and work activities as well as getting along with others would ensure adequate coverage of people with psychosocial disability as well as other forms of disability associated with particular conditions, for example, autism.   

Another area in which the NDIS can make a significant impact is early intervention in relation to mental illness so that a person does not develop a psycho-social disability.  With the work of high profile professionals already gaining traction in this area, more needs to be done in relation to early intervention from the perspective of social interventions rather than only medical interventions.   In this respect, VICSERV shares the same concerns as other submissions to the Commission that the eligibility criteria based on acquiring an illness that it is one where early intervention has been shown to ameliorate does not include mental illness.  VICSERV would recommend that mental illness be one of the conditions which would allow a person to access the NDIS on the basis of early intervention.  This intervention is not only cost effective in the long-run, but may prevent a person from developing a full-blown psycho-social disability.  

The final eligibility criterion which is proposed by the Commission for individual packages is for persons who: 

‘have large identifiable benefits from support that would otherwise not be realised.  This takes account of the difficulties in slotting everyone into specific groups above.  Guidelines would inform the use of this last criteria (sic).’ (p3.1) 

It is unclear whether the Commission intends for people with a psychosocial disability to be included under this criterion.  Nevertheless, if it is proposed that they are included, VICSERV shares the same view with the Mental Health Council of Australia that those guidelines must be informed by consumers and carer perspectives. 

In not fully capturing people with psycho-social disability, the Commission would not only be doing a disservice towards such persons but also persons who have multiple or co-occurring disabilities.  The idea behind the scheme should be its inclusive nature as well as its ease of navigation.  Division of who is in and who is out based on the type of disability one has not only discriminates but also has the potential to fragment further the disability sector and is counter-productive to the scheme.   The focus should be on the individual and their support needs rather than the type of disability or age. 

3)	The Community-Managed Mental Health Sector 

The Commission has specifically sought feedback on: 

•	How the NDIS would intersect with the clinical mental health sector; and 
•	The types of mental health services that should be included in the NDIS. 

It is important from the outset to make a distinction between mental health services and community-managed mental health services. The latter comprises of mostly non-government organisations aimed at addressing the psychosocial needs of people with a severe mental illness.  Operating out of a recovery-based philosophy, services aim to ‘maximise people’s opportunities to live successfully in the community.’ 

The sector is easily distinguishable from clinical services, in that it does not provide clinical assessment and treatment.  Rather, the following are examples of the types of services provided by the sector: 

•	Psychosocial and Vocational Day programs
•	Home-based Outreach 
•	Residential Rehabilitation
•	Respite services for carers
•	Mutual Support and Self Help
•	Prevention and Recovery Care (PARC) Services (Step Up/Step Down Sub-acute Care)

In Victoria, these services are largely funded by the Victorian Department of Health however many agencies  also provide Commonwealth funded mental health programs such as the Personal Helpers and Mentors (PHaMs) program and Day to Day Living Skills.

Adjunct to the above, organisations also provide or have linkages to: 

•	Housing services including accommodation 
•	Employment programs 
•	Education and training 
•	Cultural specific services 
•	Emergency support 
The sector, whilst part of the broader mental health system, is not part of the clinical sector.  Further, whilst services are delivered by professionals, including but not limited to, occupational therapists, psychologists, and social workers, its focus is on recovery rather than clinical treatment. 

VICSERV notes the Commission’s concerns about how the NDIS could potentially interface with the mental health system.   Whilst the community-managed mental health sector might not be part of the clinical mental health sector, community-managed mental health services are part of a suite of services from which a person may choose to receive services to assist in their recovery.  Further, there are positive examples of how both sectors work in partnership to deliver services as part of a continuum of care.  These include shared individual support plans, inter-sectorial case coordination and government policy allowing access to services irrespective of how the person has entered the mental health system. 

However it is important to recognise that each sector has particular specialisations and responsibilities.  Clinical mental health services have particular expertise and responsibilities in services addressing acute needs.  The mental health sector however does not specialise in disability support services nor is it trained or funded to undertake such service provision.  Rather, many rehabilitation and support services in relation to psycho-social disability in Victoria are provided by the community-managed mental health sector.   

The general functions of the sector are key considerations as to whether community-managed mental health services should be included in a suite of services delivered under the NDIS.  Considering that in Victoria, there is a move towards more individualised packages with key community-managed mental health services as administrators, being included in a NDIS or being considered as a service which participants could access through NDIS funding, is not a far stretch.   VICSERV shares the view of Mind Australia that any potential concerns about how the mental health system will intersect with the NDIS can be addressed at the planning and implementation stages. 

4)  	Transitioning to individual support packages   

In Victoria, some community-managed mental health services are already offering consumers options for individual support packages.  Whilst there is a general recognition that individual support packages will be the way of the future within the mental health sector, much like the where the broader disability sector has already gone, there are some significant factors that need to be taken into consideration. 

With the majority of services in receipt of block funding,  transition into a competitive market without adequate sector-wide planning and support will be detrimental to some agencies and their clients.  One of the main concerns is the viability of some operators once it is left to the market to determine which services stay and which go.  The sector will be forced to rationalise in the form of amalgamations, co-location or sharing of back end functions which is neither here or there.  However, without adequate planning, a market driven sector could potentially lead to a concentration of services in the most profitable areas both in terms of geographical location and in terms of types of services provided.  There still needs to be an element of funding towards particular niche services or to services operating in remote areas with sparse populations.   Careful consideration needs to take place in relation to how best to provide individual packages without shifting costs onto those who may not be eligible under the scheme or are disadvantaged due to location or otherwise.  Furthermore, a balance needs to be achieved so that persons who are ineligible under the scheme are still able to access community-managed mental health services to address their level of need. 

There is also a recognition by VICSERV that individual packages will pave the way for more private operators entering the market.   The value of community-managed mental health sector to deliver on a range of social indicators should not be underestimated however these services may need some supports to maintain an active presence in the service system.  There needs to be service system development activities aimed at the community-managed mental health sector in order to transition the sector and good planning to address potential locational disadvantage.  It is important that the sector is supported in the transition to individual packages in this way as it continues to have a role in holding the recovery approach to service delivery.