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Joint Standing Committee on the National Disability Insurance Scheme
14/03/2018
Market readiness for provision of services under the National Disability Insurance Scheme

BRIGHOUSE, Mr Russell, Head of Community Care, Ozcare

HINES, Ms Toni, Regional Manager, Aftercare

SCHICKERLING, Mr Adam, National Disability Reform Manager, Synapse

CHAIR: I welcome representatives from Synapse, Aftercare and Ozcare. Thank you for appearing before the committee today. I invite you, if you wish, to make brief opening remarks. Who would like to lead off? Ms Hines?

Ms Hines : I'm here today to speak about the Aftercare perspective, which has a mental health focus on providing psychosocial supports.

Mr Schickerling : Synapse do a variety of work, but we're predominantly focused on working on issues related to neurocognitive disability, or brain injury. Through that there's lots of work, obviously, through communities or through engagement with things like the justice system, homelessness and domestic violence—all those sorts of things. I guess particularly relevant to Synapse today is the work we've done over a number of years, funded through the department of communities, to deliver NDIS participant readiness for Aboriginal and Torres Strait Islander people across all of Queensland. We've worked across most communities across the state and have, I guess, some different insights into some of the challenges, particularly around market readiness.

Mr Brighouse : The Ozcare organisation works across Queensland only. We've been involved in providing in-home community supports across Queensland for 20 years. So we have been involved in the implementation of the NDIS from Townsville through Mackay and Ipswich and so on. My contribution is from the perspective of being a large provider that has a range of other funding mechanisms and how that affects our involvement in NDIS.

CHAIR: This inquiry is into the market aspect in transition, although we tend to cover a range of issues in these hearings. Can I ask each of you, if you wish to, in relation to that, in the development of the markets, particularly in regional Queensland as an example, about the particular challenges that you perceive or are maybe facing at the present time, and are there any directions that should be taken to address them?

Ms Hines : From the after-care perspective, it is still very uncertain, particularly around mental health supports. I think what we have found nationally is that it is still very uncertain as to whether somebody is going to get a package. In terms of the market readiness, we do have capacity to respond but it would be more around whether we are actually getting the number of clients through and matching the level of supports that they are going to need. What we have found is that in regions where we have gone live already there is a high uncertainty for individual clients about whether they will receive support through NDIS or not, and much of that depends on the LACs, which are not necessarily mental health focused or qualified. So, our experience can be that two clients with identical presentations might get two very differential outcomes, depending on the region, the staff member and the day. We do understand that NDIS is committed to establishing a stronger mental health pathway, but the details of that are not yet known.

CHAIR: Mr Schickerling or Mr Brighouse on the same topic?

Mr Schickerling : There are so many things. I guess, from my perspective, it is probably to keep focused on some of the work we've done, particularly with Aboriginal and Torres Strait Islander communities. The notion of market readiness is an interesting one, depending on whether we are looking at the start or the end product. A lot of the work that Synapse does through participant readiness and through the significant research work that we do is facilitating what we refer to as health weeks across communities, across Queensland, which are targeted at trying to engage Aboriginal and Torres Strait Islander communities to help identify the prevalence of disability. We know that there is not a particularly great uptake of the NDIS where Aboriginal and Torres Strait Islander people are concerned. The work that we do around brain injury in particular is often not well acknowledged, or it is seen as a mental health issue. Everyone just has a mental health issue. Often there is no diagnosis, let alone any culturally appropriate or culturally safe assessment process. It is something that Synapse has developed and has been rolling out over a number of years.

From our perspective, there is partially an issue about understanding where the demand is, which is not going to be people putting their hand up saying, 'We need a service now.' It is helping work out what people and what communities are impacted and what might work, and then having the opportunity to design services that respond to those needs. One of the things, again, that we certainly talk about quite a bit is that, in its approach, the NDIS is of course based around an individual and choice and control; it is very much an individual lens. This doesn't align with the way that many communities operate. So the opportunity for people to engage with that thinking is not there to begin with.

We do a fair bit of work organisationally around trying to contextualise some of that by thinking about different wellbeing frameworks that are more accepted in Aboriginal and Torres Strait Islander communities—so, looking at connection to country and community and spirituality; all of those things. Where we look at the outcome domains of the NDIS, we are not going to see anything about connecting with spirituality or country, which are fundamental parts to wellbeing. I guess the way we come at this issue, in terms of whatever market we are trying to respond to at the moment, is probably not reflective of what it is people are looking for anyway. The risk is that organisations, of course, try to develop responses that are mainstream responses, and try and package them up in a way that's culturally safe or culturally appropriate.

Meanwhile, we're trying to take services from metropolitan or regional areas that are not ever going to work appropriately in many of those communities. I think that's a particular issue for us in the work that we do across communities. Likewise, some of those similar issues then pop up where, if there's an attempt to develop in a more remote area a service response that doesn't talk to the cultural understanding of what disability means, what connection means and the way we design roles and workforces, they are all impacted by that, and that recognition of local knowledge and culture tends to go out the window a little bit. We point to all of those issues, and I know there's lots of talk, particularly at the moment, around low utilisation of plans and people that have taken up packages. To some extent, all of those issues need to be factored in there to understand why people are not spending money, even if they have it. There's a reason that that happens, and the question has to be asked whether or not the services that we're trying to suggest need to be pushed out to communities are even the right services, or if they're things people value.

I think the other thing, which is not different to any other part of the Australian community, but particularly in Aboriginal and Torres Strait Islander communities, is that the complexity of issues and barriers for people is significant. An NDIS response to something doesn't deliver outcomes for communities. It's an NDIS response to something when you've got domestic violence issues. There is a very high prevalence in the work we do of fetal alcohol spectrum disorder, a really key issue which largely results in kids being taken away from home and going into out-of-home care. From there, they go to homelessness; from homelessness, they go into the justice system; and they continue to cycle through that for the next 50 years. This notion of what sorts of responses the NDIS will provide to communities can be a little misleading where there's not more thinking about a more comprehensive wraparound approach with community leadership.

CHAIR: Have you or your organisation had these sorts of discussions with the NDIA?

Mr Schickerling : Yes, we have; some more successful than others. It's a hard issue to deal with, but some of the work that we're doing now in running health weeks across Queensland is being supported pretty actively by the NDIA. The majority of it is funded through the state, but the NDIA is engaged in it. Just by way of example, we facilitated a health week with the community in Charleville about two weeks ago. In doing that, over the course of a couple of days, we had 80 people assessed onsite for disability, access forms completed, and they are now eligible for the NDIS. They were all people that had never had any engagement with the disability service system before. There's a really significant issue: this market readiness is about people we know, and are we doing something? The obligation is actually far greater than that.

CHAIR: Something you touched on, which we've had discussions about at many of these hearings, is this concept of diagnosis versus functionality. I think it was something you at least alluded to in your earlier remarks. Do you have any further comments on that, from your experience?

Mr Schickerling : The work Synapse has done over many, many years has been the development of the only culturally safe assessment screening tool for neurocognitive disability. The way that we deliver health weeks currently includes a team of doctors that undertakes the assessment component. Synapse then has a team of allied health professionals that works alongside the doctors to essentially translate the diagnosis information into functional impacts for an NDIS access request. So they actually look at what this means in the context of community and what it means in the context of social and emotional wellbeing for Aboriginal and Torres Strait Islander people, as opposed to what the NDIS outcome domains are. Because asking those questions of people doesn't elicit a response that means anything. So people need to be able to understand while being in that context and then shape that to fit an NDIS need in terms of what sorts of things people ask for. Still the issue is that, once people have those packages, the sorts of services that people might then need in response to that will be quite different.

CHAIR: Prior to getting to the point of the service, in terms of that kind of construct that you're talking about of what a wellbeing outcome is and then having that translated into something that fits within the four walls of the NDIS, is that working?

Mr Schickerling : No, not particularly. I wouldn't say so. I think most of the work we've done through participant readiness has been essentially having a middle player to talk and understand from community and reshape it, because the understanding of individuals is not there. Again, we in our organisation have been doing some work to try and create some different mapping tools that can help us do that. Last year, we opened a housing project in Manunda, around the corner here, for Aboriginal and Torres Strait Islander people with brain injury. That was a service solely designed to support people post injury to have some housing and to develop skills and confidence with the aim of getting back to country. Obviously one of the key issues is people being disconnected from their communities because they can't access services. So we've been using that as an example to try and build up a series of different tools and frameworks that can help us understand that a little bit better. But there is very little done in that space nationally to actually understand that.

CHAIR: Mr Brighouse, your organisation has interfaced with the NDIA. Are there any lessons out of that we should hear?

Mr Brighouse : Yes. We have been working with the northern region for two years doing some really strong work, and a challenge, I find, is that then, working with other regions, that approach hasn't necessarily translated. So there just appears to be some inconsistency between regions. I think there's great opportunity to leverage some of that, where information sessions have been run in different regions that weren't run everywhere, despite us asking the central NDIS for them. We have been connecting locally with Des's team, but they're a local implementation of the central policy. So in terms of getting back to the central and system issues, we've been working through locally but it doesn't attend to the central; there seems to be limited opportunity to connect with the core of where the issue is, which would have had to had effect nationally, but we're just experiencing it first in Townsville, Mackay, Toowoomba and so on.

Our approach and our organisation have been really conservative in the sense that we had several thousand clients who were under 65 who we were servicing in their home for Queensland Community Care services. About 50 per cent of those clients are expected to be eligible for NDIS. At the moment, we're in the process where, as those folks become eligible, we're one of the options that they might choose to just deliver the bread; it's really the activities of daily life—low risk, low level but high volume, from our perspective. We have about 350 NDIS clients at the moment across the state. About 20 per cent of those are new clients, so the majority of them are folk that we've worked with over time. When we began in Townsville, Mackay and so forth, in order to meet the viability of the market we put a lot of effort into answering: how do we restructure parts of our business in order to do that? Queensland Community Care is under 65s but the majority of our business is delivering in-home care to over 65s, and so to change one aspect of it was really difficult in the scheme of things. We also have community mental-health services. Our approach, up until really recently, has been to acknowledge that the viability of some of those services weren't viable from our perspective. We've continued to do them but we're in discussions now with the NDIA and we're needing to exit from some services, some supports, that we have been delivering because it's no longer sustainable.

CHAIR: What happens to the service that you have to withdraw from? What happens, in terms of the participant in receipt of this service?

Mr Brighouse : In this particular case, we need to look really closely with NDIA to ensure that the continuity of those supports occurs.

CHAIR: By someone else.

Mr Brighouse : Yes.

CHAIR: In relation to Queensland—and I don't know the answer; that's why I'm asking it—in other states it's been suggested to us that, for the group of people who have a disability who don't qualify for the NDIS, there has been a perceived withdrawal or ending of services by the state when it ought to continue. I'd be interested in any experience of that in Queensland. I'm not suggesting anything. I'm simply asking the question because it's been put to us elsewhere around the country. Services that should have been continued by state and/or territory governments have not necessarily been continued.

Ms Hines : We've just heard that—we've got a community management mental-health service up on Thursday Island and we've just received an extension for 12 months for that program.

CHAIR: Is that a service that won't be subsumed into the NDIS?

Ms Hines : I think there is talk that it will be. I just wanted to add to Adam's point that he was raising there around cultural issues. I guess that's where too—and about people that are already falling through the gaps that we feel will fall through the gaps more so with NDIS. Even with the PhaMs program, within Cairns, I think because of the added stigma that goes with mental illness we have a relatively low number of clients who are Indigenous. They simply don't want to come to a service that is mental-health specific. Those people, we would see as already falling through the gaps and I don't see those people necessarily coming forward to anybody else to assist them to enter into the NDIS.

We've been successful with a local program up on Thursday Island where we have Indigenous workers. It's taken us three years to build the trust and the confidence there within the community to have people from the local community being willing to come through the door of a service that has 'mental health' in its name that's not Queensland Health. It is an NGO. That's the one where we've just received notice that it should go for another 12 months. But there is talk of that program rolling into NDIS. My guess is the people that have taken three years to even walk through the door without having to fill out an NDIS application to say that they have a permanent mental illness as a disability in their lives simply won't walk through the door. We'll have people not accessing supports who are in genuine need or, in worst-case scenarios, entering more at-crisis points and coming through the public mental-health system.

Senator GALLACHER: This joint committee has been formed in three parliaments—the 43rd, the 44th and now the 45th. Low cognitive function was identified very early as a precursor to homelessness, injustice and, inevitably, incarceration. So this would not be new to the agency. As we come here in the 45th parliament, three parliaments after I started in this, what is the agency's plan in this space? Do they have a coherent view and are you able to see that? Clearly, if we stop incarcerating people as a saving and we have early intervention, it's no different from early intervention in hearing or autism or anything else. Early intervention works. You pointed out fetal alcohol syndrome. If we can intervene early and get those people on another path—it's not rocket science. Is there a coherent view from the agency as to where your organisations fit?

Mr Schickerling : There's probably no simple answer to that. From a personal perspective, I would say no or, if there is, I need to see it. I think it's a bit like the justice example: what parts is Justice responsible for and what parts are the NDIA responsible for? All the time we see issues such as someone not being able to get a parole date unless they have secure housing. If you don't have secure housing, there is no parole date. How are you going to get that if you're inside and you don't have access to an NDIS package? Where is that housing going to come from? There are people who are trapped in the system with no way out. There has been increasing discussion over the last couple of years but the issue is enormous. I don't have figures with me, but some of the current figures talk to about 75 per cent of the justice or corrections population having a cognitive impairment or other disability. It's such a huge issue. Our work is not exclusively for Aboriginal and Torres Strait Islander people, but they make up a very significant proportion of the population.

A lot of the work we've done over the last 10 years, particularly in Cairns, we started out by looking at the prevalence of cognitive disability in homelessness services. We worked alongside a number of the homelessness services around Cairns to assess and understand the impact of that. The proportion of people currently in homeless shelters with significant cognitive impairments is ridiculous. I guess you then start to have that issue across all areas, whether it's housing and homelessness or justice or whatever it may be. Working out whose responsibility it is it at what point is a complex thing. I know that many people we might identify in homelessness services at the moment may be able to go on and make an access request to the NDIS, but they don't necessarily have access to any sort of support to help them through that process, unless that service, which is generally understaffed anyway, supports them to do that. That becomes a problem because then the organisations are doing that work of trying to invest funds into things that they can't feasibly do anyway.

We've been doing a fair bit of work over the last year or so in talking to a number of prisons and justice settings about the application of the tool we have developed for people pre-exit so that at least upon exit they're able to be connected to the right things. Particularly where brain injury is concerned, we see people come out of the corrections system and their ability to maintain a tenancy or their ability to comply with parole conditions is significantly compromised. It's not a failure to do the right thing; it's an incapacity. The brain doesn't actually function in a way that allows them to do it. In all points of that system, there is significant work that is needed. At the moment it is still being pushed from one to the other, but meanwhile it's the same people who will continue to cycle through that system.

Senator GALLACHER: Ms Hines or Mr Brighouse, do you have anything to add to that?

Mr Brighouse : We talked about pre-assessment and pre-participant readiness, and our experience has often been that the person may receive, at least in the early days, some coordination of supports. The coordination of supports case management effort that's required by providers and support organisations can't be underestimated. One way in which it's underestimated is: 'Well, I'll get the person on the plan and then we'll be right.' There will be coordination of support in the first plan but it won't be in the second plan; or there will have reasonable amounts in the first plan and then, because it's a capacity-building support—irrespective in some cases of the disability the person is working with—it will be halved or even less. Particularly in the kinds of services that we share, and even in physical disability, the fact that someone has been on a plan for one year or two years doesn't mean, I don't think, that the case management load—that piece has to be recognised as an ongoing part of maintaining participant engagement and—therefore participant engagement maintaining the market. It's keeping that alive. I think to ignore that is to risk organisations like us—eight per cent or nine per cent, I think, of the hours that we do aren't billable for NDIS because it's just not there. That's going to be a sustained thing.

Senator GALLACHER: If I've got a cognitive disability or impairment, I've got to have someone do that for me, so why isn't that cost just recognised?

Mr Brighouse : It's cost is—our experience—

Senator GALLACHER: I can't do it myself.

Mr Brighouse : No.

Senator GALLACHER: You've done it.

Mr Brighouse : And, in most circumstances, you would argue that your capacity to do that will not improve so much over one year that you can say: 'I'm right, Jack. I'll cope. I'll take it from here.'

Senator GALLACHER: So this is not a new issue for the agency. I think we had a hearing in Parliament House—whenever it was; it might have been 2012 or 2013. And a New South Wales person in the sector came and told exactly this story to the committee. So they've had a lot of time to look at this. And what we're saying now, in 2018, is that a person who can't do the plan for themselves—a not-for-profit or a for-profit—whoever does the plan for them, but it has to be for free. How is that sustainable?

Mr Brighouse : The planning will be done by the agency. It's the coordination of those supports—just to separate that out.

Senator GALLACHER: That's the big job, though, isn't it?

Mr Brighouse : Yes. I think, too, our experience has been with folk with a psychosocial disability who won't be able to identify it's episodic—and episodic needs for my assistance. So how that also relates to the coordination—when I've had an episode and I want to change providers or I have some difficulty with it. It's a really episodic need with particular clients with disabilities, but in some cases it's an ongoing need.

Senator GALLACHER: So is that one of the biggest unresolved issues in your sector?

Mr Schickerling : I would say so.

Ms Hines : We found the transition in general to be quite poorly managed—and to manage that as an organisation, because we've been receiving the funding cuts a lot earlier than we're going live for in this area. So we've also found it difficult to retain staff and even to keep the client numbers during this time. So we've actually got fewer clients on our books. We know there's more people.

Senator GALLACHER: Where do they go?

Ms Hines : That's a thing—

Senator GALLACHER: Homeless? Shelters?

Ms Hines : Or they're not getting the service. Our is not housing; it's more the psychosocial supports. So it may be that they are going unsupported and, as I said before, these are the people who may then present through emergency doors and be a burden on the public system because they're not getting those supports early enough. In terms of resourcing clients—just around their applications—I think Aftercare have come up with a number of about 100 hours, and that's about supporting the person to be able to identify that they relate to what this diagnosis is and what that means and the functional incapacity, and also taking them along to gain their supporting evidence. So that's something that we're having to do from existing block-funding at the moment, while we're sort of losing money as an organisation—about one million this year alone. That under-resourcing, I guess is also something that we're seeing with GPs in the community. Already now we're supporting people around supporting evidence and access requests. That's been a bit of a hit-and-miss response from local GPs, because many just aren't prepared to spend the time, or aren't able to fit in the level of detail that is being asked for by NDIS, particularly around those mental health or psychosocial applications. So we are getting some good responses, but it's very individualistic, depending on the particular GP, that can go against that person's ability to qualify.

Senator GALLACHER: So we seem to always collect evidence of whether the scheme's not going as well as it should—or shortfalls, gaps, problems. Where is it going well? Is there anything in your organisations that you can report where stuff is working well?

Ms Hines : I think it's too early for us to tell, especially in the mental health space. But, as I said, what I think is working well is where we have had a lot of preparation time with clients, and definitely where we're continuing to receive block funding for a period of time to be able to give that level of support to help somebody to transition.

From a program perspective, where it's been working well is that as a national organisation we're able to take some learnings from other areas. That can just be some tips and tricks about how best to prepare clients or gain your evidence and make sure that you're completing the areas around functional incapacity so that it's going to help somebody's application or having some good systems in place organisationally that can be shared, whether it's IT, financial, rostering et cetera to help streamline it. I think it's been good to share those learnings, because it is also then transplanted down to the client, so that they're not panicking about the changes and are supported to be able to put in their applications.

Senator GALLACHER: Is there a workforce for your particular silo of the sector in psychosocial services? Is there a readily available workforce that people exercise choice and control, so they can go and get whatever they need?

Ms Hines : There is a level of choice and control within Cairns, I would say, in terms of people being able to choose providers. I'm not sure whether there will be enough to keep people in a business if they're only focusing on psychosocial supports, depending on what people actually get in their packages—but that's where time will tell.

Senator GALLACHER: Mr Schickerling, are there any projects or pilots that are looking at an interventionist model? If you have foetal alcohol syndrome you're unlikely to excel at school: you're going to leave school, get chucked out of home, be homeless and end up in jail. Is there any work being done in that sector?

Mr Schickerling : There are a few different things happening in an isolated way, some of the work in Fitzroy Crossing, in particular, is looking at the FASD type scenario and is having really good success. There is a pilot that's meant to be getting up reasonably soon in New South Wales around diversion from the corrections system for people with cognitive impairment. There are a couple of things that are running at the moment, particularly in New South Wales, where there are some good outcomes.

Senator GALLACHER: Do they mesh in with the NDIS?

Mr Schickerling : That's part of the discussion at the moment. While some things appear to deliver good outcomes, they may or may not necessarily have an evidence base attached to them, because often those outcomes come from organisations that have just worked really hard over a long time to try and get things right. Whether or not there is sound evaluation and an evidence base to support it is another question. So, yes, there are bits and pieces, I guess, but the complexity is far greater in Queensland and the Northern Territory, where there's the issue of remoteness attached to all of those issues as well. Even if we can get something right in the west of Sydney or in Brisbane, being able to translate that to working in Kowanyama is a very different proposition, yet it's often people from those communities that find themselves more heavily engaged in some of those sorts of areas. Yes, I think it's quite problematic.

The other thing which comes to mind is that there has been discussion over a period of time on this issue of the provider of last resort—but no outcome that I'm aware of—around where that notion sits in the context of very remote communities. There's not necessarily a market at the current time and one's not going to pop up just because a couple of people get some plans. But they are still entitled to something, so what is the solution in the short term until a market does get established? I think we see, certainly through our engagement with many organisations in community that their capacity to even understand the implications of cash flow and stuff of moving from block grant scenarios to having to invoice for stuff and having the skills in their organisations and systems to do that stuff is significantly compromised. So there has to be something in the interim so that people who are eligible and entitled to NDIS support can still get it. That's an issue that still hasn't been addressed in the short term.

Senator GALLACHER: I've spoken to some people on the Eyre Peninsula in South Australia who had a plan. They were very well able to do all the stuff, but, when it came down to getting the services, they were three hours away. Fortunately, they had a car and probably had the option of getting some services in Port Lincoln, but not everybody is going to have that.

Mr Schickerling : No. In many communities, not just Indigenous communities but most remote communities, the best or the most sustainable way is always going to be to build capacity in community, but how does that happen? It doesn't just happen on its own just because some people got some money. There have to be the right supports around to support communities to respond to this themselves. It's a hard ask, but it's the only way it's going to be addressed.

Ms HUSAR: Mr Schickerling, my question is for you around the interaction between the justice system and the NDIS. This is not the first time that we've heard the issues. There's a case in Melbourne that we all follow since we heard about it. My question has two parts. What was the system like prior to the NDIS coming into this space? The second part of the question is: with the NDIS now there—and I appreciate that charity providers don't have the funding to get someone a plan—the gap is very obvious, so what is the solution to the gap, in your experience?

Mr Schickerling : From an organisational perspective, we have our own views on that. Again, this largely comes from an Indigenous perspective, because that forms a lot of the work that we're doing. What we're trying to push significantly at the moment is screening for neurocognitive disability at various points throughout people's life. For example, there's the justice issue at one end once someone's incarcerated. Also, when a child is taken away from their family, is any screening done? Often it's the parents with the neurocognitive issue. They're not sending Billy to school without his lunch because they don't want to feed him; their capacity to remember to put lunch in the school bag isn't there. Some support in place could change that—not always, but—

Ms HUSAR: Sorry—I just want to clarify. You mean screening for all kids in community?

Mr Schickerling : Even understanding what the triggers are. When children are removed from the home, what is the screening at that point to understand what the factors might be?

Ms HUSAR: No—I like the other model. I've been pushing for screening to be included in the developmental milestones for all the kids, so I'm happy with that.

Mr Schickerling : There's that bit and then there's the bit that I think someone spoke about earlier: kids coming out of the out-of-home system, which is a massive problem. They're generally exiting into homelessness. At that point, what screening or supports are put in place for people? Then there are the issues that we talked about already, in terms of people in the homelessness system, where they're more accessible than when they're incarcerated. There are all of those points. There's really good evidence to show the linkages. There are certainly still the points at which people are incarcerated and exit the system. At this point in time, they still do not necessarily have access to diagnosis or screening. There are potential issues that we've explored in our conversations with prisons around the additional stigma and risk created for people if they're identified as having a disability while they're in the system. That can make people more vulnerable, which is a particular issue to be addressed.

Ms HUSAR: You mentioned screening. I appreciate that there are various developments in a person's life. A 22-year-old would be screened differently to a two-year-old. Is there a current tool available to do that screening or is that a screening tool that we would need to develop?

Mr Schickerling : There are some—yes. The tool that has been developed by Synapse, in partnership with the Queensland state government, is the only culturally safe tool that looks at the cultural elements. That's the only one in use currently. There are other tools, say, around dementia, that are culturally validated. The tool that we are using at the moment is being used particularly in Cairns and in some other Far North communities, a little bit in the Northern Territory, a little bit in Western Australia and in some communities in Victoria. So we have got a number of sites across the country where we are working with communities to use this tool to build a dataset in order to understand what the prevalence of these different issues is in communities.

Ms HUSAR: Just going back to the question on the interaction of people in the justice system and the disability system before the NDIS: was it potluck, piecemeal? Maybe if you were lucky you got something?

Mr Schickerling : Yes.

CHAIR: Ms Hines, can I pick up something that you said earlier, which I want to try and clarify and make sure I understand what you were saying properly. Do I take it that one of the differences between the existing block funding system and the NDIS is that where someone potentially is dropping out of services being provided to them there is a tendency and an ability for the service under block funding to go and seek out that person and try and ensure that services are continued to be provided, whereas under the NDIS, because it is a fee-for-service model, if someone drops out then that may be the last time you hear of them or the last time anybody hears of them, unless they turn up somewhere else wanting a service? Did I hear you correctly in saying that? I want to be clear.

Ms Hines : That could happen. With the block funding, there is a whole lot more flexibility with support service that can be offered to the client. PHaMs and PIR services were never intended to be clinical services, like Queensland Health, but they can have a big role in being able to assess people's mental health. PHaMS workers can often pick if it is going up or down, because they are having regular contact and doing outreach to the client, whereas a case manager may only be seeing someone once a fortnight, and a doctor once a month to review medication. Often we are working in partnership there, so we can do a lot in terms of supporting someone around any escalation or de-escalation of their mental health and mental health deterioration. They might be people who really struggle to get out the door and turn up to an appointment. If they didn't have that PHaMS worker knocking on their door, there would be nobody else checking on them.

In the world of NDIS, that is going to work for people who have got the package. For people who have dropped off the system or who don't have that level of support in their package, they may fall through the gaps. I guess that is what we have found with mental health participants. I think they have predicted nationally 64,000 mental health participants when the scheme is fully operational, with an estimated 700,000 mental health clients against that. While there have been commitments to some replacement funding for non-NDIS clients, the amount being rumoured sounds like a small fraction of the PHaMS and PIR funding that is ending, and there is no level of detail.

CHAIR: So, potentially, a significant number of people could—

Ms Hines : Fall through the gaps —

CHAIR: drop out of being provided with services.

Ms Hines : Yes. Also, I guess they're not receiving the mental health support that they may need within the community that is going to reflect their needs and, as you were saying before, that picks up episodic times and can put extra interventions in place to sometimes help avoid it getting to the point where somebody falls off the system completely or turns up in ED or through the public system.

Senator GALLACHER: That is the central point. Who manages the plan? Someone gave some evidence which said that someone with dementia may cancel the service and then be waiting the next day for the service. I am sure that people with psychosocial episodes are capable of a similar type of inadvertent behaviour. Who is in place to make sure that there is continuity after the plan is written?

Ms Hines : I guess, as the service provider, we would be there ensuring that.

Senator GALLACHER: For nothing?

Ms Hines : Up to a point. But my point before that was the clients who do not get a package are the ones—

Senator GALLACHER: Even if someone has a package and they are not capable of managing the package because of their cognitive impairment and they don't access all of their entitlements, after 12 months they disappear off the plan because they have not been accessed. So you could end up starting off with a very good package but, because there is no sort of management or maintenance aspect to the services, it could be diminished under this current scheme.

Ms Hines : It could. I think the experience so far has been that, for the people who are getting packages, it is working if they have a good relationship with their support provider. The support provider can ensure that they are linked in. As I said, we are not trying to replicate and be the public system; we would always be referring into that where someone becomes acute. But what we also do not know yet is if people are getting enough in those packages to account for those times where we have that increased flexibility. For example, you were talking about Indigenous issues before. Under the PhaMS program at the moment, we had a client whose partner suddenly suicided. She is someone who often presents in crisis and then not at other times. We needed to drop everything and spend half a day with her to manage everything that came up around that including tenancy, her own suicide idealation and all of that. If we don't have that level of flexibility in the packages, we cannot provide that support to her and then the ongoing support through the funeral, her bereavement and other issues like that. She would have been someone presenting in a similar manner. So I guess in terms of mental health, while we understand it is not about being an acute sector, often the NGO sector does a lot in that space in partnership with Queensland Health. We have had this flexibility to be able to provide support to people when they are having intense times, where they need increased support. So I believe there are ways that the NDIS can factor that into a package but I am not sure how that is panning out in people's lives yet.

CHAIR: There is a number of distinct groups here. There are the people who have an NDIS plan. The question particularly in relation to mental health is: is that plan flexible enough to take into account episodic events or whatever they might be that can have an impact? I suppose the bottom line is it is funded so that the agency can provide those services that may be different to what is normally provided but then there is the second group that will not be NDIS participants. To what extent are services going to continue to be provided for them? Because they need services as well.

Ms Hines : The only other point I didn't touch on is the workforce and what that may look like. I think you are going to get a very different skill set for the worker who turns up thinking they are going to support them with their grocery shopping when in fact they need to take them off to the acute care centre to be assessed and use some assessment skills around that. My concern is if we have line items that are not paid enough, we are not going to have qualified social workers in that space, which we currently have.

Mr Brighouse : That is the reason for our perspective. By recent reports, 70 per cent of the supports received by folk with psychosocial disability are core supports and 30 per cent are capacity building. We can't afford for our support workers to provide core supports at the pricing level that it is. We have made the conscious decision not to send a care assistant along to do that work because it is not right for the client; hence we are exiting from that. We've looked at options. Is it the case that the plans are incorrectly balanced or not balanced as well as they could be? Should there be more capacity building, because of the episodic nature et cetera? Yes, there should be, but that will need to come through the system, so that planners in their reference packages are more alert to this shape of this need requiring that shape of plan, as opposed to, 'You need to go shopping and to appointments; here's 70 per cent of core supports.'

CHAIR: If you can't provide that service, is anybody else likely to be able to?

Mr Brighouse : We believe so from the conversations we've had with NDIS and other providers in those locations. To some extent we're working with the artefact of PHaMs and recovery programs. Our workers have therefore been working with those folk. We've made the decision that if the person was in the PHaMs program at the time of the plan then we need to exit from them, because we can't support them in the same way. They won't have the funding for it. We don't want to downscale the level of support they'll need in our organisation. We will hand them over. Our belief is a more focused mental health provider, who will work out a different scale and have different staffing capacities, will be able to pick them up.

CHAIR: I think you've exhausted our discussion for the day. Thank you very much for your contributions and for participating. We greatly appreciate it. I thank the secretariat, the audio recording staff and everybody who has participated today. We will reconvene in Townsville tomorrow morning.

Committee adjourned at 15 : 06