Mental illness and the National Disability Insurance Scheme: Lessons from Europe

Williams and Smith (2014) and Duffy and Williams (2012) discuss a number of pertinent issues regarding implementation of the National Disability Insurance Scheme (NDIS), particularly in light of European experience. The majority of disability systems in Western Europe followed the Recommendation of the European Council in 1998, which was mainly intended to provide support for elderly individuals. Others, such as the Dutch system, were developed in the early 1990s and incorporated mental illness from its onset. In Germany, the main focus was on physical disabilities and did not include mental illness and dementia until 2008.

The accumulated wealth of information on the implementation of disability schemes in Europe has been partly overlooked in the development of the NDIS. In addition to the general recommendations made by Williams and Smith, there are practical issues that deserve further analysis such as the contextualisation of the care system, the case identification, the economics of disability, and training in disability care and management.

Context of care

Local care systems vary and this leads to very different effects of budgets on outcomes in different countries (Arntz and Thomsen, 2011). Unfortunately, there is a limited number of comparisons of the mental health system in Australia with other countries, and comparisons of the social care system are virtually non-existent. As an example, to understand the outcomes of individual budgets in England and Australia it is important to consider that our national system is probably more fragmented and has lower levels of integrated care across sectors. The lack of strong coordination between the social and the health sectors, and the disability and the elderly care sectors have been identified as major problems in the implementation of disability programs in Europe.

On the other hand, social and health care systems show large differences within Australia. For example, community care and accommodation support in Victoria was nearly double that of New South Wales (NSW) in 2011 (Australian Institute of Health and Welfare (AIHW), 2012). In the AIHW report, the primary disability groups included 1401 cases with psychiatric disorders in NSW and 14,305 cases in Victoria. These differences point to future disparities in the implementation of the NDIS.

Previous experiences in Europe indicate that listing local services by their names may not provide the information required for policy analysis. The 2003 Eurostat report concluded that the statistics concerning formal support were not comparable across European countries due to problems of terminology and definitions (Eurostat, 2003). In 2011, a classification system for coding and mapping long-term care services was released to allow for comparison across European countries (Salvador-Carulla et al., 2013). Similarly, there is a need for standard mapping of mental health interventions and packages of care to improve benchmarking, case management and navigation in the care system.

Identification of cases of disability in severe mental illness

The assessment of disability in mental illness is more complex than in any other disability group due to the difficulty of differentiating symptoms from functional impairment (Wakefield, 2009), and in establishing subtypes of disabilities based on severity levels. In 2010, Germany had to revise its eligibility criteria for mental illness (Büscher et al., 2011). In Spain, a report recommended a complementary evaluation and incorporation of tools for case-mix and risk pooling and stratification. The report recommended including the level of global functioning, social characteristics (persons with severe mental illness (SMI) living alone, and working/studying), course of illness and services needed on a long-term basis (Ochoa et al., 2012). The Spanish disability scheme opted for a common evaluation system for all disabilities in 2007, and the consequent problems in the eligibility system for SMI required its revision in 2014.

The under-reporting of the rates of the ‘profound’ and ‘severe’ categories in the Australian Survey of Mental Health and Wellbeing (Australian Bureau of Statistics, 2010) indicate that similar problems may appear in the identification of SMI in the NDIS in comparison with other disability groups.

Economics of disability

A miscalculation in the costs of the various disability schemes has been reported in several European countries after their implementation. Spending on disability support services in Australia increased by 2% to $6.2 billion between 2009/10 and 2010/11 (AIHW, 2012), and a further increase is expected after the implementation of NDIS. A detailed analysis of the cost and financing of disability schemes in other countries may help to design alternative scenarios which are relevant, particularly for complex conditions such as SMI.

The field of ‘disability economics’ is in its infancy and there has been an insufficient knowledge transfer from health economics and financing. This has relevant implications for planning disability care. Basic information on the units of cost in the social care sector is missing and it is necessary to design and cost combined packages of care of social and health interventions for SMI with severe disability under the scheme. In addition, tools used in health economics may require significant changes to be applied in disability economics.

As an example, disability-adjusted life years (DALYs) is a measure derived from the Global Burden of Disease Study (GBS), which is routinely used in health policy (Whiteford et al., 2013). However, the concept of ‘disability’ in GBS (‘any short-term or long-term health loss’) is too broad to estimate the burden and related costs of groups with severe impairment in the disability scheme.

The analysis of financing of disability also deserves more attention. It is essential to identify the financial flows, their incentives and barriers, and the tentative cost-shifting across different sectors, including health, social, housing, employment, education and criminal justice.

Training

Another lesson from the development of disability schemes in Europe is the importance of a comprehensive strategy to enhance training at the different levels of the care system. Efficient use of the system requires an increase in the health and disability literacy of users and their families, and provision of specific training to informal carers, front-line carers, case-managers and professionals. The European Commission has established several funding schemes and numerous training programs during the last 15 years (http://ec.europa.eu/education/index_en.htm).

Conclusions

The incorporation of severe mental illness into the disability scheme opens a window of opportunity to increase the integration of mental health care, to improve data collection and the standard description of the care system, and to design more effective tools of case identification that incorporate functioning and course of illness. It is also an opportunity to improve the economic analysis and training skills of the different stakeholders implied in mental health care. These factors require more research in Australia to prevent the problems reported in the implementation of disability schemes in other countries.

See Viewpoint by Williams and Smith, 2014, 48(5): 391–394