Severe mental illness and work

The informative report by Harvey et al. (2013) raises an important issue about the need for public policies to be responsive to science and evidence. When the aim is to assist people with severe and persistent mental illness to realise their goals of competitive employment, the Becker–Drake Individual Placement and Support (IPS) approach is two to three times more effective than other methods in psychiatric vocational rehabilitation (Waghorn et al., 2012). In addition, it has promising generalisability outside the USA (Bond et al., 2012). IPS can also be delivered at less than half the cost of services in Australia (Sainsbury Centre for Mental Health, 2009). Yet despite the evidence, including a growing number of randomised controlled trials, IPS is not yet widely available in the USA, Canada, UK, Europe, Asia, Australia or New Zealand (Bond et al., 2012; Waghorn et al., 2012).

So why has public policy in these countries failed to translate IPS evidence into routine practice? In mental health, such translational problems are common (Sederer, 2009). They help explain why increasing resources alone, rarely improves programs. Existing policies and programs need to be responsive to new evidence. But before that can happen, someone has to make the case for revising existing policies, funding contracts and evaluation frameworks, and to encourage the adoption of the new principles and practices.

Such a case is urgently needed in Australia because the widely established national network of Disability Employment Services (DES) appears slow to embrace more effective practices. Although DES program administrators endorse the need for improved services and better outcomes, the actual policy settings for provider funding and performance evaluation remain unchanged and continue to discourage highly individualised and intensive forms of assistance (Waghorn, 2012a; 2012b). This status quo continues despite the findings of two parliamentary inquiries that IPS services should be more actively supported in Australia (Family and Community Development Committee, 2012; Standing Committee on Education and Employment, 2012).

Harvey et al. (2013) summarise recent efforts to trial IPS in Australia and in New Zealand and specify some of the translational difficulties from a mental health service perspective. They appropriately recommend that mental health services lobby and work closely with Federal and State policy makers and potentially with the many disability employment service providers. This recommendation represents the sincerity, willingness and leadership now being shown by the Australian public mental health sector. Mental health services and some DES providers are keen to initiate partnerships to develop more effective and coordinated services. Unfortunately, this enthusiasm does not appear to be reciprocated by DES program administrators.

Hence, it is no surprise that performance for this client group within DES is declining (DEEWR, 2012) and is less than half that expected for a good fidelity IPS program (Bond et al., 2012). One important policy conflict is the failure of current funding contracts to encourage intensive services to volunteer clients with severe and persistent mental illnesses. Owing to the payment of quarterly service fees in addition to payments for program commencement and employment milestones, providers are paid for keeping clients on the books (Waghorn, 2012a, 2012b). This works as a financial disincentive to adopting the intensive and individualised IPS services, which are only possible when caseloads are capped at 25 or fewer active clients per employment specialist (Sainsbury Centre for Mental Health, 2009). The DES performance evaluation framework (DEEWR, 2012) fails to counter this disincentive because it lacks the program logic, transparency, and focus on a single high-value outcome (Waghorn, 2012a, 2012b) for clients with this disability type. Hence, it is possible to be a low-performing provider to this client group by international standards, yet be considered by DEEWR to be a high-performing DES provider.

Other policy conflicts could make a difference if resolved. There are difficulties getting clients through the complex and unreliable program entry and funding level classifications in a timely manner. Challenging inappropriate client classifications is possible but can take several additional weeks. The inconsistency of outcomes and total time involved impacts on the IPS principles of zero-exclusion and rapid program commencement. There are also strict rules about the minimum hours that clients must work per week (8 hours for a job to count), and rules about gaps in employment, which, if exceeded, restart the job duration clock for 13- and 26-week milestone payments. This discourages the acceptance of clients with initial goals of less than 8 hours per week, or those who may need sick leave breaks that exceed the allowable gap in employment.

Another issue is the tendency for services to select only the clients they think will be successful, or who will require less assistance to succeed. This is known as ‘creaming’ or ‘cherry picking’ and is recognised as a long-standing problem in this industry. In theory, refusing clients is now officially discouraged. All referrals (including volunteers) are recorded and acceptance rates are monitored. However, in practice, it remains easy to discourage less attractive applicants by not sharing their enthusiasm or expectations for success, or by subtly sending the message that the service is not that interested. This can lead applicants to lose hope and miss subsequent appointments. Non-attendance can then be attributed to the client and not to the real cause – namely, purposeful selection by the provider.

In summary, IPS is an example of an effective program that can be accommodated by Australian Disability Employment Service policy. The failure to remove policy conflicts with respect to IPS principles represents missed opportunities to: (1) potentially double employment commencement outcomes for clients with severe mental illness; (2) potentially halve the costs of employment service delivery; and (3) demonstrate how Australian public policy can be responsive to science and evidence.