Policy barriers to evidence-based practices in vocational rehabilitation for people with psychiatric disabilities in New Zealand

2.1 Data search

Data searching began by reviewing summary reports from January to December 2016 from well-known national surveys conducted by Statistics NZ and two other government departments. These surveys were: the NZ Mental Health Survey [18]; the NZ Health Survey [19]; and the NZ Disability Labour Force Survey [20]. The publicly accessible data files from the NZ Household Labour Force [21] and the Disability Labour Force surveys [22] were also examined. In addition, the Google scholar database was searched using the terms labor force, employment, unemployment; combined with psychiatric disability, disability, or mental illness; and New Zealand, to identify any relevant published peer-reviewedliterature.

Next, information was sought about the availability of evidence-based practices in vocational rehabilitation for people with psychiatric disabilities, and the different ways these practices are purchased in NZ. This step was facilitated by an unpublished survey of employment support providers in the NZ mental health sector conducted in 2014 [23]. The 20 government providers of mental health services who participated in the 2014 survey were contacted. Each organization was asked about current evidence-based practices in vocational rehabilitation, and if relevant, asked to provide copies of documents such as vocational rehabilitation funding contracts, employment service evaluation reports, and staff trainingpolicies.

The wider social and economic policy context was systematically explored to assess whether it supports or hinders the availability of evidence-based practices in vocational rehabilitation. Over a two-year period from March 2015 to March 2017, the first author consulted with leaders in the field using a snowball sampling method [24]. This step also involved contacting government advisors from the health, welfare, and disability agencies, and staff of Statistics NZ responsible for the disability labor force survey. Government department websites were searched for relevant population level social and economic statistics; health, disability, and welfare strategies, or policy documents during the period January 2016 to January 2017. The most applicable government websites were: The Ministries of Health; Social Development; Business, Innovation and Employment; the Office for Disability Issues; the NZ Treasury; andStatistics NZ.

To obtain copies of vocational rehabilitation contracts, contract managers from the Ministry of Health, the Ministry of Social Development, and the non-government providers of IPS were contacted. Specific policy and contractual documents were sought that were relevant to the delivery of vocational rehabilitation services for people with psychiatric disabilities.

2.2 Data analysis

Labor force surveys were examined for information about relevant sub-populations, such as all NZ residents of working age, working age adults using mental health services, and disabled residents versus non-disabled residents. Information about labor force activity was considered relevant if based on internationally agreed definitions of labor force activity where three mutually exclusive categories apply: not in the labor force (either not available for or not seeking employment), unemployed (both available for and seeking employment), and currently employed according to a specific definition of employment [25].

Evidence-based practices were considered available if one or more of the following criteria were met by the evidence sourced: the funding contract required that IPS programs were being purchased, an assessment of IPS practices conducted in the last five years had found evidence-based practices were being provided, or the employment provider demonstrated a commitment to training staff to deliver evidence-based practices in vocational rehabilitation for people with psychiatric disabilities. Evidence sourced from all 20 health regions of NZ were mapped against these criteria.

To assess the impact of NZ’s social and economic policy settings an analysis was conducted in three parts. Namely: i) describing relevant features of the NZ social and economic context including profiles of adults receiving welfare benefits by payment types; ii) examining health, welfare and disability policies to identify references to evidence-based practices in vocational rehabilitation for people with psychiatric disabilities; and iii) evaluating the strengths and limitations of vocational rehabilitation contracts for providers targeting people with psychiatric disabilities while intending to apply evidence-based principles. Relevant government policies were considered current if published in the past 10 years and if they remained the most recent version available. The vocational rehabilitation contracts were evaluated in relation to whether they helped or hindered the implementation of the eight IPS principles [12: p. 33-39].

2.3 Data synthesis

The aim of data synthesis was to collect the general and specific implications for the availability of evidence-based practices in vocational rehabilitation for people with psychiatric disabilities (see Fig. 1). The need for such a synthesis is supported by the “Recommendations of the Council of Integrated Mental Health, Skills and Work Policy” [26]. These recommendations encourage the NZ government to develop policy in relation to employment and mental health. The latest recommendations highlight the need for concerted action in health policy, labor market policy and social policy. New policies are considered needed for: a more integrated approach to mental health and people of working-age; introducing employment outcomes into the health system’s quality and outcomes frameworks; and for more responsive social welfare systems that stimulate co-operation between employment services and the health sector [26].

OPEN IN VIEWER

Fig.1

The steps taken in data search, data analysis, and the synthesis of findings. Notes: 1. EBPs = evidence-based practices; 2. VR = vocational rehabilitation; 3. NZ = New Zealand; 4. Labor force surveys (LFS) were examined for relevant sub-populations. Information was considered relevant if based on internationally agreed definitions of labor force activity [25]; 5. Documents searched were: the NZ Mental Health Survey [18]; the NZ Health Survey [19], the NZ Disability LFS [20], and a doctoral thesis [50], and data files from the NZ Household LFS [54], and the NZ Disability LFS [22]; 6. EBPs were considered available if one or more of the following criteria were met: the funding contract required that EBPs were being purchased, an assessment of program practices conducted in the last five years had found EBPs were being provided, or the employment provider demonstrated a commitment to training staff to deliver EBPs; 7. Documents sourced were: the NZ Disability Strategy [35], the report of the Welfare Working Group [36], the State Services Commission’s Better Public Services targets [37], the NZ Mental Health Strategy [38], the NZ Health Strategy [39, 40], and the Ministry of Social Development’s annual performance report, 2013 [30]; 8. Evaluated against the principles of IPS [12: p.33-39]; 9. Informed by the Recommendations of the Organisation for Economic Co-operation and Development, 2015 [27].

3.1 The need for evidence-based practices in vocational rehabilitation

Limited national information was found about labor force activity by diagnostic groups, by extent and severity of disabilities, or by use of public mental health services. This was because health data collections and surveys, either do not measure or do not report labor force activity. Welfare surveys and data sets also had low utility because they did not use internationally agreed terms to describe and classify psychiatric disorders and psychiatric disabilities. Internationally agreed terms are reported in the regularly updated series, the International Statistical Classification of Diseases and Related Health Problems [27]. While NZ has a national disability labor force survey, mental illnesses are not differentiated from other chronic health conditions which can also cause difficulties with social and occupational functioning (see Table 2). These are described in the labor force survey in more general ways as difficulties with communicating, socializing or in everyday activities such as employment [20].

These limitations hinder estimating the unmet need for evidence-based practices in vocational rehabilitation in NZ. Table 2 summarizes the relevant information extracted during the data and literature search. Until more NZ-specific information is available, targeting those most in need of evidence-based practices in vocational rehabilitation can be informed by findings from Australia and other comparable overseas studies (see Table 2).

An unpublished survey in 2014 [23] of employment support services in the NZ mental health sector, found that there was only one non-government employment provider aligning practices to the IPS method. This provider was delivering IPS in six of 20 District Health Board regions. Subsequent contact with these mental health and employment service providers revealed that in July 2017 IPS programs were being provided in seven of 20 District Health Board regions in NZ, and were about tocommence in two more regions.

From May 2015, an IPS technical assistance program supported the implementation of high fidelity IPS in two of these seven regions [28]. However, even in regions where IPS is available, it is not yet accessible by every eligible adult under the care of public mental health services. For example, in one region IPS is available via four adult community mental health teams but is not yet linked to three specialist teams, namely the mental health team for indigenous Māori people, for Pacific people, or the early intervention in psychosis service. This is because only four employment specialist positions are funded [28].

In another region, although a full-time employment specialist is integrated into each of the adult community mental health teams, three of these clinical teams have more than 70 clinicians per team. When employment specialists are assigned to very large community mental health teams, they spend additional time building relationships with clinicians to develop efficient referral pathways, and to coordinate employment services with clinical services. Integration depends on taking referrals from each clinician, and this is unlikely in very large teams, simply because not enough of the clinical team can have a shared caseload with the employment specialist. Further, only a small proportion of the clients will have access to best vocational assistance [28].

Regions of NZ where IPS is not yet available have access to other forms of supported employment that accept people with psychiatric disabilities. Although these employment services have some features in common with IPS supported employment [23], they do not offer vocational rehabilitation integrated with mental health treatment and care services. In other regions government and non-government organizations also provide alternative forms of vocational rehabilitation such as those based in shelteredworkshops and in business enterprises [23].

3.3 Relevant features of the New Zealand economic and social context

New Zealand has a developed and growing market economy, and a small, diverse and largely urbanized population (see Table 3). However, there is an ongoing economic disparity and social inequity between the indigenous Māori and non-Māori people. This is represented by lower proportions employed [29: p.1] and more Māori people on welfare benefits than expected compared to the general population [30: p.48]. There is also evidence that greater proportions of Māori people experience common mentaldisorders than non-Māori people [18, 31]. The dual disadvantages of indigenous status and poorer mental health may exacerbate overall labor force disadvantage, suggesting that this population subgroup may also need a tailored form of vocational rehabilitation.

As of 1 April 2017, the adult minimum wage was $NZ 15.75 per hour. The purchasing power parity of the NZD to the US Dollar (USD) was 1.47 in December 2015 [32], meaning that an equivalent minimum wage in the US would be $10.71 USD per hour. The NZ minimum wage applies to all adults aged 16 or more, unless specifically exempted. Exemptions for a person with a disability in certain circumstances were introduced in 1983. A person with a disability can be exempted if it is deemed that the person’s disability reduces their ability to work and to earn the minimum wage [33]. Consequently some alternative vocational rehabilitation programs appear to have utilized this exemption and do not pay the minimum wage. Hence, it is possible that this exemption has inadvertently supported non-evidence-based practices to continue to be purchased and provided.

NZ has the advantage of one single national parliamentary government uncomplicated by State or provincial governments. However, the disability, employment, and health services sectors operate under different government departments. Each department, or governing agency, can have different policy objectives, contracting methods, and different reporting requirements to different government Ministers. This creates a barrier to the implementation of evidence-based practices in vocational rehabilitation because people with psychiatric disabilities require an integrated policy and funding framework to ensure both their mental health and vocational needs are met in a coordinated way [2, 34]. Furthermore, service providers find it more challenging, time consuming, and therefore more costly, to deal with multiple government agencies when delivering a specialized employment service that to be effective, needs close coordination with mental health services [3].

Nevertheless, the relatively small number of interested government departments and agencies permitted an exhaustive search to be completed. This search identified seven key policy documents whose contents were analyzed for references to evidence-based practices in vocational rehabilitation for people with psychiatric disabilities. These documents were: the NZ Disability Strategy [35], the report of the Welfare Working Group [36], the State Services Commission’s Better Public Services targets [37], the Ministry of Social Development’s annual performance report, 2013 [30], the NZ Mental Health Strategy [38], and the NZ Health Strategy [39, 40].

3.5 Purchasing vocational rehabilitation in NZ

Vocational rehabilitation is currently purchased through several government agencies or departments. The Ministry of Social Development purchases and provides employment assistance and vocational rehabilitation services directly through its delivery arm, Work and Income New Zealand, as well as through activity-based and results-based contracts with non-government vocational rehabilitation providers. The Ministry of Health purchases health services via the 20 District Health Boards using activity-based contracts. District Health Boards provide vocational rehabilitation services in addition to the mandated hospital and community based clinical services. They may also contract non-government organizations (including specialist providers targeting Māori people) to deliver mental health services, including vocational rehabilitation programs. The Accident Compensation Corporation is another relevant government owned agency. It both directly provides and purchases vocational rehabilitation for people who are currently employed but not attending their workplace because of injuries, a definition which includes psychological injury.

This means that vocational rehabilitation programs for people with psychiatric disabilities can be purchased by three government departments or agencies, and by up to 20 District Health Boards, all of whom can have different primary objectives, different contracting methods, and may report to different government Ministers. Although this can benefit providers through not being reliant on a single contracting source, a more standardized contract would be more efficient to administer, provided it did not hinder any particular evidence-based practices and did not create gaps in services.

This analysis identifies six main policy challenges to the expansion of evidence-based vocational rehabilitation in NZ (see Table 5). Possible policy solutions are suggested which could form the basis of a planned cross-government approach to increasing the labor force participation of people with psychiatric disabilities.

4.1 Possible solutions

The new national disability strategy, with its accompanying outcomes framework and action plan provides an opportunity for policymakers to specify the particular needs of people with psychiatric disabilities and to prescribe the provision of evidence-based practices in vocational rehabilitation (see Table 5). The new health strategy [39, 40] focus on increasing access to evidence-based vocational rehabilitation is an important part of proposed reforms to improve health outcomes and reduce welfare dependence, but as yet return to work is not a core outcome and defining feature of effective health service delivery [26, 43]. This issue has also emerged in most developed countries. OECD countries agree to encourage social and economic inclusion, and may even measure it as a part of a suite of health outcome measures, but may not regard rehabilitation as a core responsibility of a health service [3, 34].

There is also the complicating issue of overlapping responsibilities among government departments, where it can be unclear which agency has the primary responsibility [34]. To promote better policy coordination and to increase translation of the national disability strategy’s aspirations into reality, health policy could broaden the scope of the definition of health services to encompass rehabilitation, defined as returning to productive roles in society and specify what proportion of the health budget needs allocating to rehabilitation and to vocational rehabilitation in particular (see Table 5).

4.2 Comparison with other developed countries

These policy and funding issues are not unique to NZ and are found in other developed countries when evidence-based vocational rehabilitation is first introduced. In the US, evidence-based vocational rehabilitation programs are funded through a complex blending of several State and Federal government sources, Medicaid and vocational rehabilitation payments [2]. Drake et al. [2] argue that to increase access to evidence-based vocational rehabilitation, a simple, nationally integrated funding stream is needed (p.1103).

Similar problems exist in England where IPS programs are purchased mainly by regional health and social care commissioning groups and local government [45]. A recent task force on the future of mental health in England recommended that in order to improve labor force participation of people with psychiatric disabilities, a joint unit for work and health should be established [46]. Further, that the current investment in generic employment assistance programs by the UK’s Department of Work and Pensions should be re-directed to employment programs targeted to people with psychiatric disabilities. The basis for this recommendation is that these health-led employment interventions were found to deliverbetter employment outcomes as well as improved health outcomes [46].

To support implementations in the US and parts of Europe, a national learning collaborative has been established to facilitate the expansion of evidence-based practices [47]. In the US, public mental health services and employment agencies participating in the collaborative sign business associate agreements that stipulate they will adopt the practices needed to support the integration of employment services [48]. In addition, some State funders offer payment to mental health services for time spent on program integration as well as time spent on formal reviews of the quality of the collaboration [48].

In Australia, there is a single national purchaser of disability employment services but only recently has the administering department moved to officially encourage the implementation of evidence-based approaches for psychiatric disability. In the meantime, disability employment services aware of the need for evidence-based practices are independently approaching mental health services to establish jointly administered and coordinated services. In some cases the impetus for change was initiated by the mental health service [17].

4.3 Limitations

This analysis used multiple methods to search for relevant data and policy documents [49]. While it is likely that search saturation was eventually reached this may be more attributable to the relatively small size of the country, and the small number of agencies involved, than due to a comprehensive a-priori strategy. In countries with multiple levels of government as well as multiple agencies, a more formal and structured survey of key stakeholders may be required. Snowball sampling was useful in this instance, and remains a useful method in more complex settings because it enables a wider search that can capture information which might otherwise be missed bynarrowly defined search criteria.