Chapter 4 Government and other service providers
We have moved away from thinking about tackling mental health
as a health problem to thinking of it as a whole-of-government problem.[1]
...a cross-government, cross-sectoral approach is now
well-recognised to much better support people with a mental illness to achieve
a whole variety of goals and to participate more fully in the community.[2]
...consumers who are working use services less because they
keep themselves well. They are motivated and they are busy.[3]
We have gone through changes and changes. We are a tired
industry. We want to go back and focus on the people we are supposed to be
working with and I think that is really getting lost and I think that makes all
the difference in our outcomes.[4]
Setting the scene: Commonwealth, state and territory responsibilities
4.1
In Australia, states and territories are responsible for the service
delivery of health and education. This chapter will focus primarily on what the
Commonwealth Government can do to encourage education, training and workforce
participation of people with mental ill-health because the Committee can only
effectively make recommendations to the federal government. States and
territories have their own approaches and programs through their respective
departments of health and community services, education, employment and
training.
4.2
Responsibility for the national mental health and welfare reforms, the building
the future workforce agenda, and the budgetary allocations that go with these (outlined
in chapter one) are shared across several Commonwealth departments and agencies.
These issues are no longer simply confined to the health and employment
portfolios.
4.3
When considering the key issues raised by stakeholders in respect of
government and other service providers, it is useful to outline the main
department and agency players at the federal level, to sketch out their portfolio
and program interests, and the various reviews and reforms they are undertaking.
4.4
The chapter will also draw on examples of best practice from the states
and territories that participated in the inquiry, and focus on how all government
instrumentalities including those of the Commonwealth, together with contracted
service providers, can help people with a mental illness participate more fully
in the workforce.
4.5
The Committee places on the record its appreciation of the participation
in the inquiry of government departments from the following states and
territories: South Australia, Queensland, Tasmania and the Northern Territory.
This evidence has helped to build a picture of service delivery across the
country.
Commonwealth Government
DEEWR, FaHCSIA and DoHA
4.6
The three Commonwealth Government departments responsible for the policy
areas directly relevant to the topic of mental health and workforce
participation are:
n the Department of
Education, Employment and Workforce Relations (DEEWR), responsible for national
education and employment policy as well as income support policy for working
age payments;
n the Department of Families,
Housing, Community Services and Indigenous Affairs (FaHCSIA), responsible for
national policy on disability benefits and the implementation of a number of
community based mental health initiatives and other targeted early intervention
services; and
n the Department of
Health and Ageing (DoHA), responsible for national policy and programs to
improve mental health outcomes, including through targeted prevention,
identification, early intervention and health care services.[5]
4.7
DEEWR is the lead agency for policy relating to disability and
employment. However, the joint submission from the three departments refers to
their contribution as part of a ‘cross-portfolio package to drive fundamental
system improvements’. Ms Fiona Buffinton, Group Manager, Specialist Employment
Services Group, DEEWR said that there is:
a greater integration of services and joint management of
these issues across government...A key feature [of the national plans and
programs] is that they are crossing boundaries between health, education,
family and workforce settings to address the critical issues that may impact on
an individual’s capacity to gain and maintain work. [6]
4.8
As mentioned in chapter one, the 2011-2012 budget contained a number of measures
to increase the workforce participation of people with mental illnesses. A
number of these are outlined in Section A of the joint submission. Key existing
programs are also outlined at Appendix A of that document.[7]
4.9
To summarise, recap, and provide a focus for this chapter, some of the relevant
initiatives under ‘national mental health reform’ include:
n an increase in
funding to headspace (Australia’s National Youth Mental Health Foundation) to expand
existing and establish new youth focused mental health services for young
Australians aged 12-25 years, providing for 30 current, 10 developing and a
further 50 headspace centres by 2014-2015;
n engaging states and
territories to share the cost of an additional 12 Early Psychosis Prevention
and Intervention Centres (EPPIC) – there are currently four- to offer a range
of community care services to keep people at home and out of hospital -to
assist some 11, 000 young Australians with or at risk of developing a psychosis
to access education and employment opportunities;
n expanding community
mental health services, including through the provision of 425 new personal
helpers and mentors. The Personal Helpers and Mentors Scheme (PHaMS) gives
practical one-on-one support to people with a severe mental illness for
everyday living and setting and achieving educational and employment outcomes.
As part of this expansion, up to 1200 people with mental illness on DSP will
have access to PHaMs services; and
n funds towards
building the capacity of employment service providers and Department of Human
Services (DHS) staff (i.e. Centrelink) to assist people with mental illness to
gain employment and better connect them to the appropriate services.[8]
4.10
In addition to these initiatives, the Government is encouraging
workforce participation through:
n the introduction of
participation requirements for DSP recipients under 35 who are identified as
having some work capacity; amending the DSP to allow all recipients to work up
to 30 hours a week continuously for 2 years and still remain eligible for a
part-time pension;
n targeted Disability
Employment Broker projects to link job seekers with a disability to employers;
improving assessments for DSP claimants who are required to undergo a Job
Capacity Assessment to ensure appropriate options for employment support and
income are provided to them;
n 20 Job Services
Australia demonstration pilots to serve up to 5000 highly disadvantaged job
seekers – including coordinating complementary services and joint-case
management;
n and an information
campaign to promote the benefits of employing people who have experienced
labour market disadvantage, such as those with mental illness and/or the very
long-term unemployed.[9]
4.11
Under ‘Building Australia’s Future Workforce’ there are programs to
improve apprenticeship opportunities and to increase access to the language,
literacy and numeracy program (LLNP).[10]
DHS (CRS Australia, Medicare and Centrelink)
4.12
The Department of Human Services (DHS) has carriage of service delivery
policy and provides access to social, health and other payments and services.
In 2011, the Human Services Legislation Amendment Act 2011 integrated
the services of CRS Australia, Medicare and Centrelink into the one department.[11]
It is perhaps worth emphasising that DHS is responsible for service delivery,
rather than the overarching policy framework for mental health and workforce
participation, which is DEEWR’s responsibility.
4.13
CRS Australia (formerly known as the Commonwealth Rehabilitation
Service) offers disability employment and assessment services to people with a
disability, injury or health condition, including people with a mental illness.
In addition to disability management and employment services, CRS Australia
delivers return-to -work programs and workplace rehabilitation and injury
prevention services:[12]
CRS is one of many disability management services
providers...we provide services across Australia from 180 offices and also from
a number of visiting services...We have a multidisciplinary workforce,
including around 1,100 allied health professionals (e.g. rehabilitation
counsellors, occupational therapists, social workers, psychologists, skilled at
working with people with disabilities, including mental illness).[13]
4.14
Medicare describes its role as delivering health and payment programs to
Australians. Those relevant to people with a mental illness include:
n the Mental Health
Nurse Incentive Program which funds community based general practices, private
psychiatric practices and other appropriate organisations to engage mental
health nurses to assist in the provision of coordinated clinical care for
people with severe mental health disorders; and
n administering
payments for General Practitioner Mental Health Care items, which provide a
structured framework for GPs to undertake early intervention, assessment and
management of patients with mental disorders. It also provides referral
pathways to clinical psychologists and allied mental health providers.[14]
4.15
Centrelink ‘assists people to become self-sufficient and supports those
in need.’ The Centrelink program:
delivers a range of payments and services for retirees, the
unemployed, families, carers, parents, people with disabilities [including
people with a mental illness], Indigenous Australians and people from diverse
cultural and linguistic backgrounds, and provides services at times of major
change.[15]
Service delivery mechanisms for job seekers with a mental illness – JSA and
DES
4.16
In July 2009 new employment services were introduced to replace the previous
national employment service called Job Network Services. Job Services Australia
(JSA) is the Commonwealth Government’s new national employment service:
For job seekers, it provides personalised help to find and
keep a job...For employers, JSA provides a free service to help find staff to
meet their business needs.[16]
4.17
The Government (through DEEWR) contracts a mix of small, medium and
large, for-profit and not-for-profit organisations to provide employment services
in more than 2,000 locations across Australia.[17]
4.18
JSA providers work with job seekers to develop an Employment Pathway
Plan, which maps out the training, work experience and additional assistance
needed to help them people find sustainable employment.[18]
4.19
JSA providers are able to access an Employment Pathway Fund (EPF) to
purchase assistance in line with the individual job seeker’s needs including
training courses, travel assistance, work equipment and specialist counselling
services.[19]
4.20
JSA delivers employment services under four main service streams:
The streams reflect the level of disadvantage faced by
individual job seekers, with the least disadvantaged receiving services under
Stream 1 and job seekers with severe disadvantage, including non-vocational
barriers (like homelessness and drug and alcohol dependencies) serviced under
Stream 4.[20]
4.21
Disability Employment Services (DES) was introduced in March 2010 and is
a complementary specialist employment service for job seekers with a
disability, injury or health condition. Ms Buffinton, Group Manager, Disability
Employment Services Group, DEEWR elaborated on the services that DES offers:
As part of the whole new Disability Employment Services there
is a much broader package of support and information. One of the excellent
services is the Job Access Service, which is first and foremost a telephone
support service. In the last budget that was expanded to include people with
mental illness backgrounds and psychologists who can recommend and give support
in physical environments where people can get workplace modifications. An
example with mental illness would be that, before somebody goes into an
environment, mental health first aid courses are provided in the workplace so
that people are open and welcoming to people with mental illness rather than it
being something that is silent or that people feel awkward about and do not
know how to cope with.[21]
4.22
Like JSA providers, DES providers are contracted by DEEWR to provide employment
assistance, but specifically for people with a disability, including those with
a mental illness. There are 1,900 DES providers across Australia.[22]
The national network comprises public, community and private organisations.
4.23
DES consists of two components:
Disability Management Service (DMS)– provides help to
people with disability, injury or health condition who require the assistance
of a disability employment service and are not expected to need long-term or
regular support in the workplace; and
Employment Support Service (ESS) – assists people with
permanent disability who are likely to need regular long-term ongoing support
in order to retain their job.[23]
4.24
Under DES all eligible job seekers are able to receive an individually
tailored program of assistance from their DES provider to help them prepare
for, find and keep a job. DES providers seek to overcome vocational and
non-vocational barriers to employment for their clients and offer various
education, training and skills development opportunities.[24]
In addition to the Job Access Service described above, DES supports include the
wage subsidy scheme and the supported wage system (these supports have already
been outlined in some detail in chapter three).
New participation requirements for DSP recipients
4.25
As of 1 July 2012, new participation requirements will come into being
for DSP recipients, under the age of 35 and classified as having some work
capacity. DSP recipients who are assessed as able to work 8 or more hours a
week will be required to attend regular participation interviews with
Centrelink to get advice on the impact of employment on their benefit, and the
programs and supports available to help them find and keep a job. DSP
recipients may also volunteer to be referred to JSA or DES providers. DSP
recipients classified as being able to work 15+ hours a week will be required
to look for work and be connected to an employment services provider. [25]
4.26
The participation requirements for DSP recipients are determined
according to someone’s assessed work capacity, as below:
n 0-7 hours per week –
job seekers are not required to look for work but can volunteer to connect with
an employment services provider;
n 8-14 hours per week –
job seekers are not required to look for work but can volunteer to connect with
an employment services provider. To meet their participation requirements
[these] job seekers with a partial capacity of 0-14 hours must attend a
quarterly interview with Centrelink unless they are meeting requirements
through paid work;
n 15-22 hours per week
– job seekers will be required to look for work or undertake work of 15-22
hours per week and be connected to an employment services provider. They may be
required to accept an offer of paid work, provided the work is suitable;
n 23-29 hours per week
– job seekers will be required to look for work or undertake work of 23-29
hours per week and be connected with an employment services provider.[26]
Fear of losing DSP and health entitlements
4.27
The fear of losing access to the DSP and its associated benefits,
including access to a pensioner card (which discounts the sometimes expensive
medications for some mental illnesses) is a paramount concern that DSP
recipients have about seeking and securing employment, beyond the now
permissible 30 hours a week. Anglicare Tasmania summarised:
A barrier to seeking paid employment is the risk people face
of losing their DSP – and the fear of relapsing into an episode of mental
illness without any income at all.
It is a deterrent for people to do 20/30 or more hours
employment as they lose their DSP, housing rental goes up to full market rental
and there is not much extra money per week for their contribution.[27]
4.28
Mr Dale Campbell, Chief Executive Officer, Top End Association for Mental
Health, TEAMHealth agreed:
Many welfare recipients will find themselves in a situation
where they are reluctant to accept more than a minimal amount of paid work for
fear of losing benefits...In some cases they can be materially worse off
through losing benefits such as free transport, rent assistance and the like, while
at the same time incurring additional costs such as transport, work clothing
and things of that nature.[28]
4.29
The Welfare Rights Centre corroborated this sentiment:
People with mental health issues...are insecure about
engaging in the workforce due to the episodic nature of their condition. The
DSP is a safe option, not least because it provides recipients with a Pensioner
Concession Card that makes medications much more affordable.[29]
4.30
A DSP recipient described the predicament consumers face:
I don’t want to lose my Health Care Card when I earn too much
money. Medication is very expensive.[30]
4.31
Mrs Melissa Williams, Manager, Gold Coast Employment Services also spoke
to concerns families have for their loved ones about the prospect of
unaffordable medication:
Families are often very hesitant for their young person
because they are on four or five medications and if they lose their DSP or
their concession card they will jump from $5.50 a script to $35 a script and
they may have six.[31]
4.32
Open Minds similarly observed that the fear of losing welfare
entitlements and other health benefits are ‘primary reasons why people on the
DSP do not participate in training, education or employment.’[32]
4.33
The National Employment Services Association (NESA) referred to a DSP
Pilot Project undertaken by NESA providers that confirmed people perceived
changed arrangements to the DSP as a potential threat, and they felt daunted by
the prospect of having to reapply for the DSP should they become unwell and
unable to work again:
The risk of not being eligible for DSP under changed
arrangements was not generally high but seen as a major risk and deterrent to
participation which was often fed by headlines about the Government getting
tough on welfare.[33]
4.34
There certainly appears some confusion about the rules and requirements
surrounding the DSP benefit, its associated health care card, the work hours
permissible and participation requirements alike. On the allowable work hours
issue, Ms Heywood from TEAMHealth stated:
I think that is a key issue...it is about educating the
community and people so they understand that process.[34]
4.35
NESA underscored how important it is to reassure recipients that a
safety net exists should a job not work out and they will not be worse off for
venturing into employment.[35]
4.36
Orygen Youth Health proposed increasing the safety net effect saying:
Consideration should be given to easing return to the DSP
over a period of time after employment is commenced...We suggest that
consideration is given to preserving some of the benefits of the DSP such as
concessions on transport and utility bills for a period after employment
commences to ease the transition to employment.[36]
4.37
In fact, DSP recipients do not automatically lose their benefit and
health care card once they get a job: rather, it is a sliding scale. Essentially,
work can be trialled and someone’s DSP status maintained for a period of two
years. Ms Melissa Lond, National Manager, Mental Health, Disability and Carers,
from DHS explained:
We need to help people understand that they can test their
workability and that there are a lot of mechanisms to support them to do that,
but there are also safety nets if it does not turn out to be sustainable
employment. There has been a provision in the DSP legislation, since the
payment was introduced, for suspension rather than a cancellation of the
pension if a person attempts to return to work. If for whatever reason, they
are not able to maintain that employment within a two year period they can have
their pension restored without needing to go through the full assessment
procedure again.[37]
4.38
The Centrelink website alludes to the sliding scale:
The number of hours you can work and still receive DSP varies
according to when you were granted the pension. If you work more than your
allowable hours per week the DSP will not immediately be cancelled, it will be
suspended for two years. This means if you find your job too difficult because
of your disability or you need to reduce your hours of work in those two years,
you can access DSP again without the need to prove your eligibility. Access to
your Pensioner Concession Card continues for 12 months from the date your DSP
is suspended.[38]
4.39
The joint department submission stated that all DSP recipients will soon
be allowed to work up to 30 hours per week (as of 1 July 2012) – up from the 15
hours a week that was previously allowed:
DSP recipients granted on or after 11 May 2005 will be able
to work up to 30 hours a week continuously for two years and remain eligible
for part pension. This will allow recipients to maximise their working hours
without the suspension of their DSP entitlement. DSP recipients will still be
subject to the application of the income test. The purpose of this measure is
to remove a disincentive for DSP recipients to participate in the workforce and
address the inconsistent treatment of people granted DSP before or after May
2005. Note: people granted DSP before 11 May 2005 are already allowed to
work up to 30 hours a week and remain eligible for a part pension.[39]
4.40
On the health care card issue, Ms Lawson of the Welfare Rights Centre
said that people need to know that there is a low-income health care card available
[as an alternative to the pension card, should clients not be eligible for
that].[40] Ms Lawson suggested ways
to disseminate that message:
Centrelink could advertise it more or provide information to
people who are leaving the DSP after a review or after a year in employment
when their pension card runs out. That information could be sent to them to let
them know about it. We also think there is a greater issue of education and
training for the community sector and the public mental health sectors.[41]
4.41
The Committee agrees that a communications strategy that effectively conveys
these messages to all stakeholders is important, and will examine this further
on in the chapter.
4.42
The Committee notes an apparent widespread misunderstanding about or
lack of knowledge by DSP recipients of the mechanisms available to help people
to transition off the DSP into employment.
Complex unwieldy bureaucracy
4.43
Consumers, consumer advocacy groups and employment service providers repeatedly
referred to the difficulties that consumers face navigating their way through a
complex social welfare system. Consumers spoke of having to ‘explain their
story’ time and time again to bureaucrats and suggested that employment and
social services should be better integrated, with any changes to consumers’
benefit or pension entitlements more effectively communicated to them.[42]
4.44
Ms Gail Middleton, Executive Director of Welfare Rights Centre described
the Centrelink system as ‘extremely complex’:
The eligibility criteria are just becoming quite unbearable.
I have worked in this industry now for 25 years and we have gone from a chart
telling us what a person is entitled to, to booklets.[43]
4.45
Ms Georgina Lawson, Project and Research Officer, Welfare Rights
observed that changes to the pension rules, including the new participation
requirements, are but one example of change that can confound consumers and
service providers alike:
If we look at those new rules, you now have new and old rules
for people in terms of their participation requirements. You have got different
requirements depending on the person’s date of birth and, come 1 January, you
are going to have new and old rules in relation to an impairment table that is
used for your reviews. There is a lot more to it than that, so the general
community, the general recipient and many Centrelink officers do not know, and
cannot be expected to know, all that information that is governed within those
five common pieces of legislation that they use to determine someone’s
eligibility and entitlements, plus all the other policies that are used. We
have created a monster in terms of the social security system and we have not
matched that with any safeguards or quality information which is targeted
towards the recipients and those who actually work with our recipients.[44]
4.46
Ms Emma Cotterill, Acting Director, Social Support, Commonwealth
Ombudsman, referred to a system that is experiencing a high level of flux, and
the subsequent scope for causing confusion:
...with there being so many changes on the table [with DSP]
possibly means that things like the threshold for the number of hours that you
can work without losing your entitlement possibly gets lost in the mix. The
fact that the impairment tables are sort of up for review, the fact that there
are other issues around people who are under 35 now potentially being asked to
engage in participation where they previously have not been when they only have
an eight hour capacity, I think it all mixes together and creates a lot of
uncertainty about, ‘Well, yes I understand the 30-hour rule but what if I lose
it under the impairment tables?’ There are too many things to juggle
potentially that mean people will get confused and might understand one message
but not the others.[45]
4.47
Mr Adam Stankevicius, Senior Assistant Ombudsman, Commonwealth Ombudsman
spoke to the complaints his office receives. These highlight the fact that
benefit recipients are not always clear about their obligations, nor are the
explanations proffered by Centrelink always helpful:
I think there is a whole series of tapers and thresholds in
the social security system which confuses a lot of people. It happens in the
youth allowance area as well as the DSP area and parenting areas where people
are unsure about what threshold they meet and, if they go over the
threshold...periodically, and they come back what impact does that have? We see
a lot of complaints...they come to us because they have tried to go to
Centrelink to get an explanation as to how it arose. The explanation is
incredibly complex....and the response back from Centrelink has not made much
sense.[46]
4.48
The Ombudsman also referred to Centrelink’s correspondence as being
problematic:
They are usually quite good if they are about a single issue
but once they are going to two or three issues they become a mish-mash because
they are all automatically generated rather than individually generated.[47]
4.49
Mrs Hildred Kivelitz, Mental Health Coordinator, Carers, NT, described
bureaucratic hurdles and the ensuing anxiety and stress that her clients
experience when attempting to navigate the systems of Centrelink, service
providers and other agencies. She relayed one man’s story:
Every time he received a letter from Centrelink his anxiety
increased to a level of nausea and feeling physically paralysed. [48]
4.50
Ms Cherie Jolly, delegate of member organisation, Uniting Care Wesley
Port Adelaide, Disability Employment Australia pointed to the toll that various
assessment processes can place on people with a mental illness, especially when
they need to be re-referred and reclassified:
...inaccuracy of referrals...puts people back through a
system. They end up going back to Centrelink in stream 3 or 4, come back to us
and fall out the system very disillusioned.[49]
4.51
Mrs Melissa Williams, Manager, Gold Coast Employment Services raised the
issues of an increasing administrative burden on her staff of ever new
guidelines, the difficulties of trying to always connect with the right person
at Centrelink, and systems compatibility:
Do you know where my training dollar goes now? On red tape –
how to use this computer system, how we do that. It is not going on : how do
we support this person with this diagnosis? It has just grown and grown. I am
losing staff. I have just had a resignation today from somebody that basically
just got to to the starting point, and they have just said, ‘I love the job but
I do not want all that.’ So it is starting to impact.[50]
You spend half your life looking up guidelines and
cross-referencing. I guess it is an administrative burden on Centrelink and the
department but trying to even find the right person you are supposed to access
is a nightmare due to the protocols on who to ring for help. It all takes my
workers away. Because we cannot link the online diary that we have to use with
our Outlook diaries, they are running two diaries all the time.[51]
4.52
Ms Buffinton from DEEWR acknowledged the issues regarding systems
incompatibility, but countered:
Over time, out IT systems will work better so we can flag if
somebody has a concern. Service delivery will perform more broadly a
wrap-around service. In the past we have had very different systems, but as we
get better, if there is either somebody from the government or one of the
employment services who has a concern, we will be able to flag concerns.[52]
4.53
As the next few sections will attest, the Committee can certainly appreciate
how difficult it is for an outsider to get a handle on how all the elements of
the employment and social services systems work and fit together. This could be
even more difficult for someone with a vulnerability, including suffering from
a mental illness.
Assessment and referral pathways
4.54
Figure 4.0 below shows how a job seeker is processed: assessed and
referred on to generalist (streams 1 through 4 of JSA) or specialist employment
services (DES).
Figure 4.0 Centrelink pathway (JSA Provider)
![flow chart showing how a job seeker is processed by Centrelink](https://aphref.aph.gov.au/House/committee/ee/mentalhealth/report/chapter4_files/image001.jpg)
Source DEEWR
presentation on job seeker registration and assessment
NB ADE
= Australian Disability Enterprises
No
benefit = someone who is assessed as having 0-7 hours work capacity and
therefore not required to look for work.
4.55
The first assessment tool that someone encounters when registering as a
job seeker with Centrelink is the Job Seeker Classification Instrument.
Job Seeker Classification Instrument
4.56
DEEWR is responsible for the administration of the Job Seeker
Classification Instrument (JSCI). DEEWR describes the JSCI as:
an objective measure of a job seeker’s relative labour market
disadvantage based on his/her individual circumstances. These individual
circumstances are assessed using a job seeker’s answers to the JSCI
questionnaire plus other information known to influence employment prospects.
The JSCI is designed to identify job seekers who, because of
their individual circumstances, are likely to become long-term job seekers.[53]
4.57
Centrelink describes the JSCI as the tool they use to determine what
employment assistance a person is eligible for. The JSCI consists of:
a series of questions aimed at identifying what barriers you
face entering the workforce. The JSCI is not intended to provide an individual
assessment of your needs.[54]
4.58
DEEWR says that the JSCI determines the stream of services a job seeker
is eligible for and/or whether further assessment is required though the
completion of an employment service assessment:
The key components of the JSCI are the factors (including
sub-factors), questions, score and identification of the possible need for
Employment Services Assessment (ESAt).
The JSCI process involves collecting information about the
factors using questions and other information derived from existing
administrative data on the job seeker, to calculate a score used to determine a
job seeker’s eligibility for Streams 1, 2 or 3.
Through specific responses to JSCI questions, the JSCI
process may also identify the need for further assessment through an ESAt. The
job seeker’s eligibility for Stream 4 or DES is determined by the outcome
of the ESAt.
Where the ESAt recommendation is for Stream 1 to 3, the
outcome of the ESAt finalises the JSCI score and determines eligibility for the
appropriate Stream.[55]
Employment Service Assessments and Job Capacity Assessments
4.59
If a client is considered to require further assessment (that is they
are not automatically allocated to streams one through three) they undertake an
Employment Services Assessment (ESA or ESat):
An Employment Services Assessment is conducted for disadvantaged
job seekers identified as requiring further assessment of the impact of
barriers on their capacity to participate in work or employment services.
There will be two types of ESAts from 1 July 2011. These are
n Medical condition
ESAt – An assessment of the job seeker’s circumstances to determine work
capacity and the most appropriate employment service, where one or more medical
conditions are identified. ESAts are similar to the previous Job Capacity
Assessments (JCAs) for potentially highly disadvantaged job seekers with
disability, injury or illness. In a Medical condition ESAt the assessor must
rely on the available medical evidence; and
n Non-medical condition
ESAt – An assessment of the job seeker’s circumstances that determines the most
appropriate employment service, where no medical condition is identified — for
example, a young person at serious risk of homelessness. A non–medical
condition ESAt is normally less complex than an ESAt for a job seeker with
disability, injury or illness, and will be streamlined to meet the individual’s
needs.
Wherever feasible, an ESAt will be conducted through a face
to face interview. Where a face to face assessment is impractical for the job
seeker (for example, due to geographic isolation or extreme weather conditions)
or the job seeker has a medical condition or barrier which restricts them from
attending a face to face interview, a video or phone assessment will be
arranged.[56]
Eligibility for Stream 4 and Disability Employment Services
(DES) is determined through an ESAt (for job seekers) or a JCA (for customers
making claims for the Disability Support Pension).[57]
4.60
It appears that someone applying to go on the DSP must undertake a Job
Capacity Assessment (JCA), rather than an ESat. Yet, a different part of the
DEEWR website says that the Job Capacity Assessment program ceased on 30 June
2011.[58]
4.61
The Centrelink website states that it, or an employment service
provider, will refer you for a JCA if you are applying for, or are on already
on the DSP.[59]
4.62
The FaHCSIA website confirms:
A JCA is a comprehensive assessment of an individual's level of
functional impairment and work capacity, usually conducted to determine
qualification for DSP. The assessment identifies a person's:
n level of
functional impairment resulting from any permanent medical conditions,
n current
and future work capacity (in hour bandwidths), and
n barriers
to finding and maintaining employment and any interventions/assistance that may
be required to help improve their current work capacity.
A JCA can result in referral of a person to employment or
support services that meet their individual needs, including JSA providers and DES providers.
As part of the assessment process, assessors have access to relevant
available information about the person, including current and past
medical/disability details, and prior participation and employment history.
Assessors can also liaise with treating doctors and other relevant health
professionals as required.
The JCA report is used by Centrelink to inform decisions on
income support and participation requirements if applicable. A copy of the JCA
report (not including impairment information) is also made available to the
person's employment services provider.
Generally, a JCA will remain current and valid for 2
years unless there is a significant change to a person's circumstances that
affects their level of functional impairment and work capacity.[60]
4.63
The DEEWR website indicates that employment service providers can refer
Stream 4 or DES job seekers for an ESAt in the event of any significant changes
to that job seeker’s circumstances that affects their work capacity/and or
employment assistance needs.[61]
4.64
Ms Buffinton from DEEWR clarified:
ESA are the general assessment for employment. Those with
a more complex case or those potentially for disability pension requirements
are still known as job capacity assessments. These are carried out by allied
health professionals.[62]
4.65
Ms Buffinton alluded to changes that have brought employment services
assessment back into to her department, DEEWR:
Prior to 1 July [2011] there was a range of 18 providers.
About 60 per cent of them were carried out by Centrelink and CRS Australia with
the remainder carried out by another 16 providers, one government and the
remainder private.[63]
4.66
The DEEWR website says:
All ESAts are [now] conducted by qualified health and allied
health professionals, such as a Psychologists and Registered Nurses employed by
a single Government Provider under the Department of Human Services portfolio.[64]
4.67
Ms Buffinton emphasised that both JCA and ESAts are intended to build up
a comprehensive picture of the person and their personal situation:
The JCA or an ESA is not there as a diagnostic tool. It is
there to work with a diagnosis that has come through from a health professional
like a psychiatrist. These are trained allied health professionals. It is to
see what the diagnosis is, but they are also trained in a much more holistic
engagement of the person. Firstly, they are not doing a point in time of how a
person appears at that moment in time during the discussion. They are taking a
whole range of information [into account].[65]
Referral to DES
4.68
Figure 4.1 below shows how, following a job capacity assessment, clients
are referred to or back to Centrelink (depending on whether they enter the
system at a DES provider or Centrelink office level– most will enter via
Centrelink), and are then referred on to a DES provider.
Figure 4.1 Pathways to DES
![flow chart showing pathways to a DES provider](https://aphref.aph.gov.au/House/committee/ee/mentalhealth/report/chapter4_files/image002.jpg)
Source Evaluation
of Disability Employment Services Interim Report, Reissue March 2012
Impairment Tables
4.69
There is another form of assessment that anyone applying for or on the
DSP is subject to.
4.70
Eligibility for the DSP pension, in the first instance, is determined
according to an impairment rating:
As part of the qualification for DSP a person must have one
or more physical, intellectual or psychiatric impairments that attract a total
impairment rating of 20 points or more under the Impairment Tables.
Note: A claimant who has a total impairment rating of
at least 20 points, must also have a CITW (continuing inability to work) to
qualify for DSP.
Explanation: Some claimants may have an impairment rating of
at least 20 points but do not have a CITW because they can work full-time where
wages are at or below the minimum working wage or be re-skilled for such work
within 2 years. [66]
4.71
The impairment rating has nothing to do with the referral process to
employment services per se, but is mentioned here in the assessment section as
another form of assessment a job seeker with a mental illness must undertake.
Like other elements of the system, it too has been the subject of a recent
review.
4.72
As a result, the tables have been modernised:
Last year the Australian Government commissioned an expert
Advisory Committee to review the tables and recommend revisions that are up to
date with contemporary medical and rehabilitative practices...The report finds
that the current Impairment Tables are out of date and contain anomalies and
inconsistencies which have distorted the assessment process.
The Advisory Committee has developed revised impairment tables...that,
for the first time, include explicit guidelines about the impact of episodic or
fluctuating conditions, such as some mental health conditions. This will help
ensure assessments of eligibility for DSP for people with episodic conditions
are fairer and more consistent than under the current tables.[67]
4.73
FaHCSIA says that the Tables now support a greater focus on functional
ability and what people can do, rather than what they cannot do:
For example, under the old Tables, ratings for some
conditions such as back conditions were based on loss of movement. Under
the revised Tables, ratings will be based on what the back condition prevents a
person from doing.
The old Impairment Tables contained anomalies and
inconsistencies which distorted the assessment process.
For example, under the old Tables when hearing impairment was
assessed, a person with a hearing aid was not required to wear it, but someone
who was having their sight impairment assessed had to wear their glasses.
Under the revised Tables, people will be assessed when using or wearing any
aids or equipment that they have and usually use.[68]
Problems with assessment and referral processes
4.74
In addition to the issues raised earlier, namely confusion about the new
DSP participation rules, and Centrelink and the employment services’ inherent complexities,
the following areas of assessment and referral procedures were identified as
further inhibiting participation of users of services: delays in processing;
inappropriate assessments; and the re-referral process.
Delays in processing
4.75
Orygen Youth Health referred to lengthy assessment processes, as ‘the
de-motivation period’ for clients who present to employment agencies wanting a
job. Orygen said that assessment processes must be truncated in order to better
engage the job seeker:
Clients have expressed frustration at the long period of
assessment they must undergo before initiating job-seeking. This assessment
period can be up to two months in which time no job searching is done.[69]
this period must be substantially reduced to provide optimum support
and encouragement to young people with mental illnesses in their job seeking...everything
possible must be done to make the job searching process easy to access and
quick to produce results.[70]
4.76
The Evaluation of DES Interim Report- Reissue March 2012
acknowledges that assessment delays are an issue:
Streamlined access is another area for attention. The key
indicator, the number of days from referral to commencement shows that on
average job seekers are taking longer to commence service than under the previous
programs.[71]
4.77
Ms Buffinton from DEEWR pointed to some of the reasons for delays,
including people not presenting with all the necessary information or
documentation in order to progress their assessment process.[72]
4.78
She also suggested that specialist disability employment services, by
their nature, are more time intensive:
The whole notion of DES is that it might not be that the
instant you arrive you immediately get a job placement: it is a matter of what
the employment service can do to value add. They will look at the barriers-if
you have homelessness issues, if you have anger management issues, if you have
a whole range of issues – and how you deal with those things and support you to
be job ready so that when you connect with the employer, you match up very
well.[73]
4.79
Further, baseline work is often required, necessitating a stepping
approach. She elaborated:
When a person’s assessment is made, because the disability
employment services work on the basis that this could be up to two years
support, we do not necessarily expect that when you come into the employment
services in month one you are out getting employment.
...before you even start getting employment outcomes there is
a lot of baseline work done with the person, particularly in the case of mental
illness, so that when the assessment is given the assessment is the potential
work capacity of this person with intervention.[74]
4.80
The Committee is of the view that the assessment process should be
expedited as quickly as possible with a view to engaging the job seeker as soon
as practicably possible in the job search and job placement process or
connecting them to further education and training.
4.81
To streamline the various assessment processes, DEEWR, Centrelink and
employment services providers (JSA and DES) should work together to ensure that
the assessment criteria for and requirements of job seekers with a mental
illness are compatible and consistent across the services.
Recommendation 10 |
|
The Committee recommends that the Commonwealth Government
work with employment service providers to streamline assessment processes for
job seekers with a mental illness and ensure that the assessment criteria for
and requirements of job seekers with a mental illness are compatible and
consistent across the services. |
Inappropriate assessments
4.82
Witnesses were critical of the JSCI and JCA processes insofar as they
correctly identify, categorise and refer people on to the services most
appropriate for them. Edge Employment Services in Western Australia said that:
Job Capacity Assessments are not appropriately identifying
and referring individuals with mental health issues to available services.[75]
4.83
Mr Lucas Mackey, a senior case manager from Workskills, provided a
recent example where a client had not disclosed his full story to Centrelink,
and presented to Workskills as a stream 2 job seeker, early school leaver, when
he actually had a number of other vulnerabilities that should have been
factored into his assessment [placing him into a higher stream level]. Mr
Mackey elaborated:
We are reliant on someone in a face-to-face meeting with
Centrelink in the future picking up on that and then choosing further to
question it.
I know it has been freer in the past in the sense that job
service providers have had an opportunity to refer back to Centrelink or to go
to a job capacity assessor to have an assessment done. I am aware of the fact
that organisations in the past have possibly misused the instrument...I suppose
a frustration from our point of view as an operational process is that all the
organisations are tarred with the same brush as the organisation that abused
the power...[76]
4.84
The NSW Consumer Advisory Group said individuals who are mentally unwell
are not always qualifying for DSP because of inaccurate assessments. And, owing
to their illness, they are not able to adhere to the requirements of the benefit
they are put on instead, such as the Newstart allowance. This results in them
receiving participation failures and experiencing periods of no payment from
Centrelink.
4.85
One example they gave involved a mental health consumer who had a long-term
alcohol addiction, which caused severe organ damage. They say his condition
should have qualified him for DSP but he remained on Newstart allowance. His
impairments had impacted on his ability to attend appointments with his JSA
provider, he had received a participation failure and could incur an eight week
payment cut off period. The consumer said of his own situation:
I don’t see the point of the entire system. If I get breached
for eight weeks, I can’t afford to pay my rent and then I will become homeless.
If I am made homeless, I am going to be less likely to get a job than I already
am. Plus while you are a breached Job Services gives you no assistance to look
for work![77]
4.86
Disability Employment Australia (also known as ACE) emphasised that consumers
with mental illness, especially significant psychiatric or psychotic illness
can be a complex client group, with co-morbidities including substance abuse
and homelessness and putting people into the wrong stream [or not on the DSP or
into DES] means that providers are not funded to provide these people with the
full suite of services that they may require:
Funding level assessments are conducted via an independent IT
based tool which collects non-subjective data from the JSCI and JCA report.
Since the implementation of this methodology, feedback from the providers has
indicated that clients with mental illness are trending towards the lowest
funding level available.
From ACE’s perspective it is critical to ensure that the tool
is as representative of the support needs of participants as possible- as the
level of funding is directly related to the amount of support that a provider
is able to provide to a participant while still maintaining a financially
viable service that is able to meet the needs of all participants. [78]
4.87
Some witnesses argued that part of the problem with the assessment and
categorisation processes lies with the JSCI largely being conducted by
telephone, rather than in person. The National Employment Services Association
stated:
The initial implementation of the Job Seeker Classification
Instrument (JSCI) with job seekers is conducted on first contact with
Centrelink and most often is conducted by phone interview.
The industry has long contended that development of
sufficient rapport and trust to elicit disclosure is best achieved in a
face-to-face situation.[79]
4.88
Ms Helen Hudson from Workskills expressed similar frustrations:
We find that quite often job seekers will come to us for
their initial appointments and have been placed into a fairly low stream –
stream 1 in a number of cases, or stream 2 or stream 3 – because that initial
interview has been conducted over the phone.[80]
4.89
Mr Peter Ball, Service Leader, Department of Human Services, Tasmania
Office explained how and why Centrelink had moved to provide job classification
processes over the phone, rather than always via a face-to-face situation. He
said this was something phased in over the last 18 months, and Tasmania had
been part of the national trial. DEEWR and DHS believe the new model provides
better services because:
We could have more people who are better skilled available to
more people over the phone.[81]
4.90
Moreover,
My understanding is that DEEWR are comfortable with the
phone-in service, otherwise I am sure they would have had robust conversations
with Centrelink. In fact our ongoing processes are to work very closely with DEEWR
as to how all the processes are going and how effective they are...I do not
have responsibility for the national management- my understanding is that DEEWR
has worked with us nationally in that regard and are confident that the
outcomes we achieve through the phone service are comparable to those that were
achieved through the face-to-face service.[82]
4.91
DEEWR corroborated:
in 2010 no significant
difference was found in the consistency of Centrelink administered JSCIs,
irrespective of whether the JSCI was completed at a face to face or telephone
interview. Job seekers were allocated to the same service Stream between 90 to
94 per cent of occasions.[83]
Re-referral process
4.92
Concerns were raised regarding the ability to refer someone for reassessment
if it appears they have not been placed in the right stream of employment
service in the first place, or their circumstances are better identified at a
later stage, or change, subsequent to their initial assessment.
4.93
JSA customers may initially be put in a general Stream 1 or 2 category
because their illness is undiagnosed or undisclosed or they are well at the
time of their initial assessment, however, owing to the episodic nature of
their mental illness may later require assistance more in line with a Stream 3
or 4 level of vulnerability or a DES provider.
4.94
Ms Cherie Jolly, Delegate of member organisation, Uniting Care Wesley
Post Adelaide, Disability Employment Australia pointed to the need for
flexibility in the system to reclassify people, if necessary (although that too
can cause problems):
The flexibility of the program, starting with the job
capacity assessments and the job seeker classification instrument, has a real
impact...when people with a mental illness enter the Centrelink system they are
generally at a point where they are really unwell. When they come to us, they
are only partially through the recovery stage. They come to us with some stuff
going on and they have their current and future benchmark hours...but the
assessment itself should only be there to set criteria: they meet the criteria
to come to us. Currently it is more about their funding level and what stream
they go in and what their participation requirement is. That process brings an
enormous amount of stress and pressure to bear on the individual, which often
makes it difficult for us to engage. So flexibility around going back and being
able to recall and reassess is one point we would like to highlight. That then
brings inaccuracy of referrals and puts people back through a system. They end
up going back to Centrelink in stream 3 or stream 4, come back to us, and fall
out the system very disillusioned.[84]
4.95
Workskills reiterated difficulties they had experienced getting
reassessments for their clients:
If someone comes in exhibiting fairly significant symptoms of
mental health issues and they are in stream 1, we can no longer refer them
directly for a reassessment with Centrelink, which we used to be able to
do...It is up to the job seeker to go to Centrelink and explain that they have
particular problems and issues and request a further assessment or appointment
with a social worker and so on.[85]
4.96
DEEWR indicated that employment service providers can refer clients back
for reassessment. Ms Buffinton stated:
On the rare occasions where a provider thinks that things may
have not been disclosed, there are ways and means for the employment service to
alert.
It is rare but in more extreme cases they can refer for
another assessment.[86]
4.97
Mr Alastair Bissland, Social Worker, DHS, Tasmanian Office said that it
was his understanding that the inability to re-refer for streamed services
review was ‘nowadays no longer the case.’[87]
4.98
Ms Denise Frederick, Divisional Manager, Victoria/Tasmania, CRS
Australia, alluded to the fact that it can take time for people to reveal and
or realise the extent of their mental health condition, but the system can and
does accommodate that:
As a number of witnesses have identified this morning,
sometimes it takes a little bit of time in the process as job seekers might
reveal further information, and we would work with them to obtain the
appropriate medical information that would assist in getting them into the
correct service...Most of the time we are the right place if the referral comes
through, but if we are not then we need to take that forward. We would have
interaction with the assessors. We do have sessions where we can talk to the
assessor so that they really understand the service that we provide, because we
think that is really important.[88]
4.99
Mr Niko Milec, Social Worker, DHS observed that re-assessment is an automatic
part of the reconnection process when customers have participation failures:
In the discussions we have with customers, mental health is a
relatively common feature for those customers who were having significant
difficulties engaging with their job service providers and engaging with their
participation requirements...The JSCI is essentially reviewed every single time
we have contact with a customer in relation to the participation report.
Checking whether a customer is appropriately streamed is a critical part of
that assessment. Certainly for social work, when we undertake comprehensive
compliance assessments, which are an assessment that is undertaken before a
decision is made about a serious failure, that would be almost mandatory.[89]
4.100
Mr Alistair Blissland, Social Worker, DHS agreed that the referral
process can be problematic in identifying mental health issues when:
Often we get referrals which are secondary or co-morbid
issues. Those can be accommodation, drug and alcohol or domestic violence
issues. Mental health is an underlying or latent issue.[90]
4.101
However, he noted that Centrelink is regularly in contact with external
providers, including the employment services providers and they will respond to
requests for additional assistance from service providers, including the
reassessment of clients:
on several occasions they have contacted us directly and
said, ‘we have a customer we are concerned about. They are presenting in an
unusual way. They are manifesting depression, anxiety...Would you organise an
appointment for them and any referrals and support?’ which of course we do.
That happens on a regular basis. The vast majority of referrals we get would be
walk-ins or direct. Again, it would not necessarily be mental health as a
presenting issue, but it would be a latent issue.
Invariably the job service provider would ring us if there
were any concerns [about a client’s streaming for job services]. We would
organise an appointment and in the course of the appointment we would do a
brief mental health assessment. That may mean updating the JSCI, and, from
there, organising another job capacity assessment.[91]
4.102
Mr Bissland cited a recent successful example of Centrelink working
together with Workskills to re-stream a client with a mental illness:
I had contact with Workskills directly when they rang up
about a young chap that they believed was significantly depressed. He did not
have a diagnosis and he did not have a GP and they sent him through to us. We
did a brief assessment with him and it was fairly evident that he had symptoms of
depression...so we did a written referral to a GP...He attended the appointment
and got a medical certificate and doctor’s report. We organised an assessment
and from there he was streamed to a more appropriate provider.[92]
4.103
Mr Peter Ball, Service Leader, DHS advised further that:
We do have regular meetings with Job Search providers and
with DEEWR. In the case cited by Workskills, it sounds as though there has been
a deficiency of some sort—perhaps a breakdown in communication there. But we do
have in place those processes.[93]
4.104
DHS emphasised that the Commonwealth Government has sought to redress
the problems with reassessments:
The government has brought those assessment services back
into government, delivered by the DHS with previous CRS and Centrelink staff.
These are made up of allied health professionals and they cover a wide range of
areas. Where a person has information and evidence that requires a new
assessment and they are in stream services, then they will approach a
Centrelink office with that information and an appointment can be made for a
stream services review. The assessment is made up on a job seeker face-to-face,
where possible, and in the majority of cases, except if there are major
barriers to that happening.[94]
4.105
DEEWR concurred:
...one of the things is making sure that the employment
services get feedback if they have raised a query. We must make sure it is fed
back whether we think there is a need for reassessments.[95]
DES performance
4.106
Ms Buffinton from DEEWR referred to a 2008 review of the disability
employment services, and the job capacity assessments, then the gateway into
the program. Ms Buffinton said:
We developed the new Disability Employment Services learning
from what was not right with the old system...That was developed in consultation
with consumer groups, so the consumer groups were very actively involved – as
were obviously employment providers, but also employers in the broader
community.[96]
Uncapping of places
4.107
Ms Buffington stated that the ‘single biggest element’ of reform to DES
has been the uncapping of places. Whereas, in the previous system, there was a
waiting list and people could wait a year or more to get access, now people can
get access as required.[97]
4.108
Dr Geoffrey Waghorn of the Queensland Centre for Mental Health Research
endorsed this aspect of DES reform:
There have been many positive enhancements to the
program...such as uncapping program places and the introduction of an
independent ongoing assessment of support needs once people are in employment.[98]
4.109
National Disability Services agreed that the uncapping of places was an
important move:
The uncapping of the DES program in March 2010 provides an
important precedent for this reform that would open pathways to employment and
enhance flexibility and choice for employers and job seekers.[99]
4.110
Mr Todd Bamford, Team Leader, Transitional Care and Early Psychosis and
Noarlunga Emergency Mental Health Services, Southern Mental Health, Adelaide
Health Service, South Australia Health concurred and emphasised that
previously, capping had been a significant barrier:
when we consulted on the evidence based model, there was
still a lot of capping, and that was raised just about everywhere as a barrier
to being able to provide an evidence based service.[100]
4.111
The Committee learnt that subsequent to uncapping places, some agencies,
such as UnitingCare Wesley Port Adelaide, had used that opportunity to expand
into business areas they had not ventured into before. For instance, being part
of the integrated service delivery model developed with Southern Mental Health
(see later in this chapter for details).
Matching clients with DES providers
4.112
Despite the moves to uncap places, the Committee heard that some specialist
service providers actually have a shortage of clients on their books, which
they are not happy about. Mr Nick Bolto, the CEO of Ostara, a DES that focuses
wholly on mental health, described how his service wants to help more people
but is prohibited from so doing because clients are simply not being referred
to their service:
Most of our [114] sites are only half full or less than half
full. We have talked to DEEWR and Centrelink. We have even had ministerial
representation around the fact that, while government has funded specialist
mental health services, people cannot get through the door. This is largely a
policy issue of how job capacity assesses a client , interviews a client and
then makes a decision about where the client will go. There is what they call
the chocolate wheel. If the person makes no choice about the chocolate wheel
spins and they get sent to a generalist provider. They have to ask for a
specialist to get a service that meets their needs.[101]
4.113
Mr Bolto went on to explain that if a client does not explicitly ‘opt
in’ to a specialist provider such as theirs, for reasons including the stigma
of being sent off to ‘disability’ employment services, they will end up being
‘randomly allocated to another [general] labour market support provider.’[102]
Mr Bolto asserted that the problem is that:
People do not know how to exercise their choice or why that
choice is important.[103]
4.114
Ms Sharon Stuart, Branch Manager, Disadvantaged Job Seekers Branch,
Specialist Employment Services Group, DEEWR refuted this, stating that the vast
majority of people in DES do choose their own provider, after being appraised
of the options available to them, and less than 10 percent of clients are part
of any ‘spinning chocolate wheel’ system. Ms Stuart expanded:
In fact over 90 percent of our clients have exercised
choice...in some cases providers will find clients through the linkages they
create in their own community or the client themselves will see some sort of
promotion and come into a provider...People who come through the Centrelink
gateway are given the options of the providers in their local area and asked to
make a choice. If somebody has a primary psychiatric disability and there is a
mental health specialist in that area, that particular provider will certainly
show up on that list and be flagged as someone who works with that disability
type, but the client will be given the choice of all of the other providers in
that area. There are some circumstances where a provider’s name may not show up
on that list; that is where they have been sent a lot of referrals recently.
They may temporarily drop off the list so that other providers can get some
flow through.[104]
4.115
The Committee is of the view that time should be taken to explain the
benefits of a specialist employment services provider to the client when
Centrelink is going through all the options of providers in their area, and
clients should be encouraged to make their own informed choice about the
employment service provider they wish to try. This should not be immutable
either, should things not work out with the first one they try.
Criticisms of DES performance
4.116
While Dr Waghorn, and others, support the uncapping of services, he
offered an otherwise scathing assessment of the new DES’ performance and
proposed, in its place, an evidence based approach that centres on one-to-one
assistance provided by a skilled employment specialist (this concept will be
explored more fully throughout the rest of the chapter). He asserted:
At the moment in Australia we have an increasing availability
of ineffective services. The availability of services in Australia is no
longer a barrier, except in remote locations. Australia now has a multibillion
dollar disability employment industry, consisting of disability employment
services contracted to DEEWR...the effectiveness has recently crashed.
According to DEEWR’s own interim evaluation released in July this year,
specifically table 3.3 on page 31, only 10.6 percent of clients with a primary
psychiatric disability at funding level two – the client group most relevant to
our research – achieved 13 weeks of employment or an education pathway outcome
in the nine-month period of March to December 2010. How can anybody say, ‘wow’
about a program that achieves 10.6 percent?
The basic message is that it is the most populated subgroup
of people with disabilities and it is the worst performing in the system The
performance is now below what I would call a net zero effect.
This evidence suggests that declining DES performance now
represents the greatest barrier to employment for Australian community
residents with severe mental health and psychiatric disability.
The reasons for this declining performance...is a failure of
the majority of DES providers to adopt the evidence based practices shown over
the last 20 years to be the most effective in international trials for people
with severe mental illness.
It is that one-to-one arrangement that is done by a highly
motivated, skilled, knowledgeable employment specialist that is an important
part of the solution but the current DES providers do not do that. They are
still operating along the lines of a JSA type service where it is all about
volume, herding people through, coaching them in the office, giving them a list
of things to do and sending them out in the big wide world and hoping some will
make it.
...very good employment specialists do great deals with
employers, back it up with reliable support and everybody wins through that. It
is not easy but it can be done.[105]
4.117
According to Dr Waghorn the current funding structure acts as a
disincentive to DES to find jobs for their clients. He asserted:
DEEWR actually pay more for clients not to get a job than to
get a job – over $15, 000 over two years for funding a level 2 client...all the
service has to do is collect some referrals off a public mental health team,
say all the right things, say they will do the work and rake in the service
fees every quarter for having those clients on the books. They do not need to
get a single person a job, and a service that has driven up their client load,
to say, 50 clients, will collect $760, 000 fees over two years for one worker.[106]
4.118
Ms Buffinton’s assessment of DES performance was contrary to Dr
Waghorn’s, namely that ‘DES is working really well’.[107]
4.119
DEEWR has conducted an interim evaluation of the DES program. Of it, Ms
Buffinton said:
If you read the fine print on the interim evaluation, it was
almost like a post-implementation check, which was just making sure that we got
the program up and running. The new DES services started on 1 March 2010. The
evaluation was done at the end of last year. So, at that time, when some people
quoted some of those figures, the outcomes were quite narrow – as you would
expect in a new program.[108]
4.120
The DEEWR website indicates that a further evaluation of the program is
to be completed in the next financial year, 2012-2013.[109]
4.121
The Committee notes with interest Dr Waghorn’s evidence regarding the
perverse incentives that may exist in the present system, and believes his
input should be sought in future evaluations of the DES program.
Disability Employment Services Performance Framework
4.122
Ms Buffinton went on to outline the Department’s Disability Employment
Services Performance Framework (the framework) and star ratings system which,
in her words, assesses ‘whether employment services are doing what we are
asking of them and doing the best thing for the participant’:
The performance model measures the relative performance of
providers. The framework is designed to drive performance and continuous
improvement in the quality of delivery of services. We judge providers on
efficiency, effectiveness and quality...We do this so disability consumers can
see who is relatively high-performing and who is relatively low-performing.
Twice a year we publish what we call the star ratings.[110]
4.123
The Committee recognises that the star ratings of all the disability employment
services providers are published and made available on the DEEWR website.[111]
And, if an agency specialises in mental health that is indicated on the star
ratings spreadsheet. The accompanying explanatory information about how the
star ratings are calculated should appear alongside the ratings (not on a
separate web page as it presently does). A simple translation of what the star
ratings might mean for the consumer regarding their choice of a provider should
also be supplied on the website and relayed to clients in phone or face-to-face
encounters with Centrelink.
4.124
The Committee is of the view that employment service providers that
specialise in serving clients with a mental illness should be recognised and
factored into the star-ratings system.
Sustainable employment and education outcomes
4.125
Ms Buffinton outlined how payments from DEEWR to DES providers for services
rendered to people with a mental illness are increasingly weighted towards
those which procure sustainable employment outcomes:
Previously a lot of activity was rewarded whereas now we have
become more outcomes oriented in how we pay disability employment services. A
certain amount of fees are paid. Those service fees are relatively high because
intervention for people with disability involves a lot of prep work before you
are going to get outcomes. In the past there was a big focus on that activity
and preparation. Now there is a balance between activity and preparation, but
the emphasis is now on the outcome of actually helping somebody. After all, the
whole aim of disability employment services is to help somebody get a
sustainable-meaning ongoing-job in open employment. We have tried to bias the
framework in the direction of those sorts of outcomes.[112]
4.126
DEEWR supplied a table setting out a range of DES service fees. These
include job placement fees, 13 and 26 week outcome fees, quarterly ongoing
support fees, and Job in Jeopardy Services Fees. There are a range of other
reimbursements too, including ones that recognise an educational commencement
or attainment. Further to Dr Waghorn’s comments about the financial incentives
to keep clients on the books rather than find them a job, and to provide some
indication of the comparative monetary value of the one- off payments versus
the ongoing payments: DES agencies receive $4, 400 for a 26 week full outcome
for a DMS or ESS Funding Level 1 client. This increases to $7700 for an
Employment Support Service Funding Level 2 client. Agencies receive $1450 for a
26 week pathway outcome for a DMS or ESS Funding Level 1 client, compared with
$2,560 for an ESS Level 2. Ongoing support payments for DMS participants are
$440 per instance. For other clients deemed to require moderate ongoing
support, the agencies receive $1320 paid quarterly. This rises to $3300 per
quarter for clients with high ongoing support needs. All fees command a premium
for serving clients in remote areas.[113]
4.127
DEEWR officials indicated that the 13 week and 26 week outcomes inform
the star rating that an employment service gets, together with a range of other
factors:
The number of outcomes you get for that measure in comparison
to your caseload counts towards 25 % of your star rating.[114]
With the star ratings, disability type is one example of
something we take into account. Others include the service requirements of
participants, their higher-end needs, the labour market conditions of their
particular location and so forth. We put that into a statistical regression
which is used to adjust those factors. In the case of psychiatric illness, it
is traditionally harder to achieve outcomes. So in the regression it gets a
positive upweighting.[115]
We basically rank all the providers on a scale.[116]
4.128
Dr Waghorn does not agree with the star rating or regression modelling
used by DEEWR. He says to improve the efficiency of DES services, they need to
be replaced:
...with a focus on a single outcome variable as the key
performance indicator used to select or renew successful tenders. This key
outcome needs to be the most challenging outcome, namely the proportion of
clients that attain 26 weeks or more of accumulated employment during a
particular contract. To assess this fairly, both diagnostic category and
attrition also need to be accurately recorded, and employment in affiliated
businesses to the employment system need must be either excluded as a
non-competitive job or discounted in value through not being an optimal
employment outcome.[117]
4.129
Employment service providers too had concerns with the outcomes payments
and/or star ratings system. Ms Helen Hudson from Workskills Inc. stated:
The way that contract is organised, there is no financial
incentive for us to assist people with mental health issues to go that extra
distance. People are providing that assistance but to a large extent that is
unrecognised because there is no outcome, if you like, at the end of it. It is
not getting a job for somebody. But if you assist people to get some help with
their mental health issues that can be a huge positive step for many people.[118]
4.130
Similarly, Ms Cherie Jolly of Uniting Care Wesley Port Adelaide stressed
that agencies do not always get rewarded for the work they put into preparing
people for work:
We get someone a job for three hours a week; that should be
credited, but the time it takes us to get our performance up around that person
involves putting the recovery stuff in place – the psychosocial stuff. So for
speciality services there should be a lengthening of that performance. Our star
rating at Port Adelaide is hideous because we maintain our values around
preparing the person for sustainable employment.[119]
4.131
Orygen Youth Health expressed concerns that the JSA system focuses
unduly on outcome payments, and does not incentivise educational outcomes for
clients:
In the course of our work we have met a number of people who
were only a short distance away from completing various qualifications before
they became unwell. When they engaged with JSA agencies they did not receive
encouragement to return to and complete these courses. Instead they were placed
in jobs that required no qualifications and encouraged to remain there until at
least the period that corresponds with outcome payments was achieved....
We believe very strongly that there needs to be incentives to
encourage agencies to take a long-term view for the individual – to aim towards
vocational recovery rather than job placement.[120]
4.132
Ms Phyllis Quensier, Service Integration Coordinator, Gold Coast Health
Service, Queensland Health reiterated a point raised by Professor Butterworth
in the first chapter that low quality jobs are probably not beneficial for
people and self-defeating because:
That makes them very devalued to be seen as not worthy of
anything better. Their motivation goes down, their stress levels increase and
they can relapse due to the fact they are in a job that they feel they should
not be in.[121]
4.133
Ms Buffinton defended the results so far:
I will give you an indication of the current outcome rates
because people are using historical figures in presentations to you. In terms
of job placement under the Disability Management Service -38% of those
currently in the DES actually have a job placement, 26 per cent have hit a 13
week outcome and 18 per cent have hit a 26 week outcome. These figures are only
going to build because we have only been running for 18 months. Obviously, if
you came into the program in the last 6 months, you cannot possibly have a
26-week outcome. When we come back, those figures will build. Some of them are
comparing against the old system, which had been running for a number of years
and so had outcomes built up over quite a period of time. That is the
efficiency and effectiveness side of it.
On the issue of quality, all disability employment services
are required to have certification that they meet the disability service
standards.[122]
4.134
DEEWR indicated support for the new framework had been forthcoming from
a wide range of stakeholders, and furthermore, it had been independently
evaluated:
We developed a technical reference group which had people
from the former disability employment services, peak bodies, consumer groups
and so forth. We looked at a whole range of different ways that we could judge
performance. We then commissioned Access Economics to do some independent
analysis of whether the model we had come up with was robust.[123]
4.135
The Committee is reluctant to recommend another review of the DES, when
one was only conducted a few years ago and the new performance framework is
expected to redress the shortcomings of the previous one. The Committee also
notes that the Senate Standing References Committee on Education and Workplace
Relations conducted an inquiry into the administration and purchasing of
Disability Employment Services – Employment Support Services (DES-ESS) in 2011,
making a number of recommendations including that DEEWR consider alternative
purchasing models to the current one of a competitive tender process. The
Government did not support this. [124]
4.136
Given that DES-ESS will continue to be funded through tender, and the
Committee notes the current requirement that DES agencies meet disability
service standards, the Committee does consider it essential that part of that
tendering process require prospective employment service providers to be have
some expertise in working with people with mental illnesses. This might form
part of the star rating framework.
Recommendation 11 |
|
The Committee recommends that any future Disability
Employment Services tender process require prospective disability employment
services providers to provide evidence of expertise in working with people
with mental illnesses. |
4.137
The framework certainly warrants close ongoing attention, monitoring and
evaluation, with input from interested stakeholders, to maintain their support.
Presently, the star ratings appear to be heavily weighted towards quantitative
outcomes (i.e. getting someone a job). This should not necessarily be at the
expense of longer term qualitative outcomes, be these educational goals or
career aspirations. In Professor Killackey’s words, this may ‘perhaps be in
their long-term best interests.’[125]
Recommendation 12 |
|
The Committee recommends that the Disability Employment
Services Performance Framework be monitored and evaluated on a regular and
ongoing basis. DEEWR should continue to consult with a technical reference
group of stakeholders to ensure the framework’s and star ratings’ ongoing relevance
and efficacy in achieving qualitative as well as quantitative outcomes for
people with mental illnesses. |
Improving communication and engagement
Disclosure and diagnosis
4.138
People are not always comfortable declaring their mental illness to
government agencies or employment service providers. Sometimes they have an
undiagnosed mental health condition. Either of these scenarios is a potential
communication barrier to that person receiving appropriate services.
4.139
The National Employment Services Association (NESA) referred to the frustrations
felt by employment service providers who find it difficult to connect their
clients with the service they require because:
...the current classification framework is grossly inadequate
to respond appropriately to people with low insight of their mental ill-health
as it relies on self report and/or proof of diagnosis and impact to influence
service classification.[126]
4.140
Ms Helen Hudson, Senior Case Manager, Workskills Inc. described the
reluctance some job seekers with a mental illness have disclosing any
information (about their illness or circumstances) to Centrelink for fear it
might adversely influence their benefit entitlements, and the difficulties this
poses to agencies like theirs, trying to help them:
There are some job seekers with particular types of mental
health issues – paranoia and anxiety in particular- where they feel that there
is no way they are going to tell anyone from the government anything about
their circumstances...We also have a number of clients who would need assistance
through the DES and may have been recommended for those services as part of
their assessment but refused to go to those appointments because of the stigma
attached with the word’ disability’...A lot of people will not admit that they
have mental health problems and perhaps do not have any idea that they have
mental health issues...[or] people may find it is okay to admit to depression
which may be more socially acceptable to admit...rather than say that they are
on medication for psychosis and things like that.[127]
4.141
Ms Nicole Cox, National Disability Coordination Officer, Edge Employment
Solutions talked about some of the communication challenges presenting in the
Kimberley region:
Diagnosis and referrals are not occurring. ..They actually
have to have informed consent by guardians, and in Indigenous communities there
are often a lot of guardians...So it is a feat just for the psychologist to
identify who legally they can be talking to...
I sat in on a job capacity assessment by someone who came up
from Perth....They asked the young lady whether she was Indigenous and she said
‘no’ and they ticked ‘no’ in the box. I had to explain about it. I asked
questions like ‘What is your country What is your language group?’ She was able
to answer. They also asked her if she had a disability and she said ‘no’. You
could tell she had a disability. She was sitting in a wheelchair. I asked her
‘can you walk?’and she said ‘no’. I would hate to think what would have
happened if it had been an individual with a mental illness having that
assessment. It is just so uncommon for an individual to identify.
So there are huge issues around the job capacity assessments
and the Centrelink assessments , and they all need to be modified to be
culturally appropriate. [128]
4.142
Workskills referred to their Hobart site and communication challenges concerning
new migrants:
Our Hobart site observed that refugees and humanitarian
entrants circumstances are not easy to document well through existing systems,
e.g. experience of torture and trauma is not an available choice in JSCI
questions (though post traumatic stress disorder is); job seekers in these
groups often distrust (perceived) government agencies; we, and they, put a lot
of trust in their interpreters.[129]
4.143
Multicultural Mental Health Australia and the Transcultural Mental
Health Centre referred to additional difficulties faced by people with a mental
illness from cultural and linguistically diverse backgrounds, and a
corresponding need for CALD-specific support workers:
When people from CALD backgrounds with mental illness want to
seek employment, some of the issues that they encounter are naturally language
difficulties, and a lack of recognition of overseas qualifications, which often
leads to them getting jobs below their qualifications or skills base. Some
groups might not have an understanding of the recruitment process in Australia,
how to write CVS or where to look for employment...there is also the interview
process, imagine your English is not the best and you are exposed to that situation
[and that]...there is a chance they will not be selected for interview because
of the stigma attached to mental illness in the community.[130]
Employing CALD-specific support workers and migrant resource
agencies to run those PHaMs programs would be really good...
I understand Centrelink runs community consultations from
time to time to find out the needs of CALD consumers for courses and for
welfare. Centrelink needs to run a lot more with a lot of different ethnic
communities.[131]
4.144
The Commonwealth Ombudsman’s Falling through the Cracks report
identified greater consideration of the customer’s barrier to communication and
engagement as one of the four key areas for improvement for Centrelink and
DEEWR alike.[132] Earlier parts of this
chapter allude to the scope for miscommunication and disengagement, not least
owing to a series of systemic and policy changes, from the introduction of a
whole new employment services structure to streamlining the JCA process; new
participation requirements; revised impairment tables and a new performance
framework for the DES - to name but a few. Keeping all stakeholders abreast of
developments can, at best, be described as a comprehensive challenge.
4.145
DEEWR said that it is acting on the Falling through the Cracks
report recommendations, namely to update existing service delivery guidelines
and training materials, and it provided the Commonwealth Ombudsman with a
status report on those measures on 1 July 2011. The department stated that:
DEEWR has either implemented the relevant recommendations
made by the Commonwealth Ombudsman’s report, ‘Falling through the Cracks’ or
processes are well-developed to implement the recommendations.[133]
4.146
DEEWR said measures to improve communication and engagement include:
the online mental health training package incorporates
guidance for staff on how to ensure customers are aware of the benefits of
disclosing a mental illness, and feel comfortable doing so. This will include
information on how to foster an environment where disclosure can take
place...DEEWR will continue to consider this recommendation with the
development or enhancement of communication materials and staff scripts.[134]
The Direct Registration Guidelines have been updated to
include advice on what providers should consider if they identify that a job
seeker may have mental health issues. Some suggestions include, seeking the
assistance of a more experienced case manager or a JobAccess Advisor,
organising alternative contact arrangements, consulting with the job seeker’s
nominee to determine the most suitable communication and contact arrangement,
recommending that the job seeker discuss their circumstances with a mental
health services provider, or referring the job seekers to other relevant support
services.[135]
The JobAccess Service has recently been expanded to include
professionals in the mental health area who will provide information and
support relating to the employment of people with mental illness...and includes
funding to encourage employment service providers to access the expertise of
the JobAccess Service.[136]
4.147
Centrelink says it too is making changes to strengthen decision making
and reference material, specialist services and support to staff, through the
following means:
n developing standardised
‘pop-up’ text when mental illness is mentioned in reference files. This will
remind staff that consideration should be given to the various impacts on the
customer’s ability to comply, including their capacity to attend appointments;
n A Health Professional
Advisory Unit (HPAU) established in July 20120 comprising medical practitioners
and registered nurses to provide expert advice to Job Capacity Advisors, DSP
decision-makers and Authorised Review Officers seeking clarification of medical
evidence and/or information about treatment and rehabilitation regimes;
n In 2010, a total of
2, 428 staff participated in mental health first aid and mental health
awareness training; and
n Piloting
communication methodologies for people with disability as part of the DSP Workforce
Reengagement Strategy. Face-to-face, phone, seminar and combined methodologies
will be tested over a three year period.[137]
4.148
Centrelink officers described the range of communication strategies that
the agency employs for communicating with other agencies and clients alike:
n Disseminating
information to various groups through interagency forums and other seminars
about what is happening; and
n We have promotional
products which explain [concerns about losing benefits and some of the things
that go with that].[138]
4.149
Ms Desley Hargreaves, National Manager, Social Work Services, Department
of Human Services pointed to the challenges of communicating sometimes complex
messages in accessible ways; to clients, namely:
in simple ways that do help people to understand what their
eligibility and entitlements are, and, when circumstances may change for them,
what their options are.[139]
4.150
Ms Buffinton of DEEWR referred to money in the budget dedicated to training
frontline staff, Centrelink and employment services providers alike, on dealing
with people with a mental illness:
In response [to the Ombudsman’s report] we are pulling
together a package of training material for the employment services and
Centrelink staff.[140]
Training Centrelink and employment agencies staff
4.151
Ms Melissa Golightly Deputy Secretary, Health And Older Australians,
DHS, spoke to the actual training staff receive and the suite of supports
available to them to help them to do their job well:
[staff] have at their fingertips access to properly trained and
well-qualified social workers...and allied health professionals –health
workers, nurses and that sort of thing, as well as psychologists, occupational
therapists and doctors....for the frontline staff the focus is to be aware but
not to feel that they have to deal with the issue themselves, and nor are they
qualified to. We have an immediate escalation route or access route to a fairly
significantly trained professionally qualified workforce.
It is not the role of frontline staff to diagnose. Their role
is to utilise flexibility, to demonstrate empathy and to have strong
communication skills where a person is having mental issues...and to know when
to call in the health professionals.[141]
We have a range of training products targeted at staff in
different roles. ...the training for [frontline staff as opposed to health and
allied health professionals who already have tertiary qualifications in
relevant fields]is more about awareness of mental health issues and disability
awareness more generally, being able to identify where a person is having
difficulty engaging with either the social security system or the employment
assistance system, so that the person is able to exercise any flexibility that
they have in the system in recognition that this person is having difficulty
communicating, which is quite different from identifying the existence of a
mental health condition per se.
4.152
Recognising the stressful situations that can present to Centrelink call
centre and frontline staff by the very nature of the job, DHS indicated that
its in-house cadre of professionals is available to help their own staff deal
with the level of stress that can be experienced ‘every single day of their
lives and multiple times in one day’. [142]
4.153
The Committee certainly appreciates that the system can be incredibly
complicated for consumers, service providers and Centrelink staff alike to
navigate. It is not easy for anyone to follow, let alone someone with any kind
of vulnerability, be it a mental illness or other, and supports all endeavours
to enhance communication strategies, to clients, to staff serving clients and
between agencies to support clients getting the services they need.
4.154
The Committee acknowledges that DHS/Centrelink and DEEWR themselves
recognise this and are seeking to make improvements.
4.155
That noted, it is not clear that the agencies themselves are able to
keep apace of the intensive pace of reform in the area, nor that the right
messages are always reaching their intended audience.
4.156
Orygen Youth Health suggested that the marketing of employment services
for people with mental ill health as ‘disability employment services’ may actually
miss the intended target audience when:
Most of our clients do not identify as having a disability
and are consequently unlikely to follow up an ad that asks, ‘Do you have a
disability and want to work’ (the wording used in one disability employment
service that was advertised in our waiting room.[143]
4.157
A clear, effective and timely communication strategy to consumers that
relays what services are available to them, and the potential impact of any
introduced or other changes, pertinent to the client, should be of utmost
priority. A range of visual, written and verbal communications will likely be
necessary, in different languages. These might include a range of easy-to-read
flyers to hand out to people, with case-study examples of people on the DSP/with
identified mental illnesses who have ventured and/or transitioned successfully
into employment and the ramifications of such moves for their pension
entitlements, if any. Any explanatory guides and commensurate training provided
to Centrelink and employment service providers to assist their clients in these
areas should similarly disseminate information in a timely and user-friendly
manner. The communications strategy should be cognisant of a diverse audience,
inclusive of people from all backgrounds, offer a positive message of
assistance on offer and encourage engagement with the services.
Recommendation 13 |
|
The Committee recommends that DEEWR and Centrelink
prioritise the implementation of a clear, effective and timely communication
strategy that advises clients of the services and supports available to them,
including how changes like the participation requirements and revised
impairment tables will affect them.
The Committee expects that any accompanying explanatory
guides and commensurate training provided to Centrelink and employment
service providers by DEEWR and DHS to assist clients with mental health conditions
will similarly be provided in a timely manner and user-friendly format. |
Consumer input into policy change
4.158
Ms Lawson from the Welfare Rights Centre pointed out how vital it is to
incorporate consumer participation in developing and altering welfare policy:
It is the ‘nothing about us without us’ kind of concept.
There need to be people with mental health issues involved at all levels of
policy development.[144]
4.159
Ms Hargreaves from DHS referred to the existence of a national
disability reference group that includes representatives of peak bodies who
advocate on behalf of disability constituents.[145]
4.160
The Committee thinks that it is equally important to consult Centrelink
staff and employment service providers as they are the interface between the
client and the system.
Recommendation 14 |
|
The Committee recommends that any new communication
strategies be developed with input from clients and staff (from both
Centrelink and employment service providers) into how best to disseminate
information to clients so they can readily understand any changes to their
entitlement and participation requirements. |
4.161
The Committee heard anecdotal evidence that DEEWR staff
responsible for disability employment policy do not regularly visit Centrelink
sites. In addition to any inter-departmental contact that DEEWR and DHS have,
the Committee also thinks it important that DEEWR officers working on policy
that affects DHS, regularly visit Centrelink offices so that they may have a
first-hand appreciation of the impact of DEEWR policy on service delivery
practice for consumers and staff.
Community engagement officers
4.162
Dr Waghorn called for the reintroduction of disability liaison officers
as one way to improve engagement between the consumer and Centrelink. Previously
located within Centrelink offices, they had, he said, served pension recipients
well. He himself had been a disability liaison officer and seen first- hand the
benefits of being able to offer specialist one- on-one advise to clients, helping
individuals work out what they were required to do and the ramifications of any
changes for their benefit entitlements.[146]
4.163
Mrs Melissa Williams, Manager, Gold Coast Employment Support Service indicated
that the disability liaison officer positions in Centrelink had served
providers like her well too:
Years ago we had disability liaison officers at Centrelink
who were trained and who were a one-stop shop for any concerns. It was the
saddest day when they were removed. Trying to get any assistance through
Centrelink is time consuming even for me as an agency, let alone for people who
have these significant barriers. It gets all too hard and stressful a lot of
the time and, rather than linking our services and getting things more
smoothly, it is a deterrent. So I would say bring back the disability officer.
Centrelink can be overwhelming and intimidating, especially for people that are
not really well and even if you are really well.[147]
4.164
Ms Gail Middleton, Executive Director, Welfare Rights Centre did not
disagree but said:
The trouble is you cannot have a single approach. To bring
back disability officers would be good, but it does not replace the fact that
some people are fearful of Centrelink itself. Some people need other safeguards
in place and there needs to be more information out there for the people who
interrelate with recipients...[148]
4.165
Dr Geoffrey Waghorn also spoke to clients’ fear of Centrelink itself:
Even if you go through with a person and show them using a
budget calculator that their rate of DSP is only going to go down by that much,
but their earnings are going to go up by that much and are only going to pay
that much tax and the net gain is going to be $35 a week from 10 hours a week
employment...even if you show them that, they will come back and say, ‘But I
can’t deal with the stress of having to deal with Centrelink.”[149]
4.166
Ms Desley Hargreaves, National Manager, Social Work Services, DHS observed
that the right messages may be being relayed to an individual but, ‘it is not
always being processed or understood’ [when someone is ill].[150]
4.167
Mr Peter Ball, Service Leader, Department of Human Services outlined how
the presence of ‘community engagement officers’ in Tasmania had made a
difference there:
We have community engagement officers who operate in the
three rough geographic areas of Tasmania, the south, the north-east and
north-west...they go into the neighbourhood houses and the like and they work
directly with those people to make sure that they continue to be engaged.[151]
4.168
The Community Engagement Officers program offers outreach assistance in
a wide range of locations, including mental health units. Community Engagement
Officers keep services connected to the client, and can
assist clients in an environment where they can be supported by other people
such as hospital staff.[152]
4.169
This program seems to be one way to break down barriers between the
client and Centrelink, and increase the likelihood of the right connections
being made.
PHaMS Remote Service Model
4.170
Another example of a complementary service model is the PHaMs Remote
Servicing Model which aims to better service Indigenous Australians in remote
areas:
The PHaMs remote service model differs to the mainstream
service, with a strong focus on spiritual, cultural, mental and physical
healing for Indigenous Australians. The model incorporates more
traditional cultural healing practices and utilises broader community
activities to support healing. It aims to enable social inclusion and strengthening
of family and community relationships for the participant, as well as the
development of the community as a whole.
As part of this new remote servicing model, FaHCSIA partnered
with a young designer, photographer, the PHaMs team (Warra-Warra Kanyi) and the
Warlpiri people of the Yuendumu community, to develop promotional products that
better reflected the remote Indigenous communities PHaMs would now be operating
in.
A workshop was held in the community and over a week, the
local community members designed the concept that would represent PHaMs and
what mental illness means in an Indigenous context. The local landscape
was photographed and incorporated into the background and border. The
community was given final sign off of the cultural appropriateness of the
products before they could be used.[153]
4.171
The PHaMS program was outlined in some detail in Chapter two and
endorsed by a number of witnesses as adding value to their educational and
employment prospects.
4.172
The FaHCSIA website indicates that Round 4 funding (until 30 June 2012)
includes over $36 million funding for additional PhaMS services (in 17 current
and 10 new sites) focusing on particularly vulnerable people experiencing
mental illness such as:
n those who are
homeless or at risk of homelessness
n humanitarian
entrants, and
n Indigenous
Australians. [154]
4.173
The Committee believes it could be beneficial to raise the
profile of programs that help job seekers with a mental illness link to job
opportunities, such as Centrelink community engagement officers and PHaMs,, as
part of the national education campaign that the Committee recommends in chapter
one.
Encouraging inter-agency communication and case- coordination
4.174
Having effective communication channels between agencies and clients is
one very important part of the equation for assisting people with a mental
illness get the services they need to find and sustain employment. Another
integral component is effective inter-agency communication and coordination.
Collaborative partnerships, integrated employment services and strength
based approaches
4.175
One of the resounding messages of the inquiry is the importance of
leveraging collaborative partnerships and ensuring that employment services are
integrated with clinical and social services to make them easier to access and
more effective for consumers.
4.176
Disability Employment Australia would like to see employment service
specialists work together with the assessors:
To increase the appropriateness and accuracy of these judgements,
as we believe that decisions around that economic potential are best made in
context and in partnership with the participant and provider – based on a
strength based and person centred assessment approach.[155]
4.177
Ms Melissa Lond, National Manager, Mental Health, Disability and Carers,
DHS said that Centrelink, as a service agency, needs to employ strength based
strategies to help people understand that they can test their workability.[156]
4.178
Ms Malisa Golightly of DHS elaborated on a strength based perspective:
It is focusing on what [clients’] strengths are rather than
what the problems are. That is not to ignore the problems, but it is a way of
getting people into a space where you are building confidence for a start, but
you are able to talk about options. We have seen this work really well through
place based activities that we are doing.[157]
4.179
DHS added that:
Utilising a strength-based approach builds the trust and
confidence of vulnerable people to access services and support in their
community.[158]
4.180
The Queensland Government states:
Providing strengths-based training within an individual’s
recovery plan would assist in building their ability to participate in
education, training or employment.[159]
4.181
Other witnesses agreed. Headpsace:
recommends that the government focus on enabling,
strength-based policies, holistic support, and the creation of meaningful jobs
for young people.[160]
4.182
The following initiatives or models are all examples of a
strengths-building approach that integrates employment specialists and adopts a
collaborative modus operandi:
n the Place Based
Services Program (PBS), which was a precursor pilot for case-coordination;
n the Local Connections
to Work Program (LCTWP);
n Local Employment
Access Partnerships (LEAP);
n the co-location of
CRS, VETE and Headspace;
n Early Psychosis
Prevention and Intervention Centre (EPPIC) and Individual Placement and Support
(ISP) exemplified by Orygen Youth Health;
n the Queensland Health
model-complex needs panels;
n and the Southern
Adelaide Health integrated services approach.
Place Based Services Program (PBS)
4.183
DHS referred to ways it has sought to better reconnect people with
services, including through the Place Based Services Program trial:
In 2008/2009 Centrelink initiated the Place Based Services
(PBS) Program to trial more intensive support for disadvantaged and vulnerable
customers in seven geographic locations, aimed at producing more productive and
sustained connections between the customer and support services within their
community.
Each trial site developed local responses to problems
specific to their local area, developing responses to strengthen service
delivery arrangements and build the capability of these networks to better
respond to the needs of disadvantaged and marginalised people. In each case,
responses were built around local partnerships between Centrelink, state and
local governments and local business and community partners and importantly,
marginalised Australians. [161]
4.184
According to DHS, key lessons learnt from this trial are informing the
development of service delivery reform. These important lessons include that:
n Centrelink is one of
the key agencies uniquely placed to identify and connect people to appropriate
services;
n Working with people
with significant disadvantage requires the involvement of highly skilled staff,
including social workers and experienced Centrelink customer service advisors,
cross-disciplinary teams allows for the optimal use of resources;
n The collaborative
component within each initiative demonstrated the potential to improve social
inclusion through advocacy, identifying and filling service gaps, better
service delivery, networking and information sharing;
n Experience shows that
building a relationship with a person who feels marginalised requires time, and
multiple interviews. Investing this time has downstream benefits. Similarly,
investing time to ensure that the person makes an effective transition to
appropriate services is a critical element of achieving improved and
sustainable outcomes.[162]
Local Connections to Work
4.185
DHS outlined the ethos behind the Local Connections to Work Initiative
(LCTW) - which built on the PBS model. In existence since May 2010, and based
on the successful New Zealand ‘Community Links’ model, LCTW aims to bring
together a range of services under one roof to assist long-term unemployed and disadvantaged
job seekers better access services:
THE LCTW initiative brings together Australian, state and
local government services, employment service providers and other community
welfare organisations. Services provided include counselling, housing, mental
health, youth, training and financial assistance. Community partners are
co-located on rostered basis at the four Centrelink Customer Service Centres.
This means that disadvantaged job seekers can ‘tell their story once’ and
receive the range of wrap around services.[163]
4.186
Ms Malisa Golightly, Deputy Secretary, Health and Older Australians,
DHS, spoke to the successes of the initiative for job seekers with a mental
illness:
Local Connections is very much a team effort where you have
Centrelink, the employment service provider, and the local support, which might
mean the mental health advisory service and the employer, all working together
with the employee on what the strengths are of the employee and what might be
possible. That is where we can do great things.[164]
4.187
One of the strengths of the LCTW model is its emphasis on local
solutions for local people and the utilisation of community partners:
The actual services provided on-site through LCTW are driven
by local needs and tailored to the specific circumstances of job seekers and
their families.
Employment Services Providers play a vital role in this
collaboration and on-site services are provided by both Job Service Australia
and Disability Employment Services providers.
Community organisations can get involved with the LCTW
program by contacting their local office. You can be involved on-site or be a
member of the Community Partnerships Group, which works towards finding ways to
better deliver services to the community.[165]
4.188
Mr Peter Ball, Service Leader, DHS outlined the benefits to consumers
and clients alike of the LCTW process:
In our Burnie office, on the north-west coast, in February
this year we commenced a process that we call Local Connections to Work...where
we are bringing other agencies into our offices so that we can work on a
partnership basis with the other agencies and with the individual customer. So
it may well be that there is a joint interview with a job services provider and
a Centrelink person. But also then, maybe, if there is an issue to do with
alcohol and drug dependency, we have a direct referral and maybe a three-way
conversation with those people as well.[166]
4.189
The program emphasises ‘case coordination’. Mr Ball elaborated:
We are allowing our people a longer period of time to have
more in-depth conversations with people who have major or more apparent
barriers to interconnecting and staying connected, so that we can make some
direct referrals...it seems to us that what works more directly is, rather than
making a referral and saying to someone you need to go up the road, we either
make the appointment [for the client], or better still take the person round
the corner and up the road to that particular agency.[167]
4.190
The National Employment Services Association (NESA) praised the LCTW
pilots from a service provider’s point of view:
We note that provider participation in the LCTW pilots report
that in contrast to normal arrangements the assessment interviews jointly conducted
by themselves and Centrelink in a face-to –face interview were highly effective
at identifying a range of circumstances, including mental ill- health. These
interviews were comprehensive and effective and worth the investment of
resources with interviews taking an hour and a half in duration.[168]
4.191
The Centrelink website includes a video clip of one young woman citing
her experiences and the range of help that LCTW gave, from securing stable
accommodation through to finding a job and regaining self-esteem and
confidence.[169]
4.192
LCTW has built on its successes and from June 2012, the program will
operate from 14 service centres.[170]
4.193
The Committee watches the roll-out of the LCTW program to more sites
with great interest and thinks it has real potential to assist clients with
mental illnesses both find and sustain a job at the same time as deal with a
raft of other issues they may have from a drug dependency to homelessness to
need for advice on benefit obligations.
Local Employment Access Partnerships (LEAP)
4.194
The Australian Government provided $41 million to Innovation Fund
projects that ran from 2009-2012:
The Innovation Fund is a component of the Australian
Government's national employment services, Job Services Australia. It is
designed to address the needs of the most disadvantaged job seekers through
funding projects that will foster innovative solutions to overcome barriers to
employment which they may face. Innovation Fund projects also contribute to the
achievement of the Australian Government’s Social Inclusion Agenda by
supporting innovative strategies to help the most disadvantaged job seekers
find and retain employment.[171]
4.195
Social Firms Australia (SoFA) was the recipient of $1 million in funding
from DEEWR’s Innovation Fund to carry out its Local Employment Access
Partnerships (LEAP) for Job Seekers with Mental Illness.[172]
4.196
LEAP was a three year project that ran until June 2012. According to the
SoFA website:
During this time, 340 + job seekers with a mental illness
will be supported to manage anxiety and other symptoms and improve job
readiness skills to secure and sustain employment.[173]
4.197
The Social Firms Australia (SoFA) website outlines the premise and
strength of the LEAP approach, which was established in six localities in
Victoria, five in Melbourne and one in regional Victoria:
LEAP partnerships promote service integration and provide
wrap-around support for people with mental illness who are preparing for paid
employment. The partnerships meet on a quarterly basis and also collaborate to
deliver the Health Optimisation Program for Employment (HOPE).
HOPE assists job seekers with a mental illness to take
greater control of their wellbeing and has been adapted from an evidence-based
psycho-educational program.
HOPE is delivered jointly by a mental health peer educator
and facilitator.[174]
4.198
Ms Dea Morgain, Manager, Workplace Supports, SoFA, elaborated:
[LEAP] brings together the clinical mental health services,
the rehab services and the employment services and provides the opportunity for
those services to actually speak to each other outside of the requirements of
case planning, so that there are established relationships...between clinicians
and employment services...the discussions vary between the partnerships but
they undertake service-mapping, trying to identify gaps in service delivery.[175]
4.199
Ms Morgain later provided an independent evaluation from the company
‘Effective Change’ which found the successes and outcomes of the LEAP
partnerships to be:
n Improved
communication between agencies about strategies to assist job seekers with
mental illness to achieve their vocational aspirations.
n Increased inter
agency referrals and improved referral protocols. In one partnership this has
resulted in the employment service locating an employment consultant at the
mental health clinic.
n A better
understanding on the part of mental health clinicians of the services provided
by employment services, Centrelink procedures and vocational rehabilitation
approaches. Improved knowledge of mental illness diagnoses, symptoms and treatments
on the part of the employment services.
n All partner agencies
have felt that the benefits of belonging to the partnership have significantly
outweighed the time required to be involved.[176]
4.200
Ms Morgain added that while funding for the project ceases on 30 June
2012, the partner agencies from each area intend to continue meeting and SOFA
will assist as resources allow.[177]
CRS , VETE and Headspace
4.201
Headspace was launched in 2006 and is funded by the Australian
Government under the Promoting Better Mental Health –Youth Mental Health
Initiative. There are 30 Headspace centres around the country, in each state
and territory, metropolitan, regional and remote locations. These provide
youth-friendly community based services to young people aged 12-15. All
Headspace centres have a suite of services on offer, including allied health,
drug and alcohol workers and mental health practitioners.[178]
Centrelink and CRS are other services on-hand, specifically to help young people
access education, training and work opportunities.
4.202
The Committee visited the Central Coast Headspace in Gosford on the same
day that it visited Youth Connection’s[179] Green Central site (see
Chapter two for more on that visit).
4.203
In addition to Youth Connection, Headspace Gosford’s other consortium
partners comprise: NSW Government Health Central Coast Local Health District
(the lead agency); NSW Government Central Coast Local Health Network –Central
Coast Children and Young People’s Mental Health (CC CYPMH); the NSW Government
Central Coast Local Health Network – Area Drug and Alcohol Services – Central
Coast Sector; Central Coast Division of General Practice; and The Brain and
Mind Research Institute.[180]
4.204
Headspace is co-located with Y-Central at the Gosford site.
4.205
The Y-Central website sets out its mission:
Y-Central is funded by NSW Health, through the Youth Mental
Health Service Model – Central Coast pilot project.
The CYMPH Program is oriented towards mental health
promotion, prevention and early intervention. The program’s youth-friendly
venue, y-central, promotes easy access to mental health services for children
(12-25years) and their families. There are also crisis entry points for
children and young people to promote engagement and the provision of
comprehensive assessments and appropriate management. [181]
4.206
Other services available to Gosford clients on-site include Wesley
Mission’s Get it together (GIT) program and a tenancy advisory service.[182]
4.207
Headspace was another strong advocate of integrated holistic services
(drawing on and endorsing the research findings of other expert witnesses to
the inquiry, such as Professor Killackey and Dr Geoffrey Waghorn).
4.208
Headspace pointed to the many benefits of having a vocational
intervention co-located with a clinical service, including:
n [in relation to
Killackey’s 2008 study into a group of young people with first episode
psychosis], that young people receiving this intervention were more likely to
gain employment, worked more hours, earned more money and stayed employed
longer than the group of young people who did not receive the vocational
intervention; and
n [in relation to
Waghorn and Drake’s 2003 study], that integrated services have the following
advantages:
Þ Lower
client drop-out rate
Þ Clinical
information gets into vocational plan preventing job loss
Þ Both
health and vocational outcomes are optimised
Þ The
clinical team can help with assessments
Þ Employment
goals lever treatments; and
Þ Employment
staff facilitate timely re-access to mental health services.[183]
4.209
Established in 2007 to provide employment and education support to
people receiving community mental health services in the Northern Sydney and
Central Coast regions, Vocational Education, Training and Employment (VETE) is
part of Northern Sydney and Central Coast Local Health Districts. VETE
consultants with experience from federally-funded employment programs are
recruited and employed within health service funding.[184]
4.210
The service caters for people in the public mental health system, and
seeks to improve their participation in education, training and employment.[185]
A VETE employment consultant is co-located with the CC CYMH and Headspace
precinct in Gosford, working two days a week with young people with a diagnosed
mental illness.
4.211
VETE interventions are tailored to the individual and may include the
following forms of advocacy and assistance:
n Vocational
counselling
n Benefits counselling
– to assist consumers understand Centrelink guideless regarding the number of
hours they are permitted to work and the impact of income from employment on
their Centrelink benefits
n Direct referral to
Disability Employment Services
n Gathering supporting
medical documentation required by consumers attending the Employment Services
Assessment (DHS process)
n Facilitating the
communication of relevant disability related information between internal and
external service providers
n Monitoring consumers
rehabilitation progress once they have been linked with a suitable DES provider
n Supporting consumers
to identify suitable courses and to enrol at educational institutions like TAFE
n Referral to
specialist disability support services at TAFE and University
n Providing resources
to clinicians and consumers regarding vocational/career/training information
n Assisting with the
identification of suitable volunteer positions
n When required,
developing plans with consumers to make a gradual transition towards employment
taking into account their skills, mental and physical fitness, social and
interpersonal skills and understanding of the labour market.[186]
4.212
VETE provided data indicating the numbers of people helped into
employment, education and training, across all four sites, including Gosford.
4.213
VETE states that the following positive outcomes account for 70% of the
1776 individuals who proceeded with the VETE Service (out of 2000 referrals in
the last 5 years):
Figure 4.3 Vocational Outcomes 2007-2011
Outcomes
|
Number of clients
|
Employment
|
246
|
Education / Training
|
218
|
Improved Vocational Skills /
Resources
|
421
|
Linked with Employment
Service Providers
|
257
|
Volunteer Work
|
53
|
Social Participation
|
42
|
Source VETE
Submission 70, p. 8.
4.214
VETE pointed to an oversubscription of its Gosford service and the heavy
workload to-date on its one part-time (0.4 FTE) VETE consultant:
Since 2007, approximately 400 referrals for vocational and
educational services have been received, which equates to 100 referrals a year.
Data from Central Coast Headspace indicates that for the 12 month period from
July 2010-to June 2011, there were 127 young people accessing Headspace who
presented for mental health issues and also expressed an interest in or
demonstrated a need for vocational services....[but] were not eligible for VETE
services because they did not meet the criteria for CCCYPMH. Using this as a
guide, an increase in VETE would be warranted in order to provide vocational
support for more young people.[187]
4.215
VETE highlighted the importance of inter-agency cooperation and network
building between agencies providing vocational services for people with a
mental illness:
The aim of the partnerships is to break down barriers between
organisations and share information of mutual benefit by having improved access
to external programs, including TAFE and DES.[188]
4.216
VETE says it achieves this through regular interagency committee
meetings and participation in a variety of separate meetings organised by
external partners e.g. with Centrelink and the National Disability Coordination
Officer.[189]
4.217
Underpinning the success of a co-located venture such as that between
Headspace, Y-Central, VETE and various other service providers at the Gosford
site, is an agreement between the parties to work together. Physical
co-location may be an added benefit, but may not necessarily be critical. Ms
Susan Robertson, Managing Director, Edge Employment Solutions suggested:
I think the critical element is the agreement between the job
seeker, their clinical provider and the agency all signing off on the need to
contact each other regularly, and having that agreement in place at the outset.
That will produce the best outcome. The co-location is just an added issue that
may be a bonus or not.[190]
Orygen Youth Health - Individual Placement and Support (IPS)
4.218
Orygen Youth Health (OYH)’s principal recommendation to the committee
was that:
Mental health care and vocational support for young
Australians with mental illnesses should be integrated and co-located in
appropriately resourced youth platforms headspace and EPPIC.[191]
4.219
Professor Eoin Killackey believes this is important because it is so
difficult for people to have to navigate their way through separate services,
mental health, and employment.[192] OYH claims that this
difficulty is compounded by poor coordination between the two and the two
different systems have two sets of priorities that may not always align.[193]Moreover:
Employment is a key rehabilitative part of the process of
someone’s journey towards recovery; it is not something else.[194]
4.220
Orygen asserted that:
Headspace for moderate to mild mental ill-health and EPPIC
for serious mental illness –can provide this type of integrated clinical and
employment support to young Australians. Currently these service platforms are
not readily available to most young Australians who could benefit from them.[195]
4.221
As noted earlier in this chapter and in chapter one, the Commonwealth
Government, through the federal budget, has recognised the utility of and
committed additional funding to expand both the headspace and EPPIC models.
4.222
The OYH organisation, based in Melbourne, provides comprehensive
clinical services to young people aged 12 – 25 years with mental health issues
in the western and north-western areas of Melbourne. Their services include inpatient,
acute, outreach, case-management, psychosocial programs, peer and family
support.[196]
4.223
Professor Killackey, Director, Psychosocial Research, OYH, described the
service further:
It sees people from a catchment area of around one million
people, of which around 250, 000 are in the age range from 15-25. Each year it
receives around 2000 referrals and can take on around 700 of those people. It
does that under two main areas. One is the early psychosis area, which is
called EPPIC. The other area deals with people who have non-psychotic
illnesses, which is broadly called Youthscope, and there are a number of
sub-clinics to that.[197]
4.224
The website for the Early Psychosis Prevention and Intervention Centre
outlines the EPPIC program, namely that it is a dedicated early psychosis
service within a dedicated youth service, Orygen Youth Health, and involved in
research activities, primarily through the Orygen Youth Health Research Centre:
The aims of EPPIC are:
n Early identification
and treatment of the primary symptoms of psychotic illness
n Improved access to
and reduced delays in initial treatment
n Reducing frequency
and severity of relapse, and increasing time to first relapse
n Reducing secondary
morbidity in the post-psychotic phase of illness
n Reducing disruption
to social and vocational functioning and psychosocial development in the
critical period following onset of illness when most disability tends to accrue
n Promoting well-being
among family members and reducing the burden for carers
The aims of treatment are:
n Explore the possible
causes of psychotic symptoms and treat them
n Educate the young
person and their family about the illness
n Reduce disruption in
a young person’s life caused by the illness, restore the normal developmental
trajectory and psychosocial functioning
n Support the young
person and their carers through the recovery process
n Restore normal
developmental trajectory and psychosocial functioning
n Reduce the young
person’s chances of having another psychotic experience.[198]
4.225
OYH’s research arm, the Orygen Youth Health Research Centre, has
developed innovative service models and conducted leading research in the area
of vocational rehabilitation for young people with psychosis and other mental
illnesses. It is worth noting that OYH believes that many of the observations
and recommendations it makes for this cohort would also be valid for older age
groups too.[199]
4.226
The third tranche of OYH’s work is its training and communications
program which seeks to provide training and resources to improve the
understanding of mental health issues in young people and to promote the
capacity of the general public to support young people. OYH works with a range
of organisations from health services, schools, drug and alcohol services,
corporate organisations and sporting groups to achieve this.[200]
4.227
The Committee visited Orygen Youth Health premises on 12 April 2011 to
meet with staff and clients.
4.228
Professor Killackey outlined OYH’s research agenda and outcomes to-date.
He said:
We did the first-ever trial in the world of an employment
intervention for young people with first episode psychosis, and following on
from that we are doing a much bigger trial, which we just started recruiting
for last week, that will be the biggest trial of its sort in the world and
should give us a better ability to answer questions around the economics of
this sort of intervention as well as answer things like: do people who get jobs
use health services less, do they have fewer symptoms, do they use fewer drugs,
do they just generally have better and more productive lives?[201]
4.229
Essentially:
Research in Melbourne (by Orygen Youth Health Research
Centre) and in the USA demonstrates that 85% of this group of young people can
return to work or education if provided with an intervention that integrates in
one service platform both timely, evidence based clinical care and intensive
employment support.[202]
4.230
Orygen utilises the Individual Placement and Support (ISP) method of
supported employment. ISP is a group of interventions that aims to helps people
get into employment quickly and supports them there. It adheres to seven
principles:
n Competitive
employment
n Open to anyone, no
work readiness assessment
n Immediate job
searching
n Integrated within a
mental health program
n Jobs based on
consumer preference
n Time unlimited
support
n Personalised benefits
planning.[203]
4.231
Professor Killackey emphasised that IPS harnesses people’s enthusiasm
and clarified that Orygen offers 6 months of support, rather than
time-unlimited support, for funding reasons.[204]
4.232
Early intervention is integral to the IPS model. Professor Killackey
pointed to the potential to keep people away from going down the, potentially
demoralising and dispiriting DSP path:
Early intervention around these issues might actually
circumvent some people- or perhaps quite a lot of people- starting on the DSP.[205]
Being on a DSP is a safe place to be, but there would be very
few people on the DSP, I imagine, who feel that they are achieving the
potential that they wanted to achieve in their life.[206]
4.233
Professor Killackey indicated that the results so far are very
promising. Referring again to their 85% success rate, and others, he
elucidated:
There is an average return across nine studies in the US,
Europe and Asia of 61 per cent compared to 23 per cent in all the various
control groups that they were using. There have been two randomised controlled
trials in first episode psychosis now: ours and another one at UCLA. Ours got
85% back to school or work {out of 41 people in total: 20 and 21] and the one
at UCLA got 83 per cent {out of 60 people: 30 and 30].[207]
4.234
Professor Killackey stressed that the improvement is significant:
It is like a three –to fourfold difference.[208]
4.235
Ms Gina Chinnnery, employment consultant described her role at Orygen as
‘finding people the kind of work that they want to do and following that up
with support’.
4.236
Ms Chinnery described the support she offers, some of which she says
might seem ‘basic stuff’ –be it how to answer the phone to dressing
appropriately for interviews and obtaining a tax file number- but not to those
who come from families who have only ever known being on welfare:
With quite a few of the clients I work with, their parents
have never worked-they have always been on the pension or the dole...so it is a
real learning experience for them too.[209]
4.237
That said, she emphasised how keen most young people were to work, and
were supported to do so by their families:
They have volunteered for this service and they just want
things to get moving as soon as possible...we kind of steer away from that
prevocational job search training stuff, because you are just spending all this
time talking and they are getting bored waiting.[210]
4.238
Miss A, a client of Orygen Youth Health said that, by contrast, her
family had not been supportive, but she could rely on, and valued, her
professional support networks.[211]
4.239
Professor Killackey commented on the intensive level of support provided
during the six month period, and the subsequent trust and rapport built up
between the employment consultant and client. One of the benefits of this
approach is that it can act as an early warning system to detect and resolve
any problems quickly:
Quite often she will take people to work at the start and
will be in close contact with them. Because she has achieved an outcome for
them that they really quite value, quite often they will call her as a first
point of contact rather than their case manager., so she is aware of when
things begin to deteriorate, quite often, earlier than the mental health system
is and earlier than the employer. She is able to put in place a program to
manage that. For some people that involves talking to the employer.[212]
4.240
In terms of scaling up Orygen Youth Health’s employment consultant
model, Professor Killackey said that his ARC funded study will determine the
economic benefits or otherwise of so doing:
We have just finished recruiting for that study, so it still
has 18 months to run before we finish collecting that data...We did a really
rough back of the envelope analysis after the first study, looking at how much
it costs us to employ Gina and what outcome payments we would have got had she
worked through the Job Network or one of the job service agencies. It pretty
much just broke even. It is not a diligent economic analysis, but that is why I
have involved economists in the ARC study.[213]
4.241
Professor Killackey said that they cap their case load for their
employment consultant at 20: to give the client the individual support and
attention that they really require, and it was on that basis that she broken
even, but admitted that was financially difficult:
We would probably struggle now, but that is more to do with
the University of Melbourne’s pay rises in the last few years than it is with
the market rate for an employment consultant.[214]
4.242
Professor Killackey’s observations are consistent with Dr Waghorn’s
findings that case loads in the employment services can be too high. In his
experience, 25 or fewer per employment specialist tends to work very well. Dr
Waghorn advised:
What we find happens is that if we get the case load to 25 people
or fewer, even if they have severe disabilities does not matter...We then get
the employment specialist to adopt the evidence based practices and then do
things with stuck clients, like not to ignore stuck clients. ..You need to be
doing something with people every week..We have found that employment
specialists who actually do these practices and follow through with every
client and provide good post-employment support service achieve way in excess
of even the research expectations – 100 per cent employment outcomes is
possible, even in impoverished labour markets. The Thames-Coromandel Peninsula
in New Zealand is one really good example. ...there is almost no employer to be
seen. There is the occasional run down corner store...You just cannot see any
employers, but there is an employment specialist there, Workwise Employment
Agency, who gets almost all of her clients into employment, every time. ...She
gets to know everything in her territory and she is actively involved.[215]
4.243
While the studies have been with consumers with psychosis, Orygen opens
that service up to its broader client base (which includes people with
depression, anxiety and personality disorders) in between studies and has found
that:
Not that we have systematically evaluated that, but there
seems to be a great deal of satisfaction of the case managers in those clinics
that their clients are getting employment or education outcomes from that
service.[216]
4.244
Orygen mentioned an interesting research gap, namely a lack of research
on educational interventions. They say there is evidence to suggest that where
education is included in an IPS approach that people make a transition from
education to work. In a pilot study that Orygen completed with 19 young people,
they found that with a similar approach to that taken for employment
interventions, namely early intervention and intensive support, 18 of them
achieved successful educational outcomes.[217]
4.245
Orygen would ideally like to see employment consultants funded as members
of mental health services and that they be called vocational recovery or
vocational rehabilitation services, thereby moving away from an association
with disability terminology.[218]
4.246
The next section on state approaches will consider what New South Wales,
Queensland and South Australia are doing in respect to integrating employment
consultants in their public mental health services.
NSW
4.247
Professor Killackey of Orygen Youth Health told the Committee that he
believed there was some fundng in New South Wales:
I think there are about 20 people who work in the same
capacity as Gina does across a number of mental health services, but as Laura
[from Mental Illness Fellowship Victoria] said, what we probably really need is
three or four people per mental service to do that.[219]
Queensland Health
4.248
Dr Aaron Groves, Executive Director, Mental Health, Alcohol and Other
Drugs Directorate, Queensland Health, spoke to the Queensland Government’s
commitment to placing employment specialists in a number of their mental health
services.
4.249
Dr Groves described the Queensland Government’s whole-of-government
response, which targets people with a severe mental illness, in particular
psychosis, because these are the people most likely to experience difficulty
procuring employment, educational participation and social inclusion. However,
he said the benefits extend more broadly to others with mental illness in the
public mental health system. Overseeing this approach is a:
...peak government committee that consists of representatives
from not only our education and training departments but also from [the
Department of Employment, Economic Development and Innovation], Queensland
Health, police, corrective services and Commonwealth Departments that are situated
here in Queensland to make sure that all our programs can work together.[220]
4.250
Dr Groves backgrounded how, based on evidence from Dr Waghorn, and with
drive and determination from consumer consultants (people in various stages of
their own personal recovery who are now employed by Queensland Health), and
also DES providers, Queensland Health had developed a pilot program called the
Queensland Health Employment Specialist Initiative (Employment Specialist
Initiative ) in eight demonstration sites, spread across the state so that every
district has a stake:
We gave funding to organisations to come and work within
mental health teams. The idea was to try and break down the barriers- as much
as with the mental health staff who probably have some of the most stigmatising
attitudes toward people with mental illness in our community-about the issue of
people with severe mental illness having the ability to go back into the
workforce.
[Consumer consultants] were the strongest advocates for
saying to staff and to the DES providers, ‘There are a whole bunch of people
who really want to get a job; it is just that nobody has actually ever made
those opportunities available to and open for them.’ It probably took the best
part of a year, but by and large that worked quite well in terms of breaking
down some of those issues.
The other thing that impressed us was that the feedback from
the DEN providers, as they were then, was that to some extent we were probably
the best value of money for them [because the clients wanted to work]..they came
to us and said we actually do better with referrals from you that we do from
other people who are coming out of other forms unemployment.[221]
4.251
The Employment Specialist Initiative co-located an employment consultant
from a local DES in a public community mental health team to work
collaboratively with consumers in helping to find work in the competitive
employment market, using the evidence based supported employment model.
Findings from the pilot included the following successful consumer outcomes:
n Increased
independence, self-esteem and confidence;
n Increased sense of
empowerment and control in life;
n Increased work skills
and career opportunities;
n The development of
new friendships; and
n Greater connectedness
to the community.[222]
4.252
Dr Groves added:
We have been able to get hundreds of people into some level
of employment and some of them into full-time employment. This is for a group
of people who most often the mental health service would not believe they would
have got any form of employment again. There are quite staggering case studies
and histories.[223]
4.253
Queensland Health no longer funds this initiative, other than for research
and collecting data, in order to ‘better show the benefit of this’ because:
[Service providers] actually find it is a viable option for
them in terms of their placements and the funding they get from the
Commonwealth.[224]
Complex needs panels
4.254
Complex needs panels are another Queensland initiative. Dr Groves
explained how they fit into the bigger picture of care-coordination:
One of our [important whole –of-government approaches] is our
care coordination approach where we have tried to get all those Queensland
Government departments and those Commonwealth Departments that we can to agree
to a common approach to taking away any barriers towards inclusion into
programs. We noticed in 2006 when the COAG [mental health] plan was put in
place that one of the common features was that different departments had
different inclusion criteria and different exclusion criteria so somebody could
be getting services from one government department but not form another. So we
have developed MOUs and service agreements across all the Queensland Government
departments to ensure that a particular group of people with the most complex
needs get access to services as a priority, irrespective of where they might
otherwise sit on a priority list. It has also been an important part of
embedding that process that we have put in people in places to develop those
relationships between service providers to ensure that if any gaps do crop up
or if any barriers become apparent they are dealt with at the local level.[225]
4.255
Dr Groves set out how the 20 people employed as dedicated ‘service
integration coordinators’ work across 17 districts in Queensland Health:
They set up a number of things, although complex needs panels
are probably one of the most frequent things that they set up. Those people
with the highest levels of needs – that is not everybody with a mental illness-
can get referred to that panel. It is very good for sharing information without
needing it to go through the usual blockages that the health system puts on
sharing information with other agencies. That panel talks about what a person
needs from more of a problem oriented approach than a symptom oriented
approach. They key issue is identifying what types of services are required and
how to provide them rather than what particular symptoms that a person has or
obstacles that they face.[226]
4.256
One of the components key to the success of the care coordination approach
appears to be obtaining senior leadership buy in. Queensland Government
enlisted the support of director-generals of departments and regional directors
and:
In general, there is pretty good support for people to come.[227]
4.257
Another important factor is that:
It is a very structured set-up which meets monthly and they
are very committed stakeholders.[228]
4.258
The Committee met with members of the Gold Coast complex needs panel.
4.259
Ms Phyllis Quensier, Service Integration Coordinator, Gold Coast Health
Service District, Queensland Health talked about the three panels that operate
on the Gold Coast, catering for different demographics, and funded by various
organisations. She explained that they are run separately, but panellists also
work together and are ‘constantly in touch’:
I believe we are quite unique in Australia on the Gold Coast
because we actually have three panels that look at age groups from 10-64. I
work for Queensland Health and I look at the 16-64 group with severe mental
illness. Grant works for the Gold Coast Drug Council and he looks after the
panel that looks at dual diagnosis between the ages of 17-29. Tanya is not here
today, but we have another group that looks at the younger group,
10-17...auspiced by Wesley Mission.
We sit on each other’s panels. We also have annual summits
where we meet. About 70 people attended last time we had one. All the different
coordinators and panels go there. We talk about capacities, any trends or
issues that are coming up, what works and what does not work, and we might give
a case-study to show people an example of what we do on the panel.[229]
4.260
Ms Quensier explained how they work:
They are all different, but I have one for three hours once a
month. I have had up to four new clients and about three referrals of that
client at one meeting, which involves a lot of discussion. I have about 50
clients on the books now, which is a lot.[230]
4.261
Mr Robin added that sometimes clients attend, other times they do not.
The referring clinician comes and the employment services. Ms Quensier
commented that ‘Centrelink come ad hoc but they need to be there more
regularly.’[231]
4.262
Ms Quensier emphasised how critical the notion of partnerships is to the
complex needs panel concept:
Partnerships are the biggest help. The people who sit on the
panel and are committed to the panel and want to help are the biggest support
system that we have. It helps with access, it helps with streamlining referrals
and follow-up and it helps with gaps. [An example is sharing knowledge of
clients so that for instance someone on a younger age group panel can be
transitioned to another panel once they reach the age of 18].[232]
4.263
Mr Tawanda Machingura, Assistant Director of Occupational Therapy, Gold
Coast Health Service agreed:
I just want to emphasise community partnerships and give an
example of what we are doing in the Gold Coast service. We know that for
someone to have success in employment it is because there are a number of
services working together. If we have a barrier in one of those services, then
we are unlikely to get a good employment outcome. One of the things we have
done is to have employment services be available to clients within the mental
health service itself, and that works so well because they are available and it
improves access to those services.[233]
4.264
Mr Grant Robin, Program Director, Gold Coast Health Service District,
Queensland Health, spoke on behalf of his panel, the Complex Needs Assessment
Panel and Integrated Services (CNAPIS), which often has employment services
make referrals to it:
We engage them and have a look. I can give a family as an
example..she had so many issues with regard to a DV situation. ..There are a
whole lot of other priorities. We as a collective can sit around the table and
say, ‘Well, although she has come through an employment stream and she is kind
of being mandated to find a job, otherwise there will be implications for her
benefit..hang on a second, there is a whole lot of other priorities that we
need to address, there is a lot of advocacy that needs to happen, there need to
be referrals, there needs to be management not only of her situation as the
primary referral but also in the context of the family system...That is the
wonderful work we can do.[234]
4.265
Ms Christine Shaw, Acting Coordinator, Mental Health Recovery Program,
Ozcare summarised the positive impact the panels had on one of her clients:
My usual role is that of mental health support worker. ..I
work directly with clients on the ground level. I referred a client to a panel
and supported him with the panel. I just cannot emphasise how valuable it was
for this person to be at the panel. Probably one of the biggest benefits for
him was having a lot of trouble from different services that actually have the
power to say right there and then, ‘I’ll do this; I’ll do that, and it is done
and followed through. If we were to try to access those people out in the
community, it would probably take three weeks, or maybe longer, of trying to
arrange appointments and a lot of anxiety and stress for the clients waiting
for letters to come back...When we left there the client said he felt like a
weight had been lifted from his shoulders and that he hoped for a good outcome.
His issues have become manageable. So the panel was excellent for that.
South Australia Health- an integrated service delivery model
4.266
The Committee visited the Noarlunga Adaire Clinic, a specialist mental
health service providing mental health care in the community in outer suburban
Adelaide in South Australia. The clinic serves emergency presentations, first
presentation of an early disorder (early psychosis) and clients who require
mental health assistance for a period up to six months.[235]
4.267
Mr Todd Bamford, Team Leader, Transitional Care and Early Psychosis, and
Noarlunga Emergency Mental Health Services, Southern Mental Health, Adelaide
Mental Health Service, South Australia Health spoke to policy development work
he did and the preparation of a discussion paper about the benefits of bringing
into being an integrated service delivery model where employment and clinical
mental health services work together to help clients with a mental illness:
The discussion paper was intended as a synthesis of the
evidence based around better employment outcomes for people with serious mental
illness as well as triggering some thinking amongst the relevant stakeholders
around what sorts of different ways of working we would need to adopt to
actually implement the evidence based practices for employment outcomes.
The evidence was very clear that an integrated service
delivery model is far more effective when you are looking at hours worked and
the length of time in employment, and even simply rates of consumers achieving
employment...From the mapping we did, it did not look like we had anything like
that evidence based model in existence...We brought together stakeholders from
non-governmental employment services, non-governmental mental health services,
clinical mental health services, consumers and carers, education providers and
Centrelink.. We consulted around the State...We were talking about bringing
together two very complex systems, the employment services sector and the
health services sector. We needed those stakeholders to tell us about the
problems and then start working on the solutions. – and they did that.[236]
4.268
Mr John Strachan, Acting Outer South Sector Manager, Southern Mental
Health, Adelaide Health Service, South Australia Health provided some context
for Mr Bamford’s paper, saying that it complemented an earlier Stepping up
report of 2007 which set the platform for broad reform in South Australia’s
mental health system and the state’s commitment to giving staff the tools and
system design to provide the services to better consumer outcomes. He described
the very dedicated way that Southern Mental Health approached change
management:
W really worked hard on developing role clarity. One of the
most important things for our services in public mental health is to be clear
about the service, the roles and the functions that we provide. And that was
the same for the disability employment services because, again, if you want to
start busting myths around what we do, the clearer we are with our roles and
functions, the greater the opportunity to work together.
We did a lot of training and training requirements.
Information sharing was a big issue....obviously this is
driven by consumer consent. We made sure that with consumer consent, our
medical records, or out case notes, were accessible to the disability
employment staff. We wanted to make sure each one of our consumers in the
public sector has a care plan. The intent of that care plan is a
consumer-driven care plan, but we wanted the employment part of our partnership
to be reflected in each consumer’s participation in that care plan.
We made sure there were some shared values and a shared
vision for case reviews.....Other things were conflict resolution, points of
accountability and starting out an evaluation process, ensuring and really
supporting that employment is part of the rehabilitation journey that our
services provide.[237]
4.269
Mr Strachan highlighted the commitment they put into getting people on
board with the new concept:
Engagement with staff...the pre-staff surveys and the
post-staff surveys we have done really reflect a robust uptake of what people
saw as a positive way to deliver more effective rehabilitation services.
There was a strong investment in supporting families and
cares to understand that this is a positive journey for their loved ones, not
something that is going to make them lose their DSP or make them fall over and
go into hospital.[238]
4.270
From the consultative process consensus on a service model and
service-level agreement was reached.
4.271
Mr Strachan set out how the new service commenced in the Trevor Parry
Centre, a residential community rehabilitation service for consumers with
severe and enduring mental illness, and has since also been adopted by Club 84,
another psychosocial rehabilitation program in the north-east.[239]
4.272
Mr Strachan reported encouraging results thus far. At Noarlunga, over
the past 11 months, out of 21 residents that have gone through the centre, 14
have now registered with the Employment Access Service and are talking about
their employment options. Nine consumers have completed a job capacity
assessment. Six people applied for paid employment. Three have enrolled in
further study or training. And, four people have commenced voluntary work. He
said:
We feel very proud of these outcomes because prior to this
opportunity none of these consumers were actively working with us to access
open and full employment.[240]
4.273
Of Club 84’s outcomes he stated:
They have got three hours a week with a disability employment
service provider coming in and being part of the integrated team. They have had
20 consumers register with Employment Access. They have had eight complete a
JCA. Five have completed resumes. They have had four who applied for paid
employment. Six individuals attended interviews. We have had four who commenced
and been successful in gaining paid employment, and this is full employment. We
have had three who have undertaken further studying and training, and four who
have undertaken and commenced volunteer work. So again, some really wonderful
outcomes and, again, working with those consumers with the most severe and
enduring mental illness and disabilities associated with that.[241]
4.274
The success of this integrated employment service and clinical mental
health service model is underpinned by an equally committed disability employment
provider, in this instance, UnitingCare Wesley Port Adelaide Employment Access
service:
They really saw the benefit of participating in the change
management approach to try and get an agreed shared vision; they saw that real
need and the desire for change. I guess the important things from the
UnitingCare Wesley Mission service provision was that they were the specialists
that came in and were able to dispel an enormous amount of myth..including
[dealing with] issues of disclosure in the workplace. What we worked out and
started to learn really fast was that, if we were able to respectfully
disclose, with consumer consent, we could set up a really strong support system
around that consumer and employer to make sure that we give that person every
chance of genuine success in maintaining and sustaining their employment.[242]
4.275
As with the Queensland model, teamwork is key. Mr Bamford elaborated:
There is a relationship between the employment specialist
and the mental health coordinator or the mental health specialist. When they
are part of the same team....the relationship is ongoing and daily. That then
overcomes the batching of all the big decisions to a three-monthly case
conference or clinical review....There are multiple opportunities to influence
that care plan.[243]
4.276
Also, like the Queensland model, the Southern Mental Health model has so
far only dealt with and reached small numbers of people. Mr Strachan indicated
that the potential is there to scale the model up and extend it to the far
greater numbers of community-based clients who have a care plan but access it
more infrequently:
The potential is there. The desire is there. Our staff want
it. Our staff keep asking for it. But it is capacity....[244]
...rolling it out to a community team with 500 consumers is
taking a whole other journey.[245]
4.277
Mr Bamford intimated that this may not necessarily be a case of
utilising further resources; existing ones may be sufficient. Nonetheless, an
integrated model does require commitment and drive:
..for integration to happen, someone needs to support that
integration – someone to actively support that change and then embed that
change over time. John talked a bit about how they have done it with existing
resources, and that is half a day a week from the employment specialist.[246]
4.278
The Committee can see the many benefits that a service model that
integrates employment and clinical services can entail for the consumer but
notes that to-date these have only operated on a small scale.
Recommendation 15 |
|
The Committee recommends that the Commonwealth Government
explore ways, in partnership with the states and territories through COAG, to
support Individual Support and Placement (ISP) and other service models that
integrate employment services and clinical health services. |