Social experiments not the solution for mental health care

This guest blog post is by Mark Henrickson, Shirley Jülich and Ksenija Napan all of whom teach and research in the School of Social Work at Massey University in Auckland.

Over Queen’s Birthday Weekend, the New Zealand public was quietly exposed to the concept of ‘social bonds’. According to the Ministry of Health, social bonds seek private and not-for-profit organisations to partner in order to fund and deliver services to improve social outcomes. If they achieve agreed results, Government will pay the investors back their investment plus a return. According to the Ministry website, this concept has been floating around New Zealand since 2013. The fact that it was announced while we were enjoying our last holiday before Labour Weekend suggests that social bonds is not a flagship programme for this government. We have not seen the full plan. But we are deeply concerned by what we have heard so far.

Mental health disorders are the third leading cause of health loss for all New Zealanders. Women are 1.6 times more likely to have been diagnosed with a mental health disorder than men. Clearly mental health disorders require careful policy attention. Social bonds initiatives have been trialled in the United Kingdom, United States, South America, Holland, South Africa, Belgium and Australia. The number of Māori and Pasifika in these nations is tiny, yet according to the Ministry’s own data, Māori and Pasifika account for nearly half of people with mental health disorders in New Zealand. It appears that the New Zealand government is proposing to carry out a very large social experiment on already vulnerable and marginalised communities.

Social bonds are an extension of a neoliberal agenda that holds that government should get out of providing care for people, and that the private sector provides more efficient solutions and more effective incentives. Treatment success, for this government, means putting people in work. While we do not dispute the value of meaningful work, this measure assumes not only that there is adequate meaningful work to do, but that employers are willing to take on individuals with mental health histories. There are some excellent employment programmes in New Zealand that return people with mental health histories to work, but such programmes ensure that there is adequate training and support for both employee and employer. What will be the effect of repeated rejections on an anxious client’s mental health? How salubrious will a job picking up rubbish be for a depressed client? What will be the impact on a person with a bipolar disorder who starts a job, but then is told during the 90-day evaluation period that they will not be a good fit with the employer organisation? If employment is government’s outcome measure of success, government resources would be better spent identifying best practice models of preparation for work, expanding and replicating them, addressing stigma, and incentivising employers to hire and retain employees with mental health histories.

The proposed $28.8 million social bonds initiative assumes that mental health care agencies are somehow insufficiently motivated by caring for clients, and require the threat of financial penalty in order to – as the Minister of Health said – ‘sharpen their minds’.

Setting aside the implied insult in the Minister’s observation, outcomes and success are difficult to measure in mental health care. What is the outcome measure of success for a high-needs client whose weekly goal is to take a shower, or to use the toilet rather than soil his clothes or the floor? Yet there are many such high-needs clients—clients not only with chronic mental health disorders, but also with accompanying challenges such as substance misuse, brain injury, other physical health conditions, or with complicated legal and forensic histories perhaps due in part to their mental health issues. The Minister denies that ‘cherry picking’ by investors will be possible, but how likely is it that such complex clients will attract profit-motivated investors? Social workers, counsellors, nurses, psychologists, psychiatrists, physicians and other care and support staff work daily with such clients to achieve small, barely measurable successes because they are committed to the work of caring, not financial profit. These professionals are far better equipped to provide effective care than people who speak the language of investment and shares. If Government wants mental health agencies to prove that they are efficient and effective, then resources could be better spent matching technical assistance to mental health agencies to help them develop evaluation plans and measures that will appropriately demonstrate the incremental successes that occur.

If New Zealand wants to be a world leader in effective and efficient mental health care, then we need to commit resources where they will be most effective: assisting mental health agencies to develop evaluation models, addressing stigma, incentivising employers, and above all consulting with sector stakeholders about ways to improve services. Social experiments are not the solution.

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Some additional resources on social bonds

Bill English on social bonds (TVNZ, June 7th, 2015)

Panel discussion on social bonds (TVNZ, June 7th, 2015)

Bottom Line for mental health services (NZ Herald: June 4th, 2015)

Social bonds: dangerous experiment or better services? (Radio NZ: June 2nd, 2015)