Generating revenues: fiscal changes in public mental health care and the emergence of moral conflicts among care-givers.

Abstract

The author examined how the focus on financial accountability in the public mental health sector has affected direct service providers' experience of their work. This was a two-year mixed method study conducted throughout one small, state-run system. Data that were collected include field notes taken in the course of participant-observation research, tape-recorded semi-structured ethnographic interviews, as well as responses to an ethnographically-informed survey instrument that was administered to providers throughout the system. Interview materials suggest that care-givers view their jobs as a "calling," work that they perform in the service of something greater than themselves. As the public mental health sector increases its emphasis on fiscal issues, however, these employees are experiencing heightened moral tensions around their work. Jobs that were once conceptualized as being done "for love" now are being done "for money" - a change that represents a moral contamination of the workplace for many individuals. The goal of enhanced fiscal accountability in the public mental health system is to increase service effectiveness and cost-efficiency, that is, to do better work and to do it for less money. These study results suggest that this strategy could backfire, as some service providers must focus less on the qualities of the services they deliver, and more on the quantities. The study encourages mental health services researchers to incorporate ethnographic methods into study designs so that participants' experiences can be taken into account when evaluating the impact of system changes.