A call for action, not another review.
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Newspaper headlines from 20 years ago look surprisingly familiar ("Mental Health’s Revolving Door", "The Depressing State of Mental Health", "Conveyer Belt to Psychiatric Ruin").
In 1996, after a damning review, the government of the day established a Mental Health Commission to independently monitor mental health services.
The first chair of the commission (from 1996-2002) was Dr Barbara Disley, who is the current Chief Executive of Emerge Aotearoa and was made an officer of the New Zealand Order of Merit in 2011.
We spoke to Dr Disley about the current state of the mental health system and the debate about how to fix it.
The Mental Health Commission was dis-established in 2012 (the role of Mental Health Commissioner now falls under the umbrella of the Health and Disability Commissioner). Why was the original commission started in the first place?
The first Mental Health Commission was established in 1996, by the National Government, following a number of serious failures of the mental health system and an independent review headed by Judge Ken Mason.
Mental health funds were not always being spent on mental health services and community mental health services were seriously inadequate and under-resourced. He identified that it was important to address discrimination and also argued for more comprehensive Forensic Services. We are facing these same pressures again now.
I was appointed chair along with two other commissioners and a mandate to provide leadership to the sector, monitor and report directly to parliament on progress and develop the workforce and address discrimination.
The commission was to have wide sweeping powers to do the planning and funding for mental health services. The more recent Productivity Commission report suggested a similar funding agency should fund comprehensive wrap around services for the most vulnerable. Both times these recommendations have been ignored.
What did it achieve?
In close consultation with the sector, we developed the first blueprint, which set out a clear pathway for service growth and improvement. The focus of the blueprint was very clearly on more and better. Subsequent governments committed additional ring-fenced resourcing, the blueprint money enabled services to grow and new community services to be established.
The explicit plan galvanised the whole sector and people at all levels took responsibility for making things happen. The sector rose to the challenge of doing things better.
The commission took its monitoring role seriously and DHBs were required to develop comprehensive mental health plans that the commission reviewed. Their implementation of the plans was monitored as was their mental health spending and performance reported to Parliament annually by the commission.
Community services grew and the non-government sector became stronger and started providing more comprehensive services to people across a broad range of service contexts. This period also saw the voice of people who used mental health services become stronger with their ability to influence services growing.
Initially, only 1-1.5 per cent of the population were accessing mental health services and this grew over time as the blueprint money was available to 3 per cent.
Why then does it feel like we’re back in 1996, with headlines about mental health patient deaths and high suicide rates; and why are calls for another national review gaining strength?
In the intervening 20 years, the powers and effectiveness of the commission to provide leadership and monitor and report have been substantially diminished, its independence removed and its resourcing reduced.
It’s ironic that at the same time that New Zealand was reducing the powers of the Mental Health Commission and diminishing its role in the sector, the Canadian, Irish and each of the Australian State Governments were setting up commissions based on the New Zealand model.
We now have similar concerns about the quality of DHB services and their ability to meet burgeoning demands, despite the fact that many more people than the original 3 per cent of the population receive services. The DHBs are under increasing financial pressures. Such pressure can provide perverse incentives to divert resources to fund deficits and support expensive infrastructures.
It’s unbelievable that in 2017 mental health services and addiction services are often very separate ideologically and physically when we know that many people (over 70 per cent) have both issues and we also have a growing drug and alcohol problem.
The mental health system has obviously been buckling under the pressure for years now, do we need a review to take stock of the issues?
There is a view across the mental health sector that a review could be a time-wasting and costly exercise. Government has already spent money through the Productivity Commission report on better social services where there was wide consultation. The Report made substantial recommendations on how the needs of the most distressed members of our communities could be better met. These recommendations are yet to be actioned.
We know through close contact with other countries and from consumer and families’ views, that best practice includes strong community and clinical services, easy access to respite and primary health care, peer services, culturally appropriate services and trauma informed care practices.
Our view of how good mental health services can be provided has changed substantially over the last 20 years. We know that people need excellent crisis services, integrated mental health and drug and alcohol support, evidence-based clinical care, trauma-informed care, comprehensive community support options, access to peer support services, affordable primary care, affordable housing, education, training, work and family and community connection. We know services for Maori and Pacific peoples and Asian communities need to be led by these communities.
Many of these needs are outside the domain of the health system. Getting things better does require us to improve the quality of the hospital and community services and the Health Quality and Safety Commission is well placed to galvanise action around this.
What should politicians consider in their mental health policies?
We need to focus on more than hospital beds. They are an essential part of the system but it’s when services are provided locally and flexibly that real gains can be made. We don’t need to spend a larger proportion of our mental health budget on more costly hospital-based services that cannot, no matter how good they are, always meet the real needs of people in the community who present with complex mental health, drug and alcohol, trauma, social, employment and housing needs.
We need a whole of government approach that integrates the way we meet these needs for people with complex and challenging problems.
We need an independent mental health planning and funding body that has the powers and the resourcing for it to comprehensively lead, plan, fund and monitor a new wave of integrated community-based services. The new entity could galvanise sector leadership, fund new service models including DHB services that can support people early when distress emerges and identify and address the factors that contribute to it.
We need comprehensive, integrated community driven responses that coordinate with other areas like housing, that are outcome focused and support people early and well. We also need to ring-fence mental health resources and carefully monitor the funds to ensure that they are being used wisely to make a real difference to people in greatest need.
While it is argued often that more money is going into mental health and in particular primary health services, these services are not generally meeting the needs of the people with the highest levels of distress.
History clearly shows us that the moment the eye is taken off monitoring mental health resources, services and people suffer.
> LISTEN - Dr Barbara Disley interviewed on RNZ:
WHERE TO GET HELP WITH MENTAL HEALTH
Need to talk?: free call or text 1737 to talk to a trained counsellor, anytime.
Lifeline: 0800 543 354
Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO
Depression Helpline: 0800 111 757
Samaritans: 0800 726 666
Youthline: 0800 376 633 or email talk@youthline.co.nz
Healthline: 0800 611 116
Correction: A previous version of this story said the role of the Mental Health Commissioner now falls under the umbrella of the Health Quality & Safety Commission. This was incorrect. The Mental Health Commissioner is under the Health and Disability Commissioner.