What ever happened to the $2 billion that was poured into mental healthcare?

Over almost half a decade, an historic $2b was poured into mental healthcare. What has it actually achieved?

Shaun Robinson was feeling hopeful when he rocked up to a lunchtime pre-budget briefing in Wellington in the lead up to Labour’s first ever Wellbeing Budget in 2019.

The briefing was mostly for “business types” but the Mental Health Foundation chief executive snuck in with his auditor and later managed to corner then-Prime Minister Jacinda Ardern and Finance Minister Grant Robertson as they arrived.

“I told them I’m really looking forward to seeing support across the things that were in the inquiry into mental health and I’m really looking forward to seeing a strong emphasis on prevention and wellbeing, because that’s what the inquiry said was needed,” Robinson recalls.

“At that point, they both looked at me and their eyes glazed over.”

Ardern, Robinson says, told him there’s no evidence wellbeing promotion works while Robertson emphasised the importance of services.

“And I thought, oh s… we’re in trouble. They don’t understand the inquiry and support it in a meaningful way.”

The Government Inquiry into Mental Health and Addiction had just a few months prior released its final report calling for not just more money for mental health - although that was certainly needed - but a “whole new approach”.

Education about maintaining and boosting mental health and wellbeing should be just as important as the services needed when people are in crisis. It urged the government to get started on its long list of recommendations in its upcoming budget.

“The inquiry told them very clearly what they needed to do, and the three things that needed to happen,” says Robinson.

The three things are: prevention, services and wellbeing promotion. 

“Prevention addresses problems that cause mental distress and illness, such as poverty, housing, family violence and the impacts of colonisation. 

“There must also be new and diverse services that are offered earlier; and people need to be equipped with the skills and knowledge of how they can look after and improve their own mental health,” says Robinson.

“If you do those three things you will get a substantial shift.”

He likens the new approach to a stool with three legs and Robinson left that budget luncheon with the impression the stool was already wobbling.

Grant Robertson, now a senior opposition MP, says he doesn’t recall the detail of the conversation. But he says “prevention is an important part of the approach in health generally, including mental health”.

Dame Jacinda declined to comment on the conversation.

For Shaun Robinson, however, it was the point at which he started to fear “the train had left on the wrong tracks.”

How has so much money changed so little?

The day after that 2019 luncheon briefing, Grant Robertson was at Parliament to announce an unprecedented $1.9 billion package for mental health. A further $100 million was added in Budget 2022.

Nearly half a decade later, what have we actually got for all that money?

It is now harder than ever to see a counsellor or psychologist, even privately. Workforce shortages continue to cripple existing services and hamper the roll out of new ones.

Acutely unwell mental health patients can find themselves in a makeshift bed in a staff room, or in a hospital ward not fit for purpose. Resources are so stretched that children harming or starving themselves are typically only admitted if they’ve tried to take their own life, and in several regions young people in crisis are having to wait twice as long as they did five years ago to see a specialist mental health service.

Meanwhile, research shows the mental health and wellbeing of New Zealanders has been in decline over the last decade, while the number of adults unable to get help for their mental distress or substance abuse has risen.

How can this be after so much money has been poured into mental health? 

An RNZ investigation has examined this very question. The answer is in four parts:

1. Even an historic amount of money dedicated to mental health has not been enough to meet the challenge. Things were missed or ignored and little is known about what has actually been achieved.

2. The biggest single investment - $664m for “health improvement practitioners” - appears to have merit, but has come at the expense of other services.

3. There still aren’t anywhere near enough skilled workers to help the large number of people who need support.

4. There was very little targeted at young people, who are asking for help in ever increasing numbers.

This story is part one of the series: an examination of what we know about the $2b that’s gone into the problem since 2019.

Where the money went ... wrong

“I remember being really excited about the $1.9bn being an awful lot of money,” says clinical psychologist Dougal Sutherland.

“In hindsight, it wasn’t near enough.”

Out of the total package, just over half ($1.1b) has been spent on the actual health system. The rest has been spread across a range of government agencies including Corrections, Housing and Urban Development, Ministry of Social Development, Courts and the Royal Commission of Inquiry into Abuse in Care.

Within the $1.1bn that went solely to health, nearly half went towards putting more than a thousand mental health advisers into GP practices and other primary care settings, known as the Access and Choice programme.

The Access and Choice programme has been effective but take up has been lower than expected and the roll out of some services has been hampered by workforce shortages. The scheme is examined in detail in part two of this series.

The next biggest chunk of cash, $235m, went to fixing up and building new mental health facilities. Some of those projects, which have been plagued with soaring costs and delays are yet to break ground. But even when they’re complete the total number of acute inpatient mental health beds (608 as of March 2022) will only increase by an extra five to possibly seven beds. 

The third largest portion of health funding from the 2019 package was $213m for easing mental health related “cost pressures” in district health boards - essentially top up funding for hospitals to carry out their everyday job.

The rest of the money is scattered across various projects with very little going into secondary specialist mental health services, which critics say was much needed yet largely ignored.

“They seemed to put all their eggs in one basket and ignore the other baskets … particularly something that would produce short term benefits,” says Sutherland.

Some of the $800m spent outside the health system also went to propping up or expanding existing services, or easing cost pressures across other government agencies, which did not require any formal evaluation of effectiveness.

This includes $6.2m for wraparound support for crime victims and a one-off continuation of an alcohol and drug treatment court pilot at two Auckland courts; $45m to help disabled people find and keep rental homes; and $100m to help the ministries of social development and education to resolve claims from people abused while in state care or school.

A further $283m was spent creating an extra 1000 transitional housing places and $194m on an additional 1044 Housing First (which provides homes for long term homeless) places. While the homes were delivered a year early, a $128m alcohol and drug treatment programme for prisoners and after care support was labelled “mixed” and “problematic” in a June 2023 Cabinet paper, largely due to issues finding staff.

We still don't know: The data poverty problem

Considering the scale of spending, there is relatively little to say how effective it’s all been.

The Department of Prime Minister and Cabinet reviewed parts of the overall $1.9bn package in 2021 and 2022, but only assessed progress towards “delivering outputs”. Wellbeing outcomes were not assessed.

It also wasn’t part of the Mental Health and Wellbeing Commission’s remit to evaluate the quality of service being delivered by the Access and Choice programme when it looked at its first and third years of operation. 

Similar reviews for Māori, Pacific and youth services do not evaluate wellbeing outcomes for patients at all, with the youth report noting “a lack of quantitative data, particularly on service outcomes” which made it hard to assess value.

A large chunk of funding from the 2019 mental health package has not been externally reviewed at all. This includes the cash given to the Royal Commission of Inquiry into Abuse in Care, Social Development, Justice, Courts and any money spent propping up struggling health services.

Earlier this year, the Auditor-General analysed $101bn worth of spending from Budget 2023 and found in many cases it was unclear what outcomes are being achieved, including in mental health.

“There is a small number of performance measures relevant to mental health across appropriations, e.g. number of people who have access through the Access and Choice programme, but the information is not sufficient to provide a picture of proposed spending,” it says in a briefing to Parliament on the issue.

It has now asked government departments to “significantly improve their performance of reporting”.

Last year, the Auditor-General also started investigating how effective mental health and addiction services were for young people. It is due to report its findings very soon.

There’s a similar problem with the design of programmes that got funding. Many are based on data that is two decades old.

The Mental Health Survey collects information on the prevalence, severity, impairment and treatment of major mental health disorders. It was last carried out in 2003/4 and published in 2006.

Essentially, this means “we are flying blind” says child psychiatrist and Royal Australian and New Zealand College of Psychiatrists chair Dr Hiran Thabrew.

“We know we have got data gaps and therefore it is very hard to believe that continued investment is undertaken without this data. It’s also hard to advocate for improvements to our workforce or health systems without this data.”

The Mental Health and Addiction Inquiry also called for an update to the prevalence survey as a priority.

Te Whatu Ora says a study of this nature is a “significant undertaking” and it draws data from a range of sources, including the NZ Health Survey and several longitudinal studies instead.

But Thabrew says these datasets are often more focused on wellbeing than mental disorders.

“That doesn't tell me how many people are going to need inpatient services, say for treatment of severe depression or schizophrenia.

“We actually need a proper prevalence survey for that.”

Robinson agrees, but worries even up to date information may not be taken seriously by those in power.

“Even the data that is publicly available isn’t often listened to.”

He says the mental health inquiry cited longitudinal research from Christchurch showing 82 percent of the population will experience significant mental distress in their life, and the New Zealand Health Survey last year found 25 percent of youths are now experiencing significant distress, but these figures were not taken seriously by the government.

“I had a conversation with a Cabinet minister who said they found it very hard to believe.

“I thought, that’s the nub of the problem. I think it goes back to failing to grasp what mental health is about.”

The 'big disruptor'

But the Cabinet minister who was most responsible for the rollout, Andrew Little, says it’s Shaun Robinson who has got it “completely wrong”.

Little oversaw health for two years between December 2020 until February when he handed the reins over to Ayesha Verrall. He left Parliament earlier this month.

Robinson, says Little, is overlooking the havoc that Covid had on the government’s plans, and not just for mental health.

“In 2020 we had the big disrupter,” Little says.

“I can tell you that the budget for 2020, it was all pretty much ready to go, which included more and significant additional funding and mental health.

“Pretty much in the middle of March, it was ripped up. And we had to focus on just getting through Covid.”

Budget 2021 was focused on getting the Covid vaccine rolled out, he says.

“That disrupted not just things in health, but things everywhere. I certainly stand by decisions and the judgements that we made at that time.”

A prevalence survey also hasn’t been needed because there is lots of other health data that can be used to give a clear picture of the situation, says Little.

“That's why we know there's been an elevated incidence of eating disorders during the pandemic. We know that the number of people who are turning up to EDs and others with acute mental health issues, we know what those numbers are.

“There is sufficient data to inform the actions that have been taken.”

Still, no grand plan

The mental health research we do have suggests one million people a year experience mental distress needing services of some kind. But it’s nearly impossible for any government to provide services for one million people, says Robinson.

That’s why the inquiry wanted a “paradigm shift” with prevention and wellbeing at its core.

He says Britain and some states in Australia are making inroads into this, while the approach in New Zealand is still very piecemeal.

Research carried out by the foundation shows the more positive behaviours and lifestyle choices people include in their daily routine, the more likely they are to report higher wellbeing.

“Just having one in your routine gave you nearly a 50 percent chance of having positive wellbeing and it was cumulative,” says Robinson.

Farmstrong, a programme to boost wellbeing in the rural sector, has shown improving mental wellbeing reduces workplace accidents and speeds up the time taken to recover from an injury.

But again, Robinson says it was “incredibly difficult to get anybody in the Labour government to accept the evidence.”

In 2021, he presented a paper summing up global evidence for proactively investing in mental health and wellbeing to ministers Little and Verrall.

“They agreed it is important but nothing has happened. Wellbeing promotion continues to be seen as a nice to have rather than a key part.”

The exception is wellbeing promotion in response to crises, such as the Christchurch earthquakes, Covid-19 and Cyclone Gabrielle, he says.

“Interestingly, the disaster response legislation requires there to be a psycho-social response, so a cynical view is that they only prioritise wellbeing promotion when they have a legislative requirement to do so.”

Official assessments have pointed to the problem with this piecemeal approach.

In November 2020, two years after the inquiry’s report was released, Robinson and then mental health commissioner Kevin Allen called on the government to take urgent action to draw up a road map for progress.

In July 2021, the Department of Prime Minister and Cabinet’s (DPMC) implementation unit also warned individual agencies were working in silos with little communication, and an overarching plan was needed.

“Each of the agencies has raised similar issues and risks with provider capability and capacity, workforce availability, and procurement. These are common issues that would better be addressed by the agencies working together under the leadership of the Ministry of Health,” it warned Health Minister Andrew Little in a Cabinet paper.

“The Ministry of Health sees itself as the system leader for mental health and addiction within the health system but not across all of government. This is problematic because other agencies are increasingly adding forms of mental health and addiction services as part of wrap around support for the people they engage with in their core business. The scope and design of these services are not generally the core business for these agencies. Delivery of these types of services as part of their core business should have some form of oversight from the system leader for mental health and addiction.”

Still, there is no overall implementation plan.

But Little is unmoved by the criticism.

“The wellbeing approach underpins everything the government did,” he insists.

Labour’s investment in making housing more affordable, social and emergency housing and making sure people are in work are all examples of this, he says.

“The whole underpinning philosophy of our approach to Covid-19, which was a massive disrupter to all of this, was to keep people connected to their jobs and keep businesses sustainable through an incredibly disruptive period. We did all of that.”

He admits focusing on primary mental health services was a priority for Labour and “there’s still work to be done” on the acute end.

“We inherited a mental health system that literally had been neglected for years.

“The fact that part of the $1.9 billion went into just lifting the ring-fenced funding for what were then the DHBs so that they could fund mental health services to the level they were back in 2015, tells you that no serious attention had been given to it.

“I'm very confident that, even with all those factors, and in those circumstances, the stuff that has been done with the benefit of that funding has, and is, making a difference.”

The new minister’s plan

Robinson hopes the new government will invest even more in boosting wellbeing. And he hopes the appointment of the first ever Mental Health Minister Matt Doocey means there will finally be a government that understands what is needed.

“If they just invest $20 million in mental wellbeing over the next three years you would actually see a bigger outcome than if they invested $200 million in building new hospital beds.”

Doocey agrees more wellbeing promotion is needed.

“The more people we can keep, well, hopefully we can keep them from developing mental distress. I think we do need to focus more on prevention and early intervention. And I think there's a real opportunity to do that within education as well.”

His priorities are increasing access to “timely mental health and addiction support” and “addressing the mental health workforce crisis,” he says.

National has pledged to double the number of psychologists being trained and increase training of psychiatrists by about a third.

But the former counsellor, who worked for Britain’s National Health System in the 1990s and early 2000s, says it’s too early to say in detail what the new coalition government will do differently, or better than Labour.

“The last government was making announcements on mental health that even the officials didn’t think they could deliver. So what we need to do is make sure that when we raise the expectations of vulnerable Kiwis that we can actually deliver what we promised them.”

‘Doomed to fail’

Robinson believes Doocey does understand the scale of the task ahead, but it’s whether he can get his Cabinet colleagues on board.

He says when Labour came to power they had good intentions too, but mental health funding under the previous National-led government had fallen 35 percent behind the growth in demand for services, so the size of the problem it found itself facing was “overwhelming.”

In fact, he reckons ministers started to “freak out” when they realised the scale of the problem.

“Then they go in a classic political cycle of ‘we must be seen to actually do something’, rather than sit down and go, ‘actually, this is really hard and it's probably going to take 10 to 15 years to really get traction’… that's not something that any politician wants to admit to.”

That’s why governments tend to go for quick and easier solutions, he says.

“But unfortunately, quick and easy and looks good is not going to solve a complex problem.”

If Robinson sounds angry it’s because he is. 

“Every government in New Zealand has gone wrong in mental health in that we didn't get the basics right. And if you don't get the basics right, then throwing money at it is not going to be very effective.”

By basics he means a plan to implement the inquiry’s recommendations, a comprehensive workforce strategy and a prevalence study.

“Labour really wanted to do positive things about mental health but, regardless of funding and the inquiry, it did not stop to think deeply about what they needed to do."

Because of this, Robinson believes Labour’s mental health package was always “doomed to fail”.

“It became doomed to fail quite early on. We had the plan, we had this supposed commitment, and we just failed to implement. They cherry picked a few things that they did understand and ignored what they didn’t. Instead of creating paradigm change they just did more of the same but a little bit different.

“It was a massive missed opportunity.”