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Mental health system fails stress test

Tom Belford01 April 2019

BB46

Last year, a report from the OECD offered a sobering assessment of New Zealand’s mental health situation, looking chiefly through the lens of its impact on work and productivity.

It observed that poor mental health costs the NZ economy some 4-5% of GDP every year through lost labour productivity, increased healthcare expenditure and social spending on people temporarily or permanently out of work.

New Zealand was given some kudos, including for its mental health awareness campaigns and some innovative pilot programmes, but the report was largely critical.

NZ’s youth suicide rate – more than twice the OECD average – was noted, as was an overall failure for promising pilot efforts to be adequately funded and rolled out, absent linkages amongst the wide range of services and institutions involved, and under-investment, especially at the primary care level.

The report credited sound policy thinking, but observed that this had not yet translated into better outcomes for affected populations. 

With this stage set, NZ released its own comprehensive assessment in November – the Report of the Government Inquiry into Mental Health and Addiction. 

The Inquiry, chaired by Professor Ron Paterson, was a massive undertaking, including over 5,200 submissions; over 400 meetings with members of the public, health and other service providers, iwi and kaupapa Māori providers, NGOs, researchers and other experts; and heaps of literature and overseas practice review.

What exactly was the Inquiry looking at?

It defined “mental health” as “a state…in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”. And further defined “distress” as encompassing “mental illness, people who are seriously upset, and people who are reacting normally to a stressful situation such as bereavement.”

The Inquiry was very emphatic that its review covered the full range of mental wellbeing from mental distress to enduring psychiatric illness and addictions.

Their approach is critical, because the most important conclusion of the Report relates to a very deliberate policy choice, made in the aftermath of de-institutionalising policies of the 1990s, to focus the vast preponderance of public mental health spending on a targeted 3% of the population – those with the most clinically severe mental illness.

‘Missing middle’

Where that prioritisation brought us in 2016/17 is that the public sector spent $1.4b on mental health, with $1.35b ring fenced for those with the most severe challenges. DHBs are told by the Ministry of Health that they must provide mental health care to the 3% who are most severely ill in a given year. Nationwide, currently 3.7% access such specialist services. 

Only after they are cared for can any ‘leftover’ funds be devoted to others who are ‘merely’ mentally distressed. 

That leaves about $30m of public health funding for people with mild to moderate, or moderate to severe needs – covering things like counseling sessions and extended GP visits, and tightly targeted on the young, Māori and Pasifica, and low-income people.

A further $100m is spent on nationally-purchased activities – e.g., health promotion campaigns, work force development.

To put this narrow priority into focus, the Report estimates that each year, 1 in 5 New Zealanders experience “mental illness or significant mental distress”. And that over 50-80% will “experience mental distress or addiction challenges or both in their lifetime”. 

Indeed, the number accessing mental health services has increased 73% over the past 10 years; prescriptions for mental health-related medication – too often the only ‘treatment’ on offer – increased 50%.

Recounting its consultations, the Report observes: “We heard that our mental health and addiction system is not fit for purpose. We have a health system that focuses on responding to psychiatric illness, but people want a system that prevents mental distress and addiction, intervenes early when problems start to develop, and promotes wellbeing.”

Thus the cardinal recommendation of the Inquiry is that NZ must re-design and expand its mental health and addiction system to deliver effective service to 20% of the population within the next five years, reaching the “missing middle”.

The Report comments: “Our mental health system is set up to respond to people with a diagnosed mental illness. It does not respond well to other people who are seriously distressed … Many people with common, disabling problems such as stress, depression, anxiety, trauma and substance abuse have few options available through the public system.”

And recommends: “Access to (and funding for) mental health and addiction services needs to be significantly increased, from the 3.7% of the population who currently access specialist services to the 20% who experience mental health and addiction issues each year.”

More robust services

And the two most important corollaries to this expansion are that: 1) a far more robust suite of therapies and services must be offered to cover the full spectrum of needs, and 2) much of this care will be dependent upon a much greater diversity of properly trained providers at the primary/community care level.

Says the Report: “An explicit decision must be made to do this, supported by funding a wider spectrum of suitable and culturally acceptable service options (particularly talk therapies, alcohol and other drug services, and culturally aligned services) … 

“New Zealand needs to stop talking about the need for a continuum of services to address mental health and addiction needs across the spectrum and make action a priority. A clear policy decision is needed to do this, and it needs to be backed up with … an appropriate workforce.”

The Report is blunt about increased funding, starting in Budget 2019: “Additional investment in services for people with less severe mental health and addiction needs is required. We cannot simply stretch resources currently allocated to services for severe mental health and addiction needs.”

While most of the Report deals with recommended changes within the health system itself, the assessment emphasizes: “We can’t medicate or treat our way out of the epidemic of mental distress and addiction affecting all layers of our society.”

Clearly the social determinants of mental distress run deep: poverty, lack of affordable housing, unemployment and low-paid work, abuse and neglect, family violence and other trauma, loneliness and social isolation (especially for the rural and elderly) and, for Māori, deprivation and cultural alienation. Mental health, like physical health, is much more than a Health Ministry issue.

Specific recommendations are made regarding especially vulnerable populations such as prisoners, rural residents, Māori and Pacific peoples, children, and those who have experienced adverse childhood events (ACEs).

The role of alcohol and drug addiction is addressed as well, with the Report insistent that the alcohol-restricting recommendations of the 2010 Law Commission (and subsequent others) be adopted, noting “…the main impediment to stronger alcohol reform is a lack of political will.” And that personal drug use be de-criminalised in favour of more expansive treatment options.

Finally, the Report calls for a Mental Health and Wellbeing Commission to “provide system leadership and act as the institutional mechanism to hold decisionmakers and successive governments to account.”

Health Minister David Clark speaking in December to the NZ Herald called the Inquiry a “once-in-a-generation opportunity to rethink how we handle some of the biggest challenges we face as a country”. Adding, “We need to work urgently but also carefully through the recommendations. We have already identified mental health and wellbeing as a priority for the next Budget.” 

This Report deserves high marks; hopefully the Government’s response will merit high marks as well. 

Royston Hospital is pleased to sponsor robust examination of health issues in Hawke’s Bay. This reporting is prepared by BayBuzz. Any editorial views expressed are those of the BayBuzz team.

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Tom Belford01 April 2019

BB46

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