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- Introduction
- Development of Comprehensive Mental Health Services
- Workforce Development
- Strengthening Co-ordination and Collaboration Between the Mental Health and Primary Health Sectors
- Ensuring Maori Have the Same Health Outcomes as Non-Maori
- Rationing to Achieve National Mental Health Targets
- Conclusion
Introduction
Within the structural changes that have resulted from implementation of the health reforms, the mental health environment is experiencing the rigours of a collective response to meeting nationally agreed objectives.
In replacing the four purchasing organisations with a single purchasing body the Transitional Health Authority (THA) requires the four regions to develop a common strategic vision and operational policies that provide for the health and independence of all New Zealanders. This includes developing more and better mental health services in line with the Ministry of Health’s national targets for access to these services.
Providers, consumers, families and mental health interest groups have heightened expectations about additional mental health services that will result from the Mason funding.
Although the THA has made substantial progress in developing a national approach to purchasing strategies, a gap will remain between the national access targets and that which is achievable with current baseline and additional Mason funding. The regions will not be able to fund the net level of additional services required by the Ministry of Health’s national targets.
The THA will continue to work alongside the Ministry of Health and the Mental Health Commission on key national mental health issues.
The following article explores some of the challenges that the purchaser and the provider continue to meet and overcome in developing more and better health services for New Zealanders who have a mental health disorder.
Development of Comprehensive Mental Health Services
Development of comprehensive community-based services is a key strategy for the development of mental health services. The purchaser and providers proactively support the decision of mental health consumers to live compatibly in their community of choice, actioning their rights and responsibilities as citizens of New Zealand.
Both purchaser and provider are committed to purchasing and providing more and better community-based services that offer the support needed by people with a mental health disorder to live independently in the community. Community-based mental health clinical and support services are a cornerstone to the planning and implementation of mental health services nationwide. All the activities in respect of workforce development, strengthening relationships intersectorally and improving co-ordination and collaboration with primary health services are measures taken to support this cornerstone.
The National Acuity Review on New Zealand’s Mental Health Acute Inpatient Services (Ministry of Health, July 1997) indicated that a substantial number of people with a mental health disorder in the inpatient services (approximately 40%) do not necessarily need to be there. The barriers to discharge are a lack of accommodation and community support options.
A greater emphasis will be placed on the way in which access, entry, assessment, implementation, discharge and follow-up are expressed in contract service specifications in order to ensure that consumers’ needs are met in a co-ordinated and comprehensive manner. Intersectoral and inter-agency networking and co-ordination, especially with Housing and Welfare, along the achievement of National Mental Health Standards will be a contractual requirement of all providers.
People with mental health problems are becoming more visible in the community. They are increasingly accessing accommodation in regular neighbourhoods, gaining employment on the open market and educating themselves in mainstream institutions. As visibility has increased the community have become less tolerant of differences. People with mental health disorders are becoming increasingly more marginalised by the very communities with which they are seeking to have a relationship.
At a regional level, purchasing initiatives such as community support work are designed to provide the sort of individual support and community development that enhances integration and participation in the community.
At a national level, the purchaser along with the Ministry of Health and the Mental Health Commission have embarked on a five-year national and regional anti-discrimination campaign which is aimed at reducing discrimination and stigma against people who have a mental disorder and their families/whanau who support them.
The programme is being evaluated and the stakeholders will be able to monitor changes in public attitude.
Regionally and nationally the THA needs to continue to strengthen intersectoral links and relationships between health, disability, housing and education to ensure that people with mental health disorders have access to the same resources that are available for the general population.
Workforce Development
The lack of attention to the ongoing development of a mental health workforce has left many clinical areas depleted of the necessary skills and competency to deliver a good quality of service. This is particularly evident in specialist areas such as services for children and young people, services for people with both a mental health disorder and a drug and alcohol problem, or who are involved with the criminal justice system, and Maori providing services to Maori.
The capacity of the Clinical Training Agency to deliver on the timely purchasing of the workforce development in the specialist areas mentioned above may well interfere with the THA’s ability to reach the goal of improving access to mental health services for these groups of people. Alignment between the THA and the Clinical Training Agency in sequencing the purchasing of services with anticipated training needs is critical.
There is an increase nationally in the number of workers in community-based mental health who do not have tertiary health qualification, for example, community support workers, caregivers and some Maori working in Maori for Maori services. This workforce has limited access to consistent and co-ordinated quality training opportunities. Along with addressing the need for additional skills training at diploma level, there is an urgent need to address the issues facing this workforce.
The Ministry of Health and the Mental Health Commission are developing a national workforce strategy along with national unit standards that will indicate what the need is and how it will be met. This, however, does little to address the training needs to match the current purchasing initiatives. In the interim it may be necessary to purchase training for the current workforce through the same mechanisms that training for post-graduate level skills is purchased.
Strengthening Co-ordination and Collaboration Between the Mental Health and Primary Health Sectors
Another challenge that presents in the purchasing of a comprehensive and co-ordinated mental health service is the ability to improve the capacity of primary health care providers to detect mental health disorders early and to provide initial treatment to people in a consistent and co-ordinated way.
It is the role of the purchaser to ensure that mechanisms are developed that encourage primary health providers to deliver quality primary health care to people who present with a mental health disorder. The purchaser needs to research and develop best practice primary care models that demonstrate best outcomes for people who either present with early warning signs or have a diagnosed mental health disorder and require primary intervention.
Ensuring Maori Have the Same Health Outcomes as Non-Maori
Evidence exists to indicate that re-admission rates for Maori are increasing at a time when rates for Europeans are reducing. The resultant increase in access to mental health services for Maori is therefore predictable. Unless services provided can deliver assistance in a culturally effective way, then re-admission rates for Maori are likely to continue to increase.
Maori have higher use of forensic, inpatient, crisis and continuing care services than warranted by their proportion in the population. Increasing inpatient re-admission rates, the low utilisation rate by Maori of mainstream primary mental health and community therapeutic services and the inability of Maori for Maori services to meet growing demand indicate that more Maori services are needed.
Future purchasing options need to be aligned with Articles Two and Three of the Treaty of Waitangi.
By aligning future service development with purchasing options consistent with Article Two and Article Three of the Treaty of Waitangi, the purchaser will be able to offer Maori consumers and their whanau a choice of services that better meet their requirements. The purchaser needs to purchase Maori services located in mainstream mental health services as well as Iwi-based Maori services, to be delivered by Iwi or pan-Iwi providers.
Rationing to Achieve National Mental Health Targets
National targets set by Government require access to mental health services for 3% of all adult New Zealanders and 5% of children and young people in any one month. Current service purchasing is between 1%–1.5% for adults and 0.5%–1% for children and young people.
All regions have major service gaps that will not be fully addressed by the Mason funding for mental health services. Mason funding must be used to purchase new services ensuring that this funding is not used to increase the price of current services.
Rationing requires trade-offs which have yet to be debated with the public. The Mason inquiry confirmed that the public lack confidence in the ability to obtain the mental health services that they or their family members require. This debate on rationing and trade-offs will take place at time when the purchaser and the providers are trying to gain public confidence in both the quality and effectiveness of the mental health services currently being delivered to New Zealanders.
The purchaser and the providers of mental health services will continue to make decisions about the rationing of mental health services to ensure they manage and achieve best health and independence outcomes for New Zealanders within the fiscal constraints.
The THA will need to reach agreement with providers (including Crown Health Enterprises (CHEs)) regarding staffing levels, beds, community services, consumer access levels and quality of services to be provided for funding available. Providers will need to be actively monitored against contractual agreements.
Since the introduction of the health reforms, good progress towards the development of a comprehensive well co-ordinated mental health system for New Zealanders has been made. Since 1992, there have been considerable gains in the range and quality of mental health services. The strategy for developing more and better mental health services is being implemented. National Standards for the delivery of mental health services have been updated this year and are being implemented.
Consumers are participating in the planning and development of services in a positive and proactive way. They are becoming involved in planning and advocating for improved mental health services.
Quality monitoring of mental health services over the past five years has identified the areas where better service delivery will improve outcomes for service users. Providers are responding positively to quality recommendations and are working to reduce deficiencies in service delivery. Many of these recommendations are routinely added into contracts as they are renewed.
There has been a increase in the range and volume of community-based mental health services, particularly in the area of crisis and respite services available to people who become acutely unwell and require additional mental health clinical support for a short period of time.
Conclusion
The mechanisms in place to support the development of a National Funding Body will ensure that the progress we have made to date will be built upon. The THA, the Mental Health Commission and the Ministry of Health want to work together collaboratively, avoid duplication and ensure that the Mental Health Strategy Looking Forward is implemented to improve outcomes for consumers through improving mental health services.
These agencies have developed a mental health protocol with the purpose of clarifying the respective roles, confirming how the agencies intend to work together, and ensuring that the agencies’ collective efforts and expertise address key mental health issues.
The three agencies have agreed and are working towards developing shared strategies that will be reflected in their national planning and vision documents.
