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Part 1: The Waitemata Health/Crown Health Enterprise Experience
Positive Developments in Mental Health Services in New Zealand
One major development has been in the provision of 24-hour crisis services. The emphasis now with crisis services or community assessment treatment (CAT) teams is to focus on how a person can be treated in the community, not, as it was five years ago, on whether a hospital bed is available.
Funding has become flexible for things like crisis respite. If the crisis respite system had been created five years ago, it would have had an allocated number of hospital beds which would have been the only option for care. Now care is about treatment in a patient’s own home and what care is needed to achieve this. Where this cannot be achieved, alternatives are evaluated, such as care based in a motel room with a carer versus in a hospital.
Mrs X suffers from both depressive illness and a chronic back problem which flares up every so often. One problem will often trigger the other as has just happened. But this time Mr X is away and Mrs X has not only to contend with her health problems but to deal with two children at home.
After contacting Waitemata Health, Mrs X is visited by the CAT team. They establish that she is not in a position to be at home on her own and Mrs X does not want a stranger in the house, so there is no option for in-home care. The remaining option is to admit Mrs X into hospital and to place her children into some form of care.
But rather than move on that option, Mrs X’s care team look further for solutions. Mrs X has mentioned her retired parents in the South Island. The parents are contacted; crisis respite pays their airfares to Auckland to stay with their daughter and a team member visits every day to keep a check on things. Mrs X is able to recover in her own home, her parents are able to spend time with their daughter and grandchildren and in two weeks the situation is resolved. Mrs X never stepped into a hospital and her children never needed any form of external care.
As illustrated above, the crisis respite team has the jurisdiction to use available funds in managing mental illness in whatever approach it sees as appropriate and viable.
This is just one of a number of successful developments in mental health. Waitemata Health developed the crisis respite system and it is becoming a nationwide approach. The team is run out of a Crown Health Enterprise (CHE), the crisis team holds the budget and makes decisions about its allocation.
There has been a lot of positive development in mental health in New Zealand, with high standards of mental health care when compared internationally. The 24-hour crisis assistance service existed in New Zealand long before it did in Australia or the UK. Flexible use of crisis respite, actually being able to buy what is needed, is a totally new concept which does not exist in a lot of other places.
The standard of care is also much improved compared with the situation in New Zealand five years ago.
The development of the consumer movement is also very positive and consumers have a voice in this country. While there are still problems, there is better recognition of Maori as having legitimate rights as indigenous peoples compared with some countries.
New Zealand has done some things well for a long time but there tends not to be a lot of publicity around successes in mental health.
Issues in Community-based Care
One problem is that provision of community-based care is still in a transition phase. Previously, the focus was on institutional care and the community at large did not really know about mental illness. People with mental illness were effectively taken out of the community. This approach had two effects. It shielded the community from those with mental illness but it also meant longer recovery for patients in an institutional setting without whanau, family and a familiar community.
The focus now is on re-integrating people back into the community. Hospital admission should be seen as the last resort in an acute situation. The chances of rapid recovery are reduced in an acute psychiatric unit because patients, in addition to dealing with their mental illness, need time to adjust to a new and often frightening environment.
Another problem arises with community-based care in that there is a real issue balancing what the public perceives as appropriate care and what health providers see as a patient’s requirements for care. The public call after any major incident is to "lock up" people who have mental illness. The reality is that the incidents that have happened have happened before and always will. Providers get political backlash from incidents, and even have politicians talking about setting up community villages. Community villages are still secured and effectively institutions by another name. Putting people in them still means taking people from their families, stigmatising mental illness and actually discriminating against people with mental illness.
There is a need for a level of institutional care. There is a group of people, members of which, despite the best intentions of providers, have illnesses which make their behaviour antisocial and which make them to some extent a danger to themselves or others, and some sort of semi-secure care is required. It is a small group. Most in this group are already in the secure care system and have been for some years. Individually, they don’t really need to be in that level of security but sometimes because of the nature of a crime committed and the potential public outcry if they are allowed to go back to community, they are detained.
Another problem in community-based care is that a lot of planned resources have not yet become available. There is still a transition from spending funds in institutions to spending in the community and there has been an issue with the belief that community care would be cheaper. This could have been possible if there had been direct transfer of services, but because of growth in population and expectations, and a growing knowledge of illness, demand has increased and budget requirements are higher. Increases in amounts of money have paralleled increased need and expectation, and this will always will be the case.
Service Access and Community Care
The walls of the old institutions kept people out; people did not choose to go there. Once service accessibility and acceptability increases, more people wish to use services. This is particularly apparent when services are based in a location which is not seen as a mental health unit, such as North Shore Hospital or Henderson House.
Services are naturally improving with increased accessibility, but also because treatment regimens are changing. Mental illness is much better understood, not fully but better. A lot of mental illness can be controlled without some of the fairly damaging medications used in the past. For example, patients don’t suffer overwhelming extrapyramidal side effects as these can now be better controlled.
Further improvement has come from a new breed of professional which has emerged in the last five to ten years. These professionals view the consumer as a person and this represents a significant change. But there is still progress to be made. There are still issues around not fully acknowledging patients’ rights and not treating patients with the dignity that they deserve. This is tied in with not giving patients choice in terms of their involvement or non-involvement in treatment. However, there have been significant improvements.
The media have a role in assisting public understanding. There is a problem with the tendency of the media to only publish bad news or "horror stories". Of 500 consumers living successfully in the community, a story is only printed on one who is involved in an incident. Such one-sided publicity does damage to Waitemata Health as a CHE, to CHE staff and, more importantly, to consumers. Those consumers living successfully in the community are targeted; those living in community are identified as having mental illness and capable of the same behaviour.
The situation is slowly changing. Some of the problem resulted from an attitude where the CHE would not make comment. As a result, the media went elsewhere for comment. As a CHE, Waitemata Health has taken a more positive approach to the media and agreed to comment on most issues. It also tries to promote good news but this is not always published.
There has been Ministry funding set aside for a media campaign but there is concern that this may be seen as a whitewash, covering up mental health in crisis. The funds are late but are still needed; there should have been publicity before the first large psychiatric hospital closed. Ideally there should have been $5m spent on a positive media campaign over five years to educate the public on what mental illness really is. This will start with the funds now allocated.
Continuity of Care
Continuity of care was not an issue in institutional-based care but can be a problem in community care where multiple providers are involved. The situation has improved with CHEs and non-government organisations (NGOs) working much more closely and, hopefully, reducing duplication. The health reforms initially set people up to compete so the information sharing that now happens did not happen three or four years ago.
The Progress to Integrated Care
In the early days of the Regional Health Authorities (RHAs), Waitemata held all the contracts for private providers in the area, who were then effectively subcontracted from the CHE. This arrangement included the Accommodation Society, Framework Trust, Walsh Trust, rest homes, etc.
Currently, the only subcontract is with Raeburn House. The pressure for change came from the subcontracted groups, to an extent because they felt that they would have more freedom if they contracted directly with the RHA. There was also a lot of pressure created from the feeling of a need to compete which arose from the initial health reforms. How could private providers "compete" with the CHE if the CHE held their contract? Despite the reality that the CHE and private providers did not work in competitive areas anyway, there was a myth that private providers would be somehow disadvantaged by contracting to the CHE.
In 1992, Waitemata set out to develop a positive relationship with NGOs. Two groups called Shared Vision, one in the West and one in the North, brought together all NGOs, community organisations, consumers, councils, the CHE and police to create a positive working relationship. The approach works well and is still used.
Shared Vision is a move toward integrated care. The group could eventually be in a position to receive an allocation from the RHA for comprehensive services for a catchment population and to work together to deliver that service. At that point, the CHE and NGOs will have a true partnership for the first time.
The current purchasing system is complicated by poor contract monitoring. Even if a contract goes to a community provider, it is not known clearly whether the service was actually provided and the Transitional Health Authority (THA) or CHE cannot know whether the CHE can provide appropriate back-up to that service. Often contracts bear no resemblance to one another. The CHE is the provider last resort but unless the CHE knows which other services are provided, CHE input may be in conflict with that which is provided.
Integration is a necessary development. Because of the purchasing system, co-ordination of all providers, community providers included, is needed to clarify where services are duplicated and where any gaps exist.
NGO providers want integration, but at this stage do not want to put money on the table. When Shared Vision was set up in 1992, the vision was that providers would come with their funds; the Crown Health Enterprise with the most, but the CHE was prepared to pool their budget. The next stage would have been to determine, with the available pooled funds, the best way to meet the needs of the community. This vision of allocating pooled funds did not happen. But providers in Shared Vision do come with intellectual property, thoughts and views, networks and relationships. The arrangement has been very beneficial.
The publicly funded New Zealand system does not offer room for the profit margins needed in private managed care. CHEs are not badly run and are much more efficient than they were five years ago although there is a Wellington view that CHEs are not run efficiently. At this stage there is not a level playing field with respect to CHE profitability. CHEs have different levels of capital costs and different access to additional funds, for example, tertiary teaching supplements, etc, and the impact of these factors on available funding is significant.
Who Should be in Control in an Integrated System?
Shared Vision is the type of organisation which would be in a good position to run an integrated programme.
What is needed is a group that comes together to control services versus control by primary or secondary care. The problem with the latter approaches is that secondary care providers do not fully understand primary care and vice versa. The ideal would be a management board with three to four key players who fairly represent the providers; it would be the entity that held the contract for fully integrated community-based primary and secondary care services, plus secure care.
Is there a Down Side to Integrated Care?
If anything, it would be the danger of stifling innovation in a fully integrated care model where players must achieve consensus. There is a drive toward innovation in the process of competitively capturing a contract and determining how to deliver it. Stifling innovation could be avoided if the model included the right players. In an integrated system with components of care that must link, there is sometimes a need to get providers to change some of the ways that they do things to allow that link. This demands a group of like-minded people. Unfortunately, there is major potential for rifts, especially with small organisations where their whole philosophy is based around one founding individual.
If services are integrated properly, there should be no room for cost-shifting and costs of care should be much more transparent.
Is the Waitemata View of Integration Shared by Other Crown Health Enterprises?
It is a view that most CHEs share but there could be a more protectionist view in some other CHEs when it comes to integrated care.
Aligning Services with Central Strategic Goals
The provider role in service coordination starts with giving people ownership of some of the parts. This process has been started with Shared Vision (see above); providers discuss and identify common solutions.
The aim is to get all providers involved and aware of strategic goals through communication. Communication regarding mental health could improve and there has been a lot of confusion over the roles of different groups in the overall strategy. A lot of this confusion has been caused by the purchaser/provider split with resultant cherry picking versus recognition of what should be delivered and who is best to deliver each part.
Providers can do damage when there is not integrated service delivery. There will not be consistency in the way mental health is purchased unless providers take a central strategy and make it work.
Strategic intent can be included as part of a contract but this approach is only effective if contracts are monitored correctly. At this stage, contracts are poorly monitored.
Issues in Mental Health for Maori and Pacific Island Populations
Mental health for Maori and Pacific Islanders has not been seen as a high priority except in some areas. Manawanui is a regional service which was set up for Maori in Auckland. Potentially, it was a good idea, but when the CHEs were separated, less emphasis was placed on needs of Maori because it was assumed that these would be picked up by Manawanui. Clearly, the system did not function that well. Manawanui still exists but without the investment needed to reflect a growing population.
There are pockets of good practice in Maori mental health. But there has never been a sustainable strategic plan, certainly in the Waitemata area. Before the Mason report, new funding never even had a portion tagged for Maori. Now the situation is clearer and Waitemata plan to develop some Maori mental health services, services by Maori for Maori, but also mainstream services that are appropriate for Maori who prefer care through this route.
Integrated services will care for Maori better if Maori providers are part of the integrated group. Some Maori providers see themselves as part of the larger mainstream but many push for the "by Maori for Maori" approach. This is partly driven by a belief that this will mean better funding. Some Maori providers don’t believe that they get the same amount of health dollars as other providers; they probably do but they have greater level of health needs. For example, early presentation in Maori mental health is unusual. Maori tend to present once they are at a more advanced stage of mental illness and so very little early intervention takes place. The case is the same with the Pacific Island population. As a result, there is a need for much more intensive input and clients probably have longer average length of stay.
Maori are over-represented in mental health services, prison and forensic services. This is well known but there is not much action related to it. There will be more investment in "by Maori for Maori" but it is not clear how well that will work. However it is done, there will need to be some integration with mainstream services. Clearly, clients will move from mainstream services into Maori services and back again. Some clients will choose not to use a Maori service. There must be some form of integration to ensure continuity of care.
There are also major workforce issues related to care of Maori and Pacific Islanders. The existing workforce is very much part of the developing integrated system and separate Maori services will draw on that same set of personnel.
There has been a call for a Maori mental health commission because Maori do not believe that the Mental Health Commission represents them fairly. To some extent this is true. However, the danger in establishing a Maori mental health commission is that it will split the power of the existing Mental Health Commission, limiting the efficacy of both groups. A preferable solution would be to ensure that Maori had better representation in the existing commission.
The Pacific Island population differs in that there are more concentrated population pockets. Yet in Auckland, where there is a large Pacific Island population, Pacific Islanders are serviced really poorly. If Maori are receiving second class care, then the Pacific Island population are receiving third class care. Further, the new major group of Asians could be classified as receiving fourth class care. Asian needs in mental health are completely uncatered for; a Chinese psychiatrist in South Auckland, so distraught about the lack of specific services, is attempting to take on every Chinese person needing mental health care.
This issue highlights the fact that there is still a situation of running to catch up with where services need to be. There is an entirely new population group to cater for and yet the needs of the Maori and Pacific Island populations are still not dealt with.
There are moves towards greater equity for Maori. But it is important that the Pacific Island population, equally represented in forensic services as Maori, is viewed as deserving the same level of care as Maori.
The Role of the General Practitioner in Management of Mental Illness
Issues with the General Practitioner Role
A number of issues are involved when it comes to the role of the general practitioner in mental health care.
Clients must pay to see a general practitioner whereas a visit to a community mental health service is free. Thus, there is a disincentive for clients to go to general practitioners. For general practitioners to get more involved, there would have to be a way around this funding issue.
Further, in New Zealand, a patient does not need to see a general practitioner to receive care. This differs from the case in the United Kingdom where, for any care, a patient has to go through a general practitioner. In New Zealand, a client may first present, for example, to an accident and emergency clinic. Thus, there is an issue in recognition of the general practitioner as the primary carer.
There also needs to be a change in funding systems to take away any disincentive for general practitioners to handle mental health patients, for example, recognition in funding of the need for longer sessions with patients with mental illness.
Many general practitioners do want to be more involved with mental health and there is a place for them. For example, most general practitioners can manage the long term schizophrenic who has emerged from acute care with a treatment plan; the general practitioner can implement the treatment plan, provide follow-up, check medications, check blood levels, etc. However, fewer general practitioners are able to handle, for example, the dysfunctional family where one member has phobia attacks and will be in the general practitioner’s surgery three times a week.
These situations also represent an example of the gaps in treatment. The CHE cannot deal with them because they do not fall into the arbitrary 3% regarded by the Ministry to require CHE-based mental health care at any one time, ie, the 3% with the highest needs. They fall into the further 20% with unmet needs. If they are not dealt with, they will become the 3% of the future and that 3% is, of course, likely to expand.
Training can also be an issue. A lot of general practitioners do want to be involved and have asked for additional training. There needs to be awareness of the risk associated with those who believe that they have a level of expertise which does not exist; this can result in misdiagnosis and/or inappropriate treatment and possibly a patient with increased problems.
The General Practitioner Role – a Possible Approach
Most general practitioners want to work with a mental health professional who can act as a consultant. This is a logical approach, modelled on the current general practitioner/specialist interface for any other type of care, for example dermatology. A specialist is drawn in where there is a problem beyond the means of the general practitioner, but the patient returns to the general practitioner for after care once that situation is resolved. The difference with mental health arose because it was previously all handled behind the walls of institutions. The mental health system became somewhat paternalistic and, to some extent, this stopped general practitioners having involvement in mental health.
The specialist interface model is seen increasingly in the rural setting where general practitioners are much more involved in mental health care. For specialist back-up, general practitioners have usually made links with a CHE. For example, Waitemata has a rural mental health team in Warkworth who work very closely with general practitioners; they actually work on the same site.
The provision of professional mental health carers within an Independent Practice Association could be funded by the CHE. This approach for a CHE is about early intervention. If the CHE placed mental health workers with general practitioners, some clients would probably be picked up much earlier; there would be a cost to the CHE in the short term but would save money long term through avoiding acute admissions.
Within an integrated service, the integrated provider group would fund psychiatrists, psychologists or well-trained psychiatric nurses to support general practitioners.
Features of a Quality Mental Health Service
The Mason report calls for a service which is:
- readily accessible
- professional
- user-friendly
- mindful of the needs of the group it services, ie, the consumer.
Accessibility
A service should be readily accessible but one of the problems is that this approach does not pick up that health care needs to be rationed. For example, ready accessibility has meant that there are now calls to the Waitemata 24-hour crisis team from people who could be using a helpline service, for example someone in relationship difficulties who needs counselling but who uses the word suicide in order to get a response from the crisis team.
So, there is a risk with accessibility. Services should be accessible, but accessibility and acceptability can overburden services.
Services should also be accessible where the client is. Waitemata covers an area of over 3,000 square kilometres. Until a year ago, patients in Warkworth and Wellsford came to the North Shore for care. Now there is a Warkworth mental health team. There is a lot more emphasis now on care travelling to consumers versus consumers travelling to care. Use of new technology like video conferencing can contribute to this.
Consumer and Family Focussed
The Mason report refers to a service being mindful of the needs of the consumer, but actually services need to be consumer-focussed. Services now try to work in partnership with consumers. Previously, services "did things to consumers". This idea is quickly changing and the emphasis is on empowered consumers taking responsibility for their own health.
Professional
"Professional" can be interpreted in different ways. Mental health services employ much-valued consumer advocates and community support workers who don’t necessarily have recognised professional qualifications. Would they be excluded from a "professional" service?
A more acceptable interpretation could be workers operating in a professional manner and being appropriately trained.
But there is still need for care with use of the term; often "professional" has meant a barrier, for example, a number of people would never challenge their doctor.
More importantly, a mental health service needs to be user-friendly. Mental illness for most people is a frightening experience.
The Mason report does not acknowledge consumer fear of services. There are different types of consumers, those who have been in the service and first-time users. There is a lot of fear for first-time users and often the person that helps them most is another consumer who knows their way around the system.
There is still a lot of fear and much of that results from ongoing stigma associated with mental illness.
"User-friendly" relates to a service which a first-time user can enter without feeling too out of depth. It also means being "easy to understand" and this means using simple language which consumers can understand, avoiding complex medical terminology especially when a consumer may hesitate to question a "professional". There needs to be a partnership where the consumer and the family have a say in treatment.
Services need to be much more aware of the anxieties which mental illness places on an individual and the family. At times, the Privacy Act has been used as an excuse not to consult with the family. Yet services still have the expectation that the family will pick up care again after discharge.
Outcome Focussed
Outcome focus is important to determine whether services are making a difference. Currently services are measured in outputs, numbers of clients, bed days, etc. But outputs don’t measure whether the service has made a difference. Measurable outcomes are required. Baselines are beginning to be set for outcomes, using various rating scales. Outcomes are much more about asking consumers whether the service has made a difference; the important measure is patient satisfaction with their state of being. It is not only about whether the consumer’s functioning has improved on a rating scale but whether they actually feel better.
Part 2: The Broader Picture
The Role of the Mental Health Commission?
Ken Mason envisaged the Mental Health Commission as the purchaser for mental health. This did not happen; it could not be allowed at the time because Jenny Shipley, the Minister of Health, had just publicly supported the RHAs and a shift of purchasing to the Mental Health Commission would have undermined this support.
But the Mental Health Commission would not have fulfilled its role better if had been the services purchaser. The role is primarily one of watchdog, monitoring the activities of the Minister and Ministry, the RHAs, and now the THA. The Commission also serves a role in beginning to highlight best practice, working around current services and trying to pull together work already done in mental health. It serves as a conduit for good ideas.
After initial apprehension regarding one another’s roles, the relationship between the Ministry and the Mental Health Commission has settled. Clearly, both groups have a role.
The Mental Health Commission relationship is both with the Ministry of Health and the THA. A key role is to try to translate policy into something operational. Current work on the Blueprint for Mental Health, due to be completed at the end of July, is being undertaken for the THA.
Effectively, the Blueprint will attempt to identify what should be purchased in mental health. There are a number of Ministry documents but these do not tell a purchaser what to buy, how much to buy, differences between rural and urban requirements, etc.
Findings to date will be drawn together in the Blueprint for Mental Health, in an attempt to influence what will be purchased. The Commission must work to influence with very little power; they act in an advisory role.
The Blueprint creation is a legitimate role for the Mental Health Commission. The ongoing role will be in both keeping the Blueprint updated as a living document and in monitoring implementation of purchasing as per the Blueprint. The Mental Health Commission is looking for joint ownership of the Blueprint with the THA, with the THA adopting the Blueprint as a template for purchasing.
The Impact of Transition to a Single Central Funder
Effects on Integrated Services
The set-up of integrated services will be largely unaffected by the nature of funding. Other issues in getting parties to work together far outweigh the impact of the nature of the funding structure. There may be a greater impetus for integration with central funding because people may wish to take control of their area. Because RHAs were smaller and more localised, they tended to take control. Without regional offices, there would be incentives for local groups to run services.
Effects on the Role of the General Practitioner in Mental Health Services
A central funder could have an advantage in shifting the role of the general practitioner because there will be an increased tendency for the funder to look at the big picture in mental health, incorporating the role of primary care. Change may be easier with a consistent approach but there is also a risk that the task will seem too difficult to take on.
Effects on the Provision of a Centrally Managed Strategic Approach to Mental Health
A centrally managed strategic approach would, on the surface, be easier to manage with a central funder. However, the same goals would have been achieved with the RHAs if they had been left to continue.
The RHAs were not really working but they had also not been given time to work. In the United Kingdom, it took five years for the purchaser/provider arrangement to function properly.
At initial set up in New Zealand, there was power play between providers and RHAs, both thinking that they knew better. More recently, the relationship was much more open with information-sharing and people working at how to best use the health dollar.
Admittedly, there has still been a lack of trust of RHAs, a belief that they have funds that they hold back which has been evidenced by fund availability at various crisis points, for example, when Auckland Health care threatened to close a surgical unit. This has created an issue regarding the integrity of RHAs. The issue also exists in the opposite direction. RHAs claim that CHEs overestimate the funds needed for various services. RHAs have continually asked CHEs to deliver the same contract in the following year with no allowance for inflation. At this stage the last efficiencies have been "squeezed out" except for those resulting from new technology, etc.
However, the RHAs should have been left for a further three years. Then the system may have had a chance to work or, if it had failed, it would have been a proven failure. There is a fear that the move to a THA will create a vacuum where no real decisions are made until the situation settles. The RHA system introduced more transparency, poorer managers moved on, and good people have been coming in and addressing some important issues. For example, there has been a push from North Health for equity in funding. It is not clear whether the THA will look at such an issue. It would seem less likely under a central funder for a local person to point out an inequity between amounts spent per head of population in different regions.
Anticipated Changes in Purchasing
It is anticipated that the THA will give responsibility for different sets of purchasing to departments from each of the former RHAs. Hopefully, this approach will create some continuity and mental health in particular desperately needs continuity around the country because consumers are so mobile.
It is not necessary to move all purchasing to one central location and this is unlikely to happen; it does not matter where services are purchased from but location will make a difference to understanding the needs of the area for which services are being purchased.
There is a real concern that, if RHAs were dropped after three years, the THA/Central Funder will be dropped similarly after three years. This would be a road to destruction simply because no structure is being given long enough to deliver.
There has been a problem with RHAs around the issue of "he who shouts loudest gets most". This is unlikely to change with a central funder; for example, Auckland Healthcare is still a massive CHE and will still hold the focus of the THA.
The establishment of the RHAs was about someone other than Government rationing health. This worked well in the UK because purchasers were more detached from Government than they can be in small country like New Zealand where the situation arises of the Minister defending RHAs or CHEs; this does not happen in the UK. A cynical view is that the system was set up to deflect criticism from the Government.
The public are starting to recognise that public health services will not provide for all care any longer. But they see the CHE as the rationer, not RHAs or Government. Thus, protests are against CHEs; hospitals are still seen as public-owned entities that should provide what the population need.
Other Issues in the Delivery of Quality Mental Health Services in New Zealand
Workforce Problems
There is a real issue around the image which mental health portrays when it comes to the workforce. There are workforce problems but these tend to be made worse because there is continual focus on negative things happening in mental health. This does not create an incentive for workers to go into mental health.
There has been a shortage of trained people, including psychiatrists. Bringing in experts from abroad for short periods has not been a solution; they are able to do the job clinically but don’t understand the cultural issues and the wider issues, and they have no wish to become involved in that picture.
There has also been a problem with management. Good managers in mental health have tended to wish to move to the next level of management; to do this they must gain experience in other areas in the health system so they are lost to mental health. And without adequate positions at the next level, they can be lost to New Zealand.
Different Types of Patient
A major issue is in the fact that the mental health system deals with two groups: one with chronic problems created through the old system, which in 20 to 30 years’ time will not exist; and a new group, of which some members will never be inside an acute admission unit because of new treatments and flexibility around care.
There is real concern around the need to begin to shift resources from the chronic group or to find new resources for the new group. The danger is that the longer the focus remains on those with long term mental illness with less input going into early intervention, the cycle of chronic illness will not be stopped.
Stopping the cycle demands early intervention, but this is where a problem arises with one-year funding. Early intervention may not show a difference for five to ten years.
Long term budget holding would make a big difference to integrated care. It gives a "freedom" to let people get on with their job without a demand for short term focus.
The Public Eye
New Zealand is a small country and lot of news is made of incidents. This can and has resulted in knee-jerk reactions. Psychiatrists are forced to admit to hospital patients who need not be admitted simply because of fear of another incident; this forces providers into practising "safe" psychiatry which, while seemingly safe for the community, is not safe for the client. The way to turn such a situation around after an incident is through better education and destigmatisation of mental illness.
