Whakawātea te Ara is about clearing pathways that will lead to improved health and wellbeing. While Māori health has made significant gains, evidence is mounting that the system is not working for Māori and fundamental changes are needed.
The paradigm shifts in sections 3.4.1 to 3.4.8 are the eight broad areas where, in our view, a change in direction is necessary. All areas require commitments from government, Iwi, Māori communities, whānau, clinicians, specialists, primary care providers, NGOs, DHBs, funders and sectors beyond health. Significant implications also exist for health and social services, Kaupapa Māori services, education, workforce capability, local and national policies, and Māori development generally.
A focus on Māori sickness and distress needs to be expanded to include a stronger emphasis on wellbeing – wairua, hinengaro, tinana and whānau (spirit, mind, body and family). Wellbeing, mauri ora, is the right of tamariki, rangatahi, mātua and kaumātua (children, young people, parents and elders). A wellbeing paradigm requires a focus on positive aspirations with expanded treatment and care goals that go beyond the alleviation of symptoms to the attainment of wellness. Wellbeing aligns with tikanga Māori and Māori cultural norms; it demands cross-sectoral commitments. It also recognises the interdependence of mental health and physical health, the capacity of communities to generate opportunities for healthy living, and the strength and leadership of whānau so their people can live as Māori and participate fully in society.
Improving whānau wellbeing through teaching water safety skills
Te Taitimu Trust is a community initiative based in Flaxmere for Māori children, adults and families, many of whom have gang backgrounds, challenging home environments and compromised health. Since 2003, the Trust has brought groups together to learn vital water safety skills as well as basic living skills.
Awareness and changing attitudes towards the water are the main goals, but in the process, the importance of cultural values, whānau and whanaungatanga are emphasised within a marae context. Whānau are encouraged to join in.
Early indications among programme participants are of a gain in self-confidence, improved family relationships and a greater appreciation of tikanga Māori as well as the natural environment.83
Recognition of mana, dignity and self-esteem is integral to mental wellbeing. The person – te tangata – should be the main focus. The person’s concerns, hopes and priorities are more fundamental than the diagnosis, treatment plan or preconceived assumptions of clinicians or caregivers. Respecting human rights and integrity should underpin all treatment and care programmes. And kindness, empathy and rapport should epitomise the culture within mental health and addiction services.
We heard that whānau involvement is critical for successfully addressing mental health and addiction challenges: whānau should be co-participants in services, involved in decision-making and assisted to provide the support expected of families. Whānau span the human life cycle, and a life-course approach recognises the continuity between generations and the changing roles within whānau. Whānau also have the potential to prevent small problems from becoming major issues, to encourage early intervention, especially with tamariki and rangatahi, to care for older people and to promote lifestyles that lead to wellbeing.
Whānau Ora has been able to balance an individual focus with the active involvement of whānau. By incorporating tikanga, kawa and whanaungatanga into practices, whānau self-management and wellbeing are encouraged. A healing process that converts crises for individuals into whānau resilience and capability is the aim. Whānau Ora commissioning agencies have prioritised services that help whānau realise their own aspirations and attain their own outcome goals rather than focusing only on goals chosen by services.
Māori participation in conventional services has too often been hindered by the exclusion of whānau, a failed engagement process, offensive practices such as stigmatisation, seclusion, committal, over-reliance on medication, overt racism, and an inability of clinicians to understand Māori world views or te reo Māori. Obstacles to receiving timely help, especially during a crisis, or to meet the criteria required for help has further compromised Māori access to appropriate care and support. A serious shortage of acute inpatient beds and respite care adds to the lack of confidence in the system.
Kaupapa Māori health services offer alternate forms of service. They are grounded in te reo, tikanga and the use of rongoā, as well as a variety of clinical and social interventions. Typically, they address the whole person, the whānau and the socioeconomic environments that are contributing to the problem. They are guided by Māori models such as Te Whare Tapa Whā84 and aim for outcomes that create a sense of manahau (exhilaration) and riaka (energy). Some also offer respite care and access to talk therapies.
Fragmentation within the wider mental health system is a serious concern in many Māori communities – disconnection exists between primary and secondary care, prevention and treatment, NGOs and general practitioners, policy and practice, mental health services and general health services, tikanga Māori and Western approaches. Better connections between mental health services and addiction services are also needed. While the two services often overlap, addiction services are significantly different from mental health services.
Some communities have made substantial gains in reducing the fragmentation by forming community collectives that provide front-line mental health functions including mental health assessment, triage, early intervention, respite care and ongoing support. A preference exists for locating secondary specialist services in a community base and establishing a community mental health hub as a preferred alternative to emergency departments, hospital triage and a hospital psychiatric clinic.
Several Māori providers also emphasised the need for community workers to maintain contact with people who are receiving specialist care. Discharge plans made in consultation with whānau and community workers, and admission criteria that take into account the first-hand knowledge of community workers, could reduce the specialist-community disconnect. The employment of navigators has also been able to help whānau link up with key services, reduce confusion and improve continuity.
Further, instead of contractual agreements that are often short term and geared to the priorities of DHBs or other funders, Māori interest in establishing mental health commissioning arrangements with DHBs has been strong. The Whānau Ora commissioning agencies are options that are already operating, and arrangements with Iwi or Māori community organisations could also lead to commissioning agreements.
The Māori mental health workforce has greatly expanded to include Māori psychiatrists, general practitioners, nurses, psychologists, social workers and counsellors, as well as cultural experts, consumers, people with lived experience of mental illness, kaumātua and rangatahi. But there have been concerns about those who work in isolation of other Māori staff members and who, as a consequence, can be overloaded with expectations that they should manage all Māori referrals or that they should use the same type of approach as their Pākehā colleagues.
A collaborative approach that enables Māori workers to extend their skills in both Te Ao Māori and Te Ao Whānui will be important for maximising the impact of the expanded Māori health workforce. Similarly, the application of a distinctive Kaupapa Māori approach will be more consistent and effective if opportunities exist for ongoing learning, research and collaborative models of care for the entire Māori health workforce.
Māori leadership at all levels of the mental health and addiction sector will be critical for the introduction of fresh approaches. Leadership in the future will require leaders who can be effective in cross-disciplinary and cross-sectoral settings, can straddle hospital and community divides, can link policy with practice, and are conversant in mātauranga Māori and global knowledge systems. To accelerate the process, Māori health leadership programmes should be available to clinicians, therapists, managers, directors, policy makers, community workers, consumers and people with lived experience.
Whānau experiencing social and economic disadvantage, struggling to meet the needs of children, living under the legacy of intergenerational trauma, locked into poverty, experiencing violence, let down by schools, or subjected to racism will have greatly reduced chances of realising wellness. The involvement of social and economic sectors in the promotion of health and wellbeing is critical. While government facilitation will be important, Māori community leadership has the potential to magnify the impact of local initiatives.
To restore stability and confidence for whānau, Kaupapa Māori services spend considerable time working with schools, housing agencies, the Ministry of Justice, Oranga Tamariki—Ministry for Children and employment agencies. Too often that work is not recognised in contracts, yet it is key to creating environments that are conducive to health and wellbeing. Prevention and positive health promotion should be incorporated into the goals of all NGOs and both primary and secondary care services.
Some communities have established collective capacity to address the wider impacts of social and economic inequities. They have found that the prevention of poor health and the promotion of good health can be advanced through the involvement of schools, universities and tertiary providers, churches, state agencies, marae, NGOs, DHBs and the voluntary sector.
The 1988 Royal Commission on Social Policy85 concluded that Te Tiriti o Waitangi was relevant to all social policies and recommended the adoption of three principles: partnership, participation and protection. The relevance of the Treaty to mental health is also evident in a claim before the Waitangi Tribunal.86 Our Inquiry has not been party to the claim but is aware of strong interest from Māori working in the sector.
Options for reducing inequities and giving effect to the Treaty of Waitangi include ensuring Iwi are involved in strategic planning at district and regional levels and replacing short-term contracts shaped around DHB priorities with commissioning arrangements built around Māori and Iwi priorities. The establishment of a Māori health ministry or Māori health commission to address Māori participation in the wider health sector, including mental health and addictions, has also been suggested. A whole-of-health approach makes sense given the links between mind, body, spirit and family and the consequences that all too often follow a forced separation of mental health from the broader parameters of health. The establishment of a ministry or commission with that overarching function deserves further consideration by the Health and Disability Sector Review.
Meanwhile, to reduce inequities, give recognition to the Treaty and focus Māori mental health leadership, a Treaty partnership relevant to the new Mental Health and Wellbeing Commission (see chapter 12), will be important. The Commission could recognise Treaty obligations in several ways including Māori participation in governance arrangements, a partnership between the Commission and Iwi or Māori, or a Māori workstream within the Commission.
83 R McClintock and V Martin-Smith. 2016. Waka Hourua Community Initiative: Te Taitimu Trust. Wellington: Te Kīwai Rangahau, Te Rau Matatini.
84 MH Durie. 1985. A Māori perspective of health. Social Science and Medicine 20(5): 483–486.
85 Royal Commission on Social Policy. 1987. A Fair and Just Society. Wellington: Royal Commission on Social Policy.
86 The Waitangi Tribunal Health Services and Outcomes Inquiry was initiated in November 2016 to hear all claims concerning grievances relating to health services and outcomes of national significance.