One of the most striking features of our current system of mental health and addiction services, is that it focuses almost entirely on those people with the most severe needs. New Zealand has relatively few publicly funded services for people with less severe mental health and addiction challenges. This includes high prevalence conditions such as anxiety and depression, and conditions related to alcohol and other drugs.
While we have succeeded in our deliberate policy goal of expanding services and support for people with the most serious needs, the almost exclusive focus on this group means opportunities for early intervention are lost. We fail to respond adequately to many people who are experiencing high levels of personal distress, often with a significant impact on their lives, but who do not meet the eligibility criteria for specialist services.
The lack of access to a broader range of options outside of specialist mental health services means that people remain in those services far longer than they need through fear of being discharged and then not being able to access support if and when they need it. Services are hard to get into, making people and clinicians reluctant to discharge. This provides an incentive to stay in the specialist system just to get ongoing support even when a general practice could provide clinical support. The fact specialist services are free, unlike most primary care services, creates another perverse incentive.
Finally, specialist services themselves are under intense pressure. At least some of this pressure is due to gaps in earlier intervention, resulting in distress escalating to the point where needs become severe and specialist services are needed. Sometimes though, people seek access to specialist services that are not necessarily the most appropriate for their needs, simply because there is nowhere else to go. All of this puts even more pressure on these services and creates a vicious cycle with negative impacts on access and quality.
The current system is designed quite explicitly to prioritise people with the most severe needs. To understand this more, we looked closely at mental health strategies, plans, rules for mental health and addiction funding in Vote Health, district health board (DHB) service specifications and policy settings. We describe these below.
As outlined in chapter 1, most publicly funded mental health and addiction services are funded through Vote Health, with about $1.4 billion being spent on mental health and addiction services annually, of which $1.35 billion is devolved to DHBs (in 2016/17). This funding is ring-fenced so it is protected within the DHB bulk-funding environment, and tight rules determine how the ring-fenced funding is to be managed and spent. These rules are also reflected in DHB mental health and addiction service specifications that set out the services DHBs are required to fund. These rules are not the reason the system is oriented the way that it is – they merely reflect and reinforce the policy decisions that have led to this situation.
In summary, the rules109 around mental health and addiction funding are that:
In comparison, about $30 million is allocated specifically for primary mental health services for those with less severe needs. (See Appendix B for further detail about mental health and addiction funding and services.)
In some respects, the orientation of the system towards high-end, acute and specialist services and the challenge of investing more earlier is not unique to the mental health and addiction system. All health systems, including New Zealand’s, are grappling with this issue. This is reflected in New Zealand’s 2016 Health Strategy112 and as far back as the 2001 Primary Health Care Strategy.113
Mental health and addiction services have additional dynamics. The policy of deinstitutionalisation in the 1980s and 1990s saw the widespread closure of psychiatric hospitals with most services shifted out of residential institutions and into community settings. Building on the 1994 strategy for mental health services114 and the 1996 Mason Inquiry report, the first Blueprint in 1998115 set in place a plan so services would be available, and prioritised, to people with the most severe mental health and addiction needs.
This group of people – those who had very severe needs – was estimated to be around 3% of the population in any given year, but in the late 1990s only about 1.5% of the population were receiving services. Therefore, coverage of 3% became the target.
This priority was supported by the introduction of mental health ring-fenced funding and associated rules that protected mental health money for its intended use on mental health services that were prioritised towards people with the most severe mental health and addiction needs.
Concerns about focusing the system on people with the most severe needs, without a parallel focus on prevention, promotion and early intervention, have been raised over many years, including by the National Health Committee during the Mason Inquiry.116 The issue has always been that when resources are constrained, any change in priority might result in a reduction of access to services for people with severe needs.
Several strategic documents have sought to expand the focus of mental health and addiction services so services would be delivered across the spectrum of need. For example, Blueprint II for improving mental health and wellbeing for all New Zealanders stated:117
The new direction signalled by Blueprint II, and adopted as policy,118 is entirely consistent with the many calls we heard for a system with a continuum of services to address the spectrum of mental health and addiction needs, but did not seem to result in a significant shift.
Given this supposed change in policy, we were surprised to find that the current rules about what mental health ring-fenced funds can be spent on and the requirements on DHBs for the types of mental health and addiction services they must fund, still reinforce the priority of delivering services for people with the most severe mental health needs and are virtually silent on what services should be available for those with mild to moderate and moderate to severe needs.119
We conclude that a fundamental disconnect exists between stated strategic direction, funding and operational policy and ultimately service delivery.
Although the main focus has been on services for people with the most severe needs, some ability to respond to less severe needs exists, mostly through Vote Health funding, but also from other sources. This response, however, has been limited.
Some specific funding for primary mental health services is available (about $30 million in 2016/17), which DHBs have used to support initiatives in primary mental health, including counselling sessions and extended GP visits. This funding is tightly targeted to young people, Māori, Pacific peoples and people on low incomes. Under the Fit for the Future programme, $5 million was also made available for three time-limited primary mental health initiatives in 2016.
DHBs can use ring-fenced funding for primary mental health services if they meet the target of 3% of the population accessing specialist services during any year. We are aware that some DHBs have attempted to do more in primary mental health, working with primary health organisations and non-governmental organisations (NGOs), although the rules they operate within do not support this particularly well. As one former DHB mental health service planner said in relation to trying to develop services for people outside the 3% target group:120
Primary health care services are another critical part of the response to mental health and addiction needs. Although not funded specifically for these services other than by the funding identified above, primary health organisations (PHOs) and general practices are funded through general capitation funding to respond to the health needs of their enrolled populations. Capitation funding is, thus, intended to respond to the mental health and addiction needs of enrolled patients whose needs are not dealt with through DHB specialist services. It was always anticipated in the Primary Health Care Strategy that there would be a focus on mental health, including liaising with specialist services to support people with chronic conditions. PHOs were also expected to consider how they could contribute to reducing the “incidence and impact of mental health problems … specifically education, prevention and early intervention activities”.121
We note also that the service specifications for DHBs for specialist mental health and addiction services state:122
The implication of all of this is that primary health care services were expected to play a significant role in responding to less severe mental health and addiction needs. This was to be achieved through a significantly transformed primary health care sector, as envisaged by the Primary Health Care Strategy. That did not happen. We discuss the unfulfilled expectation of primary health care transformation separately in chapter 5.
Other options for people with less severe needs include accessing services funded through other agencies (for example, the Accident Compensation Corporation, Oranga Tamariki—Ministry for Children, the Department of Corrections and the New Zealand Defence Force) or accessing education-based health services. Many workplaces also fund a limited number of free counselling sessions for staff. Those who can pay for private care do so, although submitters noted that these services are often out of reach even for middle-income people as, even where they are available, they are expensive to access.
In summary, despite the rhetoric of various strategic documents, our system has not shifted significantly nor has there been explicit funding and direction to support a broader spectrum of services. This helps explain why so many people report unmet need, gaps in services and pressure on current services.
Attempts to fill the gap in services for people with mild to moderate and moderate to severe needs have been either ineffective or piecemeal. The Primary Health Care Strategy has not delivered a transformed primary care sector, and the relatively small amounts of tightly targeted primary mental health funding (or, more recently, time-limited pilots or demonstration projects) are not sufficient to fill the gaps in services. Allowing DHBs to use ‘left over’ ring-fenced funding is not a sustainable way to plan and build services to meet the needs of people with less severe mental health and addiction needs. A new approach is needed.
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 a commitment to a funding path, funding rules and expectations that align with the desired direction, and an appropriate workforce.
We were struck when looking at other countries’ approaches that several already fund broad-based access to mental health and addiction services for people in the middle ground (especially talk therapies, such as 6–10 sessions of free counselling), including the United Kingdom, the Netherlands, Australia and the United States. Of course, differences exist between the health systems of these countries and New Zealand’s, and services need to be appropriate for our population, including our indigenous population. But, overall, they demonstrate much greater commitment and investment in providing access to mental health and addiction services to address a wider range of needs than is evident in New Zealand.
The United Kingdom’s programme was introduced following analysis presented in 2005 that clearly set out the human and economic costs of failing to invest outside of, what was at that time, the 1% of the United Kingdom population who had the most severe needs.123 Similar arguments can, and should, be made here.
We recommend an explicit policy decision to expand access to mental health and addiction services beyond the group identified with severe needs requiring specialist services to include those with mild to moderate and moderate to severe needs. While this does not mean that everyone with mental health and addiction challenges needs or will seek to access a specific service intervention, over time, more people should be able to access support.
The last mental health Inquiry in 1995–1996 recommended an access target of 3%. This has been in place ever since and access rates have now reached 3.7% nationally. We propose setting a new target for significantly increased access to mental health and addiction services. Given current prevalence data suggesting one in five people experience mental health and addiction challenges at any given time, an indicative access target may be 20% within the next five years.
We recognise that further work will be required to identify a specific coverage target (since not everyone will need or want to access a service), definitions of services and access, how access might be expanded over time, and a cost-effective way to achieve the objective. Our point, however, is that a more concerted, widespread and ambitious approach is needed to expanding access to services than the piecemeal and limited approaches to date.
We recommend that the Ministry of Health undertake further work, with advice from the new Mental Health and Wellbeing Commission (chapter 12), to develop the specific target, bearing in mind that it will also be necessary to consider what mix of interventions will be both effective and cost-effective (for example, e-therapies may be a cost-effective and more easily accessible option for some people). Any target should also consider timeliness and quality.
Finally, priority for access to services should continue to be based on need. Access to services should be broad-based and related to the level of mental health and addiction need, rather than targeted on the basis of age, ethnicity or income (as current primary mental health services are). This is consistent with the approach to funding other core health services. We see no reason why mental health and addiction services should be treated differently. It is imperative that access for people with the most severe needs is not reduced in any way.
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 to also cover services for less severe needs. We expect demand for specialist services will reduce as issues are dealt with earlier, before they escalate, but shifting resources to the middle ground would pose unacceptable risks for people with the most severe needs.
To achieve the objective of significantly increased access within five years, a commitment to a clear funding path is needed (see section 4.5.3). Significant investment will also be required to build a workforce able to deliver the range of services needed to support people across the spectrum of mental health and addiction needs. This investment should start as soon as possible, as it will take time to train the workforce. Workforce issues are discussed further in section 4.5.1.
Expanded access and eligibility will also require alignment between formal policies, funding rules and expectations on key actors, such as DHBs and primary health care providers, to reinforce and support the desired direction. Strategy documents over the years have envisaged a continuum of mental health and addiction services across the spectrum of need, but they have not been translated into operational policy or funding and accountability requirements. These enablers are discussed further in section 4.5.4.
109 Ring-fence rules are set out in Ministry of Health. 2016. Operational Policy Framework 2018/19 (version 28 August 2018). https://nsfl.health.govt.nz/accountability/operational-policy-framework-0/operational-policy-framework-201819(external link)
110 Details of the types of services that DHBS must provide are set out in Ministry of Health. 2017. Mental Health and Addiction Services: Tier one service specification (last updated 1 April 2017). https://nsfl.health.govt.nz/service-specifications/current-service-specifications/mental-health-and-addiction-services(external link). Note that ‘specialist services’ is the term used to describe a variety of services, including inpatient, forensic, and community-based mental health and addiction services and other social support services.
111 National coverage was about 4% in 2016/17 with some DHBs at 5–6% coverage (data supplied by the Ministry of Health).
112 Minister of Health. 2016. New Zealand Health Strategy: Future direction. Wellington: Ministry of Health. www.health.govt.nz/system/files/documents/publications/new-zealand-health-strategy-futuredirection-2016-apr16.pdf.(external link)
113 Minister of Health. 2001. The Primary Health Care Strategy. Wellington: Ministry of Health, p 21. www.health.govt.nz/system/files/documents/publications/phcstrat.pdf(external link).
114 Minister of Health. 1994. Looking Forward: Strategic direction for the mental health services. Wellington: Ministry of Health. www.moh.govt.nz/NoteBook/nbbooks.nsf/0/DAA659934A069A234C2565D70018A75A/$file/looking-forward.pdf(external link)
115 Mental Health Commission. 1998. Blueprint for Mental Health Services in New Zealand: How things need to be. Wellington: Mental Health Commission. www.moh.govt.nz/NoteBook/nbbooks.nsf/0/0E6493ACAC236A394C25678D000BEC3C/$file/Blueprint_for_mental_health_services.pdf(external link)
116 Committee of Inquiry into Mental Health Services (K Mason, Chair). 1996. Inquiry under Section 47 of the Health and Disability Services Act 1993 in Respect of Certain Mental Health Services: Report of the Ministerial Inquiry to the Minister of Health Hon Jenny Shipley. Wellington: Ministry of Health. https://tinyurl.com/y6w4nqr5(external link)
117 Mental Health Commission. 2012. Blueprint II: How things need to be. Wellington: Mental Health Commission, p 6. www.hdc.org.nz/media/1075/blueprint-ii-how-things-need-to-be.pdf.(external link)
118 Ministry of Health. 2012. Rising to the Challenge: The Mental Health and Addiction Service Development Plan 2012–2017. Wellington: Ministry of Health. www.health.govt.nz/publication/rising-challenge-mental-health-and-addiction-service-development-plan-2012-2017(external link)
119 Rule 12.21.2 (a) of the rules for mental health funding: Ministry of Health. 2016. Operational Policy Framework 2018/19 (version 28 August 2018). ht(external link)tps://nsfl.health.govt.nz/accountability/operational-policy-framework-0/operational-policy-framework-201819.(external link)
120 Communication to the Inquiry from Dr Sue Hallwright.
121 Minister of Health. 2001. The Primary Health Care Strategy. Wellington: Ministry of Health, p 21. www.health.govt.nz/system/files/documents/publications/phcstrat.pdf(external link).
122 Ministry of Health. 2017. Mental Health and Addiction Services: Tier one service specification (last updated 1 April 2017), p 2. https://nsfl.health.govt.nz/service-specifications/current-service-specifications/mental-health-and-addiction-services(external link)
123 DM Clark. 2018. Realizing the mass public benefit of evidence-based psychological therapies: The IAPT program. Annual Review of Clinical Psychology 14: 159–183; R Layard. 2005. Mental health: Britain’s biggest social problem? Strategy Unit seminar on mental health, 20 January. http://eprints.lse.ac.uk/47428/1/__Libfile_repository_Content_Layard_Mental%20health%20Britain%E2%80%99s%20biggest%20social%20problem%28lsero%29_Mental%20health%28lsero%29.pdf.(external link)