As well as greater access to services, people have called for more choice in the types of services available. Māori want Kaupapa Māori options and Pacific peoples want access to services that align with their cultural values. Likewise, other groups such as the Deaf, Rainbow, and refugee and migrant communities want services that are culturally responsive and capable of meeting their specific and diverse needs.
People want a choice of therapies. A key thing many people asked for was ‘someone to talk to’ rather than only medication. Obviously, medication will remain an important treatment option, but our current system does not provide sufficient access to other evidence-based options such as talk therapies, alcohol and other drug services and culturally aligned therapies. Choice applies to people across the spectrum of need, not just in the middle ground.
Evidence of the cost-effectiveness of talk therapies and potential savings for health systems and other parts of government, provides support for making these therapies more widely available. For example, in the United Kingdom it has been estimated that providing free access to psychological therapies produces health service and Treasury savings (through increased tax revenues and reduced income support payments) that well exceed the cost of providing the therapies.124 Similarly, it has been estimated that the societal benefits for New Zealand of providing cognitive behavioural therapy far outweigh the associated costs.125 Making these therapies more widely available with suitable adaptions to different cultural and delivery contexts should be a priority.
While all countries are grappling with demands on mental health and addiction services, as noted above, some countries have decided to publicly fund services to provide access for a much broader range of their citizens. These programmes typically include broad-based access to a certain number of counselling sessions or other talk therapies. Examples include the Improving Access to Psychological Therapies programme in the United Kingdom126 and the Medicare-funded scheme for Better Access to Mental Health Care in Australia.127 The experience of these countries is that demand for these services stabilises, which provides a level of cost certainty each year.
A critical element to build and improve our mental health and addiction services is to develop a broader range of services to provide more choice for people seeking help. We believe one of the priorities must be to broaden access to evidence-based talk therapies. These services can be delivered in a variety of settings, such as DHB community mental health services, primary health care services, youth one-stop shops, Kaupapa Māori and Pacific services. However, regardless of the setting, a critical need is to build workforce capacity and capability to meet current and future demand, with the capability to provide new and innovative support and intervention options.
These therapies can also be delivered by different types of practitioners. While some self-help and e-mental health programmes do not depend on an expanded workforce, many talk therapies and culturally aligned models need to be delivered by skilled workers. A wide range of practitioners can deliver psychological therapy if suitably trained. They include the non-registered workforce, GPs and practice nurses, mental health professionals, peers and cultural practitioners. Higher intensity talk therapies can be delivered by people who have a qualification recognised under the Health Practitioners Competence Assurance Act 2003 and who have specialist training in talk therapies. The disciplines that currently incorporate specialist training in their professional qualifications include psychology, psychiatry, psychotherapy and counselling.
New Zealand needs to broaden the types of services available to address mental health and addiction needs, with a priority being to ensure we have the capacity and capability to provide far greater access to evidence-based talk therapies for people across the entire spectrum from mild to moderate through to severe needs that can be delivered in a range of settings including within different cultural service models. We propose that specific priority also be given to funding more alcohol and other drug services, since service options appear particularly limited for people seeking to recover from addictions.
While psychologists are not the only practitioners who can deliver these therapies, an immediate priority is to begin building this part of the workforce, given the likely lead in time to build capacity. Modelling by Health Workforce New Zealand suggests that, while the number of psychologists will increase over the next 10 years, this will not keep up with expected population growth.128 This is without the impact of the proposal we make to significantly expand service access to up to one in five of the population, which will require a large increase in the publicly funded provision of talk therapies and culturally aligned therapies that are especially relevant to Māori and Pacific peoples. Broadening the range of people who have the skills to provide more intensive interventions is critical.
We understand that psychologists generally support the concept of other practitioners delivering psychological therapies. However, the success of these approaches depends on factors such as access to high-quality training, supervision and delivering enough therapy to maintain quality. Psychologists and skilled nurse specialists may need to directly provide therapies for people with more severe and complex needs and will play an important role as members of multi-skilled and multicultural intervention teams. They may also provide advice and oversight for others delivering psychological therapies with less training and experience.
Apart from psychologists, we also see the need for psychiatrists to have an extended range of interventions that include psychotherapy, talk therapy and family therapy. We recognise that those skills have long been an essential part of psychiatric training, but all too often they are subsumed by an over-emphasis on medication. When they are combined, the dual approaches – medication and psychotherapy – provide clinicians and tāngata whaiora with a more relevant and integrated approach to mental health.
We agree with submitters who said the focus needs to be on three areas to increase access to these therapies: increased access to psychologists, psychological therapies delivered by non-psychologists and e-therapies. There also needs to be investment in supporting the development of culturally responsive therapeutic interventions and a broader range of more intensive peer-provided options. This will require investment in a suitable workforce. A further area of focus will be to consider delivery mechanisms that would expand access, such as group therapies and brief interventions for people with mild to moderate needs.
We propose that the Ministry of Health builds on existing workforce modelling, including that presented to us by the Psychologist Workforce Taskforce, and examine approaches from other countries to providing broad-based access to evidence-based talk therapies (for example, Australia, the Netherlands, the United Kingdom and the United States, including indigenous models from Alaska129). The intention should be to develop a range of approaches that are appropriate for New Zealand, ensuring ready access to talk therapies, culturally aligned therapies and a menu of alcohol and other drug services.
Increase choice of services
124 DM Clark. 2018. Realizing the mass public benefit of evidence-based psychological therapies: The IAPT program. Annual Review of Clinical Psychology 14: 159–183.
125 Te Pou o Te Whakaaro Nui. 2012. Exploring the Economic Value of Talking Therapies in New Zealand: Utilising cognitive behavioural therapy as an example. Auckland: Te Pou o Te Whakaaro Nui. www.tepou.co.nz/uploads/files/resource-assets/exploring-the-economic-value-of-talking-therapies-in-New-Zealand-utilising-cognitive-behavioural-therapy-as-an-example.pdf(external link)
126 DM Clark. 2018. Realizing the mass public benefit of evidence-based psychological therapies: The IAPT program. Annual Review of Clinical Psychology 14: 159–183.
127 Australian Psychological Society. No date. Better access to mental health care: Medicare funded services (web page). www.psychology.org.au/for-the-public/Medicare-rebates-psychological-services/Medicare-FAQs-for-the-public# www.psychology.org.au/for-the-public/Medicare-rebates-psychological-services/Medicare-FAQs-for-the-public(external link) (accessed 16 October 2018).
128 Health Workforce New Zealand, from demonstration of its modelling tool, July 2018.
129 J Derksen. 2009. Primary care psychologists in the Netherlands: 30 years of experience. Professional Psychology: Research and practice 4:493–501; S Huhndorf. 2017. Native wisdom is revolutionalizing health care. Stanford Social Innovation Review Summer: 18–23.