We have proposed extending access to services and broadening the types of services available to provide more choice to people, with a particular focus on talk therapies that can be delivered in different settings and by a variety of providers. However, to deliver on the vision for services outlined in section 3.6, fundamental changes are needed in how services are delivered.
These changes need to be planned, developed, implemented and monitored in a more structured and coordinated way than the present approach of ad hoc funding, ‘letting a thousand flowers bloom’, and encouraging innovation without clear pathways to evaluate and scale up. We propose a national co-design process followed by implementation at national, regional and local levels, with an appropriate level of support to manage a complex change process.
We need a broader range of mental health and addiction services for more people that are easily accessible, more options to access health and social services in different ways and in different contexts, easier ways for people to get support for multiple needs when required, a more diverse workforce, and to use our workforce in different ways. We have not specified the exact features of a new set of services, but Table 3 sets out a variety of approaches raised during the Inquiry.
Examples of different types of services and service models
Piri Pono: A peer-led, community-based alternative to hospitalisation
Several relatively new community-based acute alternatives to hospitalisation are showing great results for people who would otherwise be admitted to inpatient acute units. One of these is Piri Pono.
Piri Pono is a five-bed residential, acute alternative to hospitalisation provided by ConnectSR through a contract with Waitemata DHB. The service is peer-led and staffed with nurses and support workers. Piri Pono is available to those experiencing extreme mental distress, and guests can stay for up to 10 days in a home-like, personalised environment with a holistic approach to wellness.
Evaluations of Piri Pono have been positive, and tāngata whaiora and their families and whānau view it favourably.
Achieving a set of services like those listed in Table 3 will require much more integrated service planning and delivery, an expanded workforce with different types of roles, including Kaupapa Māori and Pacific workers, and more effective use of our existing workforce. An integrated set of services also has to be connected across sectors, not just within the health sector. This means ensuring appropriate linkages between mental health and addiction and other social services (for example, housing, budgeting advice, employment services, relationship and anger management, and Whānau Ora services) for people who require other types of support. It also means considering how to most effectively plan and deliver mental health and addiction services in different settings, such as schools and prisons, or for people in contact with Oranga Tamariki.
This implies any process to plan and deliver mental health and addiction services, and associated social supports, must involve a variety of agencies across sectors, including outside government, that are appropriately resourced and mandated to deliver. This would represent a very different type of process from past practice.
We appreciate that many talented and highly motivated people are doing their best in a difficult environment and excellent pockets of innovation exist. But inspiring people are not always well supported and few mechanisms exist to evaluate and scale up or cease initiatives as appropriate. Designing a new system, even with all the right elements within and across sectors, will not be sufficient without also investing in supporting change itself. We need to use implementation science to bridge the gap between strategy and practice and to ensure supporting infrastructure is in place and aligned to deliver the desired outcomes.
In summary, we need:
A shift of the magnitude envisaged will require a significant service transformation and design process. We think a robust co-design process should begin with a nationally led process for a high-level design, then work to identify priorities and develop the implementation framework for these, followed by regional or local adaptation, planning and implementation. Designing the ‘how to’ for implementation and evaluation at a national level will be essential to achieve traction locally and have a consistent evaluation framework to support shared learning and refinement. The service framework developed from this process should then inform the development of local services to meet the specific needs of the communities they will service. It should include Kaupapa Māori service frameworks.
This process should aim to develop a range of services that can address a spectrum of mental health and addiction needs, are integrated with a range of other support services, and have a significant emphasis on primary and community-based care. Five principles should underpin the development process.
The high-level service design needs to be done well, but it also needs to proceed rapidly. This work can be accelerated by building on the foundations and consensus provided by the 2016 Ministry of Health–led Fit for the Future programme and other interagency work undertaken in recent years, but needs to extend further. It can also draw on lessons from the current transformation of disability support, but must result in progressive change across the whole country, not just at prototype sites. We expect that, in line with international experience, it is likely to take three to four years to implement 80% of the desired change, even without the challenge of workforce shortages and the need for a co-design process at the outset.
The co-design process should be facilitated by the Ministry of Health in partnership with the new Mental Health and Wellbeing Commission (or an interim establishment body). This is because the Ministry of Health is currently the clear lead, within government, for mental health and addiction services.
However, many other agencies and groups will need to be involved and provide leadership in the co-design process. They include government agencies such as the Department of Corrections (around meeting the mental health and addiction needs of people entering, in or leaving the corrections system), the Ministry of Education (around the provision of mental health and addiction and wellbeing services and support in educational environments, including programmes that build resilience and wellbeing), Te Puni Kōkiri (around the funding and goals of Whānau Ora) and the Ministry of Social Development (in relation to income support and employment support). We note there are already several models to bring agencies together to tackle complex, cross-cutting problems131 and that the proposed reform of the State Sector Act 1988132 may provide additional avenues for integrated leadership on issues relevant to mental health and addiction; for example, to support coordinated service planning that requires input and commitment from multiple government departments.
We suggest the State Services Commission advises on the most appropriate models and levers to bring together agencies across government to collaborate in the national co-design process for mental health and addiction services.
The co-design process should inform many of the investment decisions in the mental health and addiction area over the medium term. We suggest strategic investment in priority developments is needed rather than ‘shopping lists’, action plans with dozens of discrete items, and multiple pilots and demonstration projects. The focus should be on making good traction on a limited number of strategic priorities. As outlined in the previous section, a good case exists for immediate investment to fill critical gaps in services. This investment will be needed regardless and can proceed ahead of the co-design process.
Investing in change itself is important. The speed and consistency of uptake of innovation or change is greatly improved by having implementation support. For example, it has been estimated that implementation support enables an 80% uptake of the intended change within three years,133 whereas without implementation support only 14% of healthcare research is adopted into day-to-day clinical practice within 17 years.134
We acknowledge those agencies that are already investing in and supporting change. The Health Quality and Safety Commission is leading prioritised quality improvements in existing services. Similarly, the mental health and addiction workforce development centres have been leaders in building workforce capability. However, there is no similar investment to support new service developments or substantive system change.
People with the passion, leadership skill, change know-how and experience in implementing system transformation will play a key role. We need to make the most of existing talent and build capability and relationships across the sector and communities to get traction in implementing the new system design. Peer and cultural leaders will play important roles.
The transformation we envisage needs to be supported by robust change methodologies, implementation science (to ensure the uptake of approaches that have proven effective into routine practice in ways that are locally relevant) and investment to support the change process itself. We have looked at examples where implementation support was provided for mental health and addiction system change to see what we could learn. Examples include a Canadian provincial support programme, a New Zealand mental health and addiction change team in a DHB, and collective impact approaches.
Ontario provincial support programme (Canada)
The Ontario provincial government commissions mental health and addiction implementation support from a central team, which helps clarify the intent of a change initiative and to define the outcomes and measures. It then designs how the change or new service will be implemented in such a way that it can be picked up locally and, with local stakeholder participation, adapted for local implementation.
Within the Canadian model, local teams also work with key local stakeholders to ensure the intended change is adopted, implemented with fidelity to a set of core features and sustained over time (but with flexibility). This arrangement also provides for knowledge exchange between local implementation sites and the centre, which helps build the body of evidence about what works.
The Ontario model is intended to address many of the problems we have identified in New Zealand and potential exists to build something similar that is adapted for our context. The new Mental Health and Wellbeing Commission (discussed in chapter 12) would be well positioned to be the hub for such a facilitative function.
DHB mental health and addiction change team
Several years ago, Counties Manukau DHB invested $1 million per year (from its underspend in new funding) in a change team to:
This investment enabled the DHB to improve the acceptability of services to the people who used them and increase staff satisfaction, without having to increase inpatient services in the face of population growth. This was at a time when the DHB’s mental health and addiction system was experiencing significant demand pressures.
Collective impact approaches
Some of the pockets of success in New Zealand seem to build on collective impact approaches either explicitly or implicitly (for example, Equally Well and Waka Hourua). Collective impact has been described as “the commitment of a group of important actors from different sectors to a common agenda for solving a specific social problem”.135 Critical success factors in collective impact approaches include:
Collective impact initiatives are, by definition, community-led. There are lessons in this for how we might approach change on national issues (and local solutions).
Adequate resources (including funding, people and the commitment of key stakeholders) will be needed for a national co-design process. Implementation support will also need to be provided at national, regional and local levels, to support change on the ground.
A new Mental Health and Wellbeing Commission (chapter 12) should be funded to provide ‘backbone support’ to the sector.136 It would support those responsible for implementing change with the tools they need and provide shared infrastructure for knowledge exchange.
The Commission’s relevant functions could be to:
The Commission might also meet some implementation costs such as initial design and evaluation and participation in hui to share experiences and findings.
Close, face-to-face, high trust relationships that respect others’ strengths and local ownership are central to this function working well. It will require significant investment in Kaupapa Māori and Pacific capability and capacity.
The Mental Health and Wellbeing Commission should work closely with the Ministry of Health, bringing the strength of its links to local communities and explicit mission to build implementation capacity across the system.
Filling the gap in support for the change process has the potential to enable the major system shifts proposed. Implementation support will enable progress to be monitored, provide missing system oversight of innovation, and allow learning and scaling opportunities. It will also provide an avenue to feed back the shared learning to the Ministry of Health to inform future policy refinement.
Facilitate co-design and implementation
130 As an example, see D King and B Welsh. 2006. Knowing the People Planning (KPP): A new practical method to assess the needs of people with enduring mental illness and measure the results. London: Nuffield Trust.
131 See, for example, State Services Commission. 2018. Machinery of government: Toolkit for shared problems (web page). www.ssc.govt.nz/mog-shared-problems(external link) (accessed 16 October 2018).
133 D Fixsen, K Blasé, G Timbers and M Wolf. 2001. In search of program implementation: 792 replications of the teaching–family model. In G Bernfield, DP Farrington and AW Leschied (eds). Offender Rehabilitation in Practice: Implementing and evaluating effective programs (chapter 7). London: Wiley.
134 EA Balas. 1998. From appropriate care to evidence-based medicine. Pediatric Annals. ٢٧:٥٨١–٤.
135 J Kania and M Kramer. 2011. Collective impact. Stanford Social Innovations Review 9(1): 36–41. https://ssir.org/articles/entry/collective_impact#.(external link)
136 ‘Backbone support’ is one of the critical elements in collective impact approaches and refers to an organisation or unit that supports the partners involved in a collaborative change effort.