Through
the Maze

Freeman is a living embodiment of the power of a change of mindset. If New Zealand’s mental health services are now “failing”, is it now time for another change?

Over the last 40 years or so, our health system has been moving from the old institutions to a more “community-oriented turn”, emphasising preventative medicine and personal responsibility for health. Deinstitutionalisation hasn’t been a straightforward story of progress, and headlines claiming the system is “broken” or “on a knife edge” are frequent, and hard to ignore.

One of the challenges of community care is navigating a broader range of services, says John Crawshaw, Ministry of Health director of mental health and addiction services. Fixing that is the next phase in the transformation, “but it’s the harder thing to do”.

“It’s not so much [the system] is broken, it’s much more we’ve allowed a diversification of people of who provide care,” he says.

“Which is a good thing. Which gives choice, and gives access to services people might not have otherwise provided. But that challenge is if you’re just coming into the system, how do you get navigated to the right place?”

The map of New Zealand’s mental health services looks more like a jigsaw puzzle, says Taimi Allan, chief executive of not-for-profit advocacy group Changing Minds, who’s trying to do a stocktake of services available in the upper North Island.

“There are hundreds of programmes, services, and projects in the northern region alone. A lot of them aren’t funded, or are only partially funded. There’s a worry if more funding isn’t made available [mental health workers] are going to get burnt out and that will put further stress on the system.”

But Kay Fletcher believes there’s enough money being spent on mental health. “We’re just not spending it in the right way.”

Fletcher started her career in the 1970s as an occupational therapist. From there, she worked in specialist services, and was involved in the transition from hospital-based to community care. For the last 12 years, she has been chief executive of Canterbury’s Comcare Trust, a community-based service for people with mental health and addiction issues.

Too much is spent on expensive clinical services, and not enough on low-cost community services, she says.

“Having worked across both sectors, I can see the agility of what you can do in an organisation like this with the same dollar … There’s still this thinking, that [NGOs] are some sort of small community agencies running nice little programmes. But these are professional organisations that have much more business rigor around them than any DHB-run service.

“We can’t run a deficit; we have to be a smart business as well as delivering high-quality services, because there are a lot of providers in our space and we have to compete.”

It can work. The Canterbury earthquakes were a tragic catalyst for cross-sector collaboration in the community, says Peri Renison, Canterbury DHB chief of psychiatry.

Immediately after the 2011 earthquake, which killed 185 people, NGOs and clinical services started sharing office spaces, “because ours had fallen over”, Renison says.

“Our integration with NGO and primary care has stayed really healthy, across the whole spectrum of services — people work much better, by and large.”

Stu Bigwood, CDHB director of nursing, agrees: “All that tribal stuff went out the window. We accelerated our future plan, and things that we weren’t sure we should be doing, we just stopped. All that small stuff disappeared. Some of us look back to that quite kindly.”

In a raised corner of the secure outdoor courtyard at Henry Rongomau Bennett Centre is a sprawling pumpkin plant. Among the tangled mess are developing fruits in varying shades of buff. One pumpkin is bigger than the others. Someone else has already noticed this — someone with more time, who has carved into the thick skin: “Leave me alone.”

The 110-bed unit, part of the Waiora Waikato Hospital Campus, provides inpatient care for those experiencing mental illness. Waikato DHB announced in April 2016 that it would be replaced — chief executive Nigel Murray at the time described the building as “sub-optimal”.

The nurses showing us around have done what they can to brighten the place; the walls are colourful with artwork, by former residents, residents, and staff. The living room is full of activity, with groups playing games, chatting, laughing. Some sit alone, following us with their eyes, or staring into space.

A new building doesn’t mean a bigger building, says Derek Wright, Waikato DHB executive director of mental health and addiction services. He hopes the future inpatient unit will actually be smaller, with more of the budget going towards community services.“The current model is fundamentally flawed,” says Wright, who started his career in Scotland as a mental health nurse.

“Yes, money is important, but it’s not going to solve the problem. The problem being that we don’t have a model fit for this century.

“What people are looking to do is tinker — and that’s what we’ve been doing since we closed Tokanui [Hospital]. But this is about a fundamental re-think of how we provide services, and also a fundamental re-education of the community.”

Mental health has become a “catch-all for society's woes”, he says. “Society has made us the default, and to be honest the media has made us the default.”

He apologises for pointing as he says that. But it’s clear his anger is borne of frustration. The kind of frustration that comes from being asked to do an impossible job, then being blamed when things go wrong.

“We spend our lives dealing with this influx of people who come in with a problem that could be dealt with in community care,” he says. “We employ highly skilled clinicians who might spend only 10 or 20 per cent of the working week actually working at the top of their scope of practice.”

Over the past decade, demand for secondary mental health and addiction services has increased from 2.3 per cent of the population, to 3.6 per cent of the population, or from around 96,000 people to almost 168,000 people.

Rees Tapsell, the DHB’s director of clinical services for mental health and addiction, agrees with Wright.

“In the 25 years I’ve been practising, there always used to be an element of that, but it’s become a much more significant element of what we’re required to respond to. Not just people with serious mental illness, but a large number of people who are simply struggling to fit into society and to function.”

There’s no doubt modern life is tough, he says, with young people in particular struggling to find employment and accommodation. On top of that, they’re often living away from family and don’t know their neighbours.

“The problem is we live in a world that is so much more about you the individual, other people don’t see themselves as having a role in helping you. Even family members.”

A few more knocks — a break up, a developing alcohol or drug addiction, a particularly rough encounter on a Saturday night — and they’re knocking on the door of mental health services.

“If we’re to avoid ending up back where we were, where we have a whole lot of people who don’t need to be in mental health services getting institutionalised, we actually have to have much more of a community capacity for dealing with what are largely social ills.”

When so much of society’s burden is placed on one sector, things go wrong. And when they do, Mental Health Foundation chief executive Shaun Robinson, says: “Mental health does become the default bogeyman.”

Real-time feedback collected by the Health and Disability Commissioner shows more than 80 per cent of consumers would recommend mental health services. Yet, says John Crawshaw, “everyone is focused on the fear aspect of doing something wrong”.

“Sensational” headlines move the debate from “how to improve services, to actually blaming the people who have mental health problems, or the people who work very hard and have to make very difficult judgment calls”.

Brad Strong, Southern DHB mental health medical director, says this tendency has created a risk-averse environment that hinders innovation and change. It’s a daily struggle to balance a patient’s safety with their autonomy, he says.

“It was much easier to keep people safe in Cherry Farm [the former psychiatric hospital in Dunedin], but we’ve chosen, as a society, a different — better — model. There’s always that tension, but we have to take some risk if people are going to be able to live independent, meaningful lives.”