This blog post is extracted from a recent editorial of the journal Aotearoa New Zealand Social Work written by Neil Ballantyne and Liz Beddoe. The editorial extract refers to a commentary in the journal by Genevieve Smith and Joanna Appleby.
In their commentary on the “Social work practice implications of upcoming mental health reforms”, Genevieve Smith and Joanna Appleby offer an informative account of the key challenges for mental health services and for people experiencing mental distress in Aotearoa New Zealand. They contextualise their discussion with reference to the impact of four decades of neoliberal reforms on our people and on our health and social services—reforms that have fostered deep economic inequality, racism, precarity and despair in the lives of the many (see, also, the review of Ferguson, 2017 in this issue). These reforms have devastated mental health services through underfunding, service rationing and managerial business models that alienate service users, pressurise frontline workers and fracture service provision. Smith and Appleby explore four challenges faced by those who would reform mental health services: the steady growth in demand for services along with the severity of presenting problems, the failure to maintain or increase the supply of services leading to issues with service accessibility, the postcode lottery of service variability between the 20 District Health Boards, and staff retention and burnout (partly a product of the first two challenges).
The material results of this long-standing neglect have been highlighted in a series of recent news reports: on the decrepit, damp, mouldy and rat-infested infrastructure of mental health units (Donovan, 2021; Lewis, 2021); on acute crises in mental health teams where staff feel scared, distressed and unsafe at work (Cook, 2020; Meier, 2021); and on long and growing wait times for access to mental health services (Cardwell, 2021; Quinn, 2021). These news reports highlight, not only the crises in the public system, but that the private sector is also becoming overwhelmed. Quinn (2021) cites comments by the Executive Advisor of the College of Clinical Psychologists that, “The private system always used to be the overflow from the public system, but now we’re getting to the point where the overflow is overflowing.”
These appalling service failures are also reflected in our stubborn youth suicide statistics, where Aotearoa New Zealand leads the world (OECD, 2017); and in the overwhelming prevalence of mental health or substance use disorders in the Aotearoa New Zealand prison system (91% of all prisoners). The Chief Executive of the Department of Corrections has declared, “The high prevalence of mental illness among prisoners means that the Department of Corrections is managing more people with mental illness than any other institution in New Zealand” (The Department of Corrections, 2017).
In a study comparing mental health services in 14 developed countries, Aotearoa New Zealand was found to have the second lowest number of general psychiatry beds per 100,000 of the population and, consequently (at 70%) the highest rate of involuntary admissions and emergency readmissions (NHS Benchmarking Network, 2019). Of course, a low ratio of psychiatric beds might indicate a positive policy preference to invest in accessible, community-based services, but the evidence above—and the emergency readmission rates—suggests otherwise. It is small wonder that Andrew Little, the health minister responsible, expressed alarm that the government’s 2019 decision to invest $1.9 billion extra in mental health services, as part of the reforms discussed by Smith and Appleby, has, to date, resulted in only five extra acute mental health beds, and that many patients are sleeping on mattresses on the floor of mental health units (Lynch, 2021).
In their commentary, Smith and Appleby argue that the “upcoming reforms provide an opportunity to address some of the long-standing issues” in our mental health services; and that “there needs to be adequate funding so that mental health services can move from a business model to a recovery model.” We agree. Indeed, arguably, one of the central barriers to achieving the reforms necessary to all public services (including Oranga Tamariki) is a bankrupt business culture with its alienating language and inappropriate processes. Despite its obsession with “stakeholder engagement”, “long-term pathways” and “transformational change” (Ministry of Health, 2021) the Ministry of Health stands accused of failing to deliver. The toxic managerial culture and lexicon of customers and business processes need to swept aside in favour of a public service orientation that values a cooperative approach, supports staff and welcomes the active involvement of service users in service delivery, design and improvement. More than this, we need to build a social order driven, not by the demands of profit or cold managerial efficiency, but one based on meeting human need—a social order that the recognises the social determinants of mental distress, one that the Marxist psychoanalyst Erich Fromm (1955) described long ago in his book, The Sane Society: “The conflict between capital and labor is much more than the conflict between two classes . . . It is the conflict between two principles of value: that between the world of things, and their amassment, and the world of life and its productivity” (p.92).
Photo by Jonathan Rados on Unsplash
Cardwell (2021, July 16). Fears lives are being put at risk due to mental health wait times. Radio New Zealand. Radio New Zealand. https://www.rnz.co.nz/news/national/447009/fears-lives-are-being-put-at-risk-due-to-mental-health-wait-times
Cook, C. (2020, September 23). Wellington Hospital mental health unit unsafe for staff, patients – union. Radio New Zealand. https://www.rnz.co.nz/news/national/426710/wellington-hospital-mental-health-unit-unsafe-for-staff-patients-union
Donovan, E. (2021, June 15). Housing the mentally ill when the roof is caving in. Radio New Zealand. https://www.rnz.co.nz/programmes/the-detail/story/2018799648/housing-the-mentally-ill-when-the-roof-is-caving-in
Fromm, E. (1955). The Sane Society. Rinehart & Company
Lewis, O. (2021, June 15). Dangerous mould found in leaky mental health units. Newsroom. https://www.newsroom.co.nz/dangerous-mould-found-in-leaky-mental-health-units
Lynch, J. (2021, June 22). Health Minister Andrew Little orders stock take of mental health spending. Newshub. https://www.newshub.co.nz/home/politics/2021/06/health-minister-andrew-little-orders-stock-take-of-mental-health-spending.html
Meier, C. (2021, August 3). Staff feeling unsafe at mental health emergency department leaving in droves. Stuff. https://www.stuff.co.nz/national/health/125953916/staff-feeling-unsafe-at-mental-health-emergency-department-leaving-in-droves
Ministry of Health (2021). Mental health and wellbeing long-term pathway. https://consult.health.govt.nz/mental-health/3420983a/
NHS Benchmarking Network (2019). International mental health comparisons 2019 Child and adolescent, adult, older adult services. https://s3.eu-west-2.amazonaws.com/nhsbn-static/Other/2019/International-MH-report-31-October-2019.pdf
OECD (2017). Teenage suicides (15-19 years old). https://www.oecd.org/els/family/CO_4_4_Teenage-Suicide.pdf
Quinn, R. (2021, July 13). Psychologists unable to take new clients fear ‘tsunami’ of mental health problems. Radio New Zealand. https://www.rnz.co.nz/news/national/446766/psychologists-unable-to-take-new-clients-fear-tsunami-of-mental-health-problems
The Department of Corrections. (2017). Change lives shape futures: Investing in better mental health for offenders. https://www.corrections.govt.nz/__data/assets/pdf_file/0018/29016/Investing_in_better_mental_health_for_offenders.pdf
3 replies on “Mental health services in Aotearoa: A system in constant crisis”
I would like to think that if the reforms proposed in the NZIER report “Hidden in plain sight” go ahead, social work will be positioned to change outcomes in mental health. I am concerned though, that social work will not get to decide what social work does, our scope will be defined by other professions, and the split between physical health social work and mental health social work will continue.
Many thanks for your comment Anne. I am far less hopeful than you that an analysis based on econometrics and argued within the dominant managerialist framework offers the hope of anything other than shuffling the deckchairs on the Titanic. The fundamental issues for the health system (both physical and mental health) pivot not on the respective influence of different professional groups, but on the dominance of many layers of management.
In the July 2021 issue of the NZNO magazine Kai Tiaki the economist Brian Easton offers the first of a two part article on the proposed public health service reforms. He writes,
“About 30 years ago, the government got it into its head that if our hospitals were to be run like businesses there would be a major productivity boost. They promised 20 per cent gains, although these never happened. Part of the disorganisation…was to appoint businessmen and women to run what were called crown health enterprises…which evolved into what we call today district health boards. The business-sourced chief executives knew little about health care. I was told of instances in which senior clinicians visited a CEO who showed much discomfort at their presence. One had 12 second-level managers reporting to him, only one of whom was a clinician.”
Things may have changed since then, but the upper echelons of all public sector organisation are still dominated by many layers of management committed to values and business practices that do not serve our people well. I’m afraid to say that the NZIER report and its recommendations do nothing to challenge that fundamental problem.
To make these changes there would need to be commitment to them, a reorganising of the way Tier 1 / GP services are funded and run with the practices directly funded rather than allowing funds to be filtered through DHBs.
I think the proposal for patient-centred medical homes, changes to the governance models of GP practices and payment models that align with service models could all make a difference – but that difference will have a developmental cost attached to it. Our government funded health and wellbeing services tend to introduce new models of care with no “hump” funding and no transition time.
Quality social work can have a positive impact on people’s lives, providing preventative services in health, education, justice, child and family protection amongst others. I’d like to see us get the opportunity to do that preventative work.