TO THE MENTAL HEALTH AND THE LAW SEMINARHealth
SHARELLA MOTOR INN
Thank you for the opportunity to speak to you today.
In my first few months as Health Minister, I have welcomed the opportunity to talk to a wide range of people involved in the mental health, both official and unofficial. In particular I have tried to talk with consumers about their concerns and perceptions. As one said to me:
``It's time you talked to us instead of talking about us.''
From advice like that, other briefings and my own observations I'm beginning to draw some conclusions about our mental health services which I will share with you today before briefly outlining some of the steps we are developing to improve things.
At the risk of adding to a litany of woes, it seems to me we need to break a negative cycle, which seems to mirror the worst experiences of people suffering from mental illness.
We have a cycle of: - tragedy - followed by investigations - then recommendations which appear to make no difference - then frustration - followed by rounds of people blaming each other - and a finally a further tragedy to kickstart it all off again.
So what's the circuit breaker?
I believe it's important to win the confidence of key people in the mental health sector.
The belief that the Government doesn't care, or that it's only concerned about the politics of mental health, holds back real progress because it generates and feeds cynicism within the sector and among the media.
No Minister can afford to get bogged down in the complex politics of the mental health sector. Ministers and governments come and go, but alliances and allegiances among the health professionals and advocate groups live on. There is a thoroughly complicated tangle of relationships that are derived from history and the political pressures on mental health which are hard to explain and even harder to fix.
What is easier to fix or at least move on from, is the culture of strategising that flourishes in mental health in place of actual delivery.
We need to move to dealing with the problem at hand rather than constantly going back to the whiteboard.
My primary job is not the complexities but rather to improve actual services for real people.
What's so striking about the mental health field is that so many people feel powerless, regardless of their experience and knowledge of the sector.
And because people are working alongside the boundaries of social acceptability, they seem to be seeking guidance, reassurance and protection from the inevitable political and judicial pressures that arise from their work.
That seeking manifests itself in the one common theme I am hearing in the sector - the call for leadership.
But the demand for leadership doesn't translate into all, or even some, of the answers coming from the Ministry or the Minister.
In my time as Minister I would like to fulfil the leadership role required of me by creating, in partnership with people in the sector, the sort of environment where the people who provide the services feel they can generate the solutions.
Part of the function of leadership is to set direction and strategy. There's a time when that's necessary of course, and my predecessor Jenny Shipley put in place the Strategic Directions for Mental Health Services. The Mental Health Commission is developing a detailed blueprint to incorporate the strategic direction in a coordinated plan.
The time comes when the necessary but limited effect of these exercises should be recognised. What we have to do is stop talking and strategising and start doing. Too much central strategising is not leadership and can get in the way of good services.
So what steps can we take?
Firstly we have started to spend the Mason money. There has been a slow start, and it's been frustrating but the Coalition Government is committed to fully funding the Mason recommendations.
Secondly we are looking to the services the Government owns to see how they can be supported to adapt to meet increasing demands.
As owner of about three quarters of mental health services in this country, I believe the Government has been responsible for insufficient progress in the development of those services.
It is unfortunate but true that our CHEs are not organisations that necessarily adapt well to the high level of public expectation for a community-based service in New Zealand of the year 2000.
CHEs are organisation which inherited a history of being unresponsive to individual needs of patients. By that, I don't mean so much patients' needs for medical treatment as their needs for customised treatment, reassurance and accountability.
This has been difficult enough in the high profile areas of medical and surgical services. I've only got to look at the stack of letters that come across my desk on integral parts of those services such as out-patient clinics and staff attitudes, to realise we have much further to go.
We have some very good secondary care mental health services in our CHEs, all of them capable of being excellent. What I am concerned about is what a consumer described to me as ``institutionalised community care"; which the public perceives as a kind of benign neglect. The services required for mental health in the year 2000 and beyond are the kind of sophisticated support and surveillance services which identify, early-on, the changing needs of the person with a mental illness.
It is by getting in early and working with the individual that such services can help reassure the individual, their supporters and the wider community that any behaviour that could cause fear and concern is being dealt with, whenever possible.
Understanding and monitoring mobile people with fluctuating needs requires a more specialised, personalised and focused service than is easily offered in currently Government-owned organisations.
CHE services need to build much closer relationships with other providers and to be willing to do so even at the expense of their own revenue or power within a service.
We need to be looking for direct cooperation between drug and alcohol mental health and other behavioural type services. After all the key aspect of the mental health problem is not the service itself or the people who work in it but the person who is mentally ill.
I have not seen sufficient evidence that everyone in our services has as their driving ethic the needs of individual patients. Too often the way our services are delivered seems to be dictated by history, professional politics, and statutory obligations.
So moving to the third step. The Government is developing, in consultation with the Mental Health Commission the sort of relationship the Mental Health Commission will have with the Transitional Health Authority. I understand the Commission sees the need for it to have a more hands-on relationship to be developed with the THA, to hasten the development of better services.
It's not an easy choice, but I am keen to see the Mental Health Commission function effectively enough to gain the confidence of the sector.
I am anxious that the Commission's work on the blueprint for mental health services should be heavily influenced by operational realities. It needs to directly channel into improving services and not end up a thick report gathering dust on shelves.
Fourthly, as owner of CHE services we have decided to sharpen CHEs' focus on their mental health services and to support them more actively than we have done in the past. CHE services are under increasing pressure from growing demands for highly visible community services, as well as close scrutiny of their professional judgement from the media.
We are now in the middle of auditing every acute mental health service in the country to check its admission criteria and the appropriateness of the in-patient load its carrying in Peter McGeorge's Acuity Study.
Step five involves looking at different ways of organising the publicly-owned mental health services. We have at the moment a number of interesting ideas.
CHE services will need to change in shape and focus as the trend to coordinated care picks up. GPs, NGOs and CHEs will be working together in mental health, and I suspect it is the CHE structure which may change in response to this.
A sixth step involves areas outside government ownership.
We want to strongly encourage the non-CHE interest in mental health. I am particularly encouraged by the growing interest of GPs in greater participation in the care of the mentally ill.
It seems odd that if you have a headache you can trot down the road to the local GP and have a highly-qualified and skilled person tell you whether you have the beginnings of a brain tumour or just a hang-over. However, if you know you are losing it mentally and even getting dangerous you can find it difficult, if not downright impossible, to get care - even if you have sufficient insight into your own condition to seek help.
Some GPs already carry out a substantial amount of that primary mental health care. We definitely want to build on that. This can fill out another dimension of the vital network of community support and surveillance services required.
The added dimension GPs bring is their multi-disciplinary understanding of people in their actual social environments along with the multiplicity of problems and stress factors they may have.
I will be encouraging CHEs to work with IPAs and other GPs who are interested because I believe it will allow us to achieve two things fairly quickly:
One: it will help up-grade the workforce in the provision of mental health services in the community.
Two: we could, by educating mental health consumers on what's available, increase their access to services considerably.
Also non government organisations who currently provide accommodation and rehabilitation services could with some support and further development widen their range of mental health services from a true community base.
There appears a growing sense of urgency and commitment to workforce development in the sector.
Some of the things we need to do in mental health are quite simple and require applied commonsense.
Throughout New Zealand there are hundreds of 'untrained' people who are family members who care and support someone with often complex mental health problems.
I can't help thinking solving the workforce issue might be more about better development and use of these type of skills than it is about professional training in specific areas.
And what about the legal issues?
I expect there will be continued debate about the scope of our mental health legislation. I hope that debate is a well-informed one, because the current Act has seen the successful rehabilitation of thousands of New Zealanders who have at times needed compulsory treatment.
The Act is limited in its function because it is limited in its purpose. It provides a framework only for those with a mental illness, not other behavioural disorders and only where the need for compulsion is clear. A suicide does not represent a failure of the Act, nor necessarily a failure of the services. If we are to restrain people who have a wide range of diagnoses or who represent a wider range of threats, then we shall need broader legislation. The Mental Health Act is not a cure-all for every symptom of personal distress.
I am also concerned about the statutory structure of District Inspectors and various Directors of Mental Health. I sympathise with CHE services which are subject to two separate formal accountability regimes, as well as their political and media accountabilities.
We need to look at whether current regulations can deliver the kind of protection, reassurance and quality consumers and the community expect for the year 2000. I believe sweeping changes to the Mental Health Act would be a major distraction from better services. If we can create a positive political environment, spend the Mason money wisely, and give our mental health services permission and support to be innovative and flexible, then the need for significant law changes will lessen.
If in a few years the pressure for change is less, we will have succeeded.
I would like to finish by emphasising three key elements of the Government's approach.
Mental Health is a priority for me. I want to improve the services as they are received rather than focus on continually refining strategies.
The driving force has to be integrating the care and ensuing it is designed and delivered to meet the complex and fluctuating needs of people with mental health problems.
We haven't got time for sector politics, we haven't got time for organisations or policies that don't put the people in need out front.
Perhaps what we need most is courage, particularly in the publicly-owned mental health services - courage to change the way we do things - courage to work with others who can help us do thing better and finally courage to tell our community that a mental health service cannot solve every distress, heal every wound or prevent every risk.