OPENING ADDRESS ROYAL COLLEGE OF PSYCHIATRISTS CONFERENCE

  • Bill English
Health

CHRISTCHURCH TOWN HALL

Thank you for the invitation to speak to you today.

Psychiatrists occupy a special case in popular mythology. More than most health professionals, what you do, and what you can do, is shrouded in mystery.

In recent times the pressure to be right, the risk of being on the front page, has grown markedly. Expectations of your magical capacities are perhaps too high. Demystifying psychiatry has and will play a crucial role in reducing the stigma of mental illness.

This evening I want to talk about a number of things. The first is to briefly outline our work to date in implementing the Coalition Agreement.

Secondly I'll look at how we're going on its implementation in mental health - namely how we have followed the two major recommendations of the Mason Report. That involves a bit of updating on the work of the Mental Health Commission in particular.

I then want to talk about what I think are a couple of major issues in the mental health sector, and some ways I think we can improve on what we are doing there.

Finally I'll give you an idea of what it feels like from this side of the fence. We've all got important jobs to do - the more we understand of how it feels for everyone doing those jobs, the better I hope we can do them.

Let's look at what we've done in the Coalition Agreement on Health first.

The Coalition Agreement on health consists of two important parts. One is a number of statements of value with respect to the public health system. There has been quite a strong political perception, and that I think reflects a public perception, that the previous Government was not committed to a public health system.

The Coalition Agreement makes it clear the Coalition Government is committed to not just the maintenance, but also the ongoing development growth of a publicly funded health system.

In the second part of the Agreement are a number of particular policy changes. Some of these you will be familiar with, but I'll just draw your attention to them and tell you where we're up to.

There were four particular policy changes to be made. These are all now nearly completed:

We have implemented the policy of free GP visits and prescriptions for children under six successfully and on time.

The Transitional Health Authority took over the functions of the four regional health authorities, as planned, on 1 July.

In the Budget, hospital part-charges were abolished and health was allocated roughly the additional funding laid out in the Coalition Agreement.

The process of making the Crown health enterprises non-profit organisations is on track to be completed by 1 July next year.
In addition, we have also had the Steering Group report completed, on time.

Having a Steering Group of 13 people from very different health backgrounds looking at the implementation issues around the Coalition Agreement on health could have been a long and rather painful exercise.

It wasn't.

The Group's work showed there is widespread agreement within the health sector about basic shared values.

I am pleased with progress so far. These policies have been welcomed in the health sector and have represented real opportunities to build a better public health system. It all augurs well for further work implementing the Coalition Agreement.

The Coalition Agreement is an outline. It is a document that was produced under a particular, even peculiar, political set of concerns. Writing good health policy was not at the top of the list.

The Agreement had some dotted lines, which needed joining up. I think we've basically done that with the Steering Group Report. Now it's time to do some colouring in - time to think about putting our values into practice.

The process of bringing this picture to life involves everyone in the health sector.

When it comes to mental health, the Coalition Agreement simply states: "The recommendations of the Mason Report are to be fully funded and implemented."

So, let's turn to the Mason Report. It had two major recommendations. They were:

Additional funding for mental health
The establishment of a Mental Health Commission.
I'll deal with the first recommendation first. Some commentators (no bearded cartoonists disguised among you today?) would solve mental health crises by throwing lots of money at them. I wish it were that simple. As you all know, and as I want to talk about later on, a few other factors do come into play. Money can never replace good relationships.

However I do agree more funding was needed, and it is being provided. We have been throwing, with careful aim, a lot more money into mental health care. The money spent on mental health has been increasing steadily since 1993. Last year that total was about $432 million up from $286 million in 1993.

$142m is tagged specifically as the "Mason money", and this is now moving out into new areas of mental health care. That money is to be spent over a five year period.

We are putting more funding into mental health care.

What is causing some misunderstanding, for some of the public anyway, is that much of it is going into new areas. A couple of exciting programmes from Capital Coast are the programme for dual diagnosis, and their early intervention programme for young people. I can understand the public's worries when it seems, for example, that there are just not enough acute beds to go around. But in fact Peter McGeorge's recent acuity study showed us there are enough acute beds. The bigger problem is where to put people when their illness abates. And that is where the money should be spent - rather than in the high profile areas such as acute psychiatric care.

Some new funding is taking its time to work its way out into the mental health community. But it is on its way.

Let's now look at the second major recommendation of the Mason Inquiry - the establishment of a Mental Health Commission. As you know, the Mental Health Commission is well and truly up and running. What is happening now is that its existence is being given a further emphasis of autonomy and purpose through legislation before Parliament.

The Commission has got a mandate. What is important now is that it operate in as realistic a way as possible. It is a watchdog, but it can't be so far outside the system that it can't comment adequately upon it. Again, building up relationships is crucial for its effective functioning.

One very important relationship for the Commission is the relationship with the funder, the Transitional Health Authority. A Heads of Agreement is going to be signed between the Commission and the THA about the particular roles of each agency. This basically deals with using the mental health blueprint, aligning national and regional planning, clarifying funding, and sharing information.

But it is not just with the THA, but with every part of the sector, that the Commission is trying to establish good constructive working relationships. The initial points of contact are their many reviews and projects, but they also see those relationships as an essential part of their work.

The Commission has been given three main goals, and I'll touch a bit upon these.

The Commission's first main goal to make sure that the National Mental Health Strategy is implemented.
This is currently been worked on in a number of ways. To list just a few - the financial tracking project, the blueprint for mental health services project, the early intervention integrated care strategy, work on dual diagnosis issues, the promoting best practice programme, and the analysis of CHE business plans.

I must say here that the CHE business plan analysis, which was carried out by the Commission and the Crown's Monitoring Unit CCMAU, has thrown up some very interesting, very useful information. It has shown me that there are many differences in the ways CHEs contract for mental health care, so much so that in many cases it is difficult to know exactly what is being purchased. And often the schemes are of such grand generality that they must be of very little use to anyone really working in the field.

As a result of this analysis, the next contracting round should be a much clearer and more standardized process.

The second goal for the Commission is to reduce discrimination against people with mental illness.
Again, a lot of work in going on here in a lot of ways.

Many of you will have already seen the booklet Discrimination Against People with experiences of Mental Illness, which was produced by the Commission.

Discrimination against those with mental illness is a human rights issue, and one fundamental to the care of people and the outcome of that care. The stigma of mental illness prevents many from accessing help when it would be most effective, and easiest to deliver. And when people are trying to get better, they need the opportunity to grow through positive relationships. This essential part of healing is why people are better moving out, when appropriate, into the community. That's not possible when community housing for those with mental illness is stopped by uninformed fears.

Discrimination not only affects the lives of those suffering mental illness, it also affects the lives of those who care for them. It makes it difficult to attract mental health care workers. It can mean less support from health carers in other sectors. When things go wrong, the negative and intense public interest is very stressful.

In addition to the Commission's work on discrimination, the Government has funded an $11 million public awareness campaign to run over the next four years. The campaign will focus on changing public attitudes to mental illness. As part of this campaign a documentary will be televised next month which tells the stories of five people who have, or have recovered from a mental illness. I have seen a preview of this documentary and it is compelling viewing.

Workforce planning is the third major task of the Commission.
There was a major forum on this issue at the beginning of June, from which some clear pointers emerged. The Best Practice Programme will underline workforce development. They are also looking at how workforce development is funded.

There is one final objective for the Commission, which is any other matter agreed with myself. In that respect, apart from the monitoring role it has, it seems to me the Commission has more than enough to go on with!

All this work adds up to a whole lot of activity, a whole lot of thinking about mental health care, how we view, fund and deliver it.

Throughout the sector some quite basic things are being put into place, things that have never been there, or were lost along the way if they ever were. The catchcry of more and better mental health care services is actually happening.

This is directly as a result of this Government?s commitment to the Coalition Agreement.

All these improvements do not mean that I am happy with everything in the mental health sector.

I would be a very strange politician if I were. I have a couple of concerns that I do think are going to be quite difficult to deal with, but they are of such fundamental importance that they cannot be ignored.

The first problem is the continued dominance of clinical models of mental health care. CHEs are still the dominant providers of mental health care, and their focus has traditionally been on the clinical and institutional side of things. We need more emphasis on the social and rehabilitative models of mental health care.

There are a lot of issues involved here, not least of which is the problem of getting changes in the workforce to reflect changes in appropriate support for those with mental illness. I am not saying we do not need clinical skills. I am saying we need also need a lot of other kinds of skills, ones that may be less academic but no less essential. Knowing there are people that can help you to manage your benefit, or teach you interview skills, or just knowing that there is someone you can always talk to, are very important things to a lot of people recovering from mental illness. And we must not underestimate the quality of the work family and friends do for those with mental illness.

I expect that there will be tensions when the changing patterns in mental health care, in workforce development, in more and more social rehabilitation take effect, when the balance gets shifted from the clinical to the community-based.

Community care is a far from easy option, but I believe it is a fundamentally healthier one for most people with mental illness,

What may also cause tensions here is that many non-government organisations are in fact experienced, poised and eager to be more involved in this kind of social rehabilitation.

They can often teach the CHEs quite a lot. It is a pattern that those who have been working from the margins actually have to think quite hard and so they come up with ideas for the provision of service that are new and innovative. It's been voluntary, religious welfare agencies who have come up with, for instance, better ways of caring for our elderly and that's brought about a wholesale change in the continuing care of the elderly in New Zealand.

The second major problem I see in the mental health sector is harder to quantify but probably more pernicious.

It is the learned helplessness I still see in many parts of the sector. I am still surprised at the extent to which people look to Wellington for answers. They seem to expect coercion or a leadership model that just isn't appropriate, and probably just doesn?t exist. A dictatorial approach from on high will do nobody any good. My idea of leadership is to ensure the kind of environment that allows people to make their own decisions, where the work is being done.

This looking to other people for solutions often leads to looking for other people to blame.

Everyone works hard in this sector. Providing good mental health care is difficult. It demands personal strength and commitment. We must support one another. Let's by all means be vigorous about challenging ideas. That's a healthy, necessary process. But this is one area where good relationships are crucial, for carers, and their clients.

If we don't hand down solutions, how do we find them?

I've spent some time since becoming Minister thinking about what really does make good health policy. I've developed a few principles which I've been talking about regularly lately that indicate a general approach rather than specific policy. None of this is rocket science material. But I do think these general principles provide good ways of tackling the two problem areas I've just talked about.

The first thing is we want to organise our services and our funding around the patient and the community.
Traditionally we've done the opposite. We've organised our communities and our patients around the institutions and the funding and that has to change.

This is of huge importance in mental health care. The one thing I hear again and again from consumers is their plea to be treated with respect. Far too often people with mental illness have been objectified, dehumanized by labelling. The disease is not the person. A small but telling example of this was brought out in that discrimination booklet. It says that in most hospitals the psychiatric ward is the only one where people are not offered a choice of menu or an individual tray. It shows people with mental illness can be treated like children, or worse. People with mental illness get better, most of the time, but especially if they are given the respect and the space in which to do it.

Secondly, we can greatly improve health services with no extra money by building better relationships between the carers, and their clients.
I am talking about the relationship between the hospital and the GP, the pharmacist and the psychiatrist, the social worker and the whanau.

Again, this principle of building good relationships is particularly important in building good mental health care. Mental illness is marked by stressed relationships. Good relationships are not only sensible, they are part of the healing.

The various carers have different jobs and different funding for doing them. What they do have in common is the people they serve - and that is more important than any differences. One thing we do have to remember is that families are often the basic carers, and should be communicated with as such - whenever possible. A number of families have mentioned to me the problems they have encountered with issues associated with the Privacy Act. I will be launching new Guidance Notes on the Act for agencies in the mental health sector tomorrow, which I am sure will go some way in improving the understanding of this legislation.

A third principle is that we're looking for local solutions to local problems.
I come from about as far away from Wellington as you get, right down in the deep South. You don't have to be very smart to figure out that what works in fairly harmonious rural pakeha communities in Southland is not going to work in quite a different community in Northland. The idea of someone sitting in Government halfway between the two generating some particular model of service and telling people that's what they're going to get is something that is no longer acceptable to the public at large. I hope politicians have learned enough humility not to try doing it.

We also know that local solutions work better because they'll reflect local tradition, local history, local culture, and local relationships. Last week I opened Te Pito Ora Maori Mental Health Unit here in Christchurch which is a good example of what I am talking about. Local solutions carry with them a degree of commitment that you'll never get from a solution handed down from Wellington.

The fourth and final principle is that decisions about resources and clinical decisions should be made as close to the need as possible.
We've got to get decisions about the balance of resources and clinical requirements as close to the need as possible.

This should be quite possible to achieve for people with chronic mental illness - complex recurrent needs aren't met by fragmented services.

Getting decisions made close to the need requires public agencies to give up some power - to whom is the big question. It requires all of us to move on from centralised, detailed descriptions of services, and I hope the Commission won't bring all decision-making back to Wellington.

These four principles tie in well with the idea of social capital.

They are about putting power back into the community, about dealing with needs as nearly as possible to where those needs are. Communities are built up, and grow creatively, when each individual is respected and where relationships are nurtured.

Communities get strength and confidence from actually taking charge of their own future, making the decisions that matter. As the Playcentre saying goes, "Confidence comes from doing". So does a lot of learning. I think this is something you can see in education. A lot of learning has happened, a lot of relationships have grown, a lot of new confidence is around, since parents became Trustees of their children's schools. You can also see it in the new Maori health providers. That?s one reason why we're keen to support their development.

The idea of social capital is especially important for mental health.

Caring for people with mental illness does have a strong clinical element, but it's also got a strong social and cultural element, which isn't susceptible to highly centralized control or understanding. A broken leg is a broken leg in any culture, and the treatment and outcomes are pretty standard. A great deal of mental illness, its diagnosis and treatment, is culturally determined. Often what's important is the social process around the care as much as the care itself.

So, finally, I would like to talk about my role as a politician working with you in mental health, and how our roles differ.

You are professionals who have to deal with the practical issues of people showing up and needing your help. I've got to deal with the realities of the politics around mental health. This involves the overall strategic structure and what funding ultimately goes where.

I've also got to meet the expectations of a primed and worried public. Few other areas of public interest arouse so much of it.

Meeting the public's expectations does require some pretty fundamental shifts in accountability. I have to account to the public for perceived failures in mental health care. Some of those perceived failures are unavoidable, in the sense that clinical judgments involve an element of risk. I accept that. I will defend any professional who did their best, but at the end of the day, made the wrong call.

What I can no longer accept are failures in basic steps in the care of people with a mental illness. These are the things that should happen for every patient 100 percent of the time. The Paki case was an example of that kind of failure. It is publicly indefensible to get the basics right 80 or 90 percent of the time. That just isn't good enough. Not only for the sake of the people with mental illness, but because I don't think the public can take any more.

There is quite a lot of urgency about getting this bit right. I simply can? t stand up and announce yet another inquiry into yet another service failure.

I am told there have been 68 official mental health inquiries between 1987 and 1996. Next time around I have to do something fairly fundamental, like provide for someone else to provide a service, if that service has failed to meet expectations of basic skill and professionalism.

Things are changing, and are going to have to change.

Maybe we should think about where we want this thing to be in five years' time, and go straight there, rather than dragging ourselves through another cycle of instability, new management, cynicism, staff shortages? These things have been a feature of a lot of CHE services, and it may be that we should think quite hard about these.

You who work in mental health are our greatest resource in it. Your commitment to mental health is what we need most. I thank you for it.

I am also asking that it translate into courage

courage to do things still better
courage to work with people you haven?t worked with before
courage to use channels of communication you haven't used before
courage to look at old problems in new ways
courage to accept and bring about changes that will empower others.
We no longer have the choice of defending things the way they have been in the past. We no longer have the choice of taking our time about improving them. I need your commitment, your skills of self-analysis, your courage now.

I want to work with you. My job is to change the rules to fit the solutions. The solutions that provide services that work for the patient and the community.

Thank you.