It was one of the Government’s top priorities, but those with experience of the mental health sector are concerned progress on transforming the system has stalled
A new report from the Mental Health and Wellbeing Commission shows those working across the sector, and people with lived experience, are concerned at the continued fragmentation and lack of transformation of the mental health system.
A thematic analysis of 41 interviews conducted with stakeholders, including people with lived experience, NGOs, primary health organisations (PHOs), government agencies, workforce agencies, and Māori and Pacific peoples, has highlighted ongoing concerns about the lack of progress.
Those who spoke to the commission pointed to a lack of leadership, fragmentation, barriers to accessing funding, barriers to accessing services, and tokenistic consultation with Māori, Pacific people, and those with lived experience.
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The interviews were conducted last year, to inform the commission’s interim report on the implementation of the He Ara Oranga recommendations.
And while there was general positivity about the landmark mental health and addictions inquiry, and a belief that there was a strong desire to transform the sector and focus on wellbeing, the views and quotes in the newly released thematic analysis show that desire has not translated into tangible change.
The analysis comes as outgoing Mental Health Commissioner Kevin Allan has laid out the critical challenges standing in the way of the Government’s promised system overhaul.
With the recent passing of the Mental Health and Wellbeing Commission Act, the interim Mental Health and Wellbeing Commission has taken on permanent status as an independent Crown entity. This means there is no longer a need for a mental health commissioner within the Health and Disabilities Commission.
The new commission is charged with monitoring mental health and addiction services, advocating for improvements, and holding the Government to account in implementing the accepted recommendations of He Ara Oranga.
But in his final days as commissioner, Allan penned a letter to Health Minister Andrew Little laying out his concerns about the pace of change, and lack of a long-term action plan for the sector’s transformation.
As Newsroom reported in September, both Allan and He Ara Oranga chair Professor Ron Paterson have raised concerns about the lack of a clear roadmap.
They said progress was at risk of stalling without an action plan to deliver on the promised He Ara Oranga reforms.
In July last year, Allan called on former health minister Chris Hipkins to have a plan ready by the end of the year. There is still no plan.
The Covid-19 psycho-social plan, which has been used as a sort of placeholder for a longer-term roadmap, will not do the trick, he said.
“It’s over two years since the He Ara Oranga report was delivered, and there is considerable concern from sector leaders, and the community, about the absence of a clear long-term plan to implement He Ara Oranga,” he said in his outgoing statement.
“He Ara Oranga called us to disrupt the system and transform it. But we don’t see too much disruption that’s enabling a different way of doing things yet.” – Person with lived experience
An overhaul of the mental health and addiction sector was one of the Labour-led Government’s top priorities when coming into power in 2017.
The promise of a national inquiry – something National refused to undertake while in government – was a Labour campaign platform, and after forming government in 2017, Ardern added this to her 100-day plan.
At a cost of $6m, He Ara Oranga was the first national mental health inquiry since the watershed report by retired judge Ken Mason in 1996.
The inquiry’s process was largely praised for its inclusiveness, as was its vision for transformation.
Then in 2019, mental health and addiction was the centrepiece of the Government’s first ever Wellbeing Budget, where $1.9 billion was pledged to mental health and addiction services and support.
But more than two years since the conclusion of the inquiry very little change has been felt on the ground, both by the frontline workforce, and by those who need to access services.
The 41 interviews conducted by the new Mental Health and Wellbeing Commission reinforce these concerns about a lack of direction.
And NGOs, Māori, Pacific, and consumer organisations all said they had not yet seen signs of system transformation, or evidence the system was trying to do things differently.
“He Ara Oranga called us to disrupt the system and transform it. But we don’t see too much disruption that’s enabling a different way of doing things yet,” said one person with lived experience.
“And so we’re forced into doing the same old, same old, and calling it transformative and it’s seriously not,” an NGO representative said.
Fragmentation
Some of the discussions with NGOs and DHBs found people believed the fragmentation of the system and decision-making process was continuing as it had before He Ara Oranga.
PHOs, consumer organisations and government described the response to He Ara Oranga’s call for transformation as “varied and uncoordinated”.
They noted a lack of a joined-up, system-wide response to changing the way the system operated, with different ‘parts’ of the system responding in different ways.
Funding
Consumer organisations noted that in general, the increase in funding since He Ara Oranga had yet to trickle down to the frontline and create a tangible improvement to access and choice.
Those who spoke to the commission said the short timeframes and competitive nature of the funding tender process put Māori and Pacific NGOs and smaller community organisations at a disadvantage. They had to compete with larger, better resourced mainstream organisations.
And while mainstream organisations were doing more to increase cultural competency, which often made them seem a more viable option to deliver services, they did not offer the same culturally-focused approach.
Some even said their ability to secure funding has worsened since He Ara Oranga.
Meanwhile, Māori and Pacific organisations both spoke about undertaking unfunded work to support clients.
For example, cultural activities that are central to how Māori organisations operate and engage with whānau, such as karakia, attending tangi, pōwhiri, and general manaakitanga to whānau, are carried out without any additional funding or support, despite cultural engagement being a crucial part of a more holistic approach to achieving wellbeing.
Access to services
One of the Government’s priority areas was the expansion of services and support in primary care, to help people – particularly the ‘missing middle’ – access help sooner.
It allocated $455 million over five years for new primary mental health and addiction services. As Newsroom has previously reported, the Government has struggled to get this money out the door.
“In terms of getting the change bottom-up, part of the problem is I don’t think there is a quick solution.” – NGO representative
But Māori and Pacific organisations also told the commission this effort to expand choice was not working, as current initiatives – such as increasing access via GP clinics – did not meet the needs of their communities.
They said GP clinics were not the first point of entry for Māori and Pasifika, and therefore increasing access via general practice settings will not necessarily improve outcomes for Māori and Pasifika.
The commission was also told people continued to have difficulty accessing a range of support options including talking therapies, alcohol and other drug services, peer support, and community-based support.
Diversity
Māori, Pacific peoples, and those with lived experience all talked about the need to be more included in consultation processes and in leadership positions.
People told the commission that currently consultation with diverse groups often happened late in the process, and often once a direction was already set in stone. They said this type of consultation felt tokenistic.
Meanwhile, Pacific organisations said they were often called upon last-minute to provide a (single) Pacific voice in a conversation. They said it was unfair to expect a lone Pacific representative at the leadership table to speak on what was needed for all Pacific peoples.
They called for a strategy to strengthen a diverse representation in leadership and governance positions so that individual representatives do not have to hold the weight of their entire communities on their shoulders.
Culture change
More generally, those who were interviewed acknowledged a system-wide culture shift would take time and investment.
Workforce organisations and Pacific organisations said structural cultural changes needed to happen first, to create environments and processes that upheld behavioural and attitudinal changes in the workforce.
NGOs, Māori organisations, government and whānau organisations said the culture of the current system remained medically focused and deficit oriented. They said people in distress were still often labelled as risky or dangerous, which reinforced a paternalistic and risk-averse approach to services.
And Māori organisations, government, DHBs, and consumer organisations said that the impacts of colonisation and breaches of te Tiriti o Waitangi remained unaddressed in the current system, and institutional racism persisted, resulting in high rates of seclusion.
While the comments largely focused on the significant work ahead, and the lack of change thus far, there was also an acknowledgement that there was a desire for change.
Stakeholders acknowledged transformation would involve significant changes to the culture, and other enablers such as workforce development and procurement processes, to shift the way the system operated.
“In terms of getting the change bottom-up, part of the problem is I don’t think there is a quick solution. Some of this is we’ve got workforce issues, we’ve got capacity issues, we’ve got capability issues, but the sector had been run down substantially over a long period of time and you can throw money at it but it’s not going to change quickly,” one person from an NGO said.
