As the Government moves forward its reform of the health and disability system, Dr Paul Skirrow argues we should consider replacing the currently stretched, fragmented and discriminatory system with a single system of psychological health care

If you’re experiencing a mental health condition, an addiction, a relationship issue, psychological trauma, work-related burnout, or just need some help adjusting to difficult life experiences, research suggests the most useful thing we can offer you is some psychological therapy.

Now, I’m not minimising the important role of medication in supporting people with mental health conditions here – I’ve personally seen medication make an enormous difference to a great many people, including some good friends of mine, but research suggests that therapy is generally much more effective than medication and potentially works with a far greater range of issues.

Throughout 2018, the Mental Health Inquiry team heard from thousands of people across New Zealand, summarising what they had been told in their 219-page He Ara Oranga report.

The report includes the words ‘therapy’, ‘therapies’ or ‘counselling’ 132 times – more than once every two pages – calling on the Government to “ensure we have the capacity and capability to provide far greater access to evidence-based talk therapies for people”.

At the same time, the report speaks to a traditional “over-reliance on medication”, partly due to the lack of access to appropriate therapy services.

While psychological therapies are clearly not the answer to every problem – therapy involves time and work, and many people feel it’s not right for them – currently, most people in New Zealand simply can’t get access to an appropriately qualified therapist.

The current approach to psychological therapy provision in New Zealand is fragmented, ridden with inequity and ripe for a complete redesign.

With just 1600 clinical psychologists currently registered in New Zealand, we are spread thinly across the 20 District Health Boards, primary care organisations, ACC, Corrections, Oranga Tamariki and, increasingly, in private practice.

Nearly all psychologists in New Zealand – particularly those in the major centres – have increasingly lengthy waiting lists and the lack of a coordinated public service has driven many psychologists into private practice, working predominantly with the small minority of New Zealanders who can afford to pay.

The pattern is one of poor coordination between services, a lack of continuity of care, a lack of choice for the public, and, ultimately, growing levels of inequity.

The He Ara Oranga report particularly draws our attention to the lack of flexibility in the system, which has led to extra challenges for Māori, Pacific people, the ‘rainbow’ community, those living in rural locations, refugees and migrants and people with additional disabilities. In other words, a fairly sizeable chunk of the New Zealand population.

Last month, the Government announced one of the biggest shake-ups of the health and disability system in a generation, which offers us a fantastic opportunity to rethink how psychological services are delivered in New Zealand. So, what might a national approach to psychological care offer us? 

The current system lacks accountability. Responsibility for therapy delivery is dispersed across multiple different services and sub-teams, with psychological leadership the exception, rather than the norm.

A single psychology service, with a national director (or perhaps two, with an equivalent in the Māori Health Authority), would make accountability for access extremely clear, with no opportunity for services to ‘pass the buck’ to other providers.

A national director, who should certainly be a psychologist themselves, would not only be responsible for service delivery, but also for workforce development, as the current registered workforce is small, specialised and spread thinly.

We need to develop a brand new workforce of psychological therapists, supervised and supported by clinical psychologists.

We need a system that promotes flexibility and innovation, as current service structures allow very little opportunity for the services to ‘flex’ to meet the needs of the person, nor to develop innovative approaches to care.

The system redesign is intended to reduce arbitrary barriers between services, which rarely offer ‘joined up’ care, so it makes little sense to continue to ‘carve up’ psychological services again between ‘primary’ and ‘secondary’ care, between ‘mental health’ and ‘physical health’, or between health and social care providers.  

A single provider would allow for resources to be used where they are needed, rather than where they have ‘always’ been allocated.

If that sounds ambitious, we should remember that we already do have a national psychology service, with a national manager, within the Corrections service, as well as a national behaviour support service for people with disabilities, similarly run by psychologists.

In the UK, with a population more than 12 times that of New Zealand, the vast majority of publicly-funded psychological therapies are delivered by a single provider – the national Improving Access to Psychological Therapies (IAPT) service, which was set up in 2008.

Successive governments from both the political left and right have sought to expand the IAPT programme, which has not only led to significant help for a large number of people but is projected to have ultimately ‘paid for itself’ in terms of the reduction in disability benefit claims and increased tax revenues (from people returning to work).

What is clear is that the current health and disability reform represents an unbelievable opportunity to redesign psychological health care in New Zealand. We cannot waste it by continuing with the same, ineffective, inflexible and uncoordinated approaches. As the oft-quoted saying goes: “Insanity is doing the same thing over and over again and expecting different results.”

Dr Paul Skirrow is a clinical psychologist and senior lecturer in the Department of Psychological Medicine at the University of Otago, Wellington, as well as an executive advisor to the NZ College of Clinical...

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