A psychiatrist who worked for decades in New Zealand hospitals says the Government’s health reforms have the potential to fix a mental-health service crippled by the district health board system and underfunding.
Christchurch-based Alma Rae retired in May after 35 years at the coal face, treating patients with major mental illness in hospitals from Auckland to Timaru.
It’s been a career spanning turn-about regimes of Labour and National governments since 1988, when she moved from general practice into the specialist training she’d had in her sights since adolescence.
“I actually decided at the age of 13 that I would be a psychiatrist. I was a bit of an odd child, I suppose, but when we were all being prepared for confirmation as Anglicans, the curate told us we should pray about what we should do in the world.
“And the answer came back loud and clear that I was going to be a ‘shrink’.”
Rae is no longer an Anglican, but the vocation never left her.
“I thought the worst thing in the world for anyone would be not to know what was real and what was not. If your mind is telling you lies, what could possibly be worse?”
Helping hundreds of deeply psychotic patients over the years to resolve those questions, and regain control of their minds and lives, has been Rae’s life work.
At times it’s been hugely rewarding, she says.
“I think my particular talent was being able to find the right mix of meds for a patient. There is so much more choice than there used to be and with treatment some people’s lives can really change.”
People with major mood or thought disorders such as schizophrenia or bipolar illness are not “cured” with medication, Rae says.
“But they can be relatively well, and to see that change in a patient is incredibly wonderful.”
The frustrations, though, have been there all along, Rae says, because successive governments have failed to maintain an adequate mental-health workforce and consistent support for people once they leave hospital.
Rae blames the neo-liberalism first unleashed on the country in the 1980s for creating conditions that stripped meaning and security from the lives of thousands of working class New Zealanders: unemployment, poverty, homelessness and drug use are all grist to the mill of mental illness, she says.
“I came in at the point where the big mental hospitals had just been closed, and the new anti-psychotic drugs were making it possible to treat people with major disorders without locking them up forever. The rather vague idea was they would be cared for in the community.”
But by and large that part of the brave new plan has never happened.
Community care, such as it is, was left to non-government organisations contracted by district health boards to do the job or not, Rae says.
“It varies enormously. In some places, such as South Auckland, there are excellent NGOs providing good care, but in other regions, some have contracted for almost nothing.
“Or there’s an NGO doing some jobs but not others and no one’s making sure they do what they’re contracted to do.”
Community services can include housing and daily visits to make sure patients recovering from psychosis are taking their drugs.
“But whether they get that service depends on what the local DHB decided was needed.”
Ongoing care for people with major psychiatric disorders should never have been that random, Rae says.
For a psychiatrist who’s nursed a psychotic patient back to relative sanity, the crunch comes when the person is well enough to be discharged from the ward but needs support to live outside it, she says.
“Often there’s nowhere safe and decent to send them. Families can be reluctant to have them back so they end up alone in boarding houses, on the street or in prison.”
NGOs providing accommodation and support often do so only on a temporary basis, Rae says.
“They’ll kick people out after a set time, because according to their policy they’re supposed to have recovered. So they end up struggling again, looking for somewhere to live.”
Some end up on the streets, others back in hospital.
Would a coherent mental-health system provide more beds in psychiatric wards or the sort of community care that doesn’t require quotation marks?
“Both – we need more of everything,” Rae says.
“More nurses, more doctors, more beds. The need has been there for years. John Key’s government flooded the country with immigrants; our population’s grown to 5 million and we never trained the additional staff we knew we’d need.”
The present Labour Government has upped the intakes for trainee nurses and doctors and the first cohort of new nurses is about to graduate, Rae says.
But doctors take longer.
A new mental-heath ward at Middlemore Hospital remains unopened, she says, because there are no staff to work in it.
And while there’s no call for a return to the old days when Christchurch’s Sunnyside mental hospital in Christchurch had 1100 inpatients, its replacement, Hillmorton, now has fewer beds than it had when she started work there in 1988.
In that time the city’s population has grown by 100,000.
In 2015, working conditions at Hillmorton triggered Rae’s resignation as consultant psychiatrist, following a series of serious attacks on nurses by patients.
“I resigned because of professionally unsafe conditions brought about by incompetent management.
“We could have got more psychiatrists at that time but they just lumped the extra work on us, reorganised the workload so it was possible to be needed in three places at once and ignored the ways in which our employment agreement was constantly violated.”
She told Radio NZ at the time Hillmorton was a “terrifying’’ place to work, with synthetic cannabis and meth use ramping up violence levels in patients ending up on the ward.
As well as one nurse being attacked with boiling water, another was stabbed and one strangled.
Still making headlines
Hillmorton hit the news again this year when a patient released on leave from the forensic unit stabbed and killed mother of four Laisa Tunidau in a random attack outside her home.
Rae says it should not be assumed that staff shortages were a factor in the attack.
“There may or may not have been tired nurses but the consultant psychiatrist at Te Whare Manaaki would have had to assess the risk in letting the patient out on leave, and obviously in this case, for whatever reason, they got it wrong, with catastrophic results.
“Psychiatrists make these decisions all the time, but we are human and humans make mistakes.”
Research shows that no matter what methods are used, risk prediction will be wrong about two-thirds of the time, Rae says.
“This will be no comfort to the bereaved family, to whom I extend my deepest sympathy. It is hard to imagine a more senseless or painful loss.”
The consultant involved, whom Rae knows, went on distress leave after the stabbing, she says.
She has no doubts about the psychiatrist’s professional abilities.
“Knowing them, they will be beside themselves over what happened.”
Rae has been attacked twice by psychotic patients – one who whacked her leg when he lashed out at Mental Health Act papers she was holding, and another who made a grab for the pass key on a cord around her neck, half-strangling her in the process.
She was saved from further injury by the male nurses in the room.
Her would-be strangler, who was admitted in a deeply psychotic state and growling like an animal, made a good recovery, she says.
But such incidents are a reminder that mental illness is not just about depression or anxiety.
“We have made progress in that people now feel they can talk about these conditions.
“But I think there are people in the health system who like to believe mental illness is about feeling bad for a while then getting better. The fact is that some people have major psychiatric disorders all their lives and they should be getting decent care and support.”
Rae is optimistic that the health reforms will improve mental-health care for Māori but less certain that they will fix the gaping holes elsewhere in the services.
“It has to be better if Māori gain control over the services they need and how they’re delivered. We [psychiatrists] are mostly all old white people, and there is institutional racism in the health system.”
Ditching the DHBs and their fragmented services and replacing them with one centralised health system makes obvious sense, she says.
“Especially having one IT system. But it’s going to take serious investment and very strong advocacy for mental health within Health NZ to get the standard of services people deserve.”
Te Whatu Ora chair Rob Campbell says mental-health services is one of the key targets of Te Whatu Ora activity in its first two years.
“There are significant issues with mental-health facilities and a programme of building for these is lined up for us to implement as promptly and efficiently as we are able. These are vital for severe distress and complexity,” he told Newsroom.
But such facilities are nothing like a full answer to the need for increased effectiveness of services in the community, the new health boss agrees.
“It is most likely that these will be best delivered in an integrated manner with other housing, social, educational and health services at the local level.
“I would like to say that we had a plan and structure ready for this to go but that is not the case. Services reaching out from hospital locations, and the plethora of funded community initiatives, are not in that shape either regionally or nationally.”
On top of that, the service is facing workforce deficits and surging demand, Campbell says.
“Te Whatu Ora working with Te Aka Whai Ora and existing services will do the best we can for immediate needs while a more solutions-directed structure is developed.
“But there are no easy answers or short fixes.”
After 35 years on the wards, Rae’s world now is all about sailing, gardening and the fabric arts that have helped keep her life in balance over the years.
She’s heartened by Campbell’s plain-speaking approach to the health reforms – including his recent promise to clear the health corridors of consultants flogging software.
And for the sake of her long-suffering colleagues and their patients, she’s hoping the reforms will finally end the prejudice that’s made mental health the Cinderella of the health system for far too long.
Health New Zealand (Counties Manukau) got in touch in touch with Newsroom after the original version of this story ran to say the unused mental health ward Rae refers to at Middlemore is now being used for psychogeriatric patients, and this has freed up additional medical beds.
“(Mental health facility) Tiaho Mai was built with extra capacity as it was anticipated that demand for services would grow,” a spokesperson says. .
“Building ‘shell’ spaces which enable services to manage growth is not unusual.”
Meanwhile, a purpose-designed ward is being fitted out for the psychogeriatric patients, which will free up more capacity at Tiaho Mai once it’s completed next year, the spokesperson says.
Alma Rae says she’s glad to hear the ward is now being used, but her basic point remains.
“There was an entire ward unused, while I was discharging the sickest patients I have ever discharged, because there were no staffed beds for them.”
The closed ward was hardly ‘spare’ in the sense that the capacity wasn’t needed, she says
“I had never in my career had to discharge such unwell people, solely to free up beds for those coming in. The level of acuity in the patients at the Middlemore unit was the direst I have seen in my career.
“It decided me not to go back, it was just too awful. Discharging people who are miles from being recovered is horrible.”
Rae returned to her home in Canterbury to work as a locum before her recent retirement and says of all the mental health units she has worked in, Timaru’s small facility was the most functional and pleasant.
Made with the support of the Public Interest Journalism Fund