This month, the government released a much-awaited report from the Mental Health and Addiction Inquiry. The document, He Ara Oranga, predictably makes a case for increased funding but it is insistent that this is not to provide more of the same. It calls for fundamental change, a bold paradigm shift.
The report’s 40 recommendations include expanding access to publicly-funded services, establishing a commission on mental health and well-being, setting a target to reduce suicide rates by 20% by 2030, and removing criminal sanctions on the possession of drugs for personal use. Collectively, the recommendations are intended to catalyse a transformation of the mental health system.
Promotion of mental wellbeing
The inquiry was one of the Labour-led coalition government’s “first 100 days” commitments. It was part of the government’s reform agenda and one of several interrelated reviews of health, social welfare, education and other services.
In contrast to the last major national mental health inquiry in 1996, the present inquiry is far more wide ranging. Its terms of reference called for examination of the full spectrum of mental distress and disorders, addictions and substance use. They include consideration of underlying social determinants, prevention and mental health promotion.
During the past decade there has been growing concern about mental health services. This concern has been expressed by many people affected by metal health issues – service users and their family members, academics and health professionals working in primary care, NGOs and District Health Boards, and coroners who pointed out shortcomings and perceived increases in suicide numbers. New Zealand has the highest youth suicide rate among OECD countries, and this was one of the catalysts for the inquiry.
A crowd-funded review, the People’s Mental Health Report, collated stories from people who used and worked in mental health services. Some major themes emerged, including problems with access, long wait times, over-reliance on drug treatments, under-resourcing and staff strain, over-use of compulsion, social and economic stress, and difficulty in challenging current practice and holding service providers to account.
The inquiry’s task
The inquiry commenced in February and included 400 well attended public meetings across New Zealand. More than 5,000 written submissions and 16 petitions with 339,217 signatures were received.
The most significant finding was a high degree of consensus about the main shortcomings and a call for major change. The new direction includes a strong emphasis on well-being, amplification of prevention and early intervention, significant expansion of access to a wider range of treatment and support options, greater consumer and community involvement in planning and service delivery and cross-government action.
A number of the recommendations are directed towards greatly increasing service access and choice. Currently public funding is largely confined to the 3% of people with the most severe disorders. The goal is to extend this to the 20% of the population with less severe disorders including depression, anxiety and substance and behavioural addictions. This requires much greater availability of psychological therapies, transforming primary care and strengthening NGOs.
The report calls for a whole-of-government approach to tackle social and economic determinants and promote prevention. Major changes are called for in approaches to alcohol and other drugs and suicide prevention. Recommendations here include strong measures to reduce alcohol-related harm, decriminalisation of the possession of all drugs and a substantial increase in detox and treatment services. In all of these areas there is an expectation of strong consumer involvement in planning and service delivery.
What the inquiry missed
The time was right for stepping back and conducting a stocktake of mental health matters in New Zealand. The inquiry team did an excellent job in a short time. However, I would have liked to see recommendations concerning behavioural addictions alongside those for alcohol and drugs. Recent [Victorian](https://responsiblegambling.vic.gov.au/about-us/news-and-media/assessing-gambling-related-harm-victoria-public-health-perspective/) and New Zealand studies have found gambling-related harm to be greater than harm associated with drug abuse.
Given current workforce shortages and the larger and different workforce required to staff a reconfigured and expanded mental health and addictions sector, it is surprising this was not picked up in the recommendations.
The country has not had a national mental health survey since 2006. It is not known whether the prevalence of mental disorders has increased or decreased. There has never been a prospective study that examines incidence, remission, recovery and relapse. Effective policy, service development and evaluation requires a solid information base. Recommendations did not address research.
The inquiry has advanced nationwide discussion and expectations for change are high. The inquiry’s breadth is its strength and weakness. The 40 recommendations, if accepted by government, cannot be actioned overnight.
There is a huge task to follow in sorting out which ones to act on immediately and how to phase the others. This task, initially, has been given to a group comprised mainly of ministry officials and district health board staff. There is some risk of dilution and capture.
In major social reform and politics, timing is everything. I agree with the commissioners that this is a once in a generation opportunity. When I met with the minister of health the day after the report was released, his copy was clearly well-read, dog-eared and passages underlined. Sustained political commitment and funding increases will be essential.