Cross-Examination: The Ambulance at the Bottom of the Cliff - The Sorry State of Mental Health Funding in NZ
Content Contributor, Claudia Russell
Circumstances are growing increasingly grim for New Zealand’s public Mental Health system, and it seems like every week a new article is published about the so-called ‘crisis.’ In the past month news hit that our suicide rates, which are already the highest in the OECD, could be as much as three times higher than reported.[1] Due to strict coroner’s guidelines, death will only be ruled as a suicide if it is absolutely clear that the deceased intended to take their own life. The standard of ‘absolutely clear’ is so strict that when a 26 year old Wellington woman took her life and left a suicide note beside her bed, coroners ruled there was insufficient evidence to prove "whether she was mentally capable of forming an intention to take her life."[2] Furthermore, Platform Trust warns that the number of homicide cases involving people with mental health issues is alarming. What this means for New Zealand is that our lack of accessible mental health services is becoming truly deadly.
This is an urgent and worsening issue which has elicited little response from the Government. In the 2015-2016 health targets, mental health is nowhere to be seen. From this year's substantial health budget of $16.1 billion, mental health services receive the smallest portion, though they are the sector most starved of funding.[3] These health targets presumably are written in response to the level of demand for services, yet the number of people trying to access mental health services has risen by 25 per cent in the last five years. Sources warn that NGO providers have not seen a real increase in funding in six years.[4] It would be easy to suggest that mental health isn’t as big a problem as other illnesses, but this is simply not true. Mental disorders are responsible for about 12 - 15 % of the world’s total disability – more than cardiovascular diseases, and twice as much as cancer.[5] At their most severe, mental illness can be just as debilitating as physical illness, leaving the affected unable to work, sleep, or leave the house. Reports of overstretched staff and resignations are growing by the week, and those involved in the industry are at their wits end questioning why funding has not increased.
“It’s a holy mystery to me,” says deputy leader of the Labour party, Annette King, “why the government cannot see that mental health is one of the biggest issues facing us as a country.”[6] In media the National Party has stayed quiet on the topic, with Health Minister Jonathan Coleman insisting that funding has increased “21 per cent over the last five years.” However this is barely keeping up with growing demand.[7] Labour MP David Clark states that the number of people arriving at emergency departments as a result of mental health issues have more than tripled in the last four years, but statistics like these are just the tip of the iceberg.[8] A recent $20 million boost to Canterbury’s DHB system was initially met with cries of relief, however minutes from a recent board meeting suggests that the money barely scrapes the surface of what is needed.[9] Even after the boost, mental health funding for Canterbury remains $31 per person below the national average, a total shortfall of $16 million.[10]
Nearly everyone who is familiar with New Zealand’s public mental health system is of the same sentiment: there are serious improvements to be made. While funding is key, the government must recognize which specific areas are causing the most distress in order to help everyday New Zealanders. Simply being seen by a counsellor or therapist is arguably the most important step in treating mental illness, yet it is the most difficult. Long waiting periods are a huge concern within the system. Like any health issue, mental health can quickly deteriorate without treatment. An English NHS survey of over 2,000 patients reported that one in six had attempted suicide while waiting for treatment.[11] Because mental illness can be viewed as something shameful or embarrassing, often people reach an absolute low before realising they need to seek help. Indeed a cross-country study from the British Journal of Psychiatry shows that on average only 39% of suicidal respondents had sought help of any kind.[12] In New Zealand and in most of the world, patients are only referred into the system if they are already “moderate to severe,” leaving them at risk of waiting with a debilitating condition for months.[13] Currently the Ministry of Health requires that 95 percent of people referred for non-urgent mental health or addiction services are seen within 8 weeks, however DHB reports state that percentages are as low as 60.7 in some areas.[14] This leaves large amounts of people untreated for too long.
Reducing waiting times between referral and treatment is a crucial area to tackle. Studies have shown repeatedly with schizophrenia, anorexia, anxiety, and other illnesses, that “delay in initial treatment is associated with slower, less complete response and overall poorer outcome” for patients.[15] Particularly with anorexia, it has been shown that unless treatment is given within the first three years of the illness, the probability of lifetime recovery is low.
Left untreated for too long, one’s mental health can become a lifelong battle. Countless Ministry of Health reports over the past year recommend early treatment, particularly for youth. Unfortunately these recommendations rarely translate into reality. When funds are low, any money that is available tends to go towards improving inpatient DHB units for acute cases, failing to filter down into the community-based early treatment centres.[16] Notes from The Mental Health Commission support this, stating that funding is tied to secondary sources rather than early intervention.[17]
The acute services we provide in New Zealand are, of course, essential. They offer specific, targeted and long-term treatment of serious mental illnesses, with constant monitoring and rehabilitation which allows patients to lead relatively normal lives once discharged. Inpatient units provide access to medication, trained nurses and clinical psychologists with expert knowledge. The fact that we have these illness-specific units is fantastic and should not be discounted. However, experts fear that they can be an “ambulance at the bottom of the cliff” response if earlier treatment is not available.[18] The danger in providing treatment almost exclusively to the most unwell is that those seeking help may simply have to wait until their situation worsens.
Annette King suggests that low funding is at the heart of waiting lists, as there are simply not enough staff or facilities to provide routine care to those who need it. “You can’t provide a service if you starve it of staff and funds,” she states. “staff follow funding, and funding follows staff.”[19] Because of low funding, existing staff members are overstretched, meaning that even once entering a service, patients may not receive the regular or attentive service they may need.
Community counts
Experts state that the community is the most beneficial place for patients to access treatment. Around ninety per cent of mental health patients receive community care, while the remaining ten per cent receive a mixture of community and inpatient services.[20] Studies show that the community is the best place to activate health promotion, prevention, early detection and intervention programmes.[21] Community-based care is where those in the early stages of mental illness can access the treatment they need so that acute or residential care is not necessary. An agreed amount of funding each year is given to the District Health Boards to deal with acute cases, while community-based non-governmental services tend to provide counselling and aid to less acute cases. What we have seen over recent years, however, is that there are no mechanisms providing that DHB funding actually carries on to the NGO services. Money given to the DHB can go anywhere – and looking at this year’s health targets, service providers have a much bigger incentive to channel funding to the six health priorities. National’s attempts to help so far have not brought about desired outcomes. While the $20 million funding boost to Canterbury’s DHB earlier this year looked like a step in the right direction, interviews with the board’s CEO hints that funding in the area remains dangerously low.[22] Perhaps the most positive action taken by the government has been the opening of a 23-bed mental health unit in Hawke’s Bay opened by Health Minister Jonathan Coleman. Providing intensive day programs for patients, the unit is a godsend to those mentally unwell in the Hawke’s Bay area. These incremental boosts are helpful, but are far from the scale of changes this country needs to halt our suicide rates.
Where to from here?
Obviously increased funding is the primary route by which we can provide better mental health services. This will come through raising awareness, creating incentives, and managing existing funds. The Ministry of Health suggested in a 2015 review that the government allocate funding tied to specific goals and reward compliant DHBs with cash flow advantages to promote better services. The Labour Party also suggested that we re-introduce the ring-fencing system by which funding for mental health is closely monitored. This method aims to ensure that funding put towards mental health is not used in any other area, and that un-utilised funds from other areas be reserved for mental health purposes.[23]
Improved organization and tangible goals within the system will absolutely improve our quality of services within New Zealand. Having said this, the first step towards better services is to ensure that there are simply enough staff and spaces for patients in both acute and community-based services. Getting patients into regular and consistent treatment should be a major priority.
Part of this involves simply talking about the issue. As a nation, we have a tendency to mask our struggles. Arguably, our ideal of the staunch, strong male can be harmful, in that anyone who reveals their emotions may be told to ‘toughen up.’[24] Initiatives such as John Kirwan’s famous television campaign help to encourage conversation within the household. It is true that in a society where mental illness is looked down on, the hardest step is asking for help. If we as a society can become comfortable enough discuss mental illness in the same way we talk about physical illness, it is likely an increase in funding for mental health services will follow.
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[1] Amy Maas “The story of one woman, a sucide note, and blind justice” Sunday Star Times (online ed, 29 May 2016) <http://www.stuff.co.nz/national/health/80450197/The-story-of-one-woman-a-suicide-note-and-blind-justice>.
[2] Ibid.
[3] Bill English “Budget 2016: Overview” (26 May 2016) National <https://national.org.nz/news/2016-05-26-budget-2016-overview>.
[4] Interview with Annette King, Deputy Leader of the Labour party (Claudia Russell, Equal Justice Project, 30 May 2016).
[5] What are the arguments for community-based mental health care? (WHO Regional Office for Europe’s Health Evidence Network, August 2013) at 5. <http://www.euro.who.int/__data/assets/pdf_file/0019/74710/E82976.pdf>.
[6] Interview with Annette King, Deputy Leader of the Labour party (Claudia Russell, Equal Justice Project, 30 May 2016).
[7] Jonathan Coleman “Access to mental health & addiction services” (16 May 2016) Beehive <https://www.beehive.govt.nz/release/access-mental-health-addiction-services>.
[8] Catherine Gaffaney “More front for mental health” Wanganui Chronicle (10 December 2015) <http://www.nzherald.co.nz/wanganui-chronicle/news/article.cfm?c_id=1503426&objectid=11558758>.
[9] Interview with Annette King, Deputy Leader of the Labour party (Claudia Russell, Equal Justice Project, 30 May 2016).
[10] David Clark “Underfunding set to continue for Canterbury mental health” (press release, 21 March 2016) <http://www.scoop.co.nz/stories/PA1603/S00356/underfunding-set-to-continue-for-canterbury-mental-health.htm>.
[11] Charlie Cooper “Thousands attempt suicide while on NHS waiting list for psychological help” The Independent (16 September 2014) <http://www.independent.co.uk/life-style/health-and-families/health-news/thousands-attempt-suicide-while-on-nhs-waiting-list-for-psychological-help-9734284.html>.
[12] Alexandra Pitman and David P. J. Osborn “Cross-cultural attitudes to help-seeking among individuals who are suicidal: new perspective for policy-makers” (2011) 199 Br J Psychiatry 8 at 8.
[13] Nikki MacDonald “Children and teenagers with serious mental health problems wait months for help” Stuff (2 April 2016) <http://www.stuff.co.nz/national/health/77955402/Children-and-teenagers-with-serious-mental-health-problems-wait-months-for-help>.
[14] “Mental health and addiction services data: calculating waiting times” Ministry of Health <http://www.health.govt.nz/nz-health-statistics/national-collections-and-surveys/collections/primhd-mental-health-data/mental-health-and-addiction-services-data-calculating-waiting-times>.
Nikki MacDonald “Children and teenagers with serious mental health problems wait months for help” Stuff (2 April 2016) <http://www.stuff.co.nz/national/health/77955402/Children-and-teenagers-with-serious-mental-health-problems-wait-months-for-help>.
[15] John R. DeQuardo “Pharmacologic Treatment of First-Episode Schizophrenia: Early Intervention is Key to Outcome” (1998) 59 J Clin Psychiatry 9 at 9.
[16] Interview with Annette King, Deputy Leader of the Labour party (Claudia Russell, Equal Justice Project, 30 May 2016).
[17] Te Pou o Te Whakaaro Nui (2014) “Individualised funding for New Zealand mental health services: a discussion paper” at 3. <http://www.tepou.co.nz/uploads/files/resource-assets/individualised-funding-for-new-zealand-mental-health-services-a-discussion-paper.pdf>.
[18] Interview with Natalie Khin-Carter, clinical psychologist (Rebecca Hallas, Equal Justice Project, 22 September 2015).
[19] Interview with Annette King, Deputy Leader of the Labour party (Claudia Russell, Equal Justice Project, 30 May 2016).
[20] Janet Peters “Frontline: The community mental health and addiction sector at work in New Zealand” (February 2010) Platform at 3. <www.platform.org.nz>.
[21] Ibid.
[22] Annette King “New funding won’t fill existing gap” (4 March 2016) Labour <http://www.labour.org.nz/new_funding_won_t_fill_existing_gap>.
[23] Rising to the Challenge: The Mental Health and Addiction Service Development Plan 2012-2017 (Ministry of Health, December 2012) at 10. <https://www.mentalhealth.org.nz/assets/ResourceFinder/rising-to-the-challenge-mental-health-addiction-service-development-plan.pdf>.
[24] Eleanor Ainge Roy “’We have to start talking about it’: New Zealand suicide rates hit record high” The Guardian (19 October 2015) <https://www.theguardian.com/world/2015/oct/19/we-have-to-start-talking-about-it-new-zealand-suicide-rates-hit-record-high>.