The Government has committed to setting up an inquiry into mental health as part of its frst 100 days’ work programme. 231 The catalyst for the inquiry has been widespread concern about mental health services, within the mental health sector and the broader community. Service users, their families and whānau, people affected by suicide, people working in health, media, iwi and advocacy groups have called for a wide-ranging inquiry.
The People’s Mental Health Report (2017) highlighted a range of problems, including: access to services and wait times, limited treatment options in primary and community care, compulsory treatment and seclusion practices, ineffective responses to crisis situations and underfunding of mental health and addiction services in the face of rising demand. There have been calls for a transformation in New Zealand’s response to mental health and addiction problems. Major concerns are stubbornly high suicide rates, growing substance abuse and poorer mental health outcomes for Māori.
People can experience a broad range of mental health problems on a spectrum from mental distress to enduring psychiatric illness requiring ongoing interventions. Substance abuse often occurs together with mental health problems. Poor mental health increases the likelihood of suicidal behaviour. However, not everyone who plans, thinks about, attempts or dies by suicide has a diagnosable mental disorder, and factors that contribute to suicide differ markedly across age groups.
Mental health and addiction problems are relatively common (approximately 20 percent of New Zealanders are predicted to meet the criteria for a diagnosable mental disorder each year) and prevalence is increasing. Unmet need is substantial, with at least 50 percent of people with a mental health problem receiving no treatment. This situation reflects both people not recognising their own needs for mental health support and a lack of capacity to meet those needs. Families and whānau of service users, and of New Zealanders lost to suicide, report little or no support or treatment.
Risk factors include ease of access and cultural attitudes to alcohol (which is implicated in over 50 percent of cases of youth suicide) and continued dislocation of Māori from their whānau, communities and iwi. There is also increasing dislocation within our ethnic migrant and refugee communities. Many other risk factors associated with poor mental health sit across a range of social determinants such as poverty, inequality, inadequate parenting, lack of affordable housing, low-paid work, exposure to abuse, neglect, family violence or other trauma, social isolation (particularly in the elderly and rural populations) and discrimination.
Risks are higher where deprivation persists across generations. These risk factors can contribute to a wide range of other poor life outcomes including low levels of educational achievement, poor employment outcomes, inadequate housing and criminal offending. On the positive side, many resilience and mental health-enhancing factors can be found even in difficult and deprived social settings.
There is strong evidence that prevention and early intervention is most beneficial and cost-effective. Often mental disorders are recognised only after they become severe and consequently harder to treat. Half of all lifetime cases of mental disorder begin by age 14 and three-quarters by age 24. New Zealand’s current approach to mental health is not geared towards prevention and early intervention.
Across the spectrum of poor mental health are inequalities in mental health and addiction outcomes. In addition to Māori, disproportionately poorer mental health is experienced by Pacific and youth, people with disabilities, the rainbow/LGBTIQ community, the prison population and refugees.
Many interventions, particularly in relation to preventing mental health and addiction problems and suicide, lie outside the health system. There needs to be better coordination and a more integrated approach to promoting mental well-being, preventing mental health and addiction problems, and identifying and responding to the needs of people experiencing mental health and addiction problems. Models of care such as Whānau ora and whānau focussed initiatives offer significant potential benefit. New approaches will have implications beyond the health system, for example, for education, welfare, housing, justice, disability support, accident compensation and emergency response systems.
Some actions cannot wait until the inquiry is completed. Alongside the inquiry, the Government is already taking steps to address some immediate service gaps and pressures, including increasing funding for alcohol and drug addiction services, increasing resources for front-line health workers, putting more nurses into schools, extending free doctors’ visits for all under 14 year olds, providing teen health checks for all year 9 students and providing free counselling for those under 25 years of age.
The purpose of this inquiry is to:
1. hear the voices of the community, people with lived experience of mental health and addiction problems, people affected by suicide, and people involved in preventing and responding to mental health and addiction problems, on New Zealand’s current approach to mental health and addiction, and what needs to change;
2. report on how New Zealand is preventing mental health and addiction problems and responding to the needs of people with those problems; and
3. recommend specific changes to improve New Zealand’s approach to mental health, with a particular focus on equity of access, community confidence in the mental health system and better outcomes, particularly for Māori and other groups with disproportionally poorer outcomes.
To do this the inquiry will:
1. identify unmet needs in mental health and addiction (encompassing the full spectrum of mental health problems from mental distress to enduring psychiatric illness);
2. identify those groups of people (including those not currently accessing services) for whom there is the greatest opportunity to prevent, or respond more effectively to, mental health and addiction problems;
3. recommend specific changes to create an integrated approach to promoting mental well-being, preventing mental health and addiction problems, and identifying and responding to the needs of people experiencing mental health and addiction problems; and
4. specify which entities should progress the inquiry’s recommendations, including relevant ministries and a re-established Mental Health Commission.
The recommendations of the inquiry will help inform the Government’s decisions on future arrangements for the mental health and addiction system, including:
1. roles and responsibilities of agencies in the health sector, including a re-established Mental Health Commission;
2. improved coordination between the health system and other systems such as education, welfare, housing, justice, disability support, accident compensation and emergency response;
3. the design and delivery of services (eg, kaupapa Māori approaches to mental health) and effective engagement with all relevant stakeholders including mental health service providers, and consumers and their communities and whānau;
4. governance, leadership and accountability levers to ensure access to an appropriate standard of mental health services across the country;
5. fiscal approaches, models and funding arrangements;
6. data collection, programme evaluation and information flows;
7. the suite of relevant regulatory frameworks, including the Mental Health (Compulsory Assessment and Treatment) Act 1992 and the Substance Abuse (Compulsory Assessment and Treatment) Act 2017; and
8. workforce planning, training, support and management.
In identifying the issues, opportunities, and recommendations the inquiry will consider the following:
1. mental health problems across the full spectrum from mental distress to enduring psychiatric illness;
2. mental health and addiction needs from the perspective of both:
a. identifying and responding to people with mental health and addiction problems; and
b. preventing mental health problems and promoting mental well-being;
3. prevention of suicide;
4. activities directly related to mental health and addiction undertaken within the broader health and disability sector (in community, primary and secondary care), as well as the education, justice and social sectors and through the accident compensation and wider workplace relations and safety systems; and
5. opportunities to build on the efforts of whānau, communities, employers, people working in mental health and others to promote mental health.
The inquiry will need to understand and acknowledge the wider social and economic determinants of mental health and addiction (for example poverty, inadequate housing, family violence or other trauma) and cultural factors, in particular the historical and contemporary diferences in outcomes for Māori, and consider the implications of these determinants and factors for the design and delivery of mental health and addiction services. Commentary on these matters is welcome to help inform the Government’s work programmes in these areas.
The inquiry may signal changes to be considered in subsequent regulatory reviews. It will not undertake these reviews itself.
The following matter is outside the scope of the inquiry:
1. individual incidents or cases within current services. The inquiry panel will refer these to the appropriate pathway, for example, the Health and Disability Commissioner or relevant authorities.
The inquiry will take an approach that:
1. enables consumers, carers, family and whānau to be included and heard, and ensures acknowledgement and consideration of input from previous consultations and specifc consultation with Māori communities and whānau/hapū/iwi;
2. attempts to build consensus between consumers, potential consumers, carers, family, whānau and providers about what government needs to do to transform the mental health and addiction system;
3. recognises the particular mental health and addiction inequalities for Māori, reflects the special relationship between Māori and the Crown under the Treaty of Waitangi, and the value of the work done by Māori experts and practitioners to design and deliver services that are more relevant and effective for Māori;
4. recognises and respect the needs of people with disabilities, and takes into account New Zealand’s obligations under the UN Convention on the Rights of Persons with Disabilities;
5. recognises and respects the needs of different population groups, including Pacific people, refugees, migrants, LGBTIQ, prison inmates, youth, the elderly, and rural populations;
6. is person-centred, appreciating the impact of changes on individuals;
7. takes account of the whole system, including all relevant sectors and services and how they can work better together to improve mental health and addiction outcomes;
8. focuses on opportunities for early intervention; and
9. is based on the best research, ongoing evaluation and available evidence, in New Zealand and overseas.
The inquiry is to report its findings and opinions, together with recommendations, to the Minister of Health in writing no later than 30 November 2018. 232 In order to ensure the Minister is kept appropriately informed as to progress, the Chair will provide regular updates to the Minister on the inquiry’s progress throughout the course of the inquiry.
The inquiry will consider previous investigations, reviews, reports and consultation processes relating to mental health and addiction, including:
1. the Peoples’ Mental Health Report;
2. Blueprint II: Improving mental health and wellbeing for all New Zealanders;
3. reports from the Government’s Chief Science Advisors into mental health and suicide;
4. report of the Director of Mental Health on the consistency of New Zealand mental health laws with the UN Convention on the Rights of Persons with Disabilities;
5. various workforce reviews including Mental Health and Addictions Workforce Action Plan 2016–2020;
6. consultation on A Strategy to Prevent Suicide in New Zealand: Draft for public consultation;
7. consultation on Commissioning Framework for Mental Health and Addiction: A New Zealand guide;
8. Mentally Healthy Rural Communities. RHANZ Framework to Improve Mental Health and Addiction Outcomes in Rural New Zealand (2016);
9. Puahau: Five Point Plan (1998);
10.Fit for the Future – Summary of Stakeholder Feedback (2017);
11. Understanding whānau-centred approaches: Analysis of Phase One Whānau Ora research and monitoring results (2015); and
12. relevant Waitangi Tribunal inquiry reports (including Ko Aotearoa Tenei).
The inquiry also consider and interface with other relevant inquiries and reviews currently underway, including:
1. the Wai 2575 Health Services and Outcomes Kaupapa Inquiry;
2. the inquiry into the abuse of children in state care; and
3. Disability Support Transformation.
The inquiry is established as a government inquiry under the Inquiries Act 2013, with the Minister of Health as the appointing Minister.
The Inquiry may begin considering evidence on and from 31 January 2018.
Dated at Wellington this 25th day of January 2018.
Hon Dr DAVID CLARK, Minister of Health.
231 These Terms of Reference are set out in Establishment of the Government Inquiry into Mental Health and Addiction (notice number 2018-go318). 2018. New Zealand Gazette 30 January. https://gazette.govt.nz/notice/id/2018-go318(external link).
232 See Amendment to the Notice for the Government Inquiry into Mental Health and Addiction (notice number 2018-go5089). 2018. New Zealand Gazette 18 October. https://gazette.govt.nz/notice/id/2018-go5089.(external link)