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1.4 Context

1.4.1 Mental health and addiction in New Zealand

Facts and figures

Mental health and addiction challenges are common in New Zealand, and anyone can experience them. Prevalence studies indicate that 50–80% of New Zealanders will experience mental distress or addiction challenges or both in their lifetime. Around one in five people will experience mental health and addiction challenges in any given year.¹⁰ There are some indications that prevalence appears to be increasing.¹¹ Disparities in outcomes also exist for groups such as Māori, Pacific peoples, and people in contact with the criminal justice system. In addition, New Zealand’s rates of suicide remain stubbornly high and have been trending upward in recent years.

Severity and prevalence of mental health and addiction need

In the mental health and addiction sector, level of mental health and addiction need is commonly classified as mild, moderate or severe. Estimates of prevalence for each category are used for a variety of policy, funding, service and workforce planning purposes. Two main sets of mental illness prevalence figures have been used over the last two decades: those in the 1997 National Mental Health Plan¹⁸ and those from Te Rau Hinengaro, the national mental health survey, published in 2006 and based on data collected in 2003 and 2004.¹⁹

Prevalence figures from each of these were similar, with the proportion of the adult population in each category in any given year expressed as follows:

• severe need – about 5% according to Te Rau Hinengaro (or 3% in the National Mental Health Plan)
• mild to moderate and moderate to severe need – about 16% in Te Rau Hinengaro (7% and 9% respectively) (or 17% in the National Mental Health Plan)
• no need or low need – about 79% in Te Rau Hinengaro (or 80% in the National Mental Health Plan).

It is important to note these categories do not describe individuals but rather refer to the mental illness prevalence in the population in a given year – an individual’s needs shift over time and throughout their life. The severity of need can also fluctuate, even for people with long-term, serious mental health challenges such as persistent and severe depression, bipolar disorder or schizophrenia.

We have used these severity categories and prevalence rates throughout this report primarily because they are in common usage and because they underpin so many aspects of our current system. On this basis, they form an essential part of our discussion throughout this report.

We emphasise, however, that we do not find the terms mild, moderate and severe very useful, so at times we have simply referred to people with severe needs and people with less severe needs or, sometimes, to ‘the spectrum of mental health and addiction needs’. In addition, prevalence survey methodology in the past has used definitions based on ‘mental disorder’, which is based on Diagnostic and Statistical Manual diagnostic criteria and does not capture the full range of challenges and distress we refer to in this report.

There are wider difficulties in much of the terminology used to describe mental health and addiction challenges, and no easy answers. Terms can be subjective, language can be stigmatising, and boundaries are blurred, for example, between mental distress due to mental illness and mental distress that is not diagnosable as an illness (for example, distress due to a behavioural need).

Mental health conditions do not necessarily mean the presence of mental illness, while mental distress, even when quite disabling, can often be understood and managed without a medical response. And there are many situations in which a person who has a diagnosable condition can be helped through non-medical approaches. We find distress a useful concept and have used it throughout this report. ‘Distress’ encompasses mental illness, people who are seriously upset, and people who are reacting normally to a stressful situation such as bereavement.

An important point is that, regardless of what they are called, mental health and addiction challenges exist along a continuum, including severe and sometimes long-term conditions such as bipolar affective disorder, schizophrenia and other psychoses, as well as less severe but high prevalence conditions such as anxiety and depression. People may also have problematic alcohol or other drug use, which may develop into addiction.

Finally, people who experience mental distress or addiction have different needs, influenced not only by the severity of their symptoms, but also by the duration and complexity of their symptoms and the presence of other needs.

Given this very complex picture, rather than focus too heavily on definitions, our approach in this report is broad-based. We generally refer to the spectrum of mental health and addiction needs or challenges, including the concepts of mild, moderate and severe challenges when appropriate.

Organisations and people

New Zealand’s mental health and addiction system comprises a complex network of organisations and people.

The Ministry of Health is the main government agency responsible for mental health and addiction strategy, policy and regulation. Commissioning, implementation and service delivery are the responsibility of different organisations, based primarily within the health sector, including the Ministry of Health, district health boards (DHBs), primary health organisations, private hospitals, non-governmental organisations (NGOs), Kaupapa Māori services and community groups.

Some mental health and addiction services and supports are also funded by sectors outside health. They include the justice, education, social development and defence sectors and the Accident Compensation Corporation.

A variety of arts, cultural and sporting programmes and initiatives are not typically considered ‘mental health services’. They may, however, support mental health and wellbeing. Some specifically focus on providing opportunities for people with mental health and addiction challenges to participate in these everyday activities.

Finally, some services are not publicly funded at all. For example, some services, such as phone counselling, are delivered by NGOs or community groups that rely on fundraising or grants. Employers may also provide some support, such as counselling, for their employees. Private providers deliver other services for people who choose to pay directly.

The mental health and addiction workforce is diverse, comprising workers in both clinical and non-clinical roles (for example, psychiatrists, psychologists, general practitioners, mental health nurses, social workers, community support workers, cultural advisors, peer-support workers and youth workers) across a number of environments (from hospitals to schools to community-based services, marae, hubs and people’s homes).

Mental health and addiction services

Since deinstitutionalisation in the 1980s and 1990s, most mental health and addiction services are delivered in a community setting, rather than in hospitals.

Most mental health and addiction services are funded by the public health sector. In 2016/17, around $1.4 billion (or 9% of the total Vote Health budget) was spent on these services. The vast bulk of this funding, about $1.35 billion, is ring-fenced for services focused on meeting the needs of people facing the most severe challenges (targeted to at least 3% of the population in a given year²⁰). Although these services are called ‘specialist services’, they are not provided exclusively by specialist clinicians, but include services such as community-based and respite care, as well as social support services (for example, vocational support, living skills and housing coordination services).

Outside the ring-fenced funding, about $30 million of public health funding is provided for services for people with mild to moderate or moderate to severe needs. These services are usually referred to as ‘primary mental health services’ and include psychological therapies and extended general practitioner visits. Public funding for these services is tightly targeted towards young people, Māori, Pacific peoples and people on low incomes.

A further $100 million of nationally purchased services and activities (for example, national health promotion campaigns, workforce development, adult inpatient and forensic services) are funded directly by the Ministry of Health. (See Appendix B for further information about mental health and addiction funding and services.)

1.4.2 How we approached our report

The Inquiry’s Terms of Reference are broad and we had a relatively short time to report – we began in February 2018 and were required to report by 31 October 2018.²¹ Our first priority was to give people an opportunity for their voices to be heard. What we heard confirmed that there are long-standing mental health and addiction challenges in New Zealand, increasing and unsustainable pressure on the current system, and an urgent need to tackle the problems we face.

Many people with lived experience, their families and whānau, workers, providers and funders and policy advisors argued for a radically different approach to mental health and addiction. But there was much less clarity about the best way forward.

We considered how best to approach this report, given the wide range of complex issues, our time constraints, and the risk of being overwhelmed by detail. We have not produced a strategy, a roadmap or a detailed implementation plan with comprehensive and fully costed actions. Our analysis convinced us that none of those well-trodden paths would achieve the fundamental change of direction required.

Instead, we have focused on the critical reforms necessary to create the right environment and support a significant shift in how we prevent and respond to issues of mental health and addiction. We have identified priority areas for action, many of which require decisive action by the Government and Parliament.

We have deliberately taken a ‘people first’ approach in writing this report, being guided by the needs of people and communities rather than the preferences of the various groups accustomed to the way the system is structured and services are delivered at present. We have not proposed major structural change, since we do not have any evidence to show that dismantling and rebuilding the current system is necessary or desirable. We have highlighted where roadblocks must be removed and how we can build a new system on the solid foundations already in place.

We are conscious of the need to be bold and make the most of this once in a generation opportunity. We want this report to lead to real and enduring change: the ‘paradigm shift’ that so many New Zealanders have called for.

Our report reflects the voices of the people, sets out our vision of a transformed mental health and addiction system, and identifies the key reforms needed to bring about major change.

1.4.3 Structure of this report

This report has two main parts.

Part 1 describes where we are now: the context of this Inquiry (chapter 1), what we heard (chapter 2),²² and what we think, including our vision and direction for a transformed mental health and addiction system (chapter 3).

Part 2 sets out our conclusions about what needs to happen. We detail the main areas where we recommend change:

• expand access and choice (chapter 4)
• transform primary health care (chapter 5)
• strengthen the NGO sector (chapter 6)
• enhance wellbeing, promotion and prevention (chapter 7)
• place people at the centre (chapter 8)
• take strong action on alcohol and other drugs (chapter 9)
• prevent suicide (chapter 10)
• reform the Mental Health Act (chapter 11)
• establish a new Mental Health and Wellbeing Commission (chapter 12).

A final note and two appendices complete the report.

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