Transforming the mental health and addiction system will take at least a generation. The changes required will depend on careful management, new ways of working, cultural change, and sustained system improvement and learning. New Zealanders need confidence that decision-makers will hold the vision and deliver the strategy, and that the directions will stay broadly consistent, despite political change.
Transformation requires strong leadership and accountability. Leadership of the mental health and addiction sector is necessarily dispersed across a complex system. The sector has many parts and many different people and organisations with leadership roles (including the Minister of Health, the Ministry of Health, 20 district health boards (DHBs), other service providers (including non-governmental organisations (NGOs) and primary care providers), and professional and representative groups. Several ‘watchdog’ organisations are responsible for advocacy and rights protection (such as the Health and Disability Commissioner) and quality improvement (such as the Health Quality and Safety Commission).
We note the criticisms heard during this Inquiry of mental health and addiction leadership, particularly in relation to the Ministry of Health. We have not dwelt on this, choosing instead to focus on looking forward and supporting the new Director-General of Health to provide much-needed leadership to the health and disability sector, and in particular to mental health and addiction issues. It will be important to rebuild trust and relationships with the mental health and addiction sector.
We also heard criticisms of the diminished role of the Mental Health Commissioner. The former Mental Health Commission, established in 1996, performed the role of independent oversight and was seen as a strong and effective watchdog. It had a specific function of monitoring the implementation of the national mental health strategy, including the performance of the Ministry of Health and regional health authorities (the precursors of DHBs). It developed the Blueprint on how things needed to be to guide sector development and support a monitoring framework. The Blueprint provided leadership and accountability to the sector and set funding priorities.
Over time, the powers, effectiveness and funding of the Commission were substantially reduced. It was disestablished in 2012, with the position of Mental Health Commissioner subsumed into the Office of the Health and Disability Commissioner. The statutory functions of the Mental Health Commissioner within the Office of the Health and Disability Commissioner were narrowed to focus on mental health and addiction services rather than the broader focus and functions of the disestablished commission.
The role of independent oversight of the whole system by a powerful commission is an important and missing piece of the puzzle.230
The Government has signalled its intention to re-establish a stand-alone mental health commission. We recommend that this occur as a matter of urgency and that it be named the Mental Health and Wellbeing Commission to emphasise the focus on shifting from an illness approach to a wellbeing approach.
We assessed options for a new commission’s scope, functions, powers and form, taking into consideration what we heard through submissions, advice from state sector organisations and our own commissioned research.
We consider that the fundamental purpose of the independent Mental Health and Wellbeing Commission should be to act as a system leader of mental health and wellbeing in New Zealand, with a strong oversight and monitoring role. In all its endeavours, the Commission should uphold and actively promote the Treaty of Waitangi and its principles, and this requirement should be set out in legislation. (See Figure 4.)
As noted in chapter 4, we consider that an immediate priority for the new Commission is to support the Ministry of Health in facilitating a national co-design service transformation process. The purpose of this process is to extend access to and choice of mental health and addiction services in New Zealand. The Commission should also be funded to provide ‘backbone support’ for national, regional and local implementation of the change process.
In the future, the Commission may develop a new mental health and wellbeing strategy, although we see the co-design process as being its initial priority. In addition, we consider that the Commission should play a leading role in the development and ongoing review of an investment and quality assurance strategy for mental health promotion and prevention (chapter 7). Other functions could include hosting the suicide prevention office and completing the suicide prevention strategy and implementation plan (chapter 10).
The Commission should also act as an important institutional mechanism to help New Zealanders hold decision-makers and successive governments to account. It can do this by monitoring the degree to which national strategies relevant to mental health and wellbeing are being implemented by responsible agencies and by publicly reporting on progress. It should also regularly report publicly on the progress against implementation of the Government’s response to this Inquiry’s recommendations, with the first report to be released one year after the response.
The Commission should also have the ability to provide independent expert advice to the Government, on its own initiative or as requested, on any matters relevant to mental health and wellbeing (including resources and funding). The important role of the Health and Disability Commissioner continues in promoting and protecting the rights of consumers under the Code of Health and Disability Services Consumers’ Rights and resolving individual complaints. However, the new commission should be responsible for advocating for the collective interests of people with mental health and addiction challenges and their families and whānau.
Partnerships (across government, sectors and communities) are essential because the Commission cannot achieve the desired outcomes on its own. The Commission needs to drive change while bringing others along. This work will include spreading information, innovation and best practice (including on mental health promotion and prevention) and promoting collaboration, communication and understanding about mental health and wellbeing and contributory factors to mental distress. For example, we see the Commission having an important relationship with the proposed social wellbeing agency, with the Commission having an oversight role of the mental health sector’s contribution to the wider wellbeing agenda.
Other possible functions
For the Commission to effectively undertake these functions, it must be able to obtain information or data from government departments and other state services agencies, initiate investigations and inquiries on systemic issues, publish its advice and reports, appoint advisory and expert committees, seek expert advice, and engage and consult widely in the course of its work. It should also be able to review and comment on the annual and strategic plans (and associated funding and expenditure) of agencies responsible for delivering services that affect people with mental health and addiction challenges and their families and whānau.
The Commission should be established as an independent Crown entity with a board of about three commissioners. Collectively, board members should have expertise in crucial areas (including tikanga Māori), have lived experience, and reflect the community the Commission serves. This means the form and operating model of the Commission and its board need to be informed by a strong commitment to the Treaty relationship and ensure a robust role and voice for people with lived experience.
The Commission should have the necessary resources to do its job, including stable and ongoing funding and a capable secretariat with access to data from across government.
To maintain momentum on this issue, an interim commission, established as a ministerial advisory committee, should be set up early in 2019 to undertake priority work in key areas, ahead of the Commission’s formal establishment. This could include development work with the Ministry of Health on the national co-design process.
As part of this process, legislative amendments will be needed to the Health and Disability Commissioner Act 1994 to shift some of the Health and Disability Commissioner’s current functions to the new Commission.
Establish a new Mental Health and Wellbeing Commission
230 R Cunningham, A Kvalsvig, D Peterson, S Kuehl, S Gibb, S McKenzie, L Thornley and S Every-Palmer. 2018. Stocktake Report for the Mental Health and Addiction Inquiry. Wellington: University of Otago.