4.1 Introduction

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One of this Inquiry’s conclusions is that an urgent need exists to expand access and choice in mental health and addiction services.

Gaps in services, difficulties accessing services and a threshold for mental health and addiction services that seems increasingly hard to reach were key themes in what we heard. While some attributed these themes to a general underfunding of mental health and addiction services, others questioned where funding is being directed and how well it is being spent.

The system is unbalanced in focusing almost entirely on specialist services targeted at those people with the most severe mental health and addiction needs. Beyond this group, a significant gap exists in what is commonly referred to as the ‘missing middle’ or ‘middle ground’: people with mild to moderate and moderate to severe mental health and addiction needs. This gap is the result of deliberate policy choices that have shaped our mental health and addiction system over many years. We believe it sits behind much of what we heard about people’s inability to access services and contributes to the growing pressure on specialist services. We emphasise that this gap must be addressed, but not by diverting funding away from services for people with the most severe needs. Maintaining access for this group must remain a priority.

Even for people with severe needs who are able to access services, those services are spread thin. Oversight by psychiatrists and the use of prescription medicines play a necessary and important role, although debate about the balance of harms and benefits of some psychiatric medications is growing.¹⁰⁸ However, patients often do not get access to wider talk therapies or have their broader social and wellbeing needs met. For those in the middle ground who do not meet the criteria for access to specialist services, often the only option is to obtain a prescription for medication from a general practitioner (GP). There is only limited and highly targeted funding for other interventions such as talk therapies or peer and cultural support options that would more effectively address the root cause of their distress. More choices are, therefore, needed about the types of services and treatments available.

Finally, a broader range of service models and ways of delivering services that allows people to access services in different ways and in different contexts is required, whether that be more options for Kaupapa Māori or Whānau Ora services, Pacific models, youth one-stop shops, or primary and community hubs with teams of practitioners working together to support a range of needs. As outlined in chapter 3, greater integration of services is required to provide a more seamless and joined-up experience, including between primary and secondary mental health and addiction services, between services addressing mental and physical health, and between health and other social services.

The objective of expanding access and choice will need to be supported by several enablers such as future service design, commissioning approaches, including funding and accountability rules, workforce development, information and research, and joined-up leadership.

In this section, we discuss four areas:

• expand access and eligibility to mental health and addiction services beyond people with the most severe mental health and addiction needs (section 4.2)
• provide a wider menu of service options, especially additions to medication such as talk therapies, alcohol and other drug services and culturally aligned therapies (section 4.3)
• transform services by a national co-design process, with support for implementation (section 4.4)
• enablers to support expanded access and choice (section 4.5).

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