4.4 Transform services through a national co-design process, with support for implementation

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4.4.1 Issues

We need to focus on how services are delivered

We have proposed extending access to services and broadening the types of services available to provide more choice to people, with a particular focus on talk therapies that can be delivered in different settings and by a variety of providers. However, to deliver on the vision for services outlined in section 3.6, fundamental changes are needed in how services are delivered.

These changes need to be planned, developed, implemented and monitored in a more structured and coordinated way than the present approach of ad hoc funding, ‘letting a thousand flowers bloom’, and encouraging innovation without clear pathways to evaluate and scale up. We propose a national co-design process followed by implementation at national, regional and local levels, with an appropriate level of support to manage a complex change process.

A broader range of types of services and service models is needed

We need a broader range of mental health and addiction services for more people that are easily accessible, more options to access health and social services in different ways and in different contexts, easier ways for people to get support for multiple needs when required, a more diverse workforce, and to use our workforce in different ways. We have not specified the exact features of a new set of services, but Table 3 sets out a variety of approaches raised during the Inquiry.

Table 3: Services and service models mentioned during the Inquiry

Examples of different types of services and service models
More tools, support and guidance for self-help and self-care to maintain wellbeing; for example, e-therapy, e-navigation and e-mental health programmes Expanded access to psychological therapies, alcohol and other drug services and culturally aligned therapies across the spectrum of mental health and addiction needs Co-located multidisciplinary teams or hubs including general practitioners (GPs), practice nurses, nurse practitioners, social workers, health coaches, mental health workers, cultural support, peer-support workers and youth workers A greater variety of options for individuals or groups who prefer not to use general practice as their first point of contact or ongoing relationship; for example, youth, Māori, Pacific peoples and Rainbow services GPs, practice nurses and other health sector workers with more training and ability to identify and respond to mental health and addiction needs, without just resorting to medication Extending the capability of those already working in primary and community settings to provide a greater range and depth of support (such as talk therapies and traditional therapies) Robust relationships and referral pathways between non-governmental organisation and Iwi social services, Whānau Ora providers, general practices, specialist mental health and addiction services, and other government agencies Using the specialist workforce differently to support primary and community-based services; for example, psychiatrists available for real-time telephone consults to GPs, and psychiatrists as part of multidisciplinary teams A coordination and oversight role by community providers including general practice, other social services, NGOs and Whānau Ora providers, as appropriate Seamless services for people with both chronic physical conditions and mental health needs and a workforce that is equipped to manage the interface Upskilling of other parts of the wider workforce especially for front-line workers who come into contact with people with mental health and addiction needs Alternative crisis response models such as a co-response model where police, DHB mental health services and paramedics jointly attend mental health callouts Peer-led and peer-delivered services, including community-based alternatives to hospitalisation, for people with acute mental distress; for example, Piri Pono Services for prisoners that meet the needs of specific population groups, such as youth, mothers and babies and children of prisoners.

Examples of different types of services and service models

More tools, support and guidance for self-help and self-care to maintain wellbeing; for example, e-therapy, e-navigation and e-mental health programmes
Expanded access to psychological therapies, alcohol and other drug services and culturally aligned therapies across the spectrum of mental health and addiction needs
Co-located multidisciplinary teams or hubs including general practitioners (GPs), practice nurses, nurse practitioners, social workers, health coaches, mental health workers, cultural support, peer-support workers and youth workers
A greater variety of options for individuals or groups who prefer not to use general practice as their first point of contact or ongoing relationship; for example, youth, Māori, Pacific peoples and Rainbow services
GPs, practice nurses and other health sector workers with more training and ability to identify and respond to mental health and addiction needs, without just resorting to medication
Extending the capability of those already working in primary and community settings to provide a greater range and depth of support (such as talk therapies and traditional therapies)
Robust relationships and referral pathways between non-governmental organisation and Iwi social services, Whānau Ora providers, general practices, specialist mental health and addiction services, and other government agencies
Using the specialist workforce differently to support primary and community-based services; for example, psychiatrists available for real-time telephone consults to GPs, and psychiatrists as part of multidisciplinary teams
A coordination and oversight role by community providers including general practice, other social services, NGOs and Whānau Ora providers, as appropriate
Seamless services for people with both chronic physical conditions and mental health needs and a workforce that is equipped to manage the interface
Upskilling of other parts of the wider workforce especially for front-line workers who come into contact with people with mental health and addiction needs
Alternative crisis response models such as a co-response model where police, DHB mental health services and paramedics jointly attend mental health callouts
Peer-led and peer-delivered services, including community-based alternatives to hospitalisation, for people with acute mental distress; for example, Piri Pono
Services for prisoners that meet the needs of specific population groups, such as youth, mothers and babies and children of prisoners.

Piri Pono: A peer-led, community-based alternative to hospitalisation

Several relatively new community-based acute alternatives to hospitalisation are showing great results for people who would otherwise be admitted to inpatient acute units. One of these is Piri Pono.

Piri Pono is a five-bed residential, acute alternative to hospitalisation provided by ConnectSR through a contract with Waitemata DHB. The service is peer-led and staffed with nurses and support workers. Piri Pono is available to those experiencing extreme mental distress, and guests can stay for up to 10 days in a home-like, personalised environment with a holistic approach to wellness.

Evaluations of Piri Pono have been positive, and tāngata whaiora and their families and whānau view it favourably.

Integrate services and support change

Achieving a set of services like those listed in Table 3 will require much more integrated service planning and delivery, an expanded workforce with different types of roles, including Kaupapa Māori and Pacific workers, and more effective use of our existing workforce. An integrated set of services also has to be connected across sectors, not just within the health sector. This means ensuring appropriate linkages between mental health and addiction and other social services (for example, housing, budgeting advice, employment services, relationship and anger management, and Whānau Ora services) for people who require other types of support. It also means considering how to most effectively plan and deliver mental health and addiction services in different settings, such as schools and prisons, or for people in contact with Oranga Tamariki.

This implies any process to plan and deliver mental health and addiction services, and associated social supports, must involve a variety of agencies across sectors, including outside government, that are appropriately resourced and mandated to deliver. This would represent a very different type of process from past practice.

We appreciate that many talented and highly motivated people are doing their best in a difficult environment and excellent pockets of innovation exist. But inspiring people are not always well supported and few mechanisms exist to evaluate and scale up or cease initiatives as appropriate. Designing a new system, even with all the right elements within and across sectors, will not be sufficient without also investing in supporting change itself. We need to use implementation science to bridge the gap between strategy and practice and to ensure supporting infrastructure is in place and aligned to deliver the desired outcomes.

4.4.2 What needs to happen

In summary, we need:

a national co-design process to build more people-centred and integrated services
support for the change process itself, including at a national, regional or local level.

National co-design process

A shift of the magnitude envisaged will require a significant service transformation and design process. We think a robust co-design process should begin with a nationally led process for a high-level design, then work to identify priorities and develop the implementation framework for these, followed by regional or local adaptation, planning and implementation. Designing the ‘how to’ for implementation and evaluation at a national level will be essential to achieve traction locally and have a consistent evaluation framework to support shared learning and refinement. The service framework developed from this process should then inform the development of local services to meet the specific needs of the communities they will service. It should include Kaupapa Māori service frameworks.

This process should aim to develop a range of services that can address a spectrum of mental health and addiction needs, are integrated with a range of other support services, and have a significant emphasis on primary and community-based care. Five principles should underpin the development process.

Involve all the right people and agencies in designing the new system (with appropriate mandates as required): people with lived experience of mental health and addiction challenges, DHBs, primary care, NGOs, Kaupapa Māori services, Pacific health services, Whānau Ora services, other providers, advocacy and representative organisations, professional bodies, families and whānau, employers and key government agencies.
Build a system and responses based around the people who use it rather than around service providers and funders. This requires a real understanding of the people who will require those services and the variety of their circumstances and needs.¹³⁰ We should also move away from some of the language we heard around ‘the 3%’ and ‘the 17%’. While useful for service and workforce planning purposes, it is not a helpful or accurate way to talk about people with mental health and addiction challenges.
Build a system that is integrated across services for mild, moderate and severe mental health and addiction needs, recognising that these are not fixed categories of people, and that is a joined-up and seamless system for the people who access it, between mental and physical health and between health and other government and social services, when needed. New language to replace ‘mild, moderate and severe’ would also be helpful.
Maintain a focus on improving outcomes for people with the most severe mental health and addiction needs and not shift resources from specialist services ahead of changes in demand.
Give effect to the specific aspirations of Māori and Pacific peoples, including the shifts of direction identified in Whakawātea te Ara and Vai Niu (sections 3.4 and 3.5, respectively) to clear the pathways for improved Māori and Pacific health and wellbeing.

The high-level service design needs to be done well, but it also needs to proceed rapidly. This work can be accelerated by building on the foundations and consensus provided by the 2016 Ministry of Health–led Fit for the Future programme and other interagency work undertaken in recent years, but needs to extend further. It can also draw on lessons from the current transformation of disability support, but must result in progressive change across the whole country, not just at prototype sites. We expect that, in line with international experience, it is likely to take three to four years to implement 80% of the desired change, even without the challenge of workforce shortages and the need for a co-design process at the outset.

The co-design process should be facilitated by the Ministry of Health in partnership with the new Mental Health and Wellbeing Commission (or an interim establishment body). This is because the Ministry of Health is currently the clear lead, within government, for mental health and addiction services.

However, many other agencies and groups will need to be involved and provide leadership in the co-design process. They include government agencies such as the Department of Corrections (around meeting the mental health and addiction needs of people entering, in or leaving the corrections system), the Ministry of Education (around the provision of mental health and addiction and wellbeing services and support in educational environments, including programmes that build resilience and wellbeing), Te Puni Kōkiri (around the funding and goals of Whānau Ora) and the Ministry of Social Development (in relation to income support and employment support). We note there are already several models to bring agencies together to tackle complex, cross-cutting problems¹³¹ and that the proposed reform of the State Sector Act 1988¹³² may provide additional avenues for integrated leadership on issues relevant to mental health and addiction; for example, to support coordinated service planning that requires input and commitment from multiple government departments.

We suggest the State Services Commission advises on the most appropriate models and levers to bring together agencies across government to collaborate in the national co-design process for mental health and addiction services.

The co-design process should inform many of the investment decisions in the mental health and addiction area over the medium term. We suggest strategic investment in priority developments is needed rather than ‘shopping lists’, action plans with dozens of discrete items, and multiple pilots and demonstration projects. The focus should be on making good traction on a limited number of strategic priorities. As outlined in the previous section, a good case exists for immediate investment to fill critical gaps in services. This investment will be needed regardless and can proceed ahead of the co-design process.

Support for the change process

Investing in change itself is important. The speed and consistency of uptake of innovation or change is greatly improved by having implementation support. For example, it has been estimated that implementation support enables an 80% uptake of the intended change within three years,¹³³ whereas without implementation support only 14% of healthcare research is adopted into day-to-day clinical practice within 17 years.¹³⁴

We acknowledge those agencies that are already investing in and supporting change. The Health Quality and Safety Commission is leading prioritised quality improvements in existing services. Similarly, the mental health and addiction workforce development centres have been leaders in building workforce capability. However, there is no similar investment to support new service developments or substantive system change.

People with the passion, leadership skill, change know-how and experience in implementing system transformation will play a key role. We need to make the most of existing talent and build capability and relationships across the sector and communities to get traction in implementing the new system design. Peer and cultural leaders will play important roles.

The transformation we envisage needs to be supported by robust change methodologies, implementation science (to ensure the uptake of approaches that have proven effective into routine practice in ways that are locally relevant) and investment to support the change process itself. We have looked at examples where implementation support was provided for mental health and addiction system change to see what we could learn. Examples include a Canadian provincial support programme, a New Zealand mental health and addiction change team in a DHB, and collective impact approaches.

Ontario provincial support programme (Canada)

The Ontario provincial government commissions mental health and addiction implementation support from a central team, which helps clarify the intent of a change initiative and to define the outcomes and measures. It then designs how the change or new service will be implemented in such a way that it can be picked up locally and, with local stakeholder participation, adapted for local implementation.

Within the Canadian model, local teams also work with key local stakeholders to ensure the intended change is adopted, implemented with fidelity to a set of core features and sustained over time (but with flexibility). This arrangement also provides for knowledge exchange between local implementation sites and the centre, which helps build the body of evidence about what works.

The Ontario model is intended to address many of the problems we have identified in New Zealand and potential exists to build something similar that is adapted for our context. The new Mental Health and Wellbeing Commission (discussed in chapter 12) would be well positioned to be the hub for such a facilitative function.

DHB mental health and addiction change team

Several years ago, Counties Manukau DHB invested $1 million per year (from its underspend in new funding) in a change team to:

identify the evidence and promising practice internationally
work collaboratively with stakeholders, including PHOs, NGOs, and DHB providers, Māori, tāngata whaiora and their families and whānau, and others, to design new services or service change and to define the desired impacts
establish evaluation frameworks
support the managers and staff responsible for implementing the changes
enable shared learning between participating sites.

This investment enabled the DHB to improve the acceptability of services to the people who used them and increase staff satisfaction, without having to increase inpatient services in the face of population growth. This was at a time when the DHB’s mental health and addiction system was experiencing significant demand pressures.

Collective impact approaches

Some of the pockets of success in New Zealand seem to build on collective impact approaches either explicitly or implicitly (for example, Equally Well and Waka Hourua). Collective impact has been described as “the commitment of a group of important actors from different sectors to a common agenda for solving a specific social problem”.¹³⁵ Critical success factors in collective impact approaches include:

an influential champion – trusted and neutral, highly skilled in relationships and engagement
adequate financial resources
consensus on urgency for change around an issue
building on successful initiatives under way, rather than building new initiatives from scratch
a backbone organisation that supports the partners in the collaborative effort.

Collective impact initiatives are, by definition, community-led. There are lessons in this for how we might approach change on national issues (and local solutions).

Adequate resources (including funding, people and the commitment of key stakeholders) will be needed for a national co-design process. Implementation support will also need to be provided at national, regional and local levels, to support change on the ground.

A new Mental Health and Wellbeing Commission (chapter 12) should be funded to provide ‘backbone support’ to the sector.¹³⁶ It would support those responsible for implementing change with the tools they need and provide shared infrastructure for knowledge exchange.

The Commission’s relevant functions could be to:

identify the evidence and promising practice both nationally and internationally
work collaboratively with stakeholders to co-design new services or service change and to define the desired impacts
establish evaluation frameworks
identify the stages of implementation – the ‘how to’ that will guide regional and local action to implement change
provide support to the people and organisations responsible for funding and implementing the changes, to enable national, regional or local collaboration, implementation and evaluation
enable shared problem-solving and learning between participating sites.

The Commission might also meet some implementation costs such as initial design and evaluation and participation in hui to share experiences and findings.

Close, face-to-face, high trust relationships that respect others’ strengths and local ownership are central to this function working well. It will require significant investment in Kaupapa Māori and Pacific capability and capacity.

The Mental Health and Wellbeing Commission should work closely with the Ministry of Health, bringing the strength of its links to local communities and explicit mission to build implementation capacity across the system.

Filling the gap in support for the change process has the potential to enable the major system shifts proposed. Implementation support will enable progress to be monitored, provide missing system oversight of innovation, and allow learning and scaling opportunities. It will also provide an avenue to feed back the shared learning to the Ministry of Health to inform future policy refinement.

Recommendations

Facilitate co-design and implementation

Direct the Ministry of Health, in partnership with the new Mental Health and Wellbeing Commission (or an interim establishment body) to:
- facilitate a national co-designed service transformation process with people with lived experience of mental health and addiction challenges, DHBs, primary care, NGOs, Kaupapa Māori services, Pacific health services, Whānau Ora services, other providers, advocacy and representative organisations, professional bodies, families and whānau, employers and key government agencies
- produce a cross-government investment strategy for mental health and addiction services.
Commit to adequately fund the national co-design and ongoing change process, including funding for the new Mental Health and Wellbeing Commission to provide backbone support for national, regional and local implementation.
Direct the State Services Commission to work with the Ministry of Health to establish the most appropriate mechanisms for cross-government involvement and leadership to support the national co-design process for mental health and addiction services.

130 As an example, see D King and B Welsh. 2006. Knowing the People Planning (KPP): A new practical method to assess the needs of people with enduring mental illness and measure the results. London: Nuffield Trust.

131 See, for example, State Services Commission. 2018. Machinery of government: Toolkit for shared problems (web page). www.ssc.govt.nz/mog-shared-problems(external link) (accessed 16 October 2018).

132 State Services Commission. 2018. Consultation on State Sector Act reform opens (web page). www.ssc.govt.nz/node/10690(external link) (accessed 24 October 2018).

133 D Fixsen, K Blasé, G Timbers and M Wolf. 2001. In search of program implementation: 792 replications of the teaching–family model. In G Bernfield, DP Farrington and AW Leschied (eds). Offender Rehabilitation in Practice: Implementing and evaluating effective programs (chapter 7). London: Wiley.

134 EA Balas. 1998. From appropriate care to evidence-based medicine. Pediatric Annals. ٢٧:٥٨١–٤.

135 J Kania and M Kramer. 2011. Collective impact. Stanford Social Innovations Review 9(1): 36–41. https://ssir.org/articles/entry/collective_impact#.(external link)

136 ‘Backbone support’ is one of the critical elements in collective impact approaches and refers to an organisation or unit that supports the partners involved in a collaborative change effort.

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Last modified: 21st December 2018