4.5 Enablers to support expanded access and choice

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Each element of our proposals to support expanded access and choice – more people able to access services, more choice of services (especially talk therapies, alcohol and other drug services and culturally aligned services) and a national co-design process and implementation – will need to be supported by core enablers. We discuss these in this section.

4.5.1 The right workforce

Earlier in this report we acknowledged the strengths of the mental health and addiction workforce and the pressures workers face. The right workforce will be fundamental to achieving a significant and successful system shift. It will need clinical, peer and cultural staff.

Workforce planning and development

We heard that current workforce planning and investment is not strategic or coordinated and that long-term workforce investment is not assured.

We agree that mental health and addiction workforce planning needs to take a long-term focus and not simply be based on service response in the past. We don’t appear to be ready for the ageing of the workforce or emerging workforce shortages. Nor has there been sufficient recognition of the needs of a different service paradigm, which equally values peers, cultural knowledge, community support and clinical competence.

The Mental Health and Addiction Workforce Action Plan 2017–2021 was developed to respond to the existing system of provision and needs. It extends past the mental health and addictions workforce to the overall health workforce and explicitly focuses on growing the primary and community care workforce. However, this plan has been developed in isolation from a forward-looking service strategy or service design process. The sector has also indicated that more resource is required to properly implement the plan.

Workforce development tends to be isolated from other strategy development and service design. We need to take an integrated approach and design our workforce as part of a broader process of assessing our population needs and desired service response. The future workforce and those responsible for its training and development should be a fundamental part of the national co-design process we have proposed. It also needs to be integrated into regional and local planning.

This approach will lead us to build a workforce that is more representative of the people it serves. Peer leadership needs to increase across the board, in governance and management of both peer-led and mainstream organisations. A substantial increase in the peer workforce is needed across all services, including within specific peer-support services, and providing peer support as a part of all other services including alcohol and other drug services, crisis services, multidisciplinary mental health teams, and support services and in health coaching roles in primary care. Much larger proportions of Māori and Pacific workers are needed at all levels, and cultural supervision should be available. We see building the peer, Māori and Pacific workforces as priorities.

If we are to take a broader lens to people’s wellbeing, we must orient the workforce towards understanding the impact of trauma and the socioeconomic determinants of health, including enabling staff to focus on ‘prevention as intervention’. Many workers will need to know about, and be connected with, other local services and supports. The wider health and social services workforce (including NGO navigators, Kaupapa Māori providers, Whānau Ora navigators and Pacific providers) will need to bring their expertise in these areas.

We must invest in building a workforce that can deliver on our goal of providing more talk therapies and a broader range of interventions and supports. As noted above, a variety of different practitioners can be trained to deliver these therapies at different levels of intensity. For some of these workforces, a long lead in time is required to build capacity and capability, and urgent attention is needed to fill critical gaps. We note that efforts to build the psychiatrist workforce, which began some years ago, are starting to yield results. Health Workforce New Zealand told us that there has been a large jump in the number of registered psychiatrists in 2018, which is probably a result of changes to training five years ago. However, we need to grow our psychologist workforce, including retaining those already in the system to meet demand. Increasing a skilled and trained peer workforce, a strong and varied cultural workforce, and further developing the skills of nurses, support workers and allied health practitioners will be necessary. We will need a strong and sustained focus on creating the workforce for the future, including to extend support to the ‘middle ground’. This is likely to include:

• an increase in the number of support workers (including peer, cultural and youth workers)
• curriculum development and upskilling of workers to meet their communities’ diverse needs (for example, training in cultural responsiveness and in the needs and preferences of higher-need population groups)
• a trauma-informed approach that underpins all support and interventions
• more comprehensive and continuing training for generalists (for example, GPs and nurses) in mental health and addiction
• extending the capability of those already working in primary and community settings to provide a greater range and depth of support (for example, talk therapies, culturally based approaches, trauma-informed care, and support for co-existing conditions)
• creating or expanding new roles (such as health or lifestyle coaches, employment specialists and people with expertise in psychological therapies)
• ensuring specialist clinical support and advice is easily and quickly accessible to primary and community services
• building all of the above across Māori and Pacific providers.

Workforce planning and development should take account of the important contribution of specialist roles. We heard that challenges in workforce recruitment and retention differ between specialties and between subspecialties (for example, infant and maternal mental health, aged care and addiction). New Zealand relies heavily on overseas-trained doctors and nurses.¹³⁷

Sophisticated data modelling and research are beginning to be used to better understand the determinants of professional career pathways and to develop effective strategies to grow the workforce and incentivise people to work in traditionally less popular fields and geographical locations.

We will have to grow our own specialist workforce and make more use of new ways of delivering services, such as telehealth and consult–liaison and outreach roles, to ensure the same timely and high-quality specialist expertise is available irrespective of where people live or receive services. The clinical skills of psychiatrists will continue to be important, but psychiatrists may shift to working more in and with the community, supporting and liaising with GPs and primary health care providers, and using a broader range of therapeutic responses, including family therapies.

Psychiatrists are increasingly expected to respond to complex social problems they may not be well equipped to deal with. This reinforces the need for a shift within psychiatry, where psychiatrists bring their clinical expertise in assessment, diagnosis and treatment, working in partnership with patients, families and whānau, multi-skilled team members and other providers.

We also need to develop some other important skills if we are to comprehensively shift our system – collective leadership, collaboration, commissioning and implementation expertise.

Worker wellbeing

We have described a workforce under pressure. Workers and their representative organisations explained this as the consequence of increasing demand for mental health and addiction services, under sometimes difficult conditions. This view is backed up by data that show demand for mental health and addiction services is increasing significantly relative to the workforce, which means that workers are supporting more people.¹³⁸

Workers and their representatives asked that workforce shortages be addressed, safe staffing levels and practices be implemented, a strong focus be placed on workforce health and safety, and that meaningful engagement occurs with staff. There were also calls for increased access to learning and development, professional support and supervision (including cultural supervision, particularly in DHBs where there are significant Māori or Pacific populations).

Workforce wellbeing issues should be explicitly considered during the recommended co-design process.

4.5.2 Data, information, research and ongoing monitoring and evaluation

Good decision-making requires good quality information, including about the population, services, funding, consumer experience and the workforce. Analysis of data helps us understand whether support is making a difference and informs service delivery and planning at all levels of the system.

A rich array of information is available about mental health and addiction in New Zealand, particularly around publicly funded secondary care. However, there are some notable gaps.

For services to be responsive to population health needs, there needs to be an understanding of mental health and addiction challenges and how they are changing over time. The results from the last population health prevalence survey, Te Rau Hinengaro, were published in 2006, but based on data collected in 2003 and 2004. It missed some key groups, including children aged under 16, and is out of date. Widespread support exists for a new and improved prevalence survey that captures those groups missed in Te Rau Hinengaro and measures wider wellbeing of people with mental health and addiction challenges. Initial planning for a new survey was undertaken in 2017.

Other gaps we have identified through the course of the Inquiry are the lack of:

• outcomes data in some areas – several people noted that we collect a lot of input data and some output data, but often we can’t identify the outcomes we’re getting
• information about what is happening in the private sector (for example, privately funded mental health services or mental health in workplaces) and devolved environments (for example, the effectiveness of some education-based interventions)
• comparable, representative data on consumers’ experiences of services and support
• primary care data, resulting in incomplete information about what services and support are being provided to people with mental health and addiction challenges.

Our view is that we should undertake a new and more comprehensive mental health and addiction survey. This information is essential for health care planning. How else will we know if the percentage of the population in need is increasing over time (as it has elsewhere in the world) or is growing in some parts of the population faster than others? If affordability and logistics are an issue, the components of the survey may need to be staggered over time. We should also plan to regularly repeat the survey.

Overarching data and information needs should also be considered as part of the wider national co-design process we have recommended. Initial priority may need to be given to the lack of information about what is happening in primary care.

New Zealand’s unique population and characteristics mean we cannot solely rely on research conducted in other countries to meet our needs. Many submitters considered that mental health and addiction research is lacking, mainly due to under-funding. Areas where more research was seen to be needed included self-harm and suicide and research on ethnic-specific population groups and other groups including young people, Rainbow communities, disabled people, refugees and migrants. Research on what works for Māori, Pacific peoples and other groups was also seen as a priority for addressing inequitable health and social outcomes.

Some submitters were concerned that our current approach to research impeded addressing long-standing inequitable outcomes for some populations. We heard, for example, that it is difficult to implement practices emerging from international indigenous research because decision-makers do not consider it robust.

Some submitters recommended a separate mental health research fund. Designated funding for Māori mental health and addiction research, informed by mātauranga Māori, was also proposed.

New Zealand has some strengths in mental health and addiction research. The Government’s social sector science advisors, the University of Otago, Wellington, and Te Pou o te Whakaaro Nui, for example, drew on a wide body of local and international evidence to assist the Inquiry. Organisations such as the Health Quality and Safety Commission and the Health Promotion Agency were identified as making good use of research and evaluation to inform service improvement and innovation.

The Health Research Council receives funding to allocate to health research. The Council advised us that, between 2006 and 2017, approximately $83 million was allocated towards research, mainly clinical, related to mental health or alcohol and other drug dependence. We must continue investment in mental health and addiction research.

New Zealand’s performance on evaluation is mixed. There are examples of programmes that have been well designed with robust evaluation built in from the outset and repeated at intervals to ensure the programme continues to be effective and a good investment, identify opportunities for improvement, and learn lessons from other countries. The world-leading web-based therapy programme The Journal, fronted by Sir John Kirwan, is a prime example of a successful innovation that is subject to ongoing evaluation.

We also heard that trials of some significant initiatives have been implemented without appropriate evaluation. There is a risk that in the haste to ‘do something’, decision-makers prioritise action over review of the evidence of effectiveness of proposed interventions. No new initiatives should be undertaken without good evaluation that builds in a continuous learning approach and draws on national, international and indigenous evidence.

Many innovations and service improvements are community-led, by groups that may lack research and evaluation skills. It is important they can access this expertise and funding to meet the costs of appropriate evaluation activity. Building the research and evaluation capacity of community and NGO providers is also highly desirable.

Many submissions emphasised the importance of building our knowledge of what works, for whom, and under what conditions, especially for groups experiencing inequitable outcomes. Evaluation is critical to achieving this. National oversight of the implementation and evaluation of new and existing initiatives is important, so we avoid duplication, build a robust knowledge base and disseminate learning. We have built this national oversight role into the new Mental Health and Wellbeing Commission.

4.5.3 Commitment to a funding path

We have already signalled the need for funding to support the co-design and implementation processes. In addition, commitment to a clear funding path to support expanded access to a broader range of services and new ways of delivering services is needed.

This path should be informed by a multi-year, cross-government investment strategy, costed and phased appropriately. Additional investment in some areas should start in Budget 2019. The priority is services for people with mild to moderate and moderate to severe needs, including more talk therapies, alcohol and other drug services and culturally aligned services. This will require increased workforce capacity and capability.

Other aspects of the investment strategy will need to be delivered over time, informed by the wider co-design process. Any investment strategy should be informed by robust cost–benefit analysis, agreement on outcomes sought, including for priority populations, and advice on the appropriate mix of services.

As the national co-design process could take some time (with regional and local implementation over a longer timeframe), a commitment to an indicative funding path is needed now to provide certainty for the sector with some interim supporting frameworks to quickly begin the change and development process. We note that this will need a cross-government approach, rather than being restricted to Vote Health. The Ministry of Health and other relevant agencies should advise on an indicative funding path, based on access rates and a broader mix of services.

While we have emphasised that funding needs to be increased rather than shifted from specialist services, we expect any analysis will consider how to make best use of existing funding to achieve value for money.

4.5.4 Funding rules and expectations that reinforce the new direction

Funding and accountability arrangements within Vote Health are still oriented overwhelmingly towards services for those with the most severe mental health and addiction needs. Current arrangements should be reviewed to ensure they properly reflect and reinforce the desired strategic direction, and make expectations of funders and providers clear. New national service specifications will be required, including service specifications for primary mental health services, which we have been unable to find.

This will require the Ministry of Health to review the DHB service specifications and any rules related to mental health and addiction funding, including ring-fence rules and primary mental health funding. Critically, funding and service specifications must enable more integrated planning and funding across the spectrum of primary, community and secondary services, rather than support the current siloed approach.

It may also be timely to review the ring fence itself. It appears the ring fence has been a reasonably effective mechanism to protect funding for mental health and addiction services from being diverted into other health services. But potential downsides also exist; for example, the ring fence can create a sense of separation of mental health from the rest of the health system or reinforce the false notion that mental health and addiction are somehow different or not core business.

We acknowledge that the ring fence is unique in health funding and recognise that, ideally, it should not be needed because mental health and addiction services should be seen as a priority by DHBs and funded appropriately. We are not prepared to recommend doing away with the ring fence without a proper review and suggest the Ministry of Health undertake this review in conjunction with the wider transformation process.

4.5.5 Enhanced primary health care and a sustainable NGO sector

Greater access and choice in responses to mental health and addiction will rely heavily on primary and community services to succeed. This will require a primary health care sector that looks very different from now, as well as a sustainable NGO sector to deliver key services. This, in turn, will require consideration of the wider primary care transformation agenda as well as broader issues of NGO sector sustainability and development. These wider issues are not unique to mental health and addiction and are discussed more fully in chapters 5 and 6.

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