One of the overwhelming themes of this Inquiry has been the need to put significantly more effort into helping people be well and stay well. Wellbeing is more than simply the absence of distress or illness. Wellbeing encompasses many domains of a person’s life, of which mental wellbeing forms one part.
People are unlikely to experience wellbeing if their basic needs – adequate food, safe environments free from abuse and violence, warm and secure homes, jobs and income – are not met. The stress and trauma that people experience from lack of appropriate housing, poverty, cultural alienation, family violence, racism and the impact of colonisation cannot, and should not, be addressed by mental health and addiction interventions alone. While we need to intensify interventions that target mental wellbeing, such as measures to counter stigma or promote resilience, mindfulness and self-care, these interventions are not sufficient on their own.
Critically, if we wish to make significant inroads into improving mental health and addiction outcomes, we need to address the wider social determinants that influence not just mental health, but overall wellbeing. These social determinants also underlie and perpetuate inequitable outcomes for many Māori and other groups in New Zealand society. We need to invest in broader prevention and promotion initiatives. Increasing evidence supports the efficacy of universal and selective preventive interventions to promote mental wellbeing and prevent mental health challenges throughout development.164 This includes taking action in early childhood to build strong foundations for wellbeing and resilience and looking for opportunities through the life course to support and maintain wellbeing.
As noted earlier, improving the wellbeing of people in our society is everyone’s business, and communities and families and whānau have critical roles to play, as do central and local government. In this section, we discuss the need for a more coordinated, whole-of-government approach to addressing these broader, cross-cutting issues related to wellbeing.
Earlier in this report, we noted that social determinants such as education, employment, family violence and poverty are underlying factors that contribute to overall wellbeing. The impacts of social determinants are complex, interactive and cumulative, and the same social determinants often influence a whole range of social outcomes.
In focusing on the social determinants of mental health and addiction and opportunities for prevention and promotion, it quickly becomes apparent that the same factors and responses have a role across multiple aspects of wellbeing and poor social outcomes, such as child abuse and neglect, offending and reoffending, family violence, educational underachievement, unemployment and homelessness.
The interventions needed to prevent poor outcomes and promote wellbeing are often similar across many social problems and sectors. For example, access to affordable, secure and stable housing contributes to child development and learning outcomes, improved management of chronic medical conditions, increased worker productivity and better mental health. Similarly, the kinds of issues typically addressed through health promotion activity, such as a healthy diet, getting enough sleep and responsible use of alcohol, contribute to better physical health, but they are also important for mental health, healthy child development, stable and loving homes and relationships, concentration and productivity in schools and workplaces, and reduction in behaviours that lead to poor decision-making, trauma, violence and crime.
Addressing homelessness using the Housing First approach
Many people spoke highly of Housing First, a programme that places people who are chronically homeless into stable housing before providing them with wrap-around services. Housing First leads to better clinical outcomes for people with severe mental illness and substance abuse issues.165
Housing First is based on a set of core principles, including immediate access to housing with no housing-readiness conditions (for example, sobriety), choice and self-determination, and social and community integration. In New Zealand, providers have evolved these principles within a Kaupapa Māori framework.
The People’s Project (a cross-agency collective led by NGO provider Wise Group and funded by the Ministry of Social Development) piloted the Housing First approach in Hamilton in 2014. The approach has since been rolled out in Auckland and Christchurch and is being rolled out in Tauranga and Wellington. It is expected to be expanded to Rotorua, Whangarei–Northland, Napier–Hastings, and Nelson–Marlborough later in 2018 and 2019.
Promoting wellbeing is also about getting ahead of problems before they arise. As noted by the Government’s social sector science advisors, developmental neuroscience has established the critical role that prenatal and early brain development plays in good mental (and physical) health over a person’s life, as well as in educational achievement, employment, friendships and relationships, and parenting. Early childhood is, therefore, a ‘critical window of opportunity’ for interventions that can be delivered through universal and targeted services. Supporting parents to better understand and be in a position to nurture, talk to and engage with their babies and young children is essential to the wellbeing of the next generation.166 Universal services, especially health and education, provide a critical foundation for wellbeing throughout life.
In addition, high-quality early childhood education such as Kōhanga Reo can promote resilience and cultural enrichment, and provide the basis of key skills such as empathy, collaboration, self-control, language and literacy. If designed and delivered effectively, early childhood education services can also promote mental health in a coordinated way. Moreover, they can provide opportunities for teachers, parents and whānau to identify and intervene in early behavioural, emotional and cognitive challenges.
Other services include parenting programmes and Well Child Tamariki Ora initiatives, as well as more intensive support such as Family Start for families with known risk factors such as a history of family violence or alcohol or other drug issues.
While the early years are a critical period of intervention, opportunities also exist for preventative and resilience-building activity throughout life. Importantly, promotion of wellbeing is not just about promoting individual wellbeing, but also the connected wellbeing of families, whānau and communities. Initiatives may take the form of community programmes, school-based activities, family therapy or relationship counselling.
Iron Māori is a community initiative supported by Ngāti Kahungunu Iwi. It is an annual half-ironman event that was first held in 2009 with 300 participants, and by 2011 had more than 1,550 participants. Apart from the overwhelming response from Māori, the significance of Iron Māori is its ability to change lifestyles by fostering keenness for change, encouraging at least a six-month period of dedicated fitness training, eating well, avoiding alcohol, and building supportive relationships with peers in a whānau-like setting. The success of Iron Māori can also be attributed to the Māori cultural context.
Results so far include anecdotal evidence of major weight loss, reduction of blood pressure, lowered blood sugars, and a renewed sense of purpose. The Iron Māori focus on physical fitness has increasingly come to include a focus on cultural strengths, mental toughness and whānau cohesion.
Despite substantial benefits of proactive investment in these areas, governments face universal challenges in shifting the balance of resources towards prevention, even when evidence about return on investment is strong.167 Much of this relates to the timeframe involved. Outcomes, by definition, are usually not expected in the short to medium term, thus providing a disincentive for investment. Other issues include the difficulty of measuring outcomes and quantifying returns, challenges in targeting on the basis of risk factors rather than actual needs, and prevention and early intervention activity being ‘crowded out’ by more urgent needs, especially in agencies or sectors with large operational delivery roles.
These issues have been recognised for some time. Over the last 20 years, addressing the social determinants of wellbeing and investing in prevention in a deliberate and integrated way has become a focus internationally. For example, the United Nations Sustainable Development Goals 2015 have a strong focus on social determinants such as poverty, housing, and child and maternal health. Wales has introduced the Wellbeing of Future Generations Act 2015, with a focus on taking preventative action for the longer term. Sweden has progressively implemented many world-leading children’s policies and now ranks as one of the world’s best performers in children’s wellbeing across a variety of health and social indicators, such as adolescent risk behaviours, teenage births and child maltreatment. Earlier this year, the Mental Health Policy Commission at the University of Birmingham recommended embedding prevention in all policies and practices that affect young people.168
Wellbeing has also been high on the New Zealand policy agenda over this period. We note that successive governments have made efforts to invest more heavily in this area. However, despite this focus, in our view, clear strategic leadership is lacking in central government on wellbeing, prevention and tackling social determinants that impact on multiple outcomes. Historically, the Ministry of Social Development (and previously the Ministry of Social Policy) filled this leadership role. We understand that the Ministry’s former cross-sector strategy role has been transferred to the Social Investment Agency, although it is not clear how or if it is intended that this role will evolve to fill the gap in leadership.
Multiple agencies take a role in leading aspects of wellbeing, but better coordination of effort and investment is needed, with clear alignment between the multiple frameworks, approaches and measurement regimes. During our stocktake, we collected information about programmes from government agencies, but we could not get a clear picture of current investment and saw gaps and duplication. Our impression was of fragmentation and a lack of coordination. While people called for more investment, we question whether we’re getting the best value from current expenditure. Government agencies we talked to said opportunities existed for agencies to be more joined up with clearer leadership and coordination around prevention. Non-governmental organisations (NGOs) also talked about the lack of a clear, overarching investment strategy within which they can operate.
Some solid building blocks are in place to improve our approach to addressing social determinants and taking preventative action. We have some enviable universal services in place, such as through our health and education systems, that we can leverage to deliver key interventions. We have made significant strides recently in building our evidence base about what works and where the opportunities for a greater return on investment are; for example, through the establishment in government of the chief science advisor and departmental science advisor roles, the Social Investment Agency and the Integrated Data Infrastructure.169 We note the recent steps to establish the Child Wellbeing Unit within the Department of the Prime Minister and Cabinet and to consult on a child and youth wellbeing strategy. Nevertheless, we see opportunities for greater coordination across agencies so that the same things everyone needs are in place to provide a good start to and throughout life.
Wellbeing initiatives in schools, such as Kāhui Ako
We were impressed by the variety of high-quality wellbeing initiatives and resources designed for implementation in schools and relating to areas such as bullying prevention, positive behaviours, healthy relationships, wellbeing and resilience – mostly by promoting ‘pro-social’ behaviour across the school environment.
However, some excellent initiatives have not been widely implemented. For example, we were disappointed to learn during a meeting with the Ministry of Education that even though the evidence-based Wellbeing at Schools survey (and related tools) has been fully funded by the Accident Compensation Corporation and the Ministry of Education to remove the cost barrier for schools, only 277 out of 2,500 schools took this up in 2018.
Several providers observed that it is extremely difficult negotiating school by school to implement wellbeing programmes. Kāhui Ako – Communities of Learning – appear to be providing new opportunities to implement initiatives at a scale that might not be possible in a single school. We were privileged to see, for example, school-based mental health practitioners in action in the Bay of Plenty. Schools belonging to the Otumoetai and Whakatane Communities of Learning noticed their students seemed to be lacking resilience. After discussions with the local district health board, two staff from the Child and Adolescent Mental Health Service are based at one of the schools as part of a three-year pilot.
We believe a clear locus of responsibility for social wellbeing with a focus on prevention, building general resilience and tackling major social determinants that lead to inequities within society, needs to be established within central government. The goal is to support a more strategic approach to investment across multiple, interconnected outcome areas; for example, by:
We consider a wellbeing entity of some kind should be created to provide this leadership. It could be a new agency, a unit in an existing agency or a reconstituted existing agency. For example, we note that the Government is consulting on the future role of the Social Investment Agency, so one option would be to reconfigure the Social Investment Agency as a social wellbeing agency to provide the necessary cross-cutting social sector leadership. This would be a significantly enhanced role for the Social Investment Agency, well beyond its focus of improving the evidence base to support investment decisions, and would require appropriate capability across a range of functions (see Figure 3).
Other possible functions
We suggest the State Services Commission be tasked with reporting back on how best to establish such an entity.
It is important that the function is not co-located in an agency where service delivery or operational demand pressures would compete with the whole-of-government strategy and policy focus needed, and that a long-term focus on social determinants and investment in prevention is protected.
We do not consider that the new Mental Health and Wellbeing Commission (chapter 12) should undertake the proposed functions of the social wellbeing agency. This is because an independent commission should act as a leader and watchdog of the mental health and addiction system. Keeping the roles of a social wellbeing agency and the Mental Health and Wellbeing Commission separate will prevent the Commission being ‘swamped’ by having to address every domain of wellbeing and all social determinants and will enable it to focus more directly on its core roles.
However, we would expect any social wellbeing agency and the new Commission to work closely together on their respective work programmes and identify opportunities to build on universal programmes to improve mental health and addiction outcomes – including promoting new ways of commissioning for flexible, innovative wrap-around services to meet people’s needs. The social wellbeing agency could also provide a stewardship and development function in relation to the NGO and community sector (chapter 6), be the lead coordination agency for broader alcohol and other drug issues (chapter 9), and host the suicide prevention office (chapter 10).
Another issue to consider is whether New Zealand should introduce a ‘Health in All Policies’ (or a ‘Mental Health in All Policies’) approach as has been done in other countries170 and use health impact assessment tools to assess the impact of government policies and programmes on the wellbeing of the population. This has already gained some traction at local government level (particularly in Canterbury), although these approaches have not been sustained at national level. We suggest consideration be given to adopting a Health in All Policies approach. This could include the development and roll-out of health impact assessment tools to assess the impact of government policies on health, particularly mental health.
Take a whole-of-government approach to wellbeing, prevention and social determinants
164 C Arango, C Diaz-Caneja, P McGorry, J Rapoport et al. 2018. Preventive strategies for mental health. Lancet Psychiatry 5: 591–604.
165 DK Padgett, L Gulcur and S Tsemberis. 2006. Housing First services for people who are homeless with co-occurring serious mental illness and substance abuse. Research on Social Work Practice 16(1): 74–83; V Stergiopoulos, A Gozdzik, V Misir, A Skosireva, A Sarang, J Connelly, A Whisler and K McKenzie. 2016. The effectiveness of a Housing First adaptation for ethnic minority groups: Findings of a pragmatic randomized controlled trial. BMC Public Health 16(1): 1 110. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3768-4;(external link) JR Woodhall-Melnik, and JR Dunn. 2016. A systematic review of outcomes associated with participation in Housing First programs. Housing Studies 31(3): 287–304.
166 Social Sector Science Advisors. 2018. Towards an Evidence-Informed Plan of Action for Mental Health and Addiction in New Zealand: A response by the social sector science advisors to the request of the Government Inquiry into Mental Health and Addiction. Wellington: Social Sector Science Advisors.
167 See Productivity Commission. 2015. More Effective Social Services. Wellington: New Zealand Productivity Commission. www.productivity.govt.nz/inquiry-report/more-effective-social-services-final-report(external link); P Burstow, K Newbigging, J Tew and B Costello. 2018. Investing in a Resilient Generation: Keys to a mentally prosperous nation. University of Birmingham.
168 P Burstow, K Newbigging, J Tew and B Costello. 2018. Investing in a Resilient Generation: Keys to a mentally prosperous nation. University of Birmingham.
169 The Integrated Data Infrastructure (IDI) is a large research database. It holds microdata about people and households. The data is about life events such as education, income, state income support, migration, justice and health. It comes from government agencies, Statistics New Zealand surveys, and NGOs. The data is linked together, or integrated, to form the IDI. More information is available at Statistics New Zealand. 2018. Integrated Data Infrastructure (web page). www.stats.govt.nz/integrated-data/integrated-data-infrastructure/(external link) (accessed 17 October 2018).
170 A Health in All Policies approach emphasises the consequences of public policies on health determinants and aims to improve the accountability of policy-makers for health impacts at all levels of policy-making. A review of Health in All Policies initiatives around the world in 2010 found examples in 16 countries or subnational areas, including Finland, Norway, Sweden and South Australia: K Leppo, E Ollila, S Peña, M Wismar and S Cook (eds). 2013. Health in All Policies: Seizing opportunities, implementing policies. Finland: Ministry of Social Affairs and Health. www.euro.who.int/__data/assets/pdf_file/0007/188809/Health-in-All-Policies-final.pdf(external link). Mental Health in All Policies is a coordinated European Union public mental health programme to implement large-scale promotion and prevention activities, together with investment in mental health services. The approach reflects that many determinants of mental health lie in ‘non-health’ policy domains such as education, employment and community design: European Union. 2016. European Framework for Action on Mental Health and Wellbeing: EU Joint Action on Mental Health and Wellbeing, cited in 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.