Part 2 sets out what we think needs to happen from here. It is striking that so much of what this inquiry has heard has been said before. Many people have been raising the issues set out in Part 1 of this report for a long time and many of the experiences people described echo those described in previous inquiries and reports. The desired direction – an emphasis on prevention and early intervention, expanded access to services, more treatment options, support closer to home, whānau- and community-based responses and cross-government action – has also been well articulated. Areas for action are outlined in multiple reports and strategies. Widespread agreement exists about the need for change and, in many respects, what change should look like.
Yet, despite so much consensus, the system has not substantially shifted. While many new and innovative approaches are being trialled in different parts of the country and dedicated people are working to bring about change, over and over again we were told that more of the same without fundamental change will not lead to widely desired improvements.
All of this adds to our sense of urgency. We cannot afford to have another report that repeats the same messages but does not result in real change. Honouring the voices of the people who shared their stories with the Inquiry means there must now be decisive action.
It is clear to us that many people in all parts of our communities, including in our mental health and addiction workforce, know what needs to be done and are working hard to move the system in the desired direction. There are many pockets of success but overall progress has been slow and inconsistent. As we said in Part 1, we believe that roadblocks need to be removed, missing foundations put in place, and a government commitment to action made.
There has been too much ad hoc and fragmented investment over a number of years, often on a short-term basis and without coordination. Promising initiatives have developed without any clear plans for evaluation and scaling up. This has contributed further to the fragmentation in the system and led to frustration at the lack of sustained traction. We do not want to perpetuate that.
Therefore, we have explicitly avoided developing another strategy or a ‘shopping list’ of activities, or short-term investments. We do not want to dilute attention from the most important things necessary to create the right environment to support a significant shift over time in how we prevent and respond to mental health and addiction challenges.
Instead, our approach to the question ‘what needs to happen?’ is to focus on a few critical measures that together will shift the whole system. Important policy decisions and legislative change backed by a commitment to a long-term funding path are needed. These changes are intended to enable a transformation in our approach to mental health and addiction, with a focus on wellbeing and community solutions. They will underpin the shift from ‘big psychiatry’ to ‘big community’ that the Wellbeing Manifesto calls for.102
The economic costs of mental illness are substantial. Recent estimates for OECD countries are that mental illness reduces gross domestic product (GDP) by approximately 5%, through disability leading to unemployment, work absenteeism and reduced productivity, and the additional costs of physical health care among people with mental health problems.
However, cost-effective treatments are available for common mental disorders for which the savings through restored employment and productivity outweigh the costs. For example, for every $1 spent treating depression, $2.50 of productivity is restored and $1 of physical health care cost is saved. In high income countries it has been estimated that increasing coverage (particularly of psychological treatments) to an additional one quarter of people experiencing mental health problems by 2030 would cost an additional 0.1% of GDP.103
We recognise and support the need for a real government commitment to the Treaty of Waitangi, with policies and services that ensure current inequities are addressed and disparities between the health of Māori and non-Māori are eliminated. This commitment to equity and the Treaty of Waitangi underpins all our proposals. It is a commitment that should be evident in all the actions that follow. We also emphasise the need for active Māori participation in the design, commissioning, management and delivery of mental health and addiction services, health promotion programmes and strategies for prevention. Investment in Kaupapa Māori services will provide more choices for Māori seeking support, and a skilled cultural workforce will be able to deliver appropriate and effective services. A Treaty-based approach that involves Iwi and Māori community leaders will also be highly pertinent to tackling the wider social determinants that underlie intergenerational trauma and inequity in our society.
Our vision in Part 1 puts people with lived experience and consumers at the centre in the system. Our proposals reflect this by affirming human rights and the rights of consumers of mental health and addiction services under the Code of Health and Disability Services Consumers’ Rights. We recognise the importance of treating people with empathy, dignity and respect and wish to see a greater role for people with lived experience in decisions about the design and delivery of services. Our proposals acknowledge the central place of families and whānau and the roles they play in supporting, nurturing and caring for family members.
Improving the mental health and wellbeing of people in our society is everyone’s responsibility. The health system is one important player but, to make genuine progress, we must look further afield to solutions outside the health system and outside government. This has long been known but has been difficult to action. For example, the 1998 Blueprint (which gave effect to the 1994 National Mental Health Strategy104) was necessarily restricted in its focus, noting that achieving a broad goal of decreasing prevalence of mental illness and mental health problems would require “a much wider approach involving other sectors”.105 It, therefore, focused only on a goal of addressing the impact of mental disorders on consumers, families, caregivers and the community.
Since that time, however, there has been increasing recognition of the need for cross-sectoral action on a whole range of complex social issues. Mechanisms to support cross-agency approaches have evolved significantly. This Inquiry builds on these developments. We now have a real opportunity to make sure all relevant sectors are fully involved in preventing and responding to mental health and addiction challenges and promoting wellbeing. This includes joined-up approaches within government and beyond. For example, we see models such as Whānau Ora commissioning and service provision as pointing the way, tackling the social determinants of health and providing wrap-around support earlier, in the community and closer to home.
In Part 1, we concluded that we should build on the foundations already in place. We have not proposed major structural change to the health system, since we do not have any evidence to show this is necessary or desirable, and we think it could lead to widespread disruption and delay progress. We also consider that mental health and addiction services should remain part of the wider health and disability system and not be separated into a stand-alone system. The goal should be greater integration of services, not further separation.106 Our overall approach is, as far as possible, to build on the structures and systems in place now.
However, given the force of some submissions, we gave a lot of consideration to whether to recommend changes in how mental health, addiction and other social services are commissioned and by whom. Many non-governmental organisation (NGO), Māori and Pacific providers voiced concern to us about the current district health board (DHB) model, with DHBs having dual roles as funders and providers. Iwi asked for direct control of resources, while some NGOs called for a new wellbeing agency to commission services. We also note the complexity of having 20 independent DHBs, a Ministry of Health with significant commissioning responsibilities, and a range of other government agencies that also commission a variety of health and social services.
We acknowledge these issues and share some of the concerns, particularly about some aspects of commissioning with NGOs (which we discuss below). We expect that the Health and Disability Sector Review will consider broader issues about roles and functions of DHBs and, as noted earlier, the establishment of a Māori health ministry or commission with broad functions also deserves further consideration.107
In the meantime, we see it as essential that commissioning approaches are improved to support a focus on wellbeing and services in the community. Necessary changes include better contracting practices and greater partnerships with Iwi and Māori, Pacific peoples, people with lived experience of mental health and addiction challenges, and NGO and other providers.
The remainder of Part 2 sets out in detail what needs to happen. We recommend major changes in current laws and policy, supported by significant increases in funding. Nine topic chapters work together as a package. The chapters are listed in Figure 2, and each chapter is summarised below.
Chapter 4 begins by setting out the case for a significant increase in access and choice to mental health and addiction services. This includes an explicit change to current policy settings that focus funding and services on people with the most severe needs, with a current target of 3% of the population being able to access services each year. We argue that coverage of services needs to expand significantly from the current 3.7% of the population who access specialist services, given figures suggesting around one in five people experience mental health and addiction challenges in any given year. We make the case for a greater range of services and therapies, particularly more talk therapies, alcohol and other drug services and culturally aligned services. This will need to be supported by a national service co-design process with support for national, regional and local implementation, and key enablers such as workforce, funding, information and evaluation and changes to funding and accountability rules.
Another main area for change is the primary health care sector to overcome barriers that have inhibited the innovation originally envisaged by the Primary Health Care Strategy (chapter 5). New models of care, including to address mental health and addiction issues, have been slow to develop. Accessing services in general practices continues to be unaffordable for too many people. We endorse the focus on primary health care by the Health and Disability Sector Review.
Supporting a sustainable NGO sector is another area of focus, given the significant role NGOs already play in mental health and addiction services (chapter 6). This role will only increase with the shifts towards more community-based services that we propose. This sector is facing challenges and a clear stewardship role is needed in central government to support NGO development and sustainability.
In chapter 7, we call for a whole-of-government approach to wellbeing to tackle social determinants and support prevention activities that impact on multiple outcomes, not just mental health and addiction. The current approach is fragmented, without clear leadership for coordinating cross-government strategy and investment. A locus of responsibility is needed, for example a social wellbeing agency, to take on this important role. This agency could also take a lead role in issues such as NGO stewardship (chapter 6) and alcohol and other drugs (chapter 9). In addition, an investment and quality assurance strategy for mental health promotion and prevention must be developed. This could be led by the new Mental Health and Wellbeing Commission (chapter 12) in partnership with a social wellbeing agency to ensure a cross-sector focus.
Chapter 8 highlights specific measures to put people at the centre (although this is also a principle that underpins all our proposals). This includes measures to support consumers and people with lived experience to play a greater role in policy, governance, service planning and delivery and to enhance consumers’ knowledge about their rights. Partnering with families and whānau in supporting people experiencing mental health and addiction issues is a priority, as is providing more support for families and whānau themselves.
We recommend strong action on alcohol and other drugs in chapter 9. This includes regulatory reform on both alcohol and other drugs and significantly increased availability of treatment and detox services. Clear cross-sector leadership is needed, possibly located in a social wellbeing agency (chapter 7).
There is an urgent need to complete and implement the national suicide prevention strategy and implementation plan (chapter 10). We recommend a new suicide reduction target to drive action. Leadership and increased resources for suicide prevention and postvention are needed, along with a review of processes for investigation of deaths by suicide.
A key piece of legislation, the Mental Health (Compulsory Assessment and Treatment) Act 1992, is outdated and must be repealed and replaced (chapter 11). The Act does not reflect a human rights approach, promote supported decision-making or align with a recovery and wellbeing model. It must more strongly support the goal of minimising compulsory or coercive treatment. We also think New Zealand needs a national-level discussion, carefully crafted, to reconsider beliefs, evidence and attitudes about mental health and risk.
Leadership is essential. A new Mental Health and Wellbeing Commission (chapter 12) will play a critical role in enhancing leadership and oversight of the mental health and addiction system, partnering with both government and non-government agencies (including any social wellbeing agency), and acting as a much-needed change agent to bring resource and expertise to support the proposed co-design and implementation process in chapter 4.
We refer broader structural and system issues relating to primary care, the DHB model and the proposal for a Māori health ministry or commission to the Health and Disability Sector Review for further consideration.
Finally, collective and enduring political commitment is needed to improve mental health and wellbeing in New Zealand. We recommend the formation of a cross-party working group in the House of Representatives (a final note).
102 M O’Hagan. 2018. Wellbeing Manifesto for Aotearoa New Zealand: A submission to the Government Inquiry into Mental Health and Addiction (prepared for PeerZone and ActionStation). www.wellbeingmanifesto.nz/(external link).
103 R Layard. 2018. Mental illness destroys happiness and is costless to treat. In Global Happiness Council. Global Happiness: Policy report 2018 (chapter 3). New York: Sustainable Development Solutions Network. www.happinesscouncil.org(external link).
104 Ministry of Health. 1994. Looking Forward: Strategic directions for the mental health services. Wellington: Ministry of Health. www.moh.govt.nz/notebook/nbbooks.nsf/0/DAA659934A069A234C2565D70018A75A/$file/looking-forward.pdf(external link)
105 Mental Health Commission. 1998. Blueprint for Mental Health Services in New Zealand: How things need to be. Wellington: Mental Health Commission, p 3. www.moh.govt.nz/notebook/nbbooks.nsf/0/0E6493ACAC236A394C25678D000BEC3C/$file/Blueprint_for_mental_health_services.pdf.
106 We note that Lord Darzi’s 10-point plan for reforming the United Kingdom’s National Health System – albeit in the context of a much larger population, with separate commissioning of social and mental health services – recommended radically simplifying structural arrangements, including explicitly reducing and streamlining the number of commissioners in the National Health System, stating that “no other system in the world has chosen to fragment rather than consolidate”. A Darzi. 2018. Better Health and Care for All: A 10-point plan for the 2020s. London: Institute for Public Policy Research. www.ippr.org/research/publications/better-health-and-care-for-all.
107 We have taken account of other Inquiries and reviews launched by the Government that touch on issues considered in this Inquiry, including the Royal Commission into Historical Abuse in State Care and in the Care of Faith-Based Institutions, Waitangi Tribunal Health Services and Outcomes Kaupapa Inquiry (Wai 2575), Review of Tomorrow’s Schools, Whānau Ora Review, and reviews by the Welfare Expert Advisory Group and the Safe and Effective Justice Advisory Group.