health & science

Labour’s wellbeing problem

The Government’s buzzword-heavy mental health vision needs to do more for those with complex and long-term illnesses. Jessica McAllen reports. 

The number looked good: $1.9 billion towards mental health. But the Wellbeing Budget had a glaring gap.

Just over a tenth of the Government’s mental health package is going towards dedicated specialist services for those experiencing severe mental illness or distress - and that funding has been mandatory since 2001.

This specialised support isn’t the kind of programme you can package into a snappy Budget Day announcement, but it’s incredibly important.

Ever since 2001, a chunk of all funding for district health boards (DHBs) has been “ring-fenced” to cover mental health and addiction spending for the three percent of New Zealanders who were estimated at the time to suffer from severe mental health and addiction issues.

The ring-fenced money is spent on services like mental health units or community mental health teams who provide free psychologists, psychiatrists and other help. 

It was introduced to stop health boards diverting dedicated funding to other areas but, more than two decades later, it is simply not viable. The number of people going to specialist services for help increased by 54 percent between 2009 and 2017. The result? Long wait-lists and suicidal people being triaged according to a financial target, with some people not “unwell enough” for free care. 

It’s not just the suicidal being affected, either. People experiencing manic episodes in Jacinda Ardern’s “year of delivery” can wait months to see a specialist psychiatrist - in the meantime, jobs are lost and relationships are ruined. 

The Government seems to be operating under the false impression that specialist services are in good shape. The real problem, they say, is those with “mild to moderate” mental health needs, people who their own inquiry called “the missing middle”.

In this year’s Budget the ring-fenced funding only increased 3.7 percent, with no extra boost to specialist mental health services. The Government branded its increase to the ring-fenced funding ($213m over four years) as part of a wider “funding boost” to DHBs. But because of the ring fence, and the reality of population growth, the funding goes up every year, and generally by a pretty similar amount — it increased by 3.5 percent in 2017 and 4.4 percent in 2018.

As the Ministry of Health said in its submission to the inquiry, while the ring fence does set a minimum investment for DHBs, “it may also have the unintended consequence of normalising or providing justification for an insufficient level of funding”.

So where’s the rest of that $1.9b going? Around $346m is for housing initiatives and $187m for historical abuse costs. There’s not much for one of the biggest problems: people receiving no follow-up care after a suicide attempt. Health Minister David Clark points to the $8m over four years carved out to improve crisis responses, but details are vague and the likelihood of anything happening in 2019 grows slimmer each day.

The number of people who access specialist mental health services is more than triple that of those who access specialist addiction services, yet there was only an extra funding boost for addiction services (a sorely needed $44m over four years).

Labour’s lack of sufficient care for our most critically distressed citizens repeats history. In the 1980s and 1990s, mental health hospitals were shut down in favour of community care. Like the Wellbeing Budget, it worked well for a significant portion: many people with manageable mental health issues were well-served by care outside of institutions. But the government at the time didn’t come through with enough funding for those with complex mental health needs. Many were left to languish in the streets and in jail — a problem we’re still catching up on today.

While changing the direction of mental health care, it’s important to have a plan in place for people experiencing a crisis while you go about changing the world. Someone who works in the sector recently told me: “You can’t cut them off at the knees in anticipation of primary care kicking into gear. Primary care doesn’t have the workforce or systems in place yet.”

Truly transformational?

The pièce de résistance of the Wellbeing Budget —a new $455m frontline service, contracted out to primary health care organisations— actually fulfils an election promise that everyone seems to have forgotten. Clark proposed a two-year pilot programme across eight sites, a proposal awfully similar to a pilot launched in July 2017 and led by four healthcare providers, which has since quietly rebranded to Te Tumu Waiora (at the time it was Closing the Loop). So after almost two years in government and a whole inquiry, we basically waited for a reheated election policy.

An additional 81,250 people are expected to access the new service by July 2020, and 325,000 per year when it is fully rolled out in five years’ time  - but it won’t provide for all people in crisis, and the services that do offer such help have been struggling for a long time. In the last week alone, it has been revealed that in the year to March there was a deficit of $264 million across the 20 DHBs where specialist services largely take place, while more than 600 psychologists across 17 DHBs have just started a five-week strike in which they won’t work overtime. 

There’s no denying that people with mild to moderate mental health needs are falling through the cracks, and that a free service for them is essential. Helping people before they spiral further will ease pressure on specialist services. But the many New Zealanders who are in crisis need help now, not in five years when the programme is fully implemented. 

And mental health doesn’t always work in such a linear way: moving from mild, to moderate, to crisis. Sometimes, manic episodes, suicidal ideation or psychosis can appear quickly and demand immediate clinical care. 

Clark acknowledged the new frontline service will need 1600 “health improvement practitioners” - but the Government did nothing to increase staff while its mental health inquiry was taking place. Only this year does the Budget have funding to provide extra training.

Just like in the 1980s and 1990s, our government continues to use the criminal justice system to “treat” those in mental health crisis. Labour last year announced plans to build a 100-bed mental health facility at Waikeria and chalked it up as a win for compassionate government, while a sizeable chunk of its mental health package has come out of Corrections coffers to help those in prison.

Truly changing the system would mean asking why we criminalise people with mental health issues and lock them away. This year a Dunedin woman whose offending was prompted by chronic OCD was sentenced to prison. A suicidal man who stood on the Terrace Tunnel for ten hours was sentenced to community detention.

In some ways we’re going backwards. The coroner inquest for Sentry Taitoko, who died in an Auckland police cell after hitting his head multiple times, is due this year - but Counties Manukau police recently decided to stop their widely-praised mental health “watch house” nurses initiative. 

Some people suffer in silence, and kill themselves without reaching out for help. But data shows many do reach out: 42 percent of Kiwis who killed themselves in 2015 saw a specialist mental health professional in the year leading up to their death (a figure that doesn't cover those who saw a GP, private therapist, or rang a helpline, as well as the 66 people who killed themselves aged 65 or older). There aren’t always services available to help them, and sometimes people die despite the best of services. 

Labour still has the chance to make real change. The move towards widening access for free mental health care could be revolutionary. But there are gaps in the current approach too large to ignore. If we do ignore these gaps, in five years time we’ll be wondering why the suicide rate continued to increase despite a $1.9b package.

A budget can be radical, but it’s how you spend the money that counts.

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