Mental Notes No. 1

Despite the many barriers, together we will get it right.

It's time for an update

As you know, the Mental Health Commission has three goals which it must achieve during its five year term.

* make sure that the National Mental Health Strategy is implemented and that services improve as a consequence,
* reduce discrimination against people with mental illness, and
* strengthen the mental health workforce.

The MHC is just as keen as the sector to see change. But, as most of you realise, there are no quick fixes. So the first stage of our work has been to be really clear about what needs to be done and get an action plan which is based on sound planning, uses mental health money wisely, targets the obvious problems and gaps, and increases cooperation and collaboration right across the sector. We are now ready to move into a focused action phase which this newsletter tells you about.

The MHC cannot change mental health services on its own. It needs to work in partnership with the sector to make these things happen. We want to work closely with consumers, families and people who provide services to make the system better. One of the things that has struck us most strongly in the last few months has been "the psyche of the sector". Despite the fact that there are places where really good services are being provided, and despite the fact that many people who work in this sector are deeply committed to what they are doing, we have noticed time and again how easy it is for this sector to be negative, to blame people, and to be critical rather than supportive of change. We understand that this is because of the long-term and deep frustration throughout the sector. But if we are to change things for the good, we need to change. It's okay to be critical of ideas, but we need to be supportive of people.

One of the other things which has struck us time and again is that people think there is already a huge amount of information about mental health services. That's true there is. But the real problem is that most of this information has never really been pulled together in sensible ways. The other problem is that a lot of this information is not the information we actually need . And of course one of the most frustrating problems of all is that a great deal of the information is not actually used! So we see one of our tasks as synthesising information.

Not just producing more of it.

But making sense of it.

We also know that people are looking for leadership. Getting it right will require strength and vision, no longer settling for second best. It means people at every level of the service identifying what is bad practice and taking the right steps to change it. Real change to mental health services delivery means not only correcting the problems and reducing the barriers to better services, but also identifying, encouraging and rewarding innovation, excellence and better ways of doing things. Most important of all, people with mental illness must be central to everything that is done.

This newsletter focuses on telling you about the projects that we have got underway. But as many of you know, our work goes far beyond a series of projects. We spend a lot of time in building relationships with other national groups and, at the moment, in planning for the shift to the Transitional Health Authority. We are also out there meeting people in the sector, visiting CHEs and communities to make sure that we have got our finger on the pulse. We'd like to thank you for the support we have received from the people we have met during our trips around the regions and from the people who have written to us.

Now, we'll move on to telling you about how we plan to achieve our goals.

Goal One: make sure the National Mental
Health Strategy is implemented

This means working closely with the Minister, the Ministry of Health, the Regional Health Authorities, the Transitional Health Agency, the CHEs and other service providers.

Our "game-plan" for achieving this goal is based on three assumptions:

1 : We believe the sector needs a clear national mental health service development plan which will set out what good mental health services should consist of and look like.

2 : We need to track mental health money at RHA and provider level so we can be sure that mental health money is going into mental health services in the right way. And we have to get the future planning and funding of mental health on track.

3 : We need to give parts of the sector support not merely to respond to crisis situations but to actually take some risks, be creative and look for better ways of doing things. We have a set of five major projects underway, which together, will make sure that the national mental health strategy is implemented.

The Blueprint Project

While there has been a number of strategic plans for mental health, these plans have usually become dead documents which simply lie on desks. What we really need is for the national mental health strategy to be translated into a clear description about what should actually happen out there where services are provided. And for this picture of services to be realistically linked to mental health funding.

The Blueprint project will do this. It will build on all the recent work of the Ministry on service specifications and standards and it will cover the full spectrum of services from child and adolescent through to those for older people. It will also cover rural and urban service variations and address Maori and Pacific people's needs.

Derek Wright is managing this project. We are not intending to reinvent the wheel here, but draw on what is already known within the sector. Derek is visiting various areas at the moment and drawing together the ideas and knowledge into a draft plan. Then we will be asking you for feed-back. The first draft of the plan will be completed at the end of July.

The Ministry of Health has initiated a project to develop an overall plan for Child and Family services and we will incorporate this into the Blueprint. We are working closely with the Transitional Health Authority and RHAs as it is intended that funding for 1997/98 will relate to the plan.

The Financial Tracking Project

We have almost finished tracking all mental health income and expenditure and identifying how mental health money is being managed. This project has been led by David Parmenter. We will provide an analysis of mental health expenditure for the 1996/7 financial year. This will tell us where things are working well and where they are going wrong. It will enable us to pin-point problems in the present system and will become the basis for future monitoring of mental health money. This work will be completed by 31 August.

There are a couple of issues we should mention now.

We are deeply concerned about the slowness of putting to use the extra money allocated for mental health services. Under our terms of reference we have been tracking the expenditure of the new money and receiving monthly reports from the Ministry of Health on expenditure. Last October $26.81 million was allocated, but by the end of April only $5.65 million has been spent. Much of the delay has been caused by RHAs and CHEs not being able to reach agreement on contracts.

There is continuing pressure for the extra money allocated for mental health services to fund price increases for existing services. This goes against the Government's intention for the new money which was clearly tagged for increased services. It is not all bad news however. The good news is that some of the blocks have been cleared and the majority of the new money should be in the sector by July. Any unspent money will be rolled over so will not be lost to mental health. The other issue which needs to be dealt with urgently is the resource difficulties in existing services. These need to be addressed if the new money is to make any real difference to people who use services and their families. Some CHEs are threatening to exit services and this creates instability for existing staff. Many community providers are finding the lack of money is placing staff under stress which often results in them leaving.

Service Review Project

The MHC is working closely with the Ministry of Health and the newly established Transitional Health Authority to make sure that the changing health structure works for mental health. We want to be sure that the Blueprint is tied to dollars earmarked for mental health. We are reviewing and monitoring the whole health structure to detect gaps that are detrimental to mental health services. We want to make sure that the links between the various agencies involved in providing services make a bridge rather than a set of hurdles.

This project will start at the Ministry of Health to make sure that the funding agreement is clear and strong about buying the services which are needed in order to achieve the national strategy.

The next link is with the RHAs. We need to find out whether their purchasing plans really do reflect the overall funding agreement. So we will review and audit the way the RHAs plan and purchase mental health services and will look at their contracts. A selection of providers will be audited to make sure that the system is working properly. If it is not, the MHC will suggest changes that need to be made. Included in this project will be the establishment of a monitoring system of the Ministry of Health, RHAs and providers.

The next link is in the CHE business plans. We need to be sure that these interpret the purchasing plans sensibly.

The Minister of Health has requested that all CHE mental health plans be thoroughly reviewed. CCMAU, the Ministry of Health and the MHC are undertaking the review. A report will be provided to the Minister on the adequacy of CHE business plans in June 1997.

The Best Practices Project

In this project, we will be working with the sector to develop some best practice in mental health. Improving mental health services means identifying successful work practices and making sure those become widely implemented. The best practice programme will support providers in selected sites to undertake some activity which has the potential to make a substantial difference for consumers and encourage and support them to really examine what they are doing, how they are doing it, and what the outcome is for people using the service.

Wayne Miles is managing this project which is on track to establish a number of best practice sites from July. We have set up a supervising panel to guide selection of sites and the first meeting took place this month. It is envisaged that this programme will operate for the lifespan of the MHC, developing new sites each year and feeding back information into the sector. Once again, we are not trying to reinvent the wheel, but make sure that that the sector really does know how to make good wheels.

The Performance Project

One of main tasks is to monitor the sector to make sure that the situation is actually improving. We must know when and how things are going wrong. We strongly believe that there has to be a sound logic behind mental health service delivery. We should be clear about why we are doing what we are doing, we should be able to be confident that we are doing it well, and we should know that the outcomes are really positive for people using the services.

Similarly, we need to monitor what we are doing. We are only here for five years and we need to know that we have made a difference to the sector. We have no intention of monitoring simply for the sake of monitoring, but we do need to be systematic about knowing that the right changes are occurring in the right places. Michelle Farrell has been leading our Performance Indicators Project. We have almost finished choosing a set of performance indicators to cover all the work we are planning to do over the next four years. We will use these to guide us in what we do. Our ultimate success, of course, will be measured by the success across the sector. So this means that our monitoring framework will also include monitoring of the sector.

Goal One: Extra work on priority areas

In this first year, we have also been doing some extra work on a few areas which we believe need some special attention. These are areas where services are particularly poor and which need to be tackled immediately.

Maori Mental Health Service Needs

We are still consulting Maori about the best way we can ensure that they have a real say over how Maori mental health needs are incorporated into all our work. We are talking with Maori providers, Te Puni Kokiri and the Ministry of Health to make sure new initiatives are established and supported. Backing this up will require training for Maori staff and new providers. This is a critical issue and immediate priority.

Pacific People's Mental Health Service Needs

An advisory group of Pacific people's mental health workers and consumers has been established. The group has identified several priority areas for action. One is the shortage of Pacific people working in the mental health sector. This shortage is being addressed under the Workforce Project (see below). The advisory group is also keen to get rid of the discrimination that exists within Pacific people's communities toward those who have a mental illnesses. This often prevents people from seeking help with the result that people often enter services later and stay longer. This shortage is being addressed under the Discrimination Project (see below).

Housing within the Community

There is a lack of adequate community supported accommodation at all levels. The costs of accommodation and the non-availability of cheap, smaller places mean that people with psychiatric disability often miss out. Sympathetic landlords are few. The accommodation shortfall is compounded by complications with planning approvals and community resistance. The new money cannot keep pace with demand, especially as the remaining psychiatric hospitals downsize. In turn this means that there are bed blockages in acute and forensic services.

In order to address these concerns the MHC has:

* Met with Community Housing to address the interface issues between mental health services and that agency.
* Sought clarification from CHE mental health managers on the extent of the concerns.
* Initiated specific work with the "Homes" (National Accommodation Provider Network) on current levels of provision, price variations, costs, workforce training and barriers to better service provision.
* Begun a review of the purchasing plans of RHAs in respect of accommodation provision.
* Sought legal clarification on planning issues in respect of supported housing.
* Begun to address the issues of discrimination and misinformation that impact on housing availability.

We are designing a plan to make sure that there is more effective planning and project management at national and regional levels to improve this critical situation.

Early Intervention Services

We have to have good early intervention services. They are critical in determining the outcome of mental illness. Good early intervention can mean the difference between a mental illness crippling someone and them knowing how to live with it. It is easier to stay well than to get well.

There are some fledgling services across the country working on this and an enthusiastic group have done some valuable work to develop the ideas for a New Zealand situation. We are developing a comprehensive strategy for early intervention in the assessment and management of major mental illness. We have recently held a small workshop, led by Pauline Hinds and Jim Crowe, in co-operation with the NZ Early Intervention Group to identify the key components of an early intervention strategy and training needs. An information paper will be produced by the end of June, to be fed into the draft blueprint.

People with Dual Diagnosis

There is ongoing public, professional and political concern about the treatment of people with mental illness and substance abuse problems. The MHC has taken immediate action to clarify the legal situation and avenues of help for people with both needs. We are reviewing what is currently being funded and what dual diagnosis services are being provided. We will have this information by the end of June. We are also working with the Ministry of Health and ALAC on guidelines for best clinical practice. Once this is done training will be offered to those working in this area.

People with Personality Disorders

The needs of people with personality disorders are not understood. This group often fall out of services or, if treated, need a lot of resources and require specialised management. Because of the confusion over the legal options for treatment we are looking at international experiences and also examining the effective clinical management of people with personality disorders. These information documents will be finished at the end of June. We will then be able to offer some training to support better treatment of people with personality disorders.

Rehabilitation/Vocational Services Model for Mental Health Services

One of the most neglected areas in mental health has been that of rehabilitation and vocational training. This area is poorly funded and there is no national or regional structure to support development and training for better services. We are examining in detail the current service provision, best practice models and training requirements and will incorporate this information into the national service development Blueprint. Chris Harris from Framework Trust is leading this task for us.

Support, self help and training for people with mental illness

A project is being undertaken with ANOPS and will result in an information package on mental illnesses, treatment and current management practices.

Support, self help and training for people with mental illness and their families

We are producing a training and information package to assist families of people with mental illness. June Read and Maxine Gay from the Commission's Advisory Board are involved in this project.

Privacy concerns There are concerns that the Privacy Act is being misinterpreted and misused. Information withheld from the family can prevent adequate treatment and we have asked the Privacy Commissioner to develop clearer guidelines for mental health. A first draft of the guidelines has been done and will be finalised by the end of June. A second set of guidelines is being prepared to explain privacy issues to people who use mental health services.

Primary health care pilot

We are working with North Health and the Ministry of Health to set up a GP run pilot to encourage early detection of mental health illness. The pilot will lead to a training model that can be distributed to all GPs to enable them to detect early patients with mental illness and then to effectively treat them or refer them to specialised treatment.

Goal Two: reduce discrimination against people with mental illness

Discrimination against people with mental illness can be seen as a thread which ties together all problems in the mental health sector. Discrimination is systematic unfairness and is responsible not only for individuals being treated badly by services and by the community, but also for mental health services themselves being treated badly within the health system.

So if we are to make any real improvements in the way our society deals with mental health, we need to systematically fight discrimination at the same time as we set out to improve services. This is an area where it is crucial we work together. There is a lot of work already going on in the sector to reduce discrimination, such as the Ministry and RHA work on improving public understanding of mental illness. But what we need to do as a sector is collaborate and get a collective energy which will drive the changes needed. Discrimination will not be reduced by one organisation trying to turn the tide of social behaviour. We can only reduce discrimination if organisations and individuals in every part of the mental health sector become committed to doing so.

We are about to publish a discussion paper ("Discrimination against people with mental illness") in which we set out the MHC's thinking about the whole question of discrimination and how it should be tackled. Margaret Thompson and Tessa Thompson wrote this paper and, in conjunction with Mary O'Hagan form our Anti-Discrimination Action Plan Team (ADAPT). The "game-plan" here is to:

* Improve the awareness of mental health workers of discrimination issues and support them to put in place anti-discrimination measures which ensure appropriate recognition of consumers' rights, human dignity and ability to make choices.
* Increase the influence of consumers in all levels of government policy, purchasing and service delivery.
* Understand the discrimination issues for Maori and Pacific Peoples' mental health consumers and support appropriate anti-discrimination initiatives.
* Ensure adequate legal protection, improve consumers' access to legal information and advice on their rights.
* Promote public understanding of mental health and consumer issues.
* Improve the awareness of people who provide retail, financial and government services of discrimination issues for mental health consumers and support them to put in place anti-discrimination measures.

Once again, we have several interlinking projects which are planned to achieve our objectives. Some of those under way include:

* Media monitoring to shape the way the media deals with mental health building relationships with the media and by a concerted strategy of responding with both positive and negative feedback. This is an ongoing project.
* The production of a source document on legal rights of mental health consumers is planned for the end of 1997.
* The production of an easy-to-read fact book on mental illness is planned for September. The preliminary work is due at the end of June.
* Identification of existing anti-discrimination initiatives being undertaken by existing agencies. This information will be in by the end of June.
* Clarification of planning requirements for community houses and a campaign to raise awareness of the issues and needs of people living in supported accommodation.
* The preparation of a book on stories of recovery which will show how people with mental illness can deal with it in a positive way and how they handle experiences of discrimination.

We recently held a discrimination forum in Wellington to which we invited a number people whom we knew were working in the area. Don't feel rejected if you weren't invited this time – we were just getting the ball rolling.

The spin-off from this first meeting will be three workshops to work out ways to deal collaboratively with three specific problem areas:

* Christine Marshall of the Australian and New Zealand College of Psychiatrists will be organising a workshop with the help of Lynne Harrison and Tessa Thompson to discuss and implement ways to coordinate all the parties in the sector who wish to respond to positive and negative media .
* Fuimaono Karl Polutu-Endemann will be organising a workshop with a focus on workforce training and the issue of discrimination by the mental health services and professionals.
* John Forman, in conjunction with "Homes", will be organising a workshop dealing with the issue of community housing , which will include legal advice, technical planning advice, the Human Rights Commission, and other interested groups.

Goal Three: ensuring the mental health workforce is strengthened

We have a long way to go in order to strengthen the workforce and address the problems inherent in training, recruitment and retention. We will be giving priority to designing a national workforce development strategy and establishing training programmes for community support workers.

In consultation with the Ministries of Health and Education and the RHAs, the MHC is developing a comprehensive workforce strategy. This will be completed by March 1998. The strategy will include a regulatory framework and the development of standards.

A two day workforce forum of all interested parties will be held on 30 June -1 July. The forum is being organised by Peter McGeorge for the World Federation of Mental Health and supported by the MHC. A specific workshop to provide feedback on the national strategy will be held on the second day by the MHC.

We are working with the Ministry of Health and RHAs on the development of standards for training of community workers. Courses will be introduced at the beginning of 1998. These will be funded by the RHAs and the Ministry of Education. This project is being led by the Ministry of Health.

The identification of Maori mental health service training needs will also be addressed. The special needs of Pacific peoples and the training requirements to enable the needs of refugees to be more adequately met will also be included in the strategy.

GIVE US SOME FEED-BACK

We are always open to ideas and suggestions about change and improvement. It may be that Wellington seems a long way from your local community or from your particular involvement with the mental health area, but the MHC does not want to be isolated from the sector. We are part of the sector. So if you want more detailed information on any of the projects mentioned here, or have any ideas you would like pass on to us, then please contact us directly.

© Mental Health Commission, 1997