Mental Notes No. 3 (December 1997)

The Working Blueprint for Mental Health Services is Now Out There

We have now distributed the working Blueprint for Mental Health Services in New Zealand throughout the country and the reaction so far has been positive. The Blueprint is our effort to provide a detailed action plan and guidelines to make the national mental health strategy a reality. It shows where the gaps are and how to fill them in.

What does the Blueprint do?

* It identifies the particular needs of different population groups with mental illness - adults, children and young people, older people, Maori, Pacific people - and sets out the services required to meet their needs.
* It states the values that must guide the planning of the services and how they are delivered.
* It indicates the percentage of the population that currently requires mental health services and the resources needed to give those people the services they need.
* It identifies the need for more mental health workers and for workers to have more knowledge and skills.
* It looks at the ways public and primary health services should support mental health services.

At the time of writing this newsletter we were holding meetings with purchasers, providers and consumers in Auckland, Rotorua, Wellington, Christchurch and Dunedin to present and discuss the Blueprint. From January to March we will be holding hui for Maori to provide feedback on the Blueprint. We will report on these meetings and hui in the next newsletter.

We have written to the chairs and chief executives of the THA and CHEs about what we expect them to achieve in 1997/1998 with regard to the Blueprint.

This is a Working Document

Firstly, we ask you to keep in mind the philosophy/kaupapa of the Blueprint when making decisions in your daily work, however large or small your responsibility or the issue at hand. In Appendix 1 we have listed the attitudes and actions that will improve the quality of life for people with mental illness.

Secondly, the Blueprint is not static or finite. It is a working document in that we intend to revise it in response to your feedback. Our job is to make sure that mental health services improve in this country. To do this, it is vital that we hear what the people working in the sector, at all levels, have to say about the Blueprint. Please call us if we don't call you!

At this stage we plan to release the revised version of the Blueprint in May 1998 based on the feedback we receive from the sector, and the additional work we will be doing to further develop and refine the proposed benchmarks.

The Information Used to Develop the Blueprint

Two of the key documents we used to write the Blueprint were Derek Wright's report on developing resource guidelines and Rehabilitation/ Recovery - An integrated focus for Mental health Services in New Zealand by Chris Harris.

If you are wanting background information on the genesis of the Blueprint, please request copies of these reports from the Commission.

What We Are Doing Now

Over the next few months the Commission will:

* review the Blueprint in light of feedback and suggestions received
* further review the suggested benchmarks and develop new benchmarks for some service areas, including:
o older people services
o eating disorders
o drug and alcohol services
o services for people with personality disorders
* begin to identify the gaps between what is currently provided and what we require to meet the targets
* identify the funding requirements to fill these gaps by the year 2004
* review the THA five year plans to see how well they reflect the intentions of the Blueprint.

Community Team Training Sessions Were Well Received

We've now completed the four practical training seminars for team leaders that were scheduled for this year. This was the first time ever that front-line community mental health team leaders have been brought together. The seminars gave them the opportunity to learn from each other's experience and refresh their skills.

Community mental health workers are dealing with back-to-back crises every day, they rarely have time to reflect on their work. At the seminars, participants learned management strategies and heard about developments around the country, for example, early intervention programmes and programmes for people with both mental illness and drug or alcohol problems.

The other important outcome of the seminars was that it gave community mental health workers a chance to recognise the worth of their work, to see that they are doing a lot of good in the community, something that can be lost sight of when theyÕre out there at the coal face.

Specific training seminars for Maori Community Health Team Leaders and Child and Family Community Team Leaders is something we are considering for the new year.

The Financial Tracking Review

Note that the Financial Tracking Review is now online on our Web site.

Our review of mental health income and expenditure will be distributed throughout the sector early next year.

The two main questions we wanted answers to were:

Is the "Mason money" being spent?
Is money allocated to mental health being used to best advantage?

The Mason Money

Following Judge Mason's report on the mental health sector, an additional $140 million was allocated to the mental health sector over a five year period.

Our review found that spending the Mason money has been delayed. By 30 June 1997, 66 percent of Mason funds were transferred to CHEs and other service providers but that money was not spent by the end of June 1997 because CHEs had not had time to organise resources and recruit staff.

More of the money has now been allocated and new services have been established. These are beginning to make a small but significant difference.

Is Mental Health Money Well Spent?

The short answer to the question, "Is mental health money being well spent?" is: it's very difficult to tell.

The reasons why it is difficult to assess how the money is being spent are:

* There has been some difficulty in tracking how and where money is spent as the sector often sees information about costs and prices as commercially sensitive. While sharing such information has been occurring a little more in recent months, this had not been evident in the early stages of the 1996/97 contracting process.
* Each of the 10 CHEs visited had entirely different ways of calculating corporate costs and direct costs. The same variance would probably be found amongst private sector providers. It is therefore very difficult to make any comparisons amongst providers on who is spending what on what, or to deduce which services are giving value for money and which are not.

Overhead Charges

It is often suggested that mental health services were being inappropriately charged for overheads. Our review found no evidence of this in the 10 CHEs visited although it was evident that overheads management differs from CHE to CHE.

What Happens Next?

The THA is responsible for the effective and efficient use of mental health money. In our review we have made a number of recommendations concerning the need for improved contractual processes and pricing models for services, the urgent need for funding and expenditure guidelines, and more uniformity across the country in performance measures. We will be working with the THA to ensure that these improvements occur.

Best Practice Conference

Over 370 people attended the Best Practice Forum in Tauranga in November and we have received encouraging feedback. The conference was organised by the CHE Mental Health Managers Association with sponsorship from us. The forum provided a unique opportunity for the sector to focus on positive initiatives in mental health and to share ideas on how to do better.

Our thanks go to Sue Lewer from Western Bay Health and her team for the enormous amount of work they put into organising the conference - a massive under-taking and very successful.

What are We Doing to Promote Effective Practices?

* No-one knows better than those who are out there working and those people with mental illness what practices have a good outcome for them and their families. Our Best Practice Programme, led by Wayne Miles, gives providers the resources to take a good look at, and evaluate, what they are doing. The providers can then write up their successful practices so that they may be shared with others in the sector. Two sites are now running and several more are finalising proposals for the Best Practice Panel. Our aim is to have six sites operating at any one time.
* We have made over 100 visits to providers to see what's happening, share ideas and support projects for effective change.
* We have sponsored training for community mental health team leaders.
* We are keeping in touch with international research and developments and support the Cochrane Collaboration to foster New Zealand's international connections in the mental health area. The group expects to issue a series of newsletters to the sector updating the latest evidence-based research findings.

Bringing the Workforce up Where it Belongs

The project we instigated to develop a strategy for those working in mental health is nearing completion. We are jointly sponsoring it with the THA. The end result of the project will be a workforce strategy that makes sure people working in mental health are:

* supported
* educated
* trained
* have plenty of colleagues

Workforce Development

The relentless restructuring of mental health services over the last decade has weakened the morale of the workforce and we need to see a dramatic change in both the way individual workers feel about the worth of the work they do and the way they feel about the whole sector. Many mental health workers with experience, commitment and integrity have burnt out and left the sector. They weren't given the training and support needed, and there were too few of them doing too much.

Our workforce project has concluded that a national co-ordination body is needed to:

* initiate change
* monitor the national workforce
* identify what makes services work (or not work)
* set goals and work out the ways they can be achieved
* promote and negotiate new, higher quality standards for workforce training in the education and health sectors.

We'll be releasing more information about this project and the new national co-ordination body early next year.

The THA is leading a project which is addressing the need for uniform training standards and a national qualification for mental health support workers. Draft standards have been submitted to the NZQA for registration on the National Qualifications Framework. These standards should influence the content of training courses run in 1998.

Training for the Maori Workforce ...

Maori are under-represented throughout the mental health workforce, a situation which needs urgent attention in light of the high number of Maori people with mental illness.

The recent emergence of Maori community mental health workers has brought new skills to many work-places. Maori need to be better represented at all levels within the services and there is a need for better training opportunities to increase the number of Maori psychiatrists, psychologists and nurses as well as community support workers.

The simple and inescapable truth is: we cannot provide appropriate services for Maori if we do not have the Maori numbers in the workforce.

Introducing the Pacific People's Advisory Committee

Talofa, Kia Orana, Malo e Lelei, Fakalofa Lahi Atu, Bula, Taloha Ni!

Members

John Wells (Samoan/Maori) is a mental health consumer from Auckland.
Pefi Kingi (Niuean) works at Lotofale, a Pacific people's mental health service in Auckland.
Eleitino Bubsy Memea-Maaelopa (Samoan) works for the Pacific Islands Health Council, Christchurch.
Marisha Wong (Tongan) is a mental health consumer who lives in Auckland and works on Pacific People's Project for the Aotearoa Network of Psychiatric Survivors.
Dr Siale Alo Foliaki (Tongan) is the chairperson and is a psychiatric registrar at Middlemore Hospital, Auckland. He is the only Pacific psychiatric registrar in the country.
Auimatagi Epa (Samoan) is a cultural officer in the Mason Clinic, Auckland and matua within the committee.
Fuimaono Karl Pulotu-Endemann (Samoan) is a mental health consultant who works extensively throughout the country.
Roine Fata-Taeao Lealaiauloto (Samoan) works at Pacific Care, a Pacific people's community mental health service in Auckland.
Dr Sitaleki Finau (Tongan) works at the Auckland School of Medicine, University of Auckland.
Kathy Stirrat (MHC).
John Siaso (Samoan) is John Wells' support person on the Committee.
Kiwi Tamasese (Samoan) works at the Family Centre in Lower Hutt.
Liz Smith Leelo (Samoan) works at Pacific Community Health in Porirua.
Luamanuvao Winnie Laban (Samoan) works at the Family Centre in Lower Hutt.
Deborah Amos (Cook Islands) works at St Lukes Community Mental Health Service, Auckland.

The Committee's Purpose

The Pacific People's Advisory Committee is our link to the needs of Pacific people with mental illness and their families. As the Committee advises us of their needs, our job is to make their recommendations known to the relevant agencies and see that the recommendations are carried out. These agencies include the Ministry of Health, the Ministry of Pacific Island Affairs, the Transitional Health Authority and others. The Committee also gives us advice on how Pacific peoples can have input into our workplan.

The Committee has identified its values and the priority areas in relation to Pacific people and mental health:

* Recognition of, and respect for, the cultural diversity of Pacific communities.
* Recognition and promotion of a holistic approach in health and healing services.
* Belief in Pacific peoples owning, designing and delivering their health services to their people.
* Acceptance of the Treaty of Waitangi and the special relationship between Pacific peoples and the other people of Aotearoa.
* Central focus on improving the quality of life for Pacific people with mental illness.

An improved quality of life for consumers is the committee's overriding concern.

While the Committee is letting us know what Pacific peoples need and want, it is also telling Pacific communities what we at the Commission are up to. The committee has translated into several Pacific languages an information sheet about its role in the Mental Health Commission, which it will distribute widely to Pacific communities.

The Discrimination Busters are Hard at Work

People with mental illnesses will not get better while they have to cope with the added burden of other people's negative attitudes towards them. As we've said previously, getting rid of this discrimination is one of our three main goals.

Our anti-discrimination team works across the whole sector to facilitate co-operation to eliminate discrimination. Tessa Thompson, our very busy anti-discrimination project worker, has given several presentations to Community Mental Health Team Leaders'

Seminars

The Journey to Discrimination-free Destinations

The Anti-discrimination team has provided a "map of the journey" to show where we want to go (destinations), how we will get there (pathways) and who has to do something (travellers). It shows which pathways are already being walked and which need to be opened up.

The map was developed in response to comment from people who found it difficult to work out how their project would fit with others and where they were all going anyway. This is not surprising given that anti-discrimination initiatives are spread across so many sectors and tackle such a wide range of issues. The map enables us to put particular projects into a wider perspective, to assess their contribution to the whole and to see who else might be involved. In other words, the map of the journey is for strategic planning.

The destinations, when reached, will mean people with mental illness will have:

* Equal power to others in the community
* No blocks when using public organisations
* No blocks when using private organisations
* Their rights upheld in law and practice
* The understanding and respect of others and will:
* Recognise and know how to deal with discrimination

The travellers are many so we'll need wide pathways.

Travellers in the mental health sector include: the THA, Ministry of Health, CHEs and NGOs, the Aotearoa Network of Psychiatric Survivors, the Mental Health Foundation, professional groups, people with mental illness and their families.

Other travellers are: the media, local government, Ministry of Housing, Human Rights Commission, the Courts, the police, the justice system, the education system, social welfare, Te Puni Kokiri, CYPS, Youth Affairs and everybody living in New Zealand.

There are several pathways to each destination. The people travelling those pathways will have to walk down several at once (figuratively, of course).

There's a version of the map in the Blueprint and we will be sending out a further developed "sketch" of the map early in the new year.

We need your feedback and will incorporate it into a revised map for the next edition of the Blueprint.

Clinical Care of People with Mental Illness

Optimum clinical care is as important as all the other needs of people with mental illness. There has been a move away from institutional, hospital-type care to the more homelike community care where people can make more choices for themselves in their daily lives and spend time in normal ways with friends and family. Living in the community is far superior to living in a hospital. When it really works, there are all sorts of positive spin-offs like reducing discrimination against people with mental illness.

But the standard of medical care of some people in community care and some in institutions is not always what it should be.

Our Review

We have commissioned a review of clinical accountability to gather information and find out what issues need attention. This was done by interviewing workers and consumers using carefully developed open-ended questions, and by presenting interviewees with a series of scenarios with associated questions.

What We Found Out

All the services the review team visited had processes in place to account for medical care but there was a huge variation in the extent to which these processes were developed. Also, some of the processes were described as unsatisfactory by the people administering them, and by the people with mental illness and their families.

The review team developed a profile of "optimum clinical accountability" which is included in its report. The profile will be widely distributed to the mental health sector in the new year and we really need your feedback to further develop it so that it can be used to improve the clinical care of people with mental illness.

The Recommendations

We have just received the report; here's a sneak preview of the recommendations, which we will be carefully considering.

* There needs to be a separate review to gather information on Maori perspectives.
* The THA service contracts should include clinical accountability issues.
* All mental health services should have clear processes for dealing with their clients' medical needs.
* Workforce training should include clinical accountability issues.
* People with mental illness and their families must have their say in any systems that are set up.
* The doctor's role in the inter-disciplinary team needs to be clarified.

Working with Maori

Maori provided significant input into the content and direction of the Blueprint. Early input was provided by our Maori Advisory Group and draft versions of the Blueprint were reviewed by Te Puni Kokiri, Te Kete Hauora within the Ministry of Health and the Maori members on our Advisory Board. We have begun to receive positive feedback from Maori about the Blueprint and look forward to working with key groups across the sector to get action in line with the Blueprint. The Maori reference group which is supporting the Commission's work met in early December and provided comment on the Blueprint and on other aspects of our work programme. In their travels around the country the Commissioners have continued to meet with Maori service providers. In the new year, the Commission's kaumatua Denis Simpson and the Commissioners will be visiting a range of kaupapa services to examine the way in which these services are provided.

Last month we met with the new Maori Health Commission to discuss our respective roles and to explore ways of working together.

The 1997 Monitoring Report

The Commission will release its first monitoring report after Christmas. This report is based on analysis of information collected by health agencies and the Commission. It includes family and consumer opinion, a review of the Ministry of Health and THA performance and regional expenditure profiles for 1996/1997.

We're Getting In On the Act

We presented our final submission on the Mental Health Commission Bill to the Health Select Committee on 22 October and provided further information on the 24 November at the request of the Committee.

We will begin our life as an independent agency when the Act is passed. We haven't yet received word on when that will be.

Improving our Consumer Focus

Over the last few months we've been looking at how best to incorporate a stronger consumer perspective in our work. While weÕve had good consumer input into our various projects, we heard from consumers how they want to give information to us about their concerns and how they want to hear from us and be involved with our work. Based on this feedback, we plan to establish a consumer liaison position within the Commission and are looking to hold a series of regional forums for consumers in the coming year.

Nga Mihi o te Tau Hou ki a Koutoa Katoa

Season's Greetings and very best wishes for the New Year from the Commissioners and staff of the Mental Health Commission We want to thank everybody who is helping us with our task. We can't do it alone, we're not doing it alone and we shouldn't be doing it alone.

As we see it, we are steering a joint effort.

Whatever you do over the holiday period, we hope the stress levels don't rise, you enjoy yourselves and keep safe.

We're on the Net

You'll find our website at:

http://www.mhc.govt.nz

On the site you can read about the commission and access key documents such as the Commission's Blueprint.

There's Been a Bit of a Problem With Our E-mail Address

We thrive on your feedback but some people have reported trouble e-mailing us. This could be the result of a system fault or because our e-mail address is not clear.

Lindsay Denton is our e-mail contact person and her address is:

ldenton@mhc.govt.nz

PS: The first letter of Lindsay's address is l for Lindsay, not i for Ingrid.

© Mental Health Commission, 1998