Mental Notes No. 5 (June 1998)

Barbara’s Broadsheet

The release of the Anti-discrimination Map this month was, a milestone in the development of a mental health service in New Zealand which will truly serve the people for whom the service exists.

We have made it a priority to put in place a process that will eventually eliminate discrimination against people with mental illness. Why? Because when discrimination is present it becomes doubly difficult to improve all aspects of the mental health system; it undermines what appear to be improvements in the system.

Our strategic plan emphasises that all our goals are inter-twined and must be developed together - levels of funding, allocation of resources, workforce development, appropriate service delivery, attitudes towards people with mental illness - none of these are isolates, no area can be left dragging if the others are to improve.

When Members of Parliament, government officials, health workers and the person in the street can respect and care about the well-being of others, can see individuals in their entirety without applying labels, then the whole of society will benefit. There is no excuse for any kind of discrimination.

Anti-Discrimination News

We’re On the Road!
The Anti-discrimination Journey Has Begun

Last month the Commission launched its anti-discrimination Map, A travel guide for people on the journeys towards equality, respect and rights for people who experience mental illness.

The Minister for Health, the Hon Bill English officiated at the launch and endorsed the Map and the Journeys we have all embarked upon. Commissioner Judy Leibrich said the ongoing exclusion of people with mental illness can be a bigger burden than the illness itself.

"We all in some way have experienced, perpetuated or witnessed this kind of discrimination. All New Zealanders are part of the problem. For that reason, each one of us can be part of the solution".

The Map will be used in the HFA’s Project to Counter Stigma and Discrimination Associated with Mental Illness to guide and co-ordinate their and the Commission’s work.

The Whole World is Watching

Julie Leibrich’s April presentation of the Map to the British National Conference on Social Exclusion and Stigma in London was very well received.

The Map will be sent to groups who can assist in eliminating discrimination, both within the mental and general health sectors and also key agencies outside the heath sector.

Why a Map? Why Are We Calling It a journey?

The movement to eliminate discrimination is described as a ‘journey’ because it can be embarked on from many different starting points. People can choose their own mode of transport and their route. Journeys take time and effort but can also be enjoyable; if we support each other’s efforts we can all arrive in the end.

The Commission developed the Map as an overview of the journey including the many different tasks to be done by many different people to combat discrimination. The metaphors ‘map’ and ‘journey’ are a move away from the frequently used war metaphors such as ‘strategic’.

"One in three New Zealanders have a mental health problem at some point in their lives.

"The Truth is people with mental illness come from all walks of life. Their personalities, abilities and values are as varied as the communities from which they come. It is foolish and unfair for the media or anyone else to make generalisations about them."

Dr Julie Leibrich

2001: A Health Odyssey

The Mental Health Commission has three years left before it’s disestablished in August 2001. We’re in the process of drafting our plan of action to take us through to that date, but here’s why we’re here.

Our Vision ...

is to ensure that people with mental illness live in an environment which

respects their rights

provides fair and equal opportunities

provides access to a fully developed range of mental health services that will achieve the best possible outcomes.

The National Mental Health Strategy

was launched by the Government in June 1994 and further developed and re-released in July 1997. The two key goals of the strategy are 1) to decrease the prevalence of mental illness, and 2) to increase the health and reduce the negative impact suffered by people with mental disorders, their families, caregivers and the general community.

The Mental Health Commission’s Role

While the strategy sets out goals, objectives and access targets, it doesn’t specify the range of services needed nor the actions required to meet the objectives and targets. This is where the Mental Health Commission comes in. It was established to monitor and report on the performance of the Ministry of Health and the HFA in implementing the National Mental Health Strategy. The Commission developed the Blueprint which states what service developments are required to fully implement the Government’s Mental Health Strategy.

The Commission’s other key goals are to work within the sector to:

promote a better understanding of mental illness by the sector and the public which will reduce stigma and eliminate discrimination

strengthen the workforce by promoting training, employment options and recruitment of staff with the appropriate range and quality of skills, and

maximise mental health gains for Maori.

Our Mission ...

is to take whatever action is required to get the Blueprint implemented by 2004.

The Commission has identified the factors that are crucial to accomplishing its mission.

• The Commission itself must be effective. It must provide leadership by setting clear pathways that will lead to:

- more and better services

- the elimination of discrimination

- monitoring the sector in a way that leads to continued improvement.

• Everyone working in the sector must have the will, and make it a priority to implement the National Mental Health Strategy.
• Funding must be sufficient to enable continued progress towards achieving the access targets.
• All health sector agencies must have effective monitoring systems to measure their performance.
• The social and economic environment must support people with poor mental health. Neither the health sector nor the mental health sector can realise the National Mental Health Strategy on their own.
• It must be quite clear which sectors and which agencies within the sectors are responsible and accountable for actions that affect people with mental disorders.
• Services must work better for Maori by giving more choices and higher quality.

Welcome to Margaret Hamilton - Consumer Advisor

The Commission is delighted to welcome Margaret Hamilton, whose role is to provide a consumer perspective into all aspects of the Commission’s work.

Margaret comes from MidCentral Health in Palmerston North where she was a consumer consultant in mental health services. She has also been involved in the Commission’s workforce development project.

"My new job is very much about networking with consumers and being able to influence policy at a national level to improve services and outcomes for consumers. Working at the CHE level you can only influence how services are delivered." says Margaret.

"It’s about empowering health organisations to have consumer input as a natural part of their work. I’ll be happy if when I leave the Commission, the Ministry of Health, the HFA the CHEs and other providers have active consumer participation in their organisations as a matter of course," she said.

While Margaret will be actively seeking information from consumers, she says that consumers, whether groups or individuals, are welcome to contact her at any time to give their concerns, and also to tell her about the good things that are happening out there. "We need to know what works," she said.

Monitoring requirements will be released late this year

The Commission is charged with monitoring and reporting on the performance of the following in implementing the National Mental Health Strategy:

the Ministry of Health

the Health Funding Authority

government agencies responsible for services that affect people with mental illness and their families.

In our first year we collected a range of information on the Ministry of Health, the Transitional Health Authority and providers against which future progress will be measured. A report summarising the opinions of consumers and families of mental health services, collected at that time and against which we will measure future changes, will be available for the public later this year.

What’s getting better

The Commission asked CHEs to report on four critical areas: risk management and safety; dual diagnosis (drug/alcohol disorders and mental illness); discharge planning; and Privacy Act guidelines.

The Commission is using the CHEs’ reports to identify good practice and recommend areas for improvement.

The information gained is being used to contribute to the Ministry’s development of guidelines to promote better risk management practices.

How best to monitor the monitors

Now, the Commission is developing its monitoring framework for 1998/1999. The Commission’s focus is to ensure that the Ministry monitors the HFA effectively and that the HFA monitors the performance of providers in implementing the National Mental Health Strategy. Monitoring is most useful when those being monitored are committed to using the information to change.

The Commission is negotiating with both the Ministry of health and the HFA so an explicit monitoring framework is developed which provides information that will substantiate progress or otherwise.

Clinical Accountability Review exposes worrisome trends

The results of our initial scan of the sector were worrying. Asked about their individual responses and lines of accountability, many of those interviewed were unsure about what they were accountable for.

The Commission has contracted further work to analyse the survey’s findings and identify a way to improve the management of clinical practices so that agencies and people working in the sector at all levels know where their corporate and personal responsibilities lie.

The analytical work will be completed in the next few months and made public together with a companion paper which sets out actions for improvement.

New Drugs Overly Restricted

The Commission is concerned that many people with severe psychoses have limited access to a newer group of anti-psychotic drugs, including respiridone, clozapine and olanzapine.

The Commission has undertaken an initial review of the funding and provision of these pharmaceuticals and is currently examining ways to improve access with the Ministry of Health and the HFA.

Positive Progress on Revising the Blueprint
Revising the Draft Benchmarks

Following the release of the Blueprint, the Commission received nearly 60 comprehensive submissions on the resource benchmarks and the issues people wanted us to consider more carefully. Many of the submissions were from people working in specialised services areas wanting to elaborate on needs and practices. These submissions were very helpful in our review of the benchmarks.

In March, the Ministry of Health and the Commission convened a panel of experts from around New Zealand and Sydney to evaluate the Commission’s approach to estimating the mental health resources needed to meet the strategy’s access targets. The group was fully supportive of the Commission’s approach and confirmed many of the Commission’s proposed revisions to previous benchmarks. The Ministry of Health and the Commission have continued to develop this work.

Section 5 of the Blueprint which describes the essential services for each needs group is being amended to incorporate this work. The Blueprint changes will reflect what was learned about resource requirements for Maori mental health from the nationwide-hui held earlier this year.

Funding the Full Strategy

When the revised benchmarks are finalised the Commission will be in a position to estimate how much of the National Mental Health Strategy may be implemented by 2001, how much more progress will be needed and the size of the remaining funding gap beyond that date when all the Mason money has been spent. This work is being done in conjunction with the HFA.

Community Housing

The Commission wants to see adequate provision in all councils’ district plans for community care facilities and accommodation services.

Some councils are using district plan reviews to put up barriers that make it difficult for accommodation and support services to be established. The Commission believes local authorities are using the Resource Management Act 1991 to restrict the provision of health and support services for people with a disability.

The Commission was concerned to learn that the proposed district plans for local authorities included a clause which requires a resource consent application for community care housing for people with mental illness.

Commissioner Barbara Disley says it is the Mental Health Act 1992, not the Resource Management Act 1991, which is the appropriate legislation for restricting an individuals’ freedom if their mental illness requires that.

From a social, humanitarian and anti-discrimination angle, Councils have a responsibility to treat all members of their community in a fair manner.

Barbara says "Access to good and welcoming accommodation and community facilities is crucial to everyone’s mental well being, and this is particularly so for vulnerable members of our community."

Pacific People’s Advisory Committee

The Commission’s Pacific Peoples Advisory Committee met for two days in May. To ensure that Pacific peoples’ mental health needs are better met in the future it has developed several recommendations including:

a consultation and review process with Pacific providers of mental health services

the appointment of a part-time Pacific worker to carry out work on the priorities identified by the Committee and to provide Pacific input into the Commission’s work programme.

The Committee was involved in consultations about the anti-discrimination map and is also represented on the National Workforce Coordinating Committee. It is currently developing its input for the next version of the Blueprint.

The search for the best "best practice" programme continues

The Best Practice programme is all about the continual quest for improving services to consumers. It’s a bit like childrearing; just when you think you’ve got it sussed, something changes and you have to re-evaluate your methods again.

A large part of the Commission’s Best Practice Programme involves the trialling and development of a research method for mental health practices where the researchers are the actual people involved in the process being researched.

Participatory Action Research

The method, called Participatory Action Research, is seen to be a suitable method of improving, at a very local level, mental health services for and by the people involved. This includes mental health workers, the people with mental illness and their families and support people. This process is about developing a culture of questioning and searching for a better way of doing things.

How You Do It?

The focus of participatory action research is quite different from traditional scientific research. The latter usually maintains a stable environment, changing only those aspects under investigation, to see what measurable difference the changes have made. With participatory research, the people involved in a process decide that they want to improve that process. They gather as much information as they can on what affects, or could be affecting the process and they decide how they will construct or alter the process in light of the data collected. They analyse the changes that result from their alteration of the process which may lead to another cycle of information gathering and system changes.

The Method is Part of the Result

The main thing about this sort of research is that the people involved are doing it because they want to do it. No-one told them to do it - that would defeat the purpose. The other thing is that the results of participatory action research do not necessarily transfer to other workplaces or communities. The results may be useful to others (which is a marvelous spin-off) but this is not the Commission’s primary reason for investigating this process. It is the process itself, because it is owned by the participants, that the Commission believes could work to find best practice solutions.

The Commission is supporting several sites around the country in participatory action research projects. When those involved are in a position to explain their processes and results we’ll look at the best way to help them share their information. In the mean time, we don’t want outside publicity to get in the way of what they’re doing.

If you want to find out more about Participatory Action Research contact:

Dr Wayne Miles
PO Box 12-479
Thorndon
Wellington

Wonderful web-site

Some members of the Commission recently ‘hit’ on Framework Trust’s website and were impressed with its layout and content. This major NGO provider in Auckland is using cyberspace well so we thought we would take this opportunity to say "Well done Framework Trust!" If you would like to visit the site, you can find it at:

www.framework.org.nz

What the Hui Uncovered

Earlier this year nine hui were held throughout the country for people working in Maori mental health to find out just what is happening in this area and what the people have identified as their greatest needs to improve mental health services for Maori.

The hui were concerned with detailing the specific problems that inhibit effective service for Maori with mental illness both in kaupapa and mainstream services, and associated workforce deficiencies.

Funding is an impediment

Our report on the hui states: "The funding issue permeated every hui and is regarded as the single largest impediment to satisfactorily addressing Maori mental health issues."

This is what the hui said loudly and clearly about funding for Maori mental health.

• However fluent the rhetoric, the imbalance between Maori and non-Maori mental health will not be corrected until adequate funding is provided for services for Maori.
• Providers said contracts between funders and kaupapa providers are totally unrealistic in terms of services expected for money provided. Providers have to rely on voluntary labour and salaried staff working extra hours for nothing.
• Short-term contracts, non-Maori policies and non-acceptance of cultural differences set up Maori providers to fail.
• Maori want more integrated ways of delivering the full range of support, social welfare, housing and health services to their people. They expressed a desire to have more flexible funding paths so that real needs could be met and the existing boundaries between the services of different agencies and sectors smoothed. Funding of √ɬ¢√¢‚Äö¬¨√ã≈ìone-stop√ɬ¢√¢‚Äö¬¨√¢‚Äû¬¢ marae services were wanted.

Undervalued Kaupapa Services
Proving the Benefits

The people working in kaupapa services know, and can see the benefits of a Maori service for Maori people. But they need the resources to collect information, record progress and report on their work. While they are not reporting their progress and successes the health sector cannot know or appreciate the improvements made to the lives of Maori who use their services.

Mainstream services are not appropriate

Hui participants gave the overwhelming impression that mainstream mental health services for Maori are not working as well as they should. Most of the funding for Maori people with mental illness goes to mainstream services, but participants believed there is no accountability for how that funding is being used to benefit Maori. Meanwhile, Maori mental illness statistics remain disproportionately high.

In view of hui participants, wrong diagnoses, no tikanga, problems with access to resources and services were hindering the recovery of Maori people in mainstream care.

Not Enough Maori Workers

Any workforce should reflect the composition of the people it serves. As long as Maori are significantly under-represented in the professional mental health workforce, cultural difference will not be appreciated in assessment, treatment and rehabilitation. It’s as simple as that.

The hui recommended that resources be provided to fund a recruitment drive to encourage Maori into the mental health profession and listed specific components for its success.

Since the Hui ...

The Commission is developing means of addressing the issues raised to ensure that real and lasting changes are put in place.