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Commissioner letter to Health Committee on mental health

1 August 2017

Simon O’Connor
Health Committee
House of Representatives

Dear Mr O’Connor
Petition 2014/89 of Corinda Taylor and others
Thank you for the opportunity to make an oral submission to the Health Committee regarding Petition 2014/89 of Corinda Taylor and others which requests an inquiry by the House of Representatives into mental health services. This letter is in support of my submission and, in summary, sets out the following points.
• An action plan is required to improve mental health and addiction services. In my opinion that will be the fastest way to:
(a) develop and improve services for current consumers; and
(b) ensure services meet the mental health needs of all New Zealanders now and in the future.
• Collaborative leadership from a sector leadership group, which includes people with lived experience, is essential for the action plan to deliver results.
• The public needs to be kept informed about the development of the action plan and see demonstrable progress.
Mental Health Commissioner’s Role
As the Mental Health Commissioner, I have a unique and wide ranging insight into the state of mental health services in New Zealand and in particular how they are perceived by consumers of those services.
My role has two major responsibilities:
• to ensure the rights of consumers of mental health and addiction services are upheld. An important aspect of this is making decisions on complaints about services; and
• to monitor and advocate for improvements to mental health and addiction services.
I consider over 200 complaints each year in relation to mental health and addiction services. The most commonly received complaints in 2016/17 relate to:
• care and treatment (60%);
• communication (55%);
• consent and information (32%);
• facility issues (17%);
• medication (17%); and
• access and funding (15%).
Those issues of concern have also arisen in the People‘s Report and recent reports from the Auditor-General, Ombudsman and Human Rights Commission, and align with the issues being addressed through the Quality Improvement Programme led by the Health, Quality and Safety Commission.
Monitoring and Advocacy
There are four components of my monitoring work.
• Identifying the themes and trends from complaints I receive about services. They are summarised above and are vitally important because they reflect the day-to-day reality for consumers and families/whānau using services.
• Considering other consumer feedback including from national consumer and family/whānau advocates, and information from the Mārama Real Time Feedback survey. The survey provides consumer and their family/whānau perspectives of their experiences with services. It is now used by 16 DHBs, and a number of NGOs. Over 13,000 consumer and family ‘voices’ have been collected since the tool was first piloted in 2014. Over 80% of respondents have reported saying that they would recommend their service to friends and family/whānau in need of similar care or treatment. Similar numbers report they feel respected, are involved in decision-making, have a plan that is reviewed regularly and have the support they need for the future.
• Sector engagement. I regularly meet with a range of policy makers, funders, providers, service leaders and professional groups.
• Analysing a range of information about sector performance. Developing this aspect of my work is a high priority for me. It will enable me to provide an on-going public overview of services based on information from consumers, HDC complaints and provider information in a way which has not been done before in New Zealand.

I will be reporting on my monitoring work publicly from early next year. The report will include recommendations for actions to improve services and, in subsequent years, report on progress with the implementation of those recommendations.
Monitoring role to date – what am I seeing?
The main features that emerge from my monitoring role to date are summarised below.
Access – A rapid increase in access to specialist services over the past ten years from 96,000 to 168,000. Specialist mental health services in New Zealand are designed to provide for the 3% of the population with the most severe disorders and highest needs. Access has been sitting at 3.5% of the population for a number of years now following successive annual increases over the last decade. This is a significant, positive achievement and reflects the gains that have been made through investment in mental health and addiction services following the 1996 ‘Mason Inquiry’. However, increased access has put pressure on services and is impacting on the quality of services provided.
Demand – Growth in demand for services is partly but not fully reflected in growth in the number of people accessing services. That growth is likely to increase considerably in the future with growing recognition of mental health issues, growing willingness to access services and increased expectations of health services. Again that is positive but requires a better approach to reducing demand and to the development of new service models to meet people’s needs.
Variation in service quality – This is apparent from what I see in complaints and, as noted above, reinforced by other evidence such as:
o the People’s Report (access, treatment options and consent issues);
o the Auditor-General’s report (discharge planning); and
o the Human Rights Commission report about seclusion and restraint.
International experience – These challenges are not unique to New Zealand – other countries are facing the same challenges as reflected in WHO’s focus on depression for its World Health Day campaign this year.

However, there are also important indicators of high service quality and ongoing improvement efforts including the below.
• The Mārama Real Time Feedback surveys, with over 13,000 consumer voices so far, reporting that over 80% of consumers surveyed would recommend their service to others. It is important that those consumers are heard.
• Seclusion rates have been reduced. Services need to continue to reduce restrictive practices but some DHBs have made substantial progress in this area.
• New services initiatives, such as recent tele-health initiatives, have improved access to mental health advice for both consumers and GPs.
• The quality improvement programme led by HQSC is focusing on important areas including medication, coordination of care and reducing restrictive practices.
A number of the comments above relate to specialist services, however, the New Zealand Mental Health Survey, published in 2006, indicates that 20% of the population will meet the criteria for a mental disorder in any given year, and that half the population will meet the criteria for a mental disorder at some point in their lifetime. Funded treatment and care options for the approximately 17% of people with mental health needs who do not qualify for specialist services are limited and there is no systematic plan in place for addressing these needs.
Action plan needed to respond to growing pressures
An action plan is required to respond to growing demand, gaps in services, variable service quality and inadequate coordination of sector effort (including health, education, housing and justice sectors).
There is a high level of agreement about current challenges and what needs to change and improve. The plan should identify and build on the many strengths in the sector. Some of the things that need to happen are:
• more emphasis on prevention and early intervention;
• sharper focus on individuals and families/whānau with high and complex needs;
• improved access to evidence-based services;
• increased primary care support (both access and options, and improving primary care access to specialist advice and support); and
• clear progress on longstanding challenges including:
o enabling health, education, justice and welfare services to work better together in a consumer-focused way;
o improving quality of care (e.g. the HQSC quality improvement programme);
o improving outcomes for Māori; and
o coordinating care better – ensuring seamless, compassionate support.
Progress in those areas also requires progress in determining:
• the relative investment in prevention, early intervention, primary and secondary services (that will require careful assessment to ensure people experiencing mental illness can access specialist services to obtain the care they need); and
• future workforce requirements – ensuring we have a workforce equipped and supported to deliver services which best meet consumers’ needs now and in the future. We also need to build capability in our workforce to continuously improve services (immediate action to address pay equity issues is also required to ensure NGO capability is retained).
Reducing suicide
An essential component of any action plan to improve mental health and addiction services is a specific focus on reducing suicide. I share the widespread community concern about our high rate of youth and teen suicides, and that we are not reducing the overall rate of suicides in New Zealand. We must do more.

Forty percent of people who committed suicide are known to be receiving specialist mental heath services at the time. Some ways we can reduce suicide by people using those services is by addressing issues which have arisen in complaints I have considered including improving:
• communication with consumers and their families/whānau;
• risk assessment and safety plans and ensuring they are linked to carefully considered treatment plans; and
• coordination of care amongst services.

New Zealand also needs a target for our suicide prevention plan. I understand why some people have concern about the government being held to account for something beyond its direct control. However, any target which is adopted must be seen as our collective responsibility as New Zealanders. Everyone has a role to play. The target needs to be considered carefully but I note the World Health Organisation suggests that countries should be guided by its Mental Health Action Plan 2013–2020 that aims for a 10% reduction in the suicide rate over that time (and that some countries may go further). I support the WHO target.
Essential components for an action plan
Four components are important for the success of an action plan to improve mental health and addiction services.
• It needs to be consumer-centred – focused on the needs of consumers and their families and others who support them.
Collaborative leadership is required from the start. A sector leadership group led by the Ministry of Health is required. No one part of the sector can develop or deliver an action plan in this area alone. A draft plan followed by written feedback will not achieve the required results. People with lived experience need to be an integral part of the group as do leaders from district health boards and NGOs including primary health organisations. Group composition needs to be based on people with proven success in achieving sector and service improvements and achieving results collaboratively with others including people with lived experience.
Delivering results. I recommend a twelve month timeframe for the action plan to provide a strong focus on results.
Transparency. Good communication with consumers, the sector and the wider public is important to ensure people are kept informed about the pace and progress of the action plan.

Yours sincerely

Kevin Allan
Mental Health Commissioner

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