By Sarb Johal 30/10/2017

The first article in this short series looked at the scale and scope of the problem of increasing mental health related presentations in New Zealand. In that first article, I argued that ‘Capitalism with a Human Face’ can take its place in altering the settings of the economy in favour of the experience of those who live and work in it, in balance with the goods and services that are produced, rather than being subservient to those.

Centred on the ideas of social support, this second article focuses more on the principles which we can draw upon to help address this problem, the practical implications of these principles, and how these contribute towards a solid platform for reform.

1. Relationships and Connectedness

Drawing from the literature on what works best in times of crisis, I believe that the first principle to base mental health sector reform is valuing and promoting relationships and connectedness. At the heart of what it takes to buffer us from life’s ups and downs, at the heart of what it is that we value when we laugh with our friends and whānau, at the heart of what we value when we play together, when we team up together is connectedness.

We know that social support is an important contributor to community functioning and wellbeing, as well as the values we hold and live our lives by. We know that how connected we are with each other determines how we develop a shared sense of purpose and meaning as individuals, families, communities and in our nationhood. We know from the literature that social capital, social identity, social networks, even simply who you can borrow $100 from in a time of need – these all affect our social wellbeing and collective and individual mental health.

So, we need to ensure that there are opportunities to build relationships between patients and clients and clinicians and service providers like community or youth workers within the health system to better coordinate and deliver high quality mental health care, wherever and whenever people need support. We need to create the room and space for the level of connectedness, and continuity of connectedness that begins to make a difference in people’s lives, so that relationships endure and become meaningful and help to promote positive change. This is challenging in the contract state that has emerged in recent decades, where we have seen the separation of purchaser and provider roles, managed through the extensive use of contracts for services and market relations. This has had the unfortunate by product of fragmenting the experience of care for those using those services, and relationship formation and continuity between those experiencing difficult times in their lives and the individual mental health worker in the system that is tasked to help them.

2. Time

In our modern lives, we have commoditised time very efficiently. Time is literally money, and we value it in these terms. But without time, you can’t truly be connected with others – and that has implications for how we effectively and efficiently invest in therapeutic relationships.

We know that people need different kinds of support when they have mental health difficulties. We need to ensure that people get the time they need with clinicians to help them move forward with their lives i.e. time for these therapeutic relationship to develop. As I mentioned in my first article, the evidence tells us that the number of contacts needed for people to experience a difference in their mental health symptoms can be as high as 16 sessions. We fund nowhere near that. EAP services often provide 3 sessions. At a well-funded and organised PHO, you might get 6. If you can afford more you can get more, but at $150-$200 a session, that’s out of reach of most people who need it. So we need to think about making room and funds available for time and relationships in radical ways, as well as preventative programmes to help to reduce need.

3. Better Standards

When mental health workers are trying to help people, often they are trying to generate new solutions or ways of working where best-practice guidelines already exist. This is often for several reasons; partly it’s due to a lack of awareness, or perhaps it’s also due to a lack of viable options, even if the awareness is there. Often, it is due to the idea that each and every geographical district is distinctly different and needs to do things their own way. Although there are definite pros to locally driven solutions, what this approach risks doing is creating new work, when existing effective evidence-backed practices and protocols can be adapted. We cannot afford to remake the wheel every time a knowledgeable member of staff leaves, or a new provider wins the contract to deliver a service. Once more, the contract state we have ended up with is a challenge requiring hard thinking and radical solutions.

As far as standards are concerned, my proposal is that we look to see how other similar countries have dealt with this problem. How should we intervene to align professional standards and guidelines across the country to deliver better outcomes based on effective best-practice on well –researched protocols, so that all New Zealanders can receive quality services, no matter where they live, and what DHB or PHO serves them? How do we commission services to achieve better outcomes using the best available evidence available from worldwide recommendations, and commission research through a funded research arm where evidence is equivocal or non-existent?

In the UK, The National Institute for Health and Care Excellence (NICE) is an executive non-departmental public body of the Department of Health in the United Kingdom. NICE publishes guidelines in four areas: the use of health technologies within the NHS (such as the use of new and existing medicines, treatments and procedures); clinical practice (guidance on the appropriate treatment and care of people with specific diseases and conditions); guidance for public sector workers on health promotion and ill-health avoidance; and guidance for social care services and users. These appraisals are based primarily on evaluations of efficacy and cost–effectiveness in various circumstances.

NICE was established in an attempt to end the so-called postcode lottery of healthcare in England and Wales, where treatments that were available depended upon the NHS Health Authority area in which the patient happened to live, but it has since acquired a high reputation internationally as a role model for the development of clinical guidelines. This must take into account both desired medical outcomes (i.e. the best possible result for the patient) and also economic arguments regarding differing treatments.

NICE has set up several National Collaborating Centres bringing together expertise from the royal medical colleges, professional bodies and patient/carer organisations (which is important) which draw up the guidelines. One of these is the National Collaborating Centre for Mental Health. They work together to assess the evidence for the guideline topic (e.g. clinical trials of competing products or protocols) before preparing a draft guideline. Then there is a process for sign-off, which is less important here, but what is more interesting is the possibility that a Government could reduce variation in access to clinical protocols by making it mandatory for commissioners to follow NICE clinical guidelines.

NICE has a service called Clinical Knowledge Summaries which provides primary care practitioners with a readily accessible summary of the current evidence base and practical guidance – extremely important to keep all stakeholders informed with best practice.

How would this work in New Zealand? The New Zealand Guidelines Group (NZGG) was an independent, not-for-profit organisation, set up in 1999 to promote the use of evidence in the delivery of health and disability services. The NZGG went into ‘voluntary liquidation’ in mid-2012. We could look at re-constituting a similar body. However, we are fortunate in that we already have a existing operations model which could be used as a proto-template for this body: PHARMAC.

PHARMAC makes it’s decisions around medicines through their Factors for Consideration. These Factors cover four dimensions: need, health benefits, costs and savings, and suitability. I don’t think it is a huge leap to apply a combination of the NICE and PHARMAC models to mental health care in New Zealand. We have too many ad-hoc decisions being made meaning that funding doesn’t necessarily flow to the right treatment protocols, and people aren’t getting access to the best treatments for their conditions. We can do better than this, and models exist to help us deliver this.

4. Workforce development

We have a workforce with varying levels of training all over New Zealand. One of the issues that I have talked with people about is that this results in a lack of confidence in the consistency of quality of the services offered in the mental health sector. Furthermore, because of the lack of nationally agreed standards and what services should be commissioned to improve mental health and wellbeing outcomes, there is a lack of drive and curriculum base upon which to train our social and mental health and wellbeing care workers, volunteers and other providers. If we don’t know what we are training for, is it any wonder that providers may feel under-prepared, and community members start to lack confidence in the competence of those providers?

We should aim support the development of the workforce in accordance with the approaches, methods and techniques recommended for various disorders and outcomes by a NZ-equivalent of the National Institute for Health and Care Excellence discussed in the previous section. This would mean working with training programmes such as medical training providers, clinical psychology, nursing, social work, psychotherapy and counselling, and community development making sure that they are delivering training according to a skills and knowledge framework developed by this NZ body. In this way, we will know that the services that are being commissioned by PHOs and DHBs are using the best in mental health knowledge and technologies to help the greatest number of people most effectively, using the best trained workforce with the skills they need to do the work.

Service users can then be confident that they are getting the best treatment that exists and is available in New Zealand, delivered to transparent best-practice protocols and treatment recommendations, where they can be agreed.

5. Service access and a wellbeing approach

At a primary care level, I propose giving all New Zealanders over 11 years of age 4 credits per years towards a personal wellness bank. Each year, this increases by 4 credits, up to a maximum of 16 credits. These credits can be used to pay for sessions with a mental health practitioner, if that is what the person is dealing with at the time. Funding continues for secondary and tertiary level care mental health services in the existing way, though I believe there needs to be an independent review of the mental health system, including funding methods and levels.

Crucially, these credits may also be used for wellness activities to have been show to build resilience and the ability to withstand life’s challenges as they arise. There are some common life transition points that need to be negotiated successfully if people are to realise their potential, and ’thrive not just survive’. For example; youth and adolescent changes, early adulthood, starting work, taking an apprenticeship, going to university / technical college / ITO, managing debt and finances, being laid off from work, finding work, re-training, making relationships, getting married, divorce and separation, becoming a parent, parenting, parenting when in a blended family, growing up in a blended family, buying a house, living longer, staying active and healthy, retiring, living alone etc.

I propose that these credits can be used against audited evidence-informed activities by local providers that benchmark against the 5 ways to wellbeing, and perhaps also comes into the commissioning recommendations purview through an adapted NICE model. The 5 ways to wellbeing for those, for whom that is unfamiliar, are based on the New Economics Foundation’s recommendations after they conducted a review of the most up-to-date evidence and found that building five actions into our day to day lives is important for the wellbeing of individuals, families, communities and organisations. Those five actions are: Connect, Give, Take Notice, Keep Learning, and Be Active. You may have seen this reflected in the work of our Mental Health Foundation and the “All Right?” public mental health campaign in the Canterbury post-quake period.

The advantage of thinking of this broadly (and not only in the health arena) is that it more accurately represents life, rather than the government structures that all too often seek to administer life but do not reflect the complexity and inter-relatedness of it. You can imagine that going to an adult education class may help someone to both connect, keep learning. They may also in the same arena have the opportunity to give, be active and also keep learning. A well-designed adult education class can address all 5 ways to wellbeing, and it would not necessarily be funded through Vote Health. This gives us an opportunity for cross-departmental cooperation and effectiveness to deliver better outcomes, at Ministerial, Departmental, regional and local levels.

Though the Government has clearly signaled key developments such as the piloting of primary mental health coordinators, school-based health services and primary school mental health initiatives as part of their programme of work, one of the reasons why I think a personalised system of credits might be something to seriously think about was my experience talking with those who helped in the Canterbury Earthquakes. What they told me was that it was hard to step forward for help when you feel like you might be taking away from those who needed help more than you. And those people I talked to – the health and welfare professionals said that they were seeing this in the people they worked with to. That people were reluctant to ask for help because others needed it more. By the time they thought they could actually take their place in the queue, the risk is that their problems had actually got worse, and they needed more help to get their lives back on track.

In a way, it’s a story of selflessness – stepping back so that others more in need can step forward. It’s a very kiwi story – it reflects our values as a nation. But, as a support system, we can do better. We need to increase our capacity to help those who need help, not making them feel like these are precious resources, and there isn’t enough to go round. We can increase the capacity if we choose to, but we must actively decide to do so, it won’t happen by itself.

What I am trying to outline here is an overarching vision that addresses the needs to take account for both the need for assistance with mental health difficulties and also for promoting preventive public mental health activities. And in that way, we start to perhaps reduce the flow of people at the end of the production line that need mental health service to address their needs.

By broadening our view once again, to take account of the social determinants of mental health, through taking an all-of-Government approach to fixing housing, health and education, by addressing increasing inequalities, but also through encouraging a culture where mental health and wellbeing is seen a public good and it is indeed rewarding, enriching, and interesting to take care of yourself and your family in activities that improve your capacity to thrive and and survive when things get tough, and to make the most of life’s opportunities when they are not. And these come in the guise of very simple activities, like being able to work in a gardening bee together, or that adult education class, or that walking group with people who share your other interests, or leading a group where you have a particular expertise or interest. Activities that promote relationships, connectedness, and time spent with others to develop those connections. Though we tend to view the past with rose-tinted spectacles, perhaps these things used to happen on their own to a certain extent. I think these activities need extra nurturance now and are perhaps particularly valuable again as we seek to gain purpose and direction in our increasing time-pressed lives for some, and precarious lives on the breadline for others.

So, to summarise, I have outlined how we need to re-engage with a broader view of the social determinants of mental health and wellbeing. We have a clear choice here. We can carry on as we are, or we can make a serious attempt to address issues like housing, work, education and community participation and connection. But to expect a different trajectory when we continue to do things as we are currently doing is beyond misguided. In my view, it’s a betrayal.

In this second article, I also propose that we view the mental health and wellbeing of New Zealanders through the lenses of relationships and time, and to think further about establishing an infrastructure for mental health system reform:

  • Standards of service based on clinical effectiveness evidence, and commissioning services to meet these standards
  • Workforce development to meet these standards consistently and reliably across New Zealand
  • Enable access for New Zealanders to services that help them when they are going through mental health difficulties, and that support them to build their resilience through engaging activities that align with their interests and promote social connectedness and cohesion.

To build this will take time. Dr David Clark, the new Health Minister was recently talked about 10 years to make an effective difference to some aspects of health care services that have been degraded over the last nine years. Those are the sorts of time frames I think we need to be thinking about here.

And we start now.


Declaration of Interests: Dr Sarb Johal is a registered clinical psychologist with over 25 years of professional experience. He was also a NZ Labour Party List Candidate in the 2017 General Election.

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