By Sarb Johal 11/12/2017

This is the text from the speech I gave to the Fabian Society in Auckland on the evening of 6 December, 2017. I have made the speech text available for viewing here via Google Docs, but have also reproduced it below with the slides I also presented that evening.

I believe that the organisers made an audio recording, and that will also be made available in due course. There are ideas in development, and I am happy to take feedback to develop these ideas further. [Ed: Sarb Johal stood as a Labour Party list candidate in the 2017 General Election]. 

Broaden and build – Key elements for a Reformed Mental Health System in Aotearoa

Speech to the Fabian Society – 6 December, 2017

Auckland, New Zealand

Sarb Johal

Thank you to the Fabian Society for inviting me here to Auckland to speak with you today. I’m looking forward to sharing some of these ideas and for further discussion and refinement of them.

This is an exciting time: a new Labour – NZ First Government, with support from the Green Party, with new leadership focused on how “capitalism must regain its human face”. This people-centred Government will also rightly be focused on addressing the mental health problems and misery experienced by many in New Zealand, and setting policy to address this.

On the day that the Government was formed, Jacinda Ardern – our 40th Prime Minister of New Zealand – gave an interview with Jon Campbell on Checkpoint as she was on her way to Government House. She said she wanted the Government to “feel different,” to be empathetic and kind. She went on:

“I know I need to transcend politics in the way that I govern for this next term of Parliament, but I also want this Government to feel different, I want people to feel that it’s open, that it’s listening and that it’s going to bring kindness back.

“I know that will sound curious but to me if people see they have an empathetic Government, I think they’ll truly understand that when we’re making hard calls that we’re doing it with the right focus in mind”

These statements are highly significant and meaningful – and I suspect not just to me, but to many. And a lot of people will be hoping that her Government will be able to live up to these ideals.

When I was a trainee clinician, one of the critical things that I learned is that people crave both empathy and structure in life. When we work as clinicians, often we can work in our dominant preferred area, to the exclusion of our non-preferred area, which may then becomes an area of neglect and potentially weakness.

We can then turn away from this area of neglect or weakness, as to pay attention to it fills us with fear that this is something that we are not good at and do not wish to address for fear of failure or exploitation by others as a weakness, closely followed by guilt and regret. If I extrapolate this out to the leadership role that the Government has with its electorate, then it may be a challenge to practice empathy while also keeping an eye on structure and the firm stewardship that this will require.

Prime Minister Ardern seems to acknowledge these requirements when on the 9th of November she said that ‘You can be empathetic and have steel’.

And it is that balance between kindness and efficiency and effectiveness, if I can frame it that way, that will be needed to help to solve the endemic pressures within our health system. Patients’ problems are becoming increasingly complex, and the care provided for them more and more fragmented. Greater population disease burden and constant pressure for cost savings place increasing pressure on resources, as well as strains on relationships between staff members, and between staff and the patients they care for.

We know that staff can be affected by the emotional demands of caring for patients which can show itself in work-related anxiety and depression, being unable to be at work, and burnout for both clinical and non-clinical staff. Staff can become rapidly depersonalised with sometimes catastrophic, fatal results.

In healthcare settings, it is not unusual for a false dichotomy to be set-up; that one must choose between compassionate or competent care, assuming that you can’t have both. The evidence indicates that this isn’t true. Organisations that focus on delivering compassionate care benefit from lower staff turnover, higher retention, recruitment of better qualified staff and better health outcomes.

Moreover, caregivers who are able to express compassion for patients, families and each other experience higher job satisfaction, less stress and a greater sense of teamwork. Similarly, there is an opportunity to explode the myth that a compassionate, kind and empathetic Government cannot be a competent one. Jacinda Ardern has made it clear that she is aware of the need for the clarity of focus that can co-exist with kindness.

So the opportunity here is for blending empathy and structure. I want to unpack these themes and talk about the conditions necessary to nurture kindness and empathy. In this respect I want to talk about how relationships and time are key principles for re-focusing the mental health system. Further to that, I want to talk about structure: namely, Better standards and regulation, workforce development, and a shifting of weight of emphasis of interventions from treatment (which will of course still take up a substantial proportion of service activity) to prevention and protection.

But first, I want to talk to spend some time outlining the problem we face in broad terms, and to frame the discussion foremost in the social determinants of mental health that must be addressed at a structural level, lest we end up just patching people up and sending them back into the toxic environments that produced their distress in the first place.

We know that the underfunded health system has not been coping with increased demand for mental health services for far too long.  Since 2007/08, there’s been a 60 per cent increase in people accessing mental health services, but funding increases have been less than half of that over the same period. The rate of youth suicide in New Zealand is the highest in the developed world, as reported by the OECD. A recent report looks at how well countries perform in relation to the UN Sustainable Development Goals. New Zealand comes last in the “Good Health and Well-Being” category – 38th overall. But it’s the high adolescent suicide rate that is really highlighted in the report. The rate of 15.6 youth suicides per 100,000 people puts NZ at the bottom of the table.

We already know that too many people get lost in the mental health care system, between primary care, acute care, and all the layers in-between. It can be confusing for patients, and service providers are hard-pressed and often aren’t funded for the number of referrals they are receiving. When people come forward for help, all too often, they see GPs who are struggling to help people presenting with mental health difficulties. Often, short time slots and patient expectations mean that they leave with a prescription for medication, which may not be the most effective way of helping them.

A recent meta-analysis showed that people are less likely to start pharmacotherapy than psychotherapy, and less likely to finish the treatment too. It’s also clear that current brief models of psychotherapeutic intervention are not long enough. Recent studies show that perhaps around 16 contacts are needed in order to make a difference in the course of mental health difficulties that patients present with. Services are funded for nowhere near this. And this is just at the primary care level. In services that were originally designed to meet the needs of people with more complex and / or enduring mental health needs, service development and provision has been lacking for some time, producing incredible strain for families and those working in these services alike, resulting in needs being unmet for those who wish to use the service, and burnout and high staff turnover for the services trying to function in very demanding circumstances.

On the one hand, the increased rate of presentations is encouraging as it means that we have a health system where people are actually going to their GPs and mental health services to get help – many don’t even make it that far, and those barriers need addressing. But it is not good that people need this help, in increasing numbers, and that our system is clearly not coping.

What is driving these terrible statistics, this real human suffering and need for help?

At a broad level, we know from much research and many reports by the WHO, the OECD and other institutions that mental health and many common disorders are actually shaped to a great extent by the social, economic, and physical environments in which people live. A whole-of-life approach seems to be important, understanding that different influences exist in the prenatal period, through pregnancy, early childhood, adolescence, working and family building years and through to our older years (and not just dementia consequences) and that all this is highly related to gender and ethnicity too. Parenting is incredibly influential: how we are parented, and how we in turn learn to parent others too.

But it is the broader social determinants of mental health and well-being that “Capitalism with a Human Face” might influence. Things like material conditions; that is, income, access to resources, food and nutrition, water, sanitation, housing, safety, and employment, as well the conditions of that employment.

Other aspects of ‘place’ also play their part in determining health and wellbeing – neighbourhood deprivation and resources, the opportunity to participate in the life of one’s community, as well as the standard and capacity of local services such as schools, healthcare, and social services. The influence of family fragmentation, dislocation from cultural practices, language, shared values and the impact of colonisation and the intergenerational impact of these experiences – all these are important determinants too. All these are social determinants of not only common mental health disorders, but also sub-threshold mental disorders that people delay seeking help for, for many different reasons.

Yet, the approach that is often taken is not to locate the source of these problems in the social, economic and physical environments in which they are generated. Rather, the dominant discourse is where the location of dis-ease, difficulty or dysfunction is located within the individual – meaning that the sufferer carries the blame for their suffering, and the onus is put upon them to make changes to fit in with the world they find themselves in, as if this is the only choice left.

Indeed, if we think of the world as an atomised universe of individuals, I can see why we might think this. And the pressure is all around us, – through the medicalisation of distress and therapies that focus upon changing how we think – to fit into a reality that is precarious and pernicious in its influence. The modern traits of society – individualism, materialism, consumerism  – have all risen at the same time as declines in levels of individual and social well-being as well as social integration. Or course, there are many economic and social advantages in living our modern lives, but at what cost to ourselves and our communities? Do we have that balance right?

I’m not advocating a return to the dark ages, far from it. But I do argue that contemporary capitalist consumer culture appears to corrode and undermine social solidarity, such that the individual is expected to stand alone, and lip-service is paid to the notion of community. Modern economic conditions mean that those who are dependent on their own labour for a living have had their conditions eroded to the point of insecurity, sometimes on a day-to-day basis. This has resulted in the proportion of the working population that can also be classified as being in poverty rising at an alarming rate.

One of the problems with a rising of materialism in consumer cultures like ours is the undermining of any deeper sense of purpose or meaning about what a good life is and should be about. I saw this in my professional advisory and research role in Canterbury after the quakes, where the very literal jolts delivered into many people’s lives made them pay attention to what is valuable to them, and many took, and are still taking, radical steps to orient their lives towards people and places and their connections to them, rather than things and objects they can purchase. There was a realisation that what defined them was not their consumption choices, rather it was how they spent their time, and who they spent that time with.

But are such levels of mental illness as we experience in New Zealand an inevitable consequence of modern life in high-income societies?

Is modern life inevitably rubbish?

That doesn’t seem to be the case at all. Rates of mental illness vary substantially between rich societies. There is a strong relationship broadly showing a much higher percentage of the population have a mental illness in more unequal countries. Inequality is associated with threefold differences in prevalence: in Germany, Italy, Japan and Spain, fewer than 1 in 10 people have been mentally ill within the past year; in Australia, Canada, New Zealand and the UK it is more than 1 in 5 people, and in the USA more than 1 in 4.

So, why do more people tend to have mental health problems in more unequal places?

Psychologist Oliver James uses an analogy with infectious disease to explain the link. What James terms the ‘affluenza’ virus is a ‘set of values which increase our vulnerability to emotional distress’, and he claims that these values are more common in affluent societies. They lead to a high value being placed on acquiring money and possessions, looking good in the eyes of others and wanting to be famous. He goes on to make the case that these values increase the risk of depression, anxiety, substance misuse and personality disorder. You can just imagine what the impact of social media has had, and the premium it has attached to looking good in the eyes of others, as we catalogue shares, likes, comments, and delete those posts that are not liked enough for fear of being perceived as not popular enough.

Philosopher Alain de Botton argues that our anxiety about our social status is ‘a worry so pernicious as to be capable of ruining extended stretches of our lives’. When we fail to maintain our position in the social hierarchy we are ‘condemned to consider the successful with bitterness and ourselves with shame’. Indeed, Professor Michael Marmot has a long and distinguished research track in his Whitehall studies of civil servants in the UK showing how important social status is to our wellbeing, without us even consciously being aware that it is.

Economist Richard Layard portrays us as having an ‘addiction to income’ – the more we have, the more we feel we need and the more time we spend on striving for material wealth and possessions, at the expense of our family life, relationships and quality of life.

And so the treadmill continues, until something happens and we fall off. And we are told that it is in our power to get back on again, if we take the right medications or get the right therapy to change ourselves, because the status quo is the status quo, and it is us that have to adapt. This minimises the significance of culture and values, and locates a deficit in the individual which needs to be rectified, rather than actually addressing the atomisation and isolation of that individual from purpose, and their lack of connection to others with whom they share beliefs and values, never mind the wider social determinants of mental health.

My argument is that unless we address precarious work, poor housing, and limited opportunity to secure a good diet, and educational opportunities addressing increasing inequalities, ultimately, we will continue with this production line for poor mental wellbeing and increasing mental health problems that we have created. When we are frozen out of good housing, good healthcare, good education, good work, we are caught up in processes that lead us to what is at best, a boring and monotonous existence, and at worst, the risk of real misery and all its attendant future focused anxieties, hopelessness, and intergenerational transmission and negative cycles of impoverishment.

This is where ‘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. Our contemporary cultural discourse of materialism and individualism is a trap which drives us into locating the problem and the solution in the individual, through medicalisation or individual therapy, when it is clear that the reality is that we are social beings and that we derive purpose and well-being largely through being connected positively with others. A huge opportunity lies before us. The attitude of the newly formed Government looks promising.

Centred on these ideas of social support, this next part of my talk focuses more on the principles which we can draw upon to help to address these mental health problems, the practical implications of these principles, and how these contribute towards a solid platform for reform.

First: 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 these 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.

Secondly, I want to talk about Time. In our modern lives, we have commoditised time very efficiently. Time is literally money, and we value it in these terms. In fact, we only really agreed on the uniform adoption of time as a result of the industrial revolution and public transport systems designed to get workers all to the workplace at the same time. Local time differences between places as close together as Manchester, London and Kent in the UK were in three different time zones. And with the arrival of public transport timetabling we effectively all sync’ed watches and it has been so ever since, wherever you go. But without making and apportioning time for it, 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 relationships to develop. As I mentioned earlier, 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.

Thirdly: Better Standards and regulation. Others have talked about the re-establishment of the Mental Health Commission tasked to regulate and exercise governance of the mental health sector as a while, for example Kyle MacDonald. I won’t go into that here, apart from acknowledging that I think that this is sorely needed.

When mental health workers try to help people, often they generate new solutions or ways of working where best-practice guidelines already exist. This may be 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 an 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.

Fourth: 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.

Fifth and finally in this talk; 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, and to encourage individuals, families and communities to take steps to prevent and protect themselves and each other from harm, for example through monitoring social media usage and connections, or suicide prevention measures. 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 signalled 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 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.

Should we have a National Mental Health System?

This is something I’ve been reflecting on a lot lately, and I do think that there is a debate to be had here. I do distinguish between a National Mental health Service and a National Mental Health System. I believe that if we are talking about a system with stronger regulation and governance in the shape of a reconstituted Mental Health Commission, and new body that commissions services to better mental health standards, and to develop a workforce better able to meet those standards, then a stronger centre can help to achieve this. The balance between the local and the centre as we have it right now means fragmented care as local health boards fund services that do not have tightly enough defined mental health service standards, and commission at a relatively micro-level without enough resources, leading to services being commissioned in a fragmented way, and a patient experience that lacks continuity of relationships and inadequate time to address their mental health needs. Furthermore, a commissioning structure that works more closely with the centre can also take advantage of closer coordination with those agencies that have influence of the social determinants such as housing, meaningful and adequately paid employment and education that influence mental health.

Where I am cautious is large players moving in to provide services and operating in ways that constitute a monopoly situation, giving very little choice for central commissioners who wish to contract to provide services. So, we are stuck in the dilemma of the contract state, where Government is the contractor, and service providers that fulfil these contracts are too small to offer continuity and capacity that our population requires to meet their mental health needs, or too large and swallow up other providers leaving no real choice for commissioners, and the danger of re-negotiated terms of trade in favour of the provider rather than the communities that they are contracted to serve.

My final thought on this is that there would need to be a lot of work done on a regulatory framework to manage these tensions, and this isn’t isolated to the case of a national mental health system. I’d be interested in your thoughts in the discussion shortly.

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 at a national level. 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 talk, 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 – looking at NICE, the New Zealand Guideline Group and PHARMAC for exemplars of practice.
  • 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 talking in the election campaign 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 we need to be thinking about here. And we should be starting now.

Thank you for your attention.

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