‘Once in a generation’: The crucial passages from the mental health inquiry

A hugely important report seeks to effect a ‘paradigm change’ in NZ mental health services. Here are the essential findings and recommendations.

The Minister of Health today released He Ara Oranga (Pathways to Wellness): the Report of the Government Inquiry into Mental Health and Addiction, a publication which followed a series of meetings nationwide by an appointed panel. The government response to the findings will not be issued until the new year.

Below, an edited extract from the report, authored by a panel chaired by Professor Ron Paterson, drawn chiefly from the executive summary.

Read more about the mental health inquiry with our cheat sheet here.

We recognised from the start that this Inquiry represented a ‘once in a generation’ opportunity for change. All over the country, people told us they wanted this report to lead to real and enduring change – a ‘paradigm shift’.

Over 2,000 people attended public meetings at 26 locations around the country. Over 5,200 submissions were made to the Inquiry. Over 400 meetings were held with tāngata whaiora, their families and whānau, other members of the public, health and other service providers, Iwi and Kaupapa Māori providers, community organisations, researchers and other experts.

Over 50–80% of New Zealanders will experience mental distress, addiction challenges or both in their lifetime. But some people are more at risk. A range of social determinants are risk factors for poor mental health: poverty, lack of affordable housing, unemployment and low-paid work, abuse and neglect, family violence and other trauma, loneliness and social isolation (especially in the elderly and rural populations) and, for Māori, deprivation and cultural alienation.

New Zealand has persistently high suicide rates. Annual suicide rates reported by the Office of the Chief Coroner have increased over the last four years, with the 2017/18 suicide rate the highest since 1999. Every year, 20,000 people attempt to take their own life.

Strong themes emerged from the people we met and submitters. People shared deeply personal experiences, motivated by a desire to tell their stories and bring about change. We heard a lot of heartache and sorrow, but also stories of hope and recovery.

For Māori health and wellbeing, recognition of the impact of cultural alienation, generational deprivation, affirmation of indigeneity, and the importance of cultural as well as clinical approaches emphasising ties to whānau, hapū and Iwi emerged as strong themes.

For Pacific peoples, the adoption of ‘Pacific ways’ to enable Pacific health and wellbeing was a theme – a holistic approach incorporating Pacific languages, identity, connectedness, spirituality, nutrition, physical activity and healthy relationships.

People said that unless New Zealand tackles the social and economic determinants of health, we will never stem the tide of mental health and addiction problems. There are clear links between poverty and poor mental health. People need safe and affordable houses, good education, jobs and income for mental wellbeing.

Submissions described a lack of clear leadership and oversight at a national level. People talked about what can be achieved when mental health and addiction is a priority area for government and there’s a clear leadership and direction from a mental health commission with a powerful statutory mandate. They asked for local leadership and innovation to be supported. We saw and heard about many examples of grassroots leadership by people with lived experience.

New Zealand’s mental health and addiction problems cannot be fixed by government alone, nor solely by the health system. We can’t medicate or treat our way out of the epidemic of mental distress and addiction affecting all layers of our society. We need to ensure practical help and support in the community are available when people need it, and government has a key role to play here. But some solutions lie in our own hands. We can do more to help each other.

Despite the current level of investment, we’re not getting the outcomes we want for our people. The outcomes for Māori are worse than for the overall population, and Māori are subject to much greater use of compulsory treatment and seclusion. There are also unmet mental health needs for Pacific peoples, disabled people, Rainbow communities, the prison population, refugees, and migrants. The estimated reduction in life expectancy for people with severe mental health or addiction challenges is 25 years. Our persistently high suicide rates are of major concern.

Our mental health system is set up to respond to people with a diagnosed mental illness. It does not respond well to other people who are seriously distressed. Even when it responds to people with a mental illness, it does so through too narrow a lens. People may be offered medication, but not other appropriate support and therapies to recover. The quality of services and facilities is variable. Too many people are treated with a lack of dignity, respect and empathy.

We do not have a continuum of care – key components of the system are missing. The system does not respond adequately to people in serious distress, to prevent them from ‘tipping over’ into crisis situations. Many people with common, disabling problems such as stress, depression, anxiety, trauma and substance abuse have few options available through the public system.

By failing to provide support early to people under the current threshold for specialist services, we’re losing opportunities to improve outcomes for individuals, communities and the country.

We also fail to address people’s wider social needs. Initial expansion of culturally appropriate services has stalled, and there has been little investment in respite and crisis support options, forensic step-down services in the community, and earlier access to a broader range of peer, cultural and talk therapies.

Despite a lot of consensus about the need for reform, we are yet to take a bold, health-oriented approach to the harmful use of alcohol and other drugs and to provide a wider range of community-based services to help people recover from addiction. Our approach to suicide prevention and the support available to people after a suicide is patchy and under-resourced. Tackling the social and economic determinants of mental health and wellbeing requires a coordinated, integrated approach from social services.

It’s time to build a new mental health and addiction system on the existing foundations to provide a continuum of care and support. We will always have a special responsibility to those most in need. They must remain the priority. But we need to expand access so that people in serious distress – the ‘missing middle’ who currently miss out – can get the care and support they need to manage and recover.

We propose major changes in current policies and laws, supported by significant increases in funding. Our recommendations cover 12 broad areas.

Expand access and choice from the current target of 3% of the population being able to access specialist services to provide access to the ‘missing middle’ of people with mental illness or significant mental distress who cannot access the support and care they need. Given current prevalence data suggesting one in five people experience mental health and addiction challenges at any given time, an indicative access target may be 20% within the next five years. New Zealand has deliberately focused on services for people with the most serious needs, but this has resulted in an incomplete system with very few services for those with less severe needs, even when they are highly distressed.

An explicit new access target must be set, supported by funding for a wider range of therapies, especially talk therapies, alcohol and other drug services, and culturally aligned services.

Transform primary health care so people can get skilled help in their local communities, to prevent and respond to mental health and addiction problems. Responding appropriately to people with these challenges should be part of the core role of any general practice or community health service.

Strengthen the NGO sector to support the significant role NGOs (including Kaupapa Māori services) will play with the shift to more community-based mental health and addiction services. The NGO sector is an increasingly important contributor to the delivery of government-funded mental health, addiction and wider health and social services.

Take a whole-of-government approach to wellbeing to tackle social determinants and support prevention activities that impact on multiple outcomes, not only mental health and addiction. Despite the substantial benefits of focusing on prevention and promoting wellbeing, especially early in life, the balance of resources has not shifted to prevention and long-term investment in our future. Multiple agencies are engaged in fragmented and uncoordinated activities that target similar outcomes. A proposed social wellbeing agency would provide a clear locus of responsibility within central government for social wellbeing, with a focus on prevention and tackling major social determinants that underlie many inequitable outcomes in our society.

Facilitate mental health promotion and prevention with leadership and oversight from a new commission, including an investment and quality assurance strategy for mental health promotion and prevention. Although there have been some excellent national campaigns, such as Like Minds, Like Mine, a plethora of different programmes are delivered by many organisations; some may not be sound. A more organised approach, with quality-assured programmes, would benefit schools, workplaces and local communities.

Place people at the centre to strengthen consumer voice and experience in mental health and addiction services. People with lived experience are too often on the periphery; they should be included in mental health and addiction governance, planning, policy and service development. Consumer voice and role should be strengthened in DHBs, primary care and NGOs. Families and whānau should be supported to be active participants in the care and treatment of their family member, subject to the wishes of the individual patient. Too often they are excluded by service practices, based on misconceived privacy concerns.

Take strong action on alcohol and other drugs by enacting a stricter regulatory approach to the sale and supply of alcohol; replace criminal sanctions for the possession for personal use of controlled drugs, with civil responses; support that law change with a full range of treatment and detox services; and establish clear cross-sector leadership within central government for alcohol and other drug policy. These steps are needed in response to the harmful use of alcohol and other drugs and the devastating impact on individuals, families and communities.

A much bolder approach to alcohol law reform is justified, given community concerns and evidence-based recommendations from the Law Commission and other agencies. The criminalisation of drug use has failed to reduce harm around the world. A shift towards treating personal drug use as a health and social issue is required to minimise the harms of drug use.

Prevent suicide. Urgently complete and implement a national suicide prevention strategy, with a target of a 20% reduction in suicide rates by 2030. New Zealand’s persistently high suicide rates were one of the catalysts for this Inquiry. Suicide affects people of all ages and from all walks of life, with thousands of New Zealanders touched by suicide every year. Suicide prevention has suffered from a lack of coordination and resources. Reducing suicide rates should be a cross-party and cross-sectoral national priority. Suicide prevention requires increased resources and leadership from a suicide prevention office. Suicide bereaved families and whānau, who are at increased risk of suicide, need more support, and the processes for investigation of deaths by suicide, which are often slow, traumatic and costly, need to be reviewed.

Reform the Mental Health Act. Repeal and replace the Mental Health (Compulsory Assessment and Treatment) Act 1992, to reflect a human rights approach, promote supported decision-making and align with a recovery and wellbeing model, and minimise compulsory or coercive treatment. The Mental Health Act is out of date, inconsistent with New Zealand’s international treaty obligations and sometimes results in trauma and harm to compulsorily treated patients. The use of compulsory treatment orders varies around the country, and there is far too much use of seclusion and restraint, especially for Māori and Pacific peoples.

Establish a new Mental Health and Wellbeing Commission to act as a watchdog and provide leadership and oversight of mental health and wellbeing in New Zealand. There has been a general lack of confidence in leadership of the mental health and addiction sector over many years, since disestablishment of the original Mental Health Commission. A new Commission is needed to provide system leadership and act as the institutional mechanism to hold decision-makers and successive governments to account.

Refer to the Health and Disability Sector Review for consideration, broader issues such as the future structures, roles and functions in the health and disability system, including the establishment of a Māori health commission or ministry. During the Inquiry, significant structural and system issues, including concerns about the current DHB model, and the transformation required in the primary health care sector, were raised. The Health and Disability Sector Review, announced part way through this Inquiry, has a wider scope and is better placed to consider those issues.

Establish a cross-party working group on mental health and wellbeing to reflect the shared commitment of diferent parties to improved mental health and wellbeing in New Zealand. Mental health is too important to be a political football. Similar initiatives are in place in the United Kingdom and Canada, and some support exists for a similar concept in New Zealand. A cross-party working group would provide an opportunity for members of the House of Representatives to collaborate and advocate for education, leadership and legislative progress on mental health and wellbeing.

The changes we have recommended are intended to transform our approach to mental health and addiction – to prevent problems developing, respond earlier and more effectively and promote mental health and wellbeing. Implementation will require policy decisions and legislative change backed by a commitment to a long-term funding path. We are confident of the cost-effectiveness of greater investment in the targeted areas.

Change will take time. It must be sustained over a long period, but we need to start now. Some of the necessary changes can and must happen promptly. People have waited long enough.

Acting collectively, we can improve our mental health and wellbeing.


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