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SocietyApril 3, 2017

Can the Ministry for Vulnerable Children succeed where CYF failed?

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New Zealand’s record on child abuse and neglect is a scar on our conscience. A new agency seeks to change that. Expert Emily Keddell explains what it’s intended to, the pitfalls it could face, and that controversial ‘vulnerable children’ label.

On Saturday the government launched the Ministry for Vulnerable Children (Oranga Tamariki), replacing Child, Youth and Family. It was one of many recommendations to emerge from a major review by the Ministry of Social Development of New Zealand’s care and protection system, culminating in the 2015 Final Report of the Expert Panel on Modernising Child Youth and Family. The review explored not only the shortcomings of CYFs, but also the wider system of agencies, community groups, and non-governmental organisations responsible for caring for NZ kids.

One who has been following every step in the new agency’s emergence is Dr Emily Keddell, a registered social worker, senior lecturer at the University of Otago, and contributor to the Reimagining Social Work blog. She will also release a report on these issues next month through The Policy Observatory.

We asked her what the new agency is hoping to achieve, how “child abuse” is defined, and how it all fits into the government’s “social investment” approach.

What was wrong with Child, Youth and Family? What are the problems that the Ministry of Social Development is trying to solve with these reforms?

Emily Keddell: There were some serious longstanding issues. The 2015 and 2016 State of Care reports show very variable practice for young people in care permanently, ranging from some very good experiences of care through to really terrible experiences. There was a lack of cohesion between CYF and other branches of the child welfare sector. There was a lack of resourcing of services of all kinds, leading to conflict over thresholds and variable services for people. There was little attention to prevention of child abuse and neglect. These are serious issues that needed addressing.

What is the Ministry of Social Development trying to achieve here?

They’re aiming to establish a more coherent system, to be more systematic in their approach to both statutory and NGO services. The basic proposal is to remove the part of the Ministry of Social Development that responds to child abuse and neglect – that is, Child Youth and Family – and to create a new central agency: the Ministry for Vulnerable Children (Oranga Tamariki). This agency will have five arms: prevention, intensive intervention, care services, transition out of care, and youth justice services. Most of these broad functions, though, as I understand it, will be contracted out to NGOs, so this central management agency will oversee how NGOs deliver these services.

A still from a Ministry for Vulnerable Children video. Inset: Emily Keddell

The name, “the Ministry for Vulnerable Children” has been controversial. What is your take on it?

The term “vulnerability” is a codeword here for children who require care and protection services. Because that’s all they’re responding to. They’re not including, for example, services for adults experiencing domestic violence. It’s quite a specific population that they’re separating out.

The main challenge is that this can exclude from the ministry’s remit the services that address known causes or contributors to child abuse. By that I mean the broader social context that parenting happens within. This is really important. We know that parenting stress has persistent correlations with poverty, with poor housing, with community factors, and with access to health services for adults, particularly mental health services. But the new ministry doesn’t have the power to address any of those issues. There’s no ability to force change in those broader factors that shape the context of parenting.

One of the foundational building blocks for these reforms is the investment approach. What does social investment mean to you and how is this way of thinking shaping the way the new ministry is being structured?

The social investment approach was first coined here in the welfare reforms of 2011, where it was clearly defined as a mechanism by which we would reduce the forward liability of the state – that is, we would reduce government spending over time.

It is important to point out that this is quite different to how other nations use the term “social investment”. Other nations use the term, for example, to mean increasing benefit payments available to improve people’s long-term outcomes over time. We’re not using it that way at all. We’re saying that we’re going to spend money now as long as it saves us money later. If we only define our desirable future outcomes in terms of reduced fiscal cost, then everything else becomes secondary.

In the child welfare context, not only is this likely to conflict with what is most beneficial for families – who may require expensive services for a long time – but achieving these outcomes is equated with earlier removal of children and placement into stranger foster care. The assumption is that providing more foster care, sooner, will stop children costing the state in the future. But these expected positive outcomes are unproven, both fiscally and in terms of outcomes for the child. The outcomes of foster care are very mixed – which is one reason why many countries are working harder to support families, wherever possible, to retain the care of their children. So, in New Zealand, we should be creating a broad policy landscape that focuses on prevention alongside foster care. I’m concerned that the focus on foster care will leave little in the kitty for the prevention side of the equation.

Has there been any pushback against this approach?

Interestingly, this conflict of aims has played out in the design of the actuarial model for supporting the social investment approach. Ernst and Young was commissioned to produce a report on this, but the report’s authors quite sensibly said that the overriding aims should be social and health goals, not fiscal goals. Ernst and Young also noted that we can’t just look at long-term outcomes, because it is methodologically difficult to assign causation or even strong correlations between events that occur in someone’s early childhood with events that occur 20 years later. Other factors could be intervening. This is especially important if a programme was not aiming to affect that outcome, because an NGO’s funding might rely on it.

Accordingly, the Ernst and Young report looks at including short-term outcomes as well as longer-term outcomes. It also includes some community variables, not just variables that relate to the individual, to get a fuller picture of what is influencing outcomes over time. For example, do they have access to good education in their local community? What’s the level of provision of community-level resources or supports? What’s the economic opportunities available in their local community, beyond what the individual has control of? If these things are not included in your actuarial model, then correlations might appear to relate only to the individual, rather than a combination of individual and community-level factors.

You’ve written before about the way that how one defines the “problem” of child abuse and neglect has implications for which solutions seem appropriate. How is this playing out here?

There are several implicit assumptions within the Expert Panel Final Report. One is that the proposed prevention policies are very much focused on the individual family. Although broader social contextual issues are mentioned, the Report implies that it is families who have the problems that cause them to abuse their children; so we need to just teach them how to be better parents – or else we remove their kids. However, a broad reading of the literature of causation says that it is multiple interacting factors that contribute to child abuse and neglect – right across the family, the community, and the macro-environment. To focus only on the family is short-sighted.

Another related assumption is that child protection should be separated out from other types of harm to children, such as child poverty and access to housing and healthcare. But from a policy perspective, it’s better to view these factors as interrelated, then to treat reducing child abuse and neglect as one of a number of “coalescing goals”. The increased emphasis on working across government might help alleviate this, but the separating out of the new Ministry for Vulnerable Children could also exacerbate it.

It’s obviously too early to say how these reforms will play out, but what do you see as the risks and opportunities?

The major concern is that there will be a big increase of permanent removals of children, because there is limited attention to addressing wider contributing factors, combined with a much stronger emphasis on removing children “at the earliest opportunity”, and a diminished emphasis on whānau and kinship-care. There is very little cognisance in the whole Expert Panel report of some of the harms of removal, or the very mixed outcomes of research into foster care. Obviously this is an issue for all families, but particularly for Māori who are overrepresented in their contact with child protection system.

That’s the doom and gloom picture. On the positive side, there is a lot more cognisance of what children in the permanent care system might need to achieve better outcomes, much more emphasis on how those young people transition into adulthood without a family to help them, and a much more systematic focus on improving service coordination. Also, our rates of hospital admission for child abuse-related injury have quietly been dropping for the last ten years. It is also possible that our child death rates, while high, might be dropping too – it’s hard to tell as they vary a lot from year to year. Finally, out in the NGO sector, there is the potential for better investment in intensive preventative services – such as Triple-P and Intense Family Preservation Services, as well as partnerships with iwi – to help them do what they’ve set out do. Time will tell.


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SocietyApril 3, 2017

Our public health system is world class, and desperately needs to be better, in mental health especially

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A range of globally recognised public health concepts could improve our current system, many of which go beyond simply chucking money at the problem, writes Haimona Gray. 

In my relatively brief 28 years of life I have been a paid defender of the public health system, a paid apologist for the public health system, a paid vocal critic of the public health system, and a patient of the public health system (no payment required).

Throughout all this I have discovered two things to be true: we have a world-class health system, and we desperately need to improve it.

The purpose of the public health system is both ethical and practical. We need our population to be supported into good health as part of the unspoken social contract we as a populace have agreed to with our government. More cynically, but no less true, we also need a working public health system so our population can continue to work, purchase things and progress through our economic system.

Burwood Hospital, Christchurch. Photo: Health.govt.nz

But merely having a health system is not enough. It also needs to deliver.

Below, some globally recognised public health concepts that could improve our current system, most of which go beyond the simplistic throw money at it! Most.

A good health service is accessible

Public healthcare being accessible is kind of the whole point, and as a nation our record is patchy.

According to Ministry of Health statistics, 94.9% of New Zealanders are enrolled with a Primary Healthcare Organisation (a GP, to you and me). An impressive statistic, but it doesn’t tell the whole story.

Inequality of access is not simply a concern around Emergency Department waiting times, though that matters. Nor is it about GP patient lists being full, though that matters, too. Often the biggest barriers to accessing health care are geographic and financial.

The issues are not having time, transport, or money to put towards attending distant health services, missing work to seek medical advice for themselves or loved ones, are a reality in so many of our communities.

These are not anecdotes but examples from Patient Experience research undertaken in New Zealand hospitals by internal DHB services and supported the Health Quality and Safety Commission, who do great work in this field.


Introducing the Spinoff’s new mental health column, Getting Your Shit Together, by Kristina Cavit


Our hospitals are filled with repeat customers, while this isn’t surprising if someone has a long term medical condition, there’s a large contingent who don’t and would be better supported outside a hospital setting.

Exact figures around what percentage of Emergency Department admissions this group makes up aren’t readily available but in my experience it is significant.

A misunderstood but important innovation our system and public psyche needs to accept is distance health services.

Telehealth and remote triaging of low-risk medical issues has been discussed widely by community health groups, and even implemented by the Ministry of Health and health service providers to positive results.

To evolve from its current state to a vital part of our public health system will require both connection to community services to really create large scale change, but it’s a positive step.

Pop culture has acclimatised us to a world of robot doctors magically fixing us with lasers and nano-robots but for many a world without a doctor in front of them is daunting. This is understandable, but once we learn how to deal with it better outcomes will follow.

A good health service communicates meaningfully with its patients

If the idea of the public health system is to achieve positive health outcomes with its patients, it should be vital to engage with patients in a way which helps them continue to get better once they are discharged.

Sadly, fear of effectively communicating with non-Anglo Saxon patients has been a cornerstone of most medical education in this country’s history.

Arguments from such notable former health ministers as Helen Clark against “Cultural Safety” practices have stifled our health education system from teaching how to treat all of its patients to achieve the same level of health.

While indigenous health academics and groups such as the New Zealand’s Nurses Organisation have been national leaders of this debate, concern around identity politics has held us back from putting patients’ needs ahead of concerns around treating people differently.

It is not too much to expect medical professionals to communicate with patients in the most effective manner: being mindful of cultural practices or beliefs, or bringing in whānau to create a support structure around medication or follow-up visits, or things as simple as not asking if they have a nickname because the doctor is too lazy and apathetic to try to learn how to say the patient’s name.

Putting patients and their families off visiting public health services for things like vaccinations risks the health of us all. The goal of public health services is to put positive patient outcomes first, regardless of distractions like anti-Political Correctness whingers without medical degrees or obligations to “do no harm”.

A good health system is interconnected

Anyone who has gone to a public health service only to be referred to another service in another building (or city, or island), will understand the time and goodwill wasting that can come with our public health system.

This is an unfortunate quirk of complex systems, but it also represents a failure by the Ministry of Health to progress secure patient data sharing and appointment booking IT systems.

In a speech to Whānau Ora services late last year, then deputy PM Bill English singled out and applauded Māori health IT company Whānau Tahi for their work in this field – specifically connecting disparate, community based health services to each other to allow one point-of-contact for their clients and making it fully auditable.

IBM, Orion Health, and others have dedicated substantial money to building similar systems. It is the future, and one with many added perks such as greater and richer data for research, and eventual cost savings.

A good health system takes mental health seriously

We have one of the worst rates of suicide in the OECD, we have jails full of people with mental health and addiction problems. We are in a serious predicament.

It is time we treat mental health support services as not just vital services on their own, but also as vital preventative measures to greater health and societal issues.

There is no revolutionary technology, policy directive, or whole-of-system approach to solve this. Only adequate funding and greater support for frontline staff will make a dent in our shameful history of negligence and underfunding.

Of all the great challenges our health system faces, including the many I didn’t have the time or knowledge to properly articulate, mental health services represent the greatest opportunity and the greatest risk if we continue to underfund it.

Television personalities raising awareness matters. Talking with our whanau about what we all can do support each other matters. Words matter, but unless our frontline services are funded to deal with the scale of mental health issues in our communities we will be applauding ourselves for doing nothing, for inaction.


The Society section is sponsored by AUT. As a contemporary university we’re focused on providing exceptional learning experiences, developing impactful research and forging strong industry partnerships. Start your university journey with us today.

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