Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

Review of the

Continuum of Mental Health

Services Funded by the District

Health Boards

in the

Auckland Region

December 2002

ForewordIn April 2002 the Minister of Health, the Hon Annette King approved the terms of reference for the Mental Health Commission to undertake an independent review of mental health services in metropolitan Auckland. The Review covered the three District Health Boards, Auckland, Counties Manukau and Waitemata. The Commission engaged a review team to undertake the work and used a reference group as a sounding board in the early stages of the process.

There have been high expectations that the Review would solve most of the problems in the mental health sector. It will not do that. What it does do is provide a way forward for Auckland which involves a change in the arrangements for planning and co-ordinating service delivery, an immediate relief from the pressure on acute inpatient beds and a longer term commitment to addressing the funding path and the contracts and service specification framework.

The Review Team listened to over 400 people, many of them staff who do the real work day in and day out and many of them consumers and families who must be the final arbiters as to whether we have a mental health system in Auckland that works.

The Review Team received a strong message from staff that despite some pockets of real innovation they had no sense of being part of a co-ordinated system with a coherent and consistent vision and were frustrated that their work was not as effective as it might be. For families and service users their experience was often of a system under pressure more intent on deciding why they did not fit than on meeting their needs.

The Review Team also analysed all the major reports on Auckland services over the years and considered all the reports provided by management. It was the voices of staff and service users that provided the most compelling case for change.

The action plan that was generated by the Review was refined in consultation with the three DHB Chairs and their CEOs. The Commission is confident that the six actions provide the basis for dealing with the problems that are adversely impacting the delivery of an effective mental health service in Auckland. The Commission is also confident there is the will and the capacity within the sector in Auckland to embrace the recommendations and move forward.

We wish to acknowledge the work of the Review Team and in particular thank the many people who willingly provided advice, guidance and information during the Review.

Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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Jan Dowland Bob Henare Mary O’HaganChair Commissioner Commissioner

Contents

FOREWORD.................................................................................................................2

CONTENTS................................................................................................................3

GLOSSARY..................................................................................................................5

EXECUTIVE SUMMARY...............................................................................................8

RECOMMENDATIONS AND ACTION PLAN.................................................................11

1. INTRODUCTION.................................................................................................14

1.1 The review process.........................................................................................151.2 Outline of this report......................................................................................16

2. THE AUCKLAND REGION CONTEXT.................................................................17

2.1 Demographic environment.............................................................................172.2 Current structure of mental health delivery...................................................192.3 Other government agencies providing services to people with mental illness..............................................................................................................................20

3. WHAT IS HAPPENING IN THE AUCKLAND REGION............................................21

3.1 People cannot move freely between the services they need...........................213.1.1 Primary care...............................................................................................223.2 Gaps and under supply in the provision of mental health services................233.2.1 Gaps after discharge from acute inpatient units.........................................243.2.2 Capped and uncapped services...................................................................263.2.3 Specialist services......................................................................................263.2.4 The ‘three percent rule’...............................................................................273.3 Access difficulties created by the standard of service provision....................273.3.1 Monitoring...................................................................................................283.4 A demoralised workforce...............................................................................293.5 Access difficulties for particular age groups.................................................293.5.1 Children and at risk youth...........................................................................293.5.2 Older people................................................................................................303.6 People with mental illness and drug and alcohol dependency......................303.7 Issues for Maori.............................................................................................303.8 Pacific Peoples...............................................................................................313.8.1 Co-ordination and access............................................................................313.8.2 Service responsiveness................................................................................313.8.3 Resourcing...................................................................................................32


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3.8.4 The Pacific mental health workforce..........................................................324. WHY THERE ARE PROBLEMS.............................................................................34

4.1 Leadership and shared vision........................................................................344.2 Funding constraints and uneven distribution of resources............................354.3 Workforce capacity and capability................................................................354.4 Planning, funding and contracting processes................................................364.4.1 Services needed...........................................................................................364.4.2 Communication between funders, providers and other stakeholders.........374.4.3 Communication between funders and providers regarding contracting... .374.4.4 Communication and co-operation between providers................................374.4.5 Clarity about the role of NGO providers....................................................384.4.6 Effectiveness of the NDSA...........................................................................384.5 Operational systems and procedures in provider organisations...................38

5. PATHWAYS TO IMPROVEMENT..........................................................................40

5.1 Action (1): Appoint a General Manager, Regional Mental Health Services and establish an Auckland Regional Mental Health Service Coalition to co-ordinate services within and across the three DHBs in Auckland..................415.2 Action (2): Provide additional capacity for accommodation with intensive support and crisis respite services.......................................................................425.3 Action (3): Allocate adequate funding to the three Auckland DHBs to provide the required service.................................................................................435.4 Action (4): Ensure all contracts and service specifications support the implementation of an integrated continuum of services.......................................435.5 Action (5): Ensure primary care practitioners are integrated into the mental health continuum of services, through the implementation of the Primary Health Strategy.....................................................................................................445.6 Action (6): Establish policy and service linkages between government agencies at national and local levels...................................................................44

REFERENCES.............................................................................................................46

APPENDIX 1: TERMS OF REFERENCE........................................................................47

APPENDIX 2: MEMBERS OF THE REVIEW TEAM:......................................................48

APPENDIX 3: LETTER OF RESPONSE FROM CHIEF EXECUTIVES, AUCKLAND REGION

DISTRICT HEALTH BOARDS (3):...............................................................................49

APPENDIX 4: LIST OF MEETINGS HELD BY THE AUCKLAND REVIEW TEAM:..........57

APPENDIX 5: REFERENCE GROUP.............................................................................63

APPENDIX 7: HISTORY OF THE DELIVERY OF MENTAL HEALTH SERVICES...............71

APPENDIX 8: EXPENDITURE CURRENT AND GUIDELINE BY DHB, AS AT 30/6/2002

..................................................................................................................................74

APPENDIX 9: REVISED METROPOLITAN AUCKLAND MENTAL HEALTH STRUCTURES

AND RELATIONSHIPS.................................................................................................75

Appendix 10: Mental Health Structures and Relationships.....................................76


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Glossary

Acute Inpatient Services Mental health services for people with severe and acute symptoms who need 24 hour care in a safe environment.

BPFP By Pacific For Pacific

Capped Services Services contracted to provide care for a set number of people, these are usually specialist services. They have well-defined entry criteria.

CATT Community Assessment and Treatment Team

Community Mental Health Services that are day or residential, located outside of a Services hospital setting.

Community Mental Health A team of health professional and support workers that

Team provides assessment, treatment and support for people with mental illness.

Crisis Respite Home based or other community-based service for people in crisis as an alternative to admission to an acute inpatient service.

Crisis Team Specialised clinical services providing emergency assessment, stabilisation, treatment and referral to other services.

CYF Child, Youth and Family

DAPs District Annual Plans

DHBs District Health Boards

GPs General Practitioners

HFA Health Funding Authority

HHS Health and Hospital Services

HNZC Housing New Zealand Corporation

Kaupapa Maori Services Maori centred services offered within a Maori cultural context.


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Level 3 Services Full time support for people living in homes run by residential providers.

Level 4 Services Residential intensive long term support.

MHC Mental Health Commission

MoH Ministry of Health

National Mental Health A set of standards developed by the Ministry of Health Standards for use by mental health service providers to

improve quality of services and ensure consistency for people who use them.

National Mental Health An overall strategy for mental health covering the Strategy Government’s goals, principles and

objectives for mental health services. The strategy is set out in two documents – Looking Forward: Strategic Directions for Mental Health Services (1994) and Moving Forward: The National Mental Health Plan for More and Better Services (1997).

NDSA Northern DHB Support Agency Ltd – responsible for regional co-ordination of planning and funding of mental health issues.

Needs Assessment Comprehensive assessment of the requirements for individuals in their recovery. The assessment includes housing, vocational, income and general support needs.

NGOs Non Government Organisations

Primary Health Care The first point of contact with health services, e.g. GPs. Services These services are also responsible for

services for people with milder mental illness.

RCS Regional Co-ordination Service – responsible for the co-ordination of all levels 3 and 4 accommodation and rehabilitation placements across Auckland.


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Recovery Living well in the presence or absence of mental illness.

Residential Intensive Long Services that provide a structured closely supervised Term Support environment and assistance with behaviour

problems, and where residents may live indefinitely.

RHA Regional Health Authority

Secondary Health Care Specialist services that people can access when their Services needs cannot be met by primary care services.

Service Provider Organisation or individual that provides direct treatment or support to the individual or their family.

Service User A person who experiences, or who has experienced, mental illness, and who uses or has used mental health services.

Support Worker Non-clinicians who work with people with mental illness.

Uncapped Services Services with no caseload limit. These are usually core services.


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Executive SummaryMental Health services in the Auckland region are characterised by a large number of very committed people working hard to provide the best possible assessment, treatment, care and support for those who experience mental health problems. Nevertheless, the Review of Auckland mental health services has found that there are significant issues demanding attention. (See Appendices 1 and 2 for the Review’s Terms of Reference and Members of the Review Team).

The planning, funding, delivery and monitoring of mental health services are not satisfactory and must be modified to better suit the complicated environment that is Auckland. Both within and across the three District Health Boards (DHBs) the range of services required do not match service users’ needs as they proceed through their different stages of recovery. While there are regional mechanisms directed to regional planning and service provision, they do not appear to adequately address the metropolitan issues. Within the DHBs themselves, funding and planning activities do not adequately take into account input from service providers and other stakeholders. There is lack of integration among service providers, not only across the three DHBs, but also across the range of services delivered within a single DHB. The funding and delivery of mental health services in discrete service units exacerbates problems of service access and uneven investment by DHBs in some services.

Providers cannot collectively deliver a continuum of services to meet the needs of service users and their families. The continuum of services is compromised by:

Poor co-ordination between services, so that service users cannot move freely between the services they need

Gaps in the provision of services – some services for which there is a demand do not exist, and other services cannot cope with the numbers seeking the service.

Like some other regions, Auckland has not got the funding commensurate with its population needs. However, while funding constraints must be acknowledged, a shortfall in funding is not the only problem, or even perhaps the most critical problem at this point. Problems arising from under funding are made all the more acute by an uneven distribution of resources. Auckland region should be doing better with the level of funding it has. While it must also be acknowledged that additional funding will be necessary for the Auckland DHBs, extra funding is not in itself sufficient to resolve the systemic problems in the Auckland region.

The symptoms of a system under stress are numerous:Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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There is poor service integration, evidenced by gaps in services and lack of continuity for service users, who need to be able to move between services and levels of service to get the care they need at any stage.

Access to services is rationed through the use of a ‘3%’ rule, without adequate assessment being undertaken. In some circumstances, when individuals cannot get the care they need, they go to the emergency department of the hospital, or are picked up by the Police.

There is lack of information on services, including the nature and range of services available, criteria for entry or referral, and the point of contact for service users and their families. Lack of such critical information forms a barrier, not only for access of service users and their families, but also for liaison and referral between service providers.

Some services, particularly acute inpatient services, are overwhelmed. They have very little flexibility in how they manage fluctuating case loads. There is evidence that pressures are being transferred to community teams.

There are tensions between various services, including between:

o Capped and un-capped services, which is affecting the resourcing of some core services and the employment choices of workers.

o Support services and clinical services, including perceptions amongst support workers that they are under-valued by health professionals. On the other hand, some clinicians express concern about the quality of services provided by non-government organisations (NGOs).

o General Practitioners (GPs) and DHBs – many GPs consider that DHBs do not see them as partners in the continuum of services and express frustration in dealing with DHB services.

o Acute and long-term supported care – there is a lack of accommodation with intensive support (providing more intensive support than level 3 and 4 services), and providers are concerned about having to take people whose needs are outside of their contracted service.

o Acute and crisis respite services – there are insufficient respite services, which means that service users are forced to access the acute system.


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The role of the so-called ‘non-contracted’ accommodation providers is unclear and the quality of services they provide variable.

There is limited contact between regional planning mechanisms such as the Northern District Support Agency (NDSA) and the Regional Co-ordination Service (RCS), and providers.

There is some disagreement amongst DHBs on how to manage the complexity and fragmentation in the planning, funding and provision of services

There is a lack of leadership and a shared vision on how DHBs and providers can work together effectively.

Distress, frustration and cynicism are evident amongst service users and families.

Stress, low morale and concern about their ability to effectively perform under current conditions are evident amongst a large number of mental health workers.

Some sections of the Auckland population experience particular impacts of a troubled mental health system. Maori, Pacific people, and new migrant and refugee populations are particularly vulnerable. Especially affected are those who move frequently, who wish to use kaupapa Maori or Pacific services, or who have a limited choice of services in their local areas. In addition, children, young people, older people and those with drug and alcohol problems are not adequately catered for in the present configuration of services.

A number of impediments stand in the way of settling problems in the Auckland region. One issue is the failure of DHBs to co-operate with one another at the planning and funding levels, as well as at the service end in a way that delivers an integrated continuum of services. However, it must be recognised that underpinning problems of co-ordination between DHBs, are the significant differences within the practices of the DHBs themselves. The main issues are:

Resource allocation, funding and planning decisions are being undertaken by the DHBs without proper engagement with the DHBs’ own service delivery arms, and other service providers. The knowledge that service providers can bring to ensure cost-effective and well-targeted resource deployment is too often not taken into account.

A lack of procedures that make services work and ensure that those in need can access them. In particular, there is a lack of procedures for co-ordinating the care of individual service users across the service spectrum. The procedures and


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criteria for assessment, service admission and discharge are not transparent.

There needs to be, within and across the DHBs, a commitment to establish continuity of services directed to recovery outcomes. Despite the complex and entrenched nature of the problems, many of them steeped in history, there is a way forward. The action plan proposes a way forward which includes:

appointing a General Manager, Regional Mental Health Services and establishing a Service Coalition to manage the contracting and co-ordination of mental health services across the three Auckland DHBs (Action1)

providing immediate relief from the pressure on acute beds through providing additional packages of care (Action 2)

allocating adequate funding to the three Auckland DHBs (Action 3)

ensuring all contracts and service specifications support the implementation of an integrated continuum of services (Action 4)

integrating primary care practitioners into the continuum of mental health services (Action 5)

establishing better policy and service linkages across governmental agencies (Action 6).

There are strongly committed people working within the sector in the Auckland region and a strong commitment among service users to assist DHBs to move forward.


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Recommendations and Action PlanThe terms of reference required the development of an action plan. It was, therefore, important that the actions proposed addressed the problems identified by the Review and were accepted by the Auckland DHBs as achievable. The process of finalising the action plan involved a number of steps as follows:

Initial actions developed by the Review were submitted in draft to the Chief Executives of the three DHBs for comment (see Appendix 3 : Letter of Response from Chief Executives , Auckland Region District Health Boards).

A draft report including a proposed action plan was submitted to the Minister of Health.

The three Auckland DHBs were invited by the Minister to respond to the draft report and the proposed action plan.

A response was received from the three Auckland DHB Chairs “generally supporting Actions 2 through 6” but offering an alternative framework for co-ordinating and managing services across the three DHBs.

Further discussion involving the Ministry of Health, the Mental Health Commission and the three Auckland DHBs resulted in a reworked Action 1 that was acceptable to all parties. Initially Action 1, as recommended by the Review, involved the establishment of a Mental Health Agency as a separate legal entity to manage the contracting and co-ordination of mental health services across the three DHBs in Auckland. Concerns expressed by the Auckland DHBs about creating a new structure and a belief that modifications to existing arrangements would achieve the desired outcomes were taken on board and are reflected in the final action plan.


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Action Plan for Auckland Mental Health Services

Action (1): Appoint a General Manager, Regional Mental Health Services and establish an Auckland Regional Mental Health Service Coalition to co-ordinate services within and across the three DHBs in Auckland.Responsibility: Three DHBs through Board of DHB Shared Service Agency and the Ministry of Health.Task TimeframeDevelop job description for General Manager, Regional Mental Health Services

Immediately

Recruit General Manger, Regional Mental Health Services

Within two months

Develop Terms of Reference for Coalition and establish Coalition

Within two months

Review existing contracts and services March 2003Develop plan to further relieve blocks in the acute services (to include respite and intensive rehab options)

March 2003

Confirm Regional Plan April 2003Integrate the proposed actions in the action plan for Maori (Appendix 6) into the Regional Plan

April 2003

Develop an action plan that specifically addresses mental health issues for Pacific people.

April 2003

Action (2): Provide additional capacity for accommodation with intensive support and crisis respite services Responsibility: Initially three DHBs and later General Manager, Regional Mental Health ServicesTask TimeframeImmediate implementation of a limited number of accommodation with intensive support and crisis respite services

Immediately

Plan additional accommodation with intensive support and crisis respite services

By March 2003 for 2003/04 implementation


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Action (3): Allocate adequate funding to the three Auckland DHBs to provide the required servicesResponsibility: Ministry of HealthTask TimeframeReview and revise present funding plans for mental health in the Auckland region

1 April 2003

Action (4): Ensure all contracts and service specifications support the implementation of an integrated continuum of services.Responsibility: Ministry of Health, General Manager Regional Mental Health ServicesTask TimeframeReview contracts and service specifications

March 2003

Establish and operationalise care pathways

5 care pathways* to be implemented by June 2003

Establish monitoring process to ensure that contracted services are provided

June 2003

Mental health needs assessment and review of international clinical best practice to meet identified needs

September 2003

* Care pathways are to be defined and developed, but are likely to include those for older people, young people, those who are new to mental health services, and those with alcohol and drug addictions.

Action (5): Ensure primary care practitioners are integrated into the mental health continuum of services, through the implementation of the Primary Health StrategyResponsibility: General Manager Regional Mental Health ServicesTask TimeframeAssess opportunities for primary care practitioners to be integrated into the mental health continuum of services

Medium term

Action (6): Establish policy and service linkages between government agencies at national and local levels


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Responsibility: Ministry of Health and General Manager Regional Mental Health ServicesTask TimeframeEstablish policy and service linkages between governmental agencies at national and local levels.

Medium to longer term


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1. IntroductionThis report presents the Mental Health Commission’s review of the continuum of services1

funded by the three District Health Boards (DHBs) in the Auckland region, Waitemata, Auckland and Counties Manukau DHBs (see Appendix 1 for Terms of Reference and Appendix 2 for members of the Review Team).

The Review was called because of a number of serious issues affecting mental health services in the Auckland Region. A major and urgent problem is the pressure on beds in acute patient services, access to those services, and provision of intensive support after discharge from acute services. Further, there are serious systemic issues regarding the planning, funding, delivery and monitoring of services across the whole continuum of services. These issues include: access to and quality of mental health service delivery, gaps in services, the relationship between funders and providers, relationships amongst providers, and the overall co-ordination of services. An effective mental health system requires a well functioning continuum of services that has good working relationships between funders and providers, and strong linkages between services throughout the continuum.

The Review has focussed on what is needed to achieve an effective and responsive continuum of services, so that the broad changes needed in the mental health sector in Auckland can be put in place. The Review has not focussed on financial management, as the Ministry of Health and Mental Health Commission are undertaking a review of the application of mental health funding to mental health services (the ‘Ringfence Project’). Nor has the Review focussed on the specific types of services needed, or the quality of particular services (although quality issues around access to services have been identified). Focusing on deficiencies in the provision or quality of particular services would merely provide a springboard for a round of reallocation of resources within a system ill prepared to deliver services in the complex environment that is Auckland.

The Review concludes that there is a fundamental need to redesign the model of funding mental health services in Auckland so that providers deliver a continuum of services to proactively meet the needs of service users and their families, as well as meeting the aspirations of the people working within the mental health system. Once an effective continuum of services is in place, matters concerning the range and quality of services can be addressed by the General Manager, Regional Mental Health.

Up until the time of the last ‘Mason’ inquiry there were as many as 67 inquiries into some aspect of mental health services in New Zealand. In the course of this Review, it was not uncommon to hear statements such as “not another review”, or, “why should we think your review will make it better?” Consequently there is some scepticism that another review will really make a difference. Nevertheless, a large number of people made efforts to contact the Review Team. People wanted to be heard, and did really care about the mental health services in Auckland. Many suggestions were made for positive and forward looking initiatives. 1 While the Review Terms of Reference uses the term ‘continuum of care’, the Review uses the term continuum of services to reflect an emphasis on a whole of system approach, where care is part of services. Particular aspects of care are covered in the review’s consideration of access and assessment issues.Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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Mindful of the wide ranging concerns expressed, the Review has identified fundamental systemic issues that must be addressed, and developed a package of recommended actions that focuses on developing and maintaining an integrated continuum of services for service users.

The Review has found serious systemic issues in service planning, delivery and monitoring. The result is that the principle of the continuum of services is lost. The continuum of services has become compromised by a labyrinth of specifications and contracts that have inhibited the establishment of collaborative and trusting relationships and behaviours. Furthermore, there are inadequate operational systems and procedures to support service users in accessing and moving between the services they need.

Without doubt there is a funding shortfall in mental health services in the Auckland region. This has a major impact, both in terms of service quality and establishing and maintaining an integrated continuum of services. There have also been increasing expectations that mental health services will manage a wider range of conditions than they had previously managed.

While funding constraints must be acknowledged, a shortfall in funding is not the only problem in the Auckland region, or the most critical problem at this point. Problems arising from under funding are made all the more acute by an uneven distribution of resources, both within the Auckland region, and between Auckland and the rest of the country. The systemic problems in the Auckland region must be resolved so that better use can be made of current resources.

1.1 The review processMany individual interviews and group meetings were conducted in order to understand the factors impacting positively and negatively on the continuum of services. Those interviews were structured around three questions:

What is working well for mental health in Auckland? What is not working for mental health in Auckland? How can mental health services in Auckland be improved?

The Review commenced on the 30th and 31st of May 2002 with meetings of introduction to the Chairs and Chief Executives of each of the three DHBs in the Auckland region. During the course of the Review, the Chief Executives were briefed on two separate occasions on progress, findings and possible actions.

A large number of interviews and meetings took place in June, July and August 2002. The Review Team met with over 450 people, including: Service users


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General Practitioners (GPs) and Independent Practice Associations (IPAs)

Families and their support networks DHB Chairs, Chief Executives and Managers of Mental Health Services Funders and planners Contracted service providers - DHBs and Non-government

organisations (NGOs) Non-contracted providers Maori and Pacific communities and services Mental health service staff Unions Government agencies such as Police, Coroners, Housing New Zealand Corporation,

Work and Income and education providers Ministry of Health and the Mental Health Commission.

A full list of individuals and organisations consulted as part of the Review are set out in Appendix 4.

The Review Team also hosted two forums. The first was a workshop of 65 people. The second was a smaller forum of 25 key people made up of service users, families, unions, providers, planners, funders, Maori, Pacific peoples and NGOs. This forum was convened for the purpose of presenting the draft findings of the Review and discussing possible ways forward.

The Review Team benefited from the guidance of a Reference Group (see Appendix 5 for detail on its composition). The Reference Group met with the Review Team three times and provided valuable perspectives.

1.2 Outline of this reportSection 2 of this report describes the demographic context in which the three Auckland DHBs operate, and outlines the current structure of mental health funding and delivery.

Section 3 presents the key findings of the Review. It provides an overview of the main areas where the continuum of services is breaking down and there is evidence of a system under considerable strain. In particular: People cannot move freely between services they need There are gaps in services There are significant access difficulties for some groups including

Maori, Pacific, children, young people, older people, and those with drug and alcohol problems

There are access difficulties created by the standard of service provision


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There is low staff morale.

Section 4 considers the multiple causes that have resulted in disjunctures in the continuum of mental health care in the Auckland region. The Review has identified the following key issues: Leadership and shared vision Funding constraints and an uneven distribution of resources Workforce capacity and capability Planning and contracting processes Operational systems and procedures.

Section 5 sets out the proposed actions to address the systemic issues facing the mental health sector in the Auckland region.

2. The Auckland Region ContextThe current mix of mental health services in Auckland has developed within the context of the demographic environment, and changes in mental health service delivery in the past twenty-five years. This section provides a brief overview of the demographic context, and outlines the current structure of mental health funding and delivery.

2.1 Demographic environmentThe three Auckland DHBs fund and provide mental health services for large proportions of New Zealand’s population. Waitemata has the largest population of all DHBs, at 11.5% of the national population. Counties Manukau has 10% and Auckland DHB 9.8% of the national population. Auckland DHB is one of only three DHBs with a sizeable population on islands (including Waiheke, Great Barrier and islands of the Hauraki Gulf).2

Table 1 shows the ethnic diversity, both within and between the three DHB areas. Across the three DHBs, the highest proportions of Maori and Pacific peoples are found in Counties Manukau DHB, at 16% and 18% of the population respectively. The highest proportion of Asian people is found in the Auckland DHB area, at 17%.

Table 1: Auckland Region DHBs: ethnic composition and age groups

DHBAuckland Waitemata Counties/Manukau

Number % Number % Number %InformationEthnicity:Pakeha 206457 56% 300103 70% 179802 48%Maori 29139 8% 39684 9% 61395 16%Pacific Island 43638 12% 26622 6% 69054 18%

2 Ministry of Health 2002 Atlas of New Zealand’s District Health Boards.Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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Asian 63240 17% 40350 9% 42501 11%Other 5169 1% 4461 1% 3264 1%Not Specified 20097 5% 18525 4% 19518 5%Total 367740 100% 429745 100% 375534 100%

Age by region and ethnicityAll 0-14 years 72423 20% 97239 23% 99945 27%All 65 + years 37935 10% 46353 11% 32646 9%

Maori 0-14 years 9036 31% 14754 37% 23964 39%Maori 65+ years 951 3% 867 2% 1971 3%

PI 0-14 years 14475 33% 9276 35% 25476 37%PI 65+ years 2133 5% 909 3% 2382 3%

Asian 0-14 years 12834 20% 9639 24% 10464 25%Asian 65+ years 2598 4% 1467 4% 1938 5%

European 0-14 years 31512 15% 58974 20% 35100 20%European 65+ years 29493 14% 40407 13% 24474 14%

Source: 2001 Census, data prepared for the Ministry of HealthThe Maori population has increased 21% between 1991 and 2001. One quarter of people of Maori ethnicity live in the Auckland region3. Although the Auckland region DHBs have lower relative proportions of Maori population compared to some other DHBs, nevertheless they include a substantial number of Maori.

The 2001 census shows dramatic changes in the Auckland region population over the last 10 years for Pacific peoples, who make up 11% of the region’s population4. There has been a 39% percent increase in the Pacific population since the 1991 census - two in every three people of Pacific ethnicity live in the Auckland region. The Auckland region DHBs are among the DHBs with the highest numbers and proportions of Pacific peoples. Manukau City has the largest proportion of Pacific peoples, with one in four residents in that city of Pacific ethnicity. In Auckland and Waitakere cities, one in seven people are of Pacific ethnicity.

The Asian population includes many ethnic groups with distinct characteristics, although 44% identify with the Chinese ethnic group. The rapidly growing Asian population rose to 6.6% of the population in 2001. Almost two thirds of the Asian population live in the Auckland urban area, with the majority living in central and southern Auckland. The three Auckland region DHBs have the highest concentrations of Asian populations, with Auckland DHB the highest5.

3 Auckland region refers to the regional council area. Source of data: Statistics New Zealand: 2001 Census Snapshot 4 Maori; Ministry of Health 2002 Atlas of New Zealand’s District Health Boards.4 Statistics New Zealand: 2001 Census Snapshot 6 Pacific Peoples; Ministry of Health 2002 Atlas of New Zealand’s District Health Boards.5 Statistics New Zealand: 2001 Census Snapshot 15 Asian People; Ministry of Health 2002 Atlas of New Zealand’s District Health Boards.Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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Table 1 shows that the Maori and Pacific populations are relatively youthful, compared to the total populations within each of the three Auckland region DHB. The proportion of the Asian population in the 0 – 14 years age group is similar to that of the total population in each DHB area. However, compared to the total New Zealand population, the Maori, Pacific and Asian populations are all relatively youthful. The median age of the Maori population in 2001 was 22 years, and three in eight were aged under 15 years. In 2001, the median age of Pacific people in the Auckland region was 21 years. Nearly two in five people (44%), of Pacific ethnicity are under the age of 15 years. In 2001 21% of the Asian population was in the 15 – 24 years age group, compared with 14% of the total New Zealand population.

The demographic data point to three substantial, and growing, populations with different age structures and associated needs, experiencing different socio-economic conditions, and having specific cultural requirements of mental health services. The mental health workforce needs to reflect the ethnically diverse populations of Auckland, and service providers need to ensure that planning, resource allocation and service development all take into account cultural needs. In the case of Maori and Pacific peoples, there are disproportionate numbers of young people who may need mental health services. Currently, there are kaupapa Maori services, but many are small and scattered throughout the region. There is no effective regional mental health strategy to eliminate health disparities for Maori. There is also an urgent need to increase the number and quality of the Pacific mental health workforce. In addition, the Asian population must rely on mainstream services as there is only one Asian psychiatrist and a small number of Asian staff employed within services. Further detail on Maori perspectives on mental health are contained in Appendix 6, which presents an action plan for Maori mental health services in the Auckland metropolitan area. Pacific issues are covered in Section 3.

2.2 Current structure of mental health deliveryAppendix 7 discusses some key changes that have occurred in the organisation, funding, planning and delivery of mental health services in the Auckland region. A primary driver of change has been deinstitutionalisation. Twenty-five years ago the majority of mental health services in the Auckland region were delivered from hospitals that provided inpatient facilities and attached outpatient clinics. The move away from residential care in large psychiatric hospitals brought considerable benefits to service users. However, there is evidence that deinstitutionalisation in Auckland also precipitated wide ranging and on-going funding problems. Furthermore, longer-term service users who had previously lived in a psychiatric hospital have experienced particular difficulties with the move to community-based services. The types of accommodation provided for service users have seen considerable change. Service users have had to rely on additional support through the benefit system for services that were formerly free. Accessing and


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negotiating such support places particular stresses on those with multiple problems.

The current structure of mental health service delivery in the Auckland region is undertaken within the framework of the NZ Public Health and Disability Act 2000, which requires DHBs to manage the funding and service provision roles within a single accountability arrangement. Each DHB has the fundamental role of securing the best health gain that it can for its population consistent with Government policy and within the constraints of the resources available to it.

The present Service Coverage document (which is the means by which the Ministry of Health on behalf of the Government, prescribes what the public should have access to) and its associated National Service Framework, have service descriptions for 8 components with 97 service specifications in total for mental health services. These comprise service specifications for alcohol and drug services (14), adult services (45), forensic (8), child adolescent and youth (16), and kaupapa Maori services (14). All these service specifications are applicable to the Auckland region DHBs, and add to the complexity and detail of what must be provided.

The three DHBs fund mental health services from 73 providers for an extensive range of services. Both the service delivery arms of the DHBs and NGOs provide, under contract, mental health services. DHBs provide most of the acute and community mental health services. NGOs predominantly provide, under contracts, residential care and supporting services. In addition to services provided within each DHB area, there are regional services funded and provided by the three DHBs. Regional services include Forensic, Alcohol and Drug and Eating Disorders. There are also a number of organisations that are not contracted by the DHBs providing accommodation services to people who have a mental illness.

There are two regional co-ordination services operating in the Auckland region: The Northern DHB Support Agency Ltd (NDSA) is responsible for

regional co-ordination of planning and funding of mental health services.

The Regional Co-ordination Service (RCS) is responsible for the co-ordination of all level 3 and 46 accommodation and rehabilitation placements across Auckland.

6 Level 3 services provide full time support for people living in homes run by residential providers, and level 4 services provide residential intensive long term support – see service descriptions in Mental Health Commission 1998 Blueprint for Mental Health Services in New Zealand, p.38.Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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2.3 Other government agencies providing services to people with mental illnessMany Government agencies either directly provide services for people with mental illness, or are involved with service users. The main agencies are:

Child, Youth and Family (CYF) provides care and protection and youth justice services to children, young people and their families. CYF interfaces closely with mental health services in providing support and care for children and young people with mental health issues.

Work and Income provides various services for service users including income support and employment search.

Police often become involved with service users when they cannot access crisis teams in a timely manner for appropriate treatment.

Housing New Zealand Corporation (HNZC) provides rental properties for community groups contracted to provide accommodation services to people with specialist housing needs, such as service users.


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3. What is happening in the Auckland regionThis section presents the key findings of the Review. It provides an overview of the main areas where the integrated continuum of services is breaking down.

The integrated continuum of services is a system where service users can move freely from service to service and get the quality of care they need for their particular stage of recovery. For a continuum to work effectively: The full range of services required by people with mental illness must

be available Individuals must be able to access those services Services need to be of the appropriate quality.

The development of pathways through a continuum of services is crucial to ensure the needs of service users are met.

The Review has found a system under considerable strain. This is evidenced by the following: People cannot move freely between services they need There are gaps in services There are access difficulties created by the standard of service

provision There is low staff morale There are significant access difficulties for some groups including

Maori, Pacific, children, young people, older people, and those with drug and alcohol problems.

3.1 People cannot move freely between the services they needClear care pathways that span the services of a number of providers are needed in the Auckland region. Care pathways are made up of connected services that provide specific treatment, care and support for people with particular types of mental illness, so that they can move through different services as required by the nature of their illness and their stage of recovery. Examples of care pathways that need to be developed include those for older people, young people, those who are new to mental health services, and those with drug and alcohol addictions.

The development of care pathways is crucial for: Overcoming the lack of shared vision in Auckland’s mental health

sector Developing consistency in procedures to smooth the transition

between services Ensuring that providers talk to each other


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Ensuring the diverse and changing needs of service users are met Ensuring that service users know what to expect from services.

Although the three DHBs have a regional approach to the planning and funding of mental health services, it does not appear to be effective. Service users who move across Auckland for whatever reason, are not always able to access the same range of services in each of the DHBs because the service configuration, access and discharge criteria, and management practices, are different. Service users and families experience problems in getting ongoing support when a service user living in one DHB area returns to the family home in another DHB area after hospital discharge. There appears to be little liaison across teams in different DHBs. Within DHBs, there are also problems in service users accessing the service they need when they need it.

Examples of the lack of a continuum of services, both within DHBs and across DHBs include: Widespread lack of knowledge across DHB specialist services and NGO

services regarding the nature of each service, the criteria for referral or entry, and the point of contact for families and service users. Lack of this critical information impedes the access of service users and their families, and also limits engagement, liaison and transfer of service users amongst service providers.

In circumstances where the service user ‘doesn’t fit’ the criteria for access to a service, often referrals are not made or assistance to access other services is not given. In desperation the service user may then seek help from the emergency department of the public hospital, or alternatively, the Police become involved.

People with various drug induced psychoses are neither catered for by acute inpatient services, nor by the regional drug and alcohol services.

Some DHBs are reluctant to contribute funding for regional services, believing that they can more efficiently provide that particular service within the DHB.

It is common for service users to be told "that's not the way we work in our service” when they try to explain their situation and the assistance they need for their distress.

A number of service users described the difficulties they have in adjusting to a new service provider when they move between different services. Service users find that they must learn their current service provider’s model of service delivery and ‘package’ their needs in a way acceptable to the provider before they can benefit from the service. If service users move between several services over time they might be confronted with having to ‘re-package’ their needs in three or four different ways to fit the service. Different service providers may need to have different emphases in their approach or treatment modalities. But it appears that service


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providers have no shared understanding of these differences, or procedures to smooth the transition between services. Service users should not have to continually adjust to the providers, and “re-package” their distress before they receive the treatment and support they need.

Many service providers find the lack of continuity between services a major impediment to delivering the best care they can for service users. Providers find it impossible to see where their service fits into the broader context. Providers want to feel that they are part of a whole, and that the work they do is validated and seen as important, not only within the organisation they work, but also within the wider health sector, and society.

3.1.1 Primary careThere are opportunities to strengthen the continuum of services through improving links between GPs and mental health services. Meetings with GPs, both as individual practitioners and as part of their IPA, confirmed that an integrated continuum of services must include access to suitable primary health care services. While the “NZ Primary Care Strategy” makes appropriate provision to acknowledge this intent, the reality for service users is quite different.

Many GPs consulted as part of the Review consider that they are not seen as partners by DHBs in the continuum of services. GPs expressed continued frustration in dealing with DHB services. In particular, they identified problems in accessing information about patients from mental health services.

GPs’ comments included:

“As a GP with a keen interest in caring for persons with mental illness in -----, I am appalled at the limited funding for health workers and the poor systems in place. We get so little information from mental health services as to when a patient is seen, what medications they take, when there is a follow up appointment, who is their case manager, the ‘passing the buck’ attitude of staff whenever a GP requests such information and hiding behind privacy issues”.

“GP access to outpatient notes and treatment is very poor. Little by way of written correspondence about patients – except from consultants. Privacy seems to override common sense”.

A critical issue is the need to remove the financial barriers to primary care that service users experience. One example of a useful approach is the ‘Procare’ initiative developed by an Auckland IPA. Funded by savings from other parts of their operation, Procare ensures responsive assessment, referral and treatment for service users. Procare considers that mental health services in Auckland would be assisted if there were:


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Specific and targeted funding for primary mental health Recognition of the efficacy of primary mental health care Recognition of GP willingness to offer expertise and strengthen their

contribution to mental health.

3.2 Gaps and under supply in the provision of mental health servicesGaps in mental health services become evident when service users cannot get the types of services and supports they need. This may be due to a lack of a particular service, or an under supply of a service. Gaps in services are not only evident in mental health and other health-related services, but also in the employment, accommodation and social services that service users need. The gaps in services experienced by particular groups are discussed in Sections 3.5 – 3.8 below.

The most mentioned gaps or under supply in services were in: Acute and intensive inpatient services Crisis respite services Medium and extended accommodation with intensive support,

preferably in a community setting.

Gaps at the more intensive end of the services continuum are often exacerbated by: "Capped" services that are contracted to provide care for a specific

caseload and consequently cannot meet demand Some specialist services that cannot meet demand The use of a ‘3% rule’ to ration access.

Service users and family members were concerned about the difficulty of accessing services when needed, rather than having to wait until the person became seriously ill.

"I know when I'm getting sick. However, I seem to have to get really crazy before they do anything to help me".

Service providers highlighted various gaps in the Auckland region, but the most mentioned gap affecting the continuum of service is the gap in provision of accommodation with intensive support. There was a widespread view among providers that this gap continues to be a major problem. Service providers also spoke of deficiencies in core clinical services, i.e. acute general psychiatry, both inpatient and community facilities. Providers find it difficult to refer service users to services that would offer them most benefit, at the time when needed.


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There was a concern expressed “that if Police are seen to be too accommodating they will get to carry more of the problem”.

The Police commented that they often become involved when individuals cannot access acute mental services, whether inpatient services or crisis teams. As a consequence, police cells are regularly used to contain people who have not offended, but who are in crisis. The Police expect mental health services to be accessible and responsive, without the need to rely on the criminal justice system to provide alternative accommodation. Nevertheless, there is considerable goodwill at a local level between the Police and mental health services.

It is considered that the General Manager Regional Mental Health Services, should undertake a mental health needs assessment and a review of international clinical best practice to meet identified needs (Action 4). This exercise would confirm those gaps in services identified in this Review, and identify any new components required for an integrated continuum of services for Auckland.

3.2.1 Gaps after discharge from acute inpatient unitsThe occupancy rates for acute inpatient services for each of the DHBs is very high. Table 2 presents occupancy rates for the year ended 30 June 2002.

Table 2: Occupancy rates for acute inpatient services, year end 30 June 2002

DHB Occupancy rate (%)Waitemata 96.8Auckland 88.3Counties Manukau 97.7Source: Auckland region DHBsThese rates clearly demonstrate that acute inpatient services have very little flexibility in how they manage the fluctuating nature of their caseloads. This has significant implications for the management of accommodation with intensive support. At any one time, all acute wards have service users that could be discharged if there were an appropriate facility available. The Regional Co-ordination Service (RCS), which is responsible for the co-ordination of all level 3 and 4 placements across Auckland, reported in July 2002 that 61 people were waiting for placements in level 3 and 4 housing. An additional 20 people were waiting for other intensive rehabilitation options. Thirteen of those 20 were in acute inpatient units. Seven weeks later 24 people were waiting in acute units for placement to residential or rehabilitation options.


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A nurse in an acute ward said “the number of acute beds is not the problem – it’s the need for and access to supplementary services such as rehab and supported accommodation”.

Frequently the acute inpatient service is confronted with the difficult decision of whether to discharge a person into supported accommodation, who is considered too unwell even though he/she may be stable enough not to require inpatient treatment. These particular service users often tend to be young, with a major mental illness complicated by substance abuse and a diagnosis of personality disorder. Some have rapidly relapsed shortly after a previous discharge, due to severe drug abuse. This group of service users has increased, both in severity and numbers in recent years.

The Review was given several examples of patients who were inappropriately discharged:

One patient was discharged to a respite facility to create a bed at short notice, although still acutely unwell. A couple of days later the patient was urgently readmitted following an incident in the middle of a very busy main road in the early evening.

Assessment indicated that inpatient care was the preferred treatment venue for one patient. Nevertheless, the patient was placed into respite at a rest home due to bed shortage in the inpatient unit. During a follow up visit a week later by a nurse, the patient picked up a carving knife, and self-inflicted wounds. Police and ambulance were called and the patient was admitted to hospital.

In acute inpatient services there is intense pressure on beds from new referrals and very limited options for other placements. In order to free an acute bed, service users are discharged into supported accommodation, although their needs are more complex than the provider is contracted to support. The lack of fit between the service and the specific needs of a service user impacts on everyone: the service user, the staff and other service users within the residence.


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NGO providers said:

“RCS talk about a match, we talk about a fit”.

“There is something missing in the design of services”.

One NGO Manager, when asked why they accepted “inappropriate” referrals stated that “if you don’t take someone, then you don’t get referrals. We waited 11 weeks to fill a vacancy in one house”.

Although there are questions about the quality of service of some non-contracted providers they nevertheless fill a gap in accommodation. The Review heard that some service users who are described as “having burned their bridges” with contracted supported accommodation providers or as “difficult,” find a home with these non-contracted providers.

There needs to be more medium term and extended accommodation with intensive support, preferably in a community setting, for people who need more on-going structured support and safety than can be provided by current supported accommodation options. Action 2 addresses this problem.

There have also been instances where service users have not received adequate assessment and treatment before discharge. The system must be robust enough to ensure that service users are properly assessed. If such requirements need legislative change, this matter should be addressed by the proposed General Manager Regional Mental Health Services in Action 4.

3.2.2 Capped and uncapped servicesOn the whole, the Review found that capped services, with their well-defined entry criteria and a specified caseload, tend to work well. Services that are contracted to provide care for a set number of people can regulate and define their workload. Specialist services tend to be capped, while core services are un-capped.

There appear to be considerable tensions between core services and specialist services, both locally and regionally, because of the practice of directing new money to specialist (and usually capped) services, while core services remain relatively poorly resourced. People who continue to work in the core services see, because of the population growth in Auckland, a rising demand for their services. Over time there has been a tendency for people working in the core uncapped services to want to work in specialist capped services where they do not have to face the pressures of unlimited demand.


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3.2.3 Specialist servicesA number of specialist services such as the Early Intervention Services and Intensive Community Teams appear to work extremely well. However, not all the specialist services are doing well. For example, the Regional Eating Disorders Service, which is uncapped, is severely under resourced. People with eating disorders cannot access inpatient and community support because of very high demands on those uncapped services.


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3.2.4 The ‘three percent rule’

The Review came across comments such as “doesn’t fit the 3%” and “not ours”.

Even if there are services available, service users may not be able to access those services when needed. In particular, service users reported experiencing considerable difficulties in accessing help that would enable them to stay out of hospital. It appears that a policy based on the National Mental Health Strategy guideline that funding should target the 3% of the population who at any given time are most severely affected by mental illness, is being used to ration access.

While it may be possible for such guidelines to be used to manage high demands on an uncapped service, this is not what the National Mental Health Strategy intended. The Blueprint makes it clear that development of this percentage was done primarily for national and regional planning, and any translation of these figures for requirements at a local level must take into account the local population and its needs.7 Targeting solely on the basis of 3% without adequate and appropriate assessment prejudices people’s access to services. It is clearly not acceptable to the service user.

3.3 Access difficulties created by the standard of service provisionConcern about standards of service creates problems of access for service users. There are quality issues, both in relation to particular services and across the continuum of services. Even though some services may be of high quality, the overall quality of service is compromised if there are gaps in the continuum, or access is difficult. Service users, families and clinicians expressed concern about the quality of services provided by some NGOs and DHBs. Some service users were satisfied with the level of service they were receiving but considered that their experience could change if their clinician moved on. Service users and family members reiterated concerns about the pervasive use of a medical model, rather than a holistic view of the circumstances and needs of service users.

"[the psychiatrist is] only interested in whether I am taking my tablets or not, not how I am doing".

A service user response to a call by clinicians for more “beds” was that, mental health services should be designed to “keep it okay for me to be in my own bed”.

Service users pointed to problems in accessing DHB crisis services. For example, they reported that some crisis teams do not return calls, particularly when they know there are other staff available. There were many comments from service users and families, about having to be in a 7 Mental Health Commission Blueprint for Mental Health Services in New Zealand p.viiReview of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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great deal of distress before they could access either their key worker or Community Assessment and Treatment Team (CATT). Refugee hostel staff reported that they have been told by crisis teams to take people to the emergency department of the hospital, or phone the Police. Families’ main concern was that their views and potential input were often ignored by services.

Concerns were raised about the difficulties in accessing CATT between 2300 and 0700 hours when calls are redirected to acute inpatient staff who respond unhelpfully; e.g. “have a hot bath – I’m awfully busy”.

While some clinicians are attempting to meet the National Mental Health Sector Standard through identifying early warning signs and developing relapse plans with the participation of service users and families, the reality is that key workers and psychiatrists in a number of teams are unable to respond as planned. The Review is aware of a call management service being piloted by the Healthline project in Hutt, Capital Coast and Waikato DHBs. The Healthline pilot may provide a more reliable means of helping to manage the acute caseload, which can be introduced in other DHB areas.

The quality of service delivered by different community based NGOs varies considerably. This diversity feeds the distrust of clinicians, is reflected on the whole NGO sector and thus fuels the tension between DHBs and NGOs in some areas. Many DHB clinical staff expressed deep concern about the quality of services provided by NGOs and a reluctance to refer individuals to them. Currently there appears to be no process in place to address quality issues, nor to provide feedback on performance to providers. However, it must be acknowledged that many providers have joined Platform, the national association of support and community development in mental health, and appear to be working collaboratively to improve quality of services provided to service users.

The Review found that a number of people currently accommodated by non-contracted providers are receiving inadequate mental health services. The mental health service in Auckland is heavily dependent on non-contracted accommodation providers that house people who are not currently able to be, or choose not to be, accommodated within the contracted supported accommodation. The standard of non-contracted accommodation appears to vary, with indications that it can be poor in some cases. Planning for the diverse housing requirements of service users needs to happen through on-going dialogue between health and housing agencies, and with the involvement of service users, so that the changing requirements of this group are addressed.

3.3.1 Monitoring Monitoring the quality of service provision, and understanding what is required in the standards, appear to be variable. It is essential to an


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integrated continuum of services that all providers meet the requirements of all relevant standards.

While the 1997 National Mental Health Standards were required to be implemented in Hospital and Health Services (HHSs) by July 2000 and by NGOs in December 2000, the Health Funding Authority (HFA) and Ministry of Health monitoring processes did not ensure that all providers understood the intent of each standard and implemented them. Two of the three Auckland DHB services have been accredited by Quality Health NZ, while the third DHB is undergoing an audit process co-ordinated by another external agency.

Some of the NGOs have either sought, or are seeking external certification or accreditation of their services, but many will struggle to meet the revised National Mental Health Sector Standard and certification by October 2004. Smaller NGOs report that they do not have the infrastructure and resourcing to undertake certification successfully.

3.4 A demoralised workforceIn the course of the Review, many staff expressed a strong desire to have an effective mental health system that clearly added value. However, for many staff working in mental health, frequent reorganisations of the sector have dampened any enthusiasm to aspire to a whole of system approach.

Large number of interviews showed that many staff working in mental health services receive little job or professional satisfaction, although there are a few exceptions. While many staff, both individually and in teams, demonstrated a very strong commitment to the needs of service users, they are working very hard and feel under considerable stress. Across the system there is widespread frustration and low morale.

Community teams are angry when they know the next call could be about a young person who is too old for Starship, too young for the acute ward, too unwell for the inpatient unit and not able to be placed through Child, Youth and Family.

Psychiatrists watch daily, with mixed feelings, their colleagues who are ‘getting out’. One psychiatrist said, “being a psychiatrist is like playing Russian roulette except that all the chambers have a bullet.”

Senior nurses watch new staff come into the workplace and ‘burn out’.

Staff do not feel that they are involved in a worthwhile and valued enterprise. One psychiatrist commented, “you can’t look families in the eye knowing that you cannot provide what is needed – the case load is overwhelming”.


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Demoralisation has significant implications for staff recruitment and retention. It is hard to recruit to a job that is seen as fighting for survival and even harder to get people to feel willing to stay when they see little reward or sense of job satisfaction. This situation also has implications for achieving and maintaining a quality service.

3.5 Access difficulties for particular age groups In Auckland those at both ends of the age spectrum – younger people and older people – are particularly vulnerable to missing out on the specific care and support they need. Services are just not available for them.

3.5.1 Children and at risk youthCYF has experienced a significant reduction in resources to provide residential placements for at risk adolescents and children. At risk youth with both care and protection needs and mental health issues are not being adequately catered for in either the mental health or the care and protection sectors. At times this situation has resulted in considerable tension between mental health and CYF staff in the Auckland region.

DHB teams identified that 15-19 year olds often cannot find services appropriate to their age group or particular needs. For some, the insular silos in both health and other social agencies that deliver specific categories of service are a major blockage to young people receiving help when it is needed. Other groups whose needs are not met include: Children and young people with mental illness who also have a head

injury or an intellectual disability Young people with both substance abuse and mental health issues.

Access criteria for specialist teams such as dual diagnosis, early psychosis or mobile intensive teams exclude young people. As a result their needs are not met.

3.5.2 Older peopleThe service specification and contracting framework make it difficult to provide the range of services that older people need. A particular example is the difficulties for older people accessing home support services as such services are for people with age-related physical disability and not for people with ongoing mental ill health who have reached the age of 65.

3.6 People with mental illness and drug and alcohol dependencyCo-existing mental illness and drug and alcohol dependency is very common, but many service users in this category cannot access services that are equipped to help them with both problems. Organisations such as Salvation Army, City Mission and other church based relief services, commented that people with drug and alcohol dependency who also have mental illness, and who are transient, tend to slip through the gaps in mental health services.Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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There are inadequate detoxification services in Auckland. These were meant to be provided when the Summary Proceedings Act was passed into law removing the ability of Police to detain those found intoxicated in public places for 24 hours. Police consider that the lack of accessible assessment services for people with alcohol and substance abuse means that by default Police become the detoxification service.

3.7 Issues for MaoriA plan specifically for Maori mental health services has been prepared and is attached as Appendix 6. The plan points out that Maori are much higher users of crisis, acute and forensic services than non-Maori, and are more likely to suffer from alcohol and drug disorders. Consultation with key Maori stakeholders identified that there are many small fragmented and stressed kaupapa Maori services scattered throughout the Auckland region. There are many gaps in services, and strong support from Maori for a more strongly preventative model of mental health services that focuses on primary health services. There is a need for Maori provider workforce development.

There is further work to be done in planning mental health services for Maori, particularly in respect to: Building effective relationships with key stakeholders in the Maori

community Establishing a comprehensive ten year regional mental health strategy

for Maori Over time, planning and funding local Maori mental health care

continuums Developing fiscally prudent objectives and long term plans for investing

in kaupapa Maori services.

3.8 Pacific PeoplesAll By Pacific For Pacific (BPFP) services that were interviewed expressed optimism and enthusiasm. There was a common view that the BPFP models of service delivery are working well in each of the DHBs. While staff, elders and service users associated with these services all had some reservations, they were adamant that these services shared the following strengths:

BPFP services were receiving good support from their respective DHBs

Good networks were developing between the BPFP services There was an increasing level of acceptance of BPFP services by

most of the ‘mainstream’ providers BPFP services were beginning to develop positive links with various

NGOs


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The two most consistent benefits these services felt they contributed to mental health care for Pacific people were:

The delivery of culturally appropriate services The ability to offer choice to Pacific service users and their

families.

Despite these positive statements; Pacific service providers, service users and their families voiced a number of significant areas of frustration, including service co-ordination, accessibility, responsiveness and resourcing. Another critical issue is Pacific workforce development.

3.8.1 Co-ordination and accessAlthough better links are being established between some services, there was also a sense that poor regional planning, co-ordination and collaboration have made it harder and more expensive to deliver services to the Pacific community. Effective co-ordination is particularly hard to achieve, given the patterns of transience and mobility of the Pacific population. Services have to work very hard to ensure that service users do not “fall through the cracks in the system”.

One person summed up the general view that “the boundaries between DHBs do not take into account the movement of people”.

3.8.2 Service responsivenessDespite positive initiatives at individual and local levels, there is also a view that there are poor links and communication between support services and clinical services. BPFP services feel undervalued and in some instances are treated with considerable discourtesy by health professionals in the clinical services.

Pacific mental health workers said that their cultural expertise is disregarded, and that the “mainstream view of Pacific providers is paternalistic”.

There is some evidence to suggest that Pacific people under-use mental health services because of cultural understandings of mental illness and the appropriate interventions. For many Pacific people, odd behaviour may be explained in terms of spirit possession, curses or visits from one’s ancestors. The tendency of health professionals to diminish these practices as superstition is simply ethnocentric arrogance, and does nothing to break down the cultural barriers to Pacific people using mental health services.


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3.8.3 ResourcingWhile there is optimism and commitment in BPFP support services, there is also a strong sense that these same services are inadequately resourced for the size of the task confronting them, and there is not a well-developed or coherent infrastructure to support them.

“Pacific people are over represented in first episode psychosis admissions. Three quarters of first episode clients are Pacific”

“Pacific clients present too late with high acuity”.

Perceived shortcomings in the range of services were highlighted: Considerable disquiet was expressed about the lack of specific Pacific

options for fulltime support for people living in homes run by residential providers, and for accommodation with intensive support.

A lack of early intervention and prevention services was identified. There is a lack of supported employment options, and no or low youth

services and drug and alcohol capacity. There are examples of Pacific health and social services that are not

contracted to provide mental health services, but nevertheless are asked to ‘step into the breach’. Apart from the obvious contractual inequity, these services do not have sufficiently or appropriately skilled staff to take on mental health care.

3.8.4 The Pacific mental health workforce

“Pacific health professionals are under pressure, feel isolated and unsupported by DHBs”.

Discussion about the Pacific workforce raised major issues. Firstly, the majority of people who spoke about Pacific workforce issues see a high need for capacity and capability development to increase the number and quality of the Pacific workforce. There are limited resources for staff development and limited opportunities to increase contracted FTEs in order to effectively address demand. The present workforce feels overwhelmed by the size of the task it is being asked to address. This in itself becomes a disincentive to recruiting more Pacific health professionals into the field of mental health.

Secondly, there are un-addressed tensions in relationships and accountabilities between mainstream clinical staff and Pacific non-clinical staff leading to ‘patch-protecting’ behaviours that deflect attention from the main task of providing quality services. There is a view that the quality of the service provided by Pacific services are clinically inadequate. There is little research on the effectiveness of Pacific models of care. Furthermore, there is a lack of national and regional strategic leadership


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and direction for Pacific mental health, and the current approach to Pacific workforce development is flawed.

There needs to be much more investment in Pacific workforce development at all levels. Clearly, if the DHBs see BPFP as the most appropriate way to address the mental health needs of Pacific service users and their communities, then there has to be a commitment to make sure they are sufficiently resourced to do the job. It is unacceptable to set up these services and then marginalise them. They must be an integrated part of the overall system.

It is proposed that the General Manager Regional Mental Health Services (Action 1) take responsibility for the development of an action plan that specifically addresses issues for Pacific peoples mental health services.


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4. Why there are problemsThere are multiple causes of the failure to provide a continuum of mental health services in the Auckland region. The issues identified in Section 3 not only reflect some of those diverse causes, but also in turn contribute to further fragmentation of services. It is clear that the integrated continuum of services has not only broken down with co-ordination failure at the regional level, but there are also practices and processes within the DHBs that are unsatisfactory. The Review has identified the following key areas affecting the development and maintenance of an effective and integrated continuum of services: Leadership and shared vision Funding constraints and an uneven distribution of resources Workforce capacity and capability Planning, funding and contracting processes Operational systems and procedures.

4.1 Leadership and shared visionA large number of people spoken to in the course of the Review highlighted the lack of any shared vision for mental health in the Auckland region. The lack of leadership and a shared vision are considered to be a critical cause of a range of problems besetting the continuum of services. For example, the lack of leadership and a shared vision are seen to be key drivers of: Low workforce morale and difficulties with recruitment and retention Differences in the way services have been planned for, funded, and

contracted The development of a number of "internally focussed services" Lack of linkages and communication between services.

The need for a shared vision is recognised by most people in the sector. However, one of the impediments to a shared vision is the existence of three DHBs in the Auckland region and the legislative requirements that each has to meet the needs of its own community.

While clearly there is leadership at the local service level, there is no single ‘metropolitan Auckland’ leadership. A number of senior clinicians with whom the Review Team met believed that leadership is as much a national issue as it is a regional or district matter. There was comment that mental health is made up of a large number of disparate groups with few connections across the system. People argued persuasively for clear mandated direction and authority at the national level, as well as for the Auckland region, especially in the planning of specialist services and the development of models of good practice.


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It is expected that the appointment of a General Manager, Regional Mental Health Services and the requirement to review existing specifications (Action 4) and develop care pathways (Action 4) will provide a sense of shared vision and leadership.

4.2 Funding constraints and uneven distribution of resourcesThere has been a 125% increase in nominal funding for mental health services in New Zealand over the period 1994/95 to 2002/038. This investment is redressing the historical legacy of under funding, but it is estimated that this increase accounts for 65% of the resourcing necessary to reach the Blueprint target across the country. The northern DHBs (comprising Northland, Waitemata, Auckland and Counties Manukau) are estimated to be funded to 58% of Blueprint requirements. Across the three Auckland DHBs there is variation in funding, with Auckland DHB funded at 67% of Blueprint target, Waitemata at 64% and Counties Manukau at 42%. The variation may be due to the distribution and local allocation arrangements between the DHBs for regional services. Overall, the Auckland region DHBs face considerable challenge and continue to be compromised in their ability to deal with the demand for services, both in the short and longer term. Consequently, a review of present funding plans for the three DHBs is recommended (Action 3). That review must be informed by the findings of the Ring-fence Project.

The Review has also found that funders and providers have misinterpreted Blueprint funding, believing it can only be applied to new services, not for additional capacity of existing services. It is unclear why this interpretation exists as it is not national policy. The capacity of the clinical base of acute inpatient services and community mental health teams has been jeopardised by this interpretation, which has favoured the development of new capped services. While ‘capped’ services are capably managing the caseload, ‘uncapped’ services are overwhelmed and in some cases have to manage in circumstances that are clearly unacceptable.

It appears that funding constraints and an uneven distribution of resources result in a short term focus on service provision and act as a disincentive to innovate or improve service delivery. Funding constraints have also impacted on the ability of funders to build an integrated continuum of services because funding has not been applied evenly across the continuum.

4.3 Workforce capacity and capabilityAn issue underlying many of the systemic problems is the development of the capacity and capability of the mental health workforce. It is difficult to develop and maintain an integrated continuum of services if there are

8 Ministry of Health August 2002 Advice to the Incoming Minister of Health: Background Briefing Papers p.65. Mental Health Commission data on current and guideline expenditure by the three DHBs vis a vis Blueprint guidelines, and compared with all DHBs, is presented in Appendix 8.Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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problems in recruitment and retention of workers. Low morale is pervasive among workers in the sector.

Both the quality and the quantity of the workforce need to be increased. There is a need for more people in specific occupations such as psychiatrists. The workforce also needs to be educated in using a recovery approach in their work, with a holistic approach to service provision, cultural responsiveness, developing the personal resourcefulness of service users and keeping service users linked to their families and communities.

The Maori and Pacific mental health workforces experience particular issues with regard to work-related stress, upskilling workers, requirements for workers in specialised areas, and supports for Maori and Pacific-based services.

People with experience of mental illness also have important roles to play in the mental health workforce, e.g. as advisors, in support roles and clinical roles. The workforce development needs of this group have been neglected. There is very little training and development for service users in advisory or support roles.

4.4 Planning, funding and contracting processes A wide variety of issues demonstrate deficiencies in planning, funding and contracting systems and procedures. The complexity of getting the right range, quality, variety and volume of services that fit together cannot be underestimated. There are many examples of fragmentation in how mental health services are currently planned, funded, and provided. Providers of mental health services in Auckland are not confident that the existing planning, funding and contracting arrangements are as informed as they need to be.

More dialogue at the planning and funding level is necessary if progress is to be made. Dialogue needs to happen between the Ministry of Health and the DHBs, as well as between the DHBs, providers and other stakeholders, including service users. There should also be opportunities to engage other government agencies in planning for mental health services, as there are significant interface issues with such agencies as the Police, CYF, HNZC and Work and Income that need to be addressed.

Contracting arrangements and supporting service specifications for mental health services do not seem to support a ‘whole of system’ approach to an integrated continuum of services. The National Service Framework does not support the need for an integrated continuum of services for people with a mental illness. Furthermore, the present contracting framework would seem to inhibit a regional ‘whole of system’ approach to the management of mental health services.

Current planning, funding and contracting issues are inhibiting:


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The identification and development of the full range of services that are needed

Communication between funders and providers and other stakeholders

Communication and co-operation between providers

Clarity about the roles of NGOs

Effectiveness of the NDSA.

These issues are outlined below.

4.4.1 Services neededWith the shift to a contracting model in the early 1990s, contracts with existing organisations that had previously delivered services through the Department of Social Welfare and Community Funding Agency were ‘rolled over’ through the new arrangements. Since that time, continued ‘roll over’ of contracts has become a consistent feature. The Review was told that some providers have contracts that are not considered to be appropriate to meet current needs but it is too hard for the funders to exit them.

Furthermore, the Review has found that formal contracts have been used extensively by funders as the vehicle to prescribe the nature of the service. The National Service Framework produces a consistent approach but also results in one-size fits all. The effect is that the contract reflects neither the specifics of the service nor the outcomes for service users.

4.4.2 Communication between funders, providers and other stakeholdersBoth the former RHA and HFA produced strategic plans for mental health using public consultative processes. These are the 1995 North Health Strategic Plan for Mental Health in 2010 and the HFA Strategic Plan for the Northern Region 1998-2003. It is unclear whether either of these documents continues to influence decision making on funding.

Unlike the earlier plans, the Regional Mental Health Plan 2002 - 03 has had little input from significant mental health stakeholders who now feel marginalised. Maori, Pacific Island, NGOs, DHB provider arms, GPs, service users and families have little confidence that the planning is inclusive, informed and relevant. During the time of the Review local and regional stakeholder networks were being set up. It is expected that these groups would have some input into future planning processes.

4.4.3 Communication between funders and providers regarding contractingThe relationship between those who fund the service and those who deliver it appears to be tenuous. Providers spoke of frustration at the lack of contact and interest from funders in the work of providers, and despair at the hoops and levels within the new bureaucracy. The Review heard from providers that had not been contacted by the funder in many years. The lack of relationship between the funder and the NGO providers contributes to the scepticism that the DHB


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funders will favour their DHB provider arm. Such scepticism is fuelled by the fact that funders have not invited NGOs to tender for any new contracts. NGO providers disputed the accuracy of NGO contract data provided by some DHBs to the Review. NGO providers said the information did not accurately reflect the contracts they had with the DHB, in terms of the nature of the services provided.

The providers also expressed dissatisfaction that there is no monitoring, feedback or research that establishes whether or not the services being funded are making a difference. Most of the providers and other stakeholders interviewed in the course of the Review have not been consulted about what they think works or does not work. Their vast experience and specialist knowledge in mental health is not considered or used by planners.

4.4.4 Communication and co-operation between providersThe previous contracting culture of the RHA and HFA operated within a competitive and commercial environment. That has led to tension between the providers of services and has created barriers, which still impede the relationships between the NGO and the DHB providers. The present contracting arrangements with supporting service specifications have also led to the emergence of service ‘silos’ that are inward looking and concentrate on delivering only what is exactly specified.

Workers at the coalface are told "your role is to meet our contractual requirements and if it is outside our contract we don't do it".

“We spend more time deciding on who we won’t see than seeing those that we are contracted to see”.

The emphasis on service prescription has been at the expense of building an integrated continuum of services with clearly defined points of access for service users. The emphasis appears to have been on the purchasing of components without resourcing the “glue” to integrate services. The present arrangements, together with the legacy of the competitive environment, have inhibited integration and collaboration between providers.

4.4.5 Clarity about the role of NGO providersWith the latest restructuring of health funding to the DHBs, the NGO sector was expected to participate in the regional networks recommended in Mental Health Commission advice to the sector in 2000. However, there has been no clarity about the future of NGO services. The removal of a community networking position to facilitate the development of community networks builds on the concern of the Auckland NGOs that they will continue to be excluded. At the NGO forum attended by the Review Team, NGOs described how they feel marginalised and patronised by the DHB system, yet some of the most innovative service delivery is occurring in the NGO sector. Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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4.4.6 Effectiveness of the NDSAThe complex arrangements of the NDSA, DHB Planning and Funding Teams, and Boards do not make it clear to NGO providers and other stakeholders exactly which organisation has the ultimate responsibility to contract services.

The Review has considered whether the NDSA should take a greater role in the overall co-ordination of mental health services, as it has a planning and funding skill set relevant to mental health. The presence of the NDSA and its role in the planning and funding of mental health services is an attempt by the three CEOs to address systemic issues across the entire service profile of Auckland collectively. The action plan builds on the intent to address matters collectively and provides for a service coalition to oversee service co-ordination and to inform the planning process across the three Auckland DHBs.

4.5 Operational systems and procedures in provider organisationsA number of shortcomings in operational systems and procedures have made it difficult to establish and maintain a successful, functional and integrated continuum of services. Areas that need to be addressed include: The inappropriate use of a 3% threshold instead of assessment to

determine access to particular services Needs assessment for individual service users Co-ordination mechanisms Criteria for discharge Protocols for the transfer of individuals from one service to another Quality control mechanisms Staff supervision procedures.

It is clear that the operational procedures of many providers are not developed to take account of their contribution to the continuum of services. There are several examples of this: One rehabilitation service received a call from the funder stating that a

new contract had been let for 15 residential intensive long term support beds and they were directed to start using them. The rehabilitation service had no idea of the model the provider used, what services would actually be provided, or what the provider’s linkages were as no one in the service had heard of this particular provider.

At times, in order to manage their caseload, teams change their admission and discharge criteria with little apparent regard for the consequential effect on other services.

Some services appear to have little or inadequate knowledge of other mental health services or of other social supports available in the community that make up the continuum. Such lack of information and


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rigorous management of entry leaves service users and families desperate at times.

The Review also found little evidence of effective co-ordination and operating protocols between mental health services and government agencies. This issue was raised in particular by Police.


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5. Pathways to improvementDespite the problems identified in this Review, there is a strong base from which to address the systemic issues facing the Auckland region mental health services. However, it will require focussed leadership, energy and passion. There are many committed people working within the mental health sector in the Auckland region, and a strong commitment among service users to assist DHBs to improve their service provision. Many staff have good collegial contact within their teams and often across agencies. The Review believes that it is within the capacity of people involved in mental health services in Auckland to fix the problems.

To enable this to happen there needs to be: A single accountability for the overall direction and leadership of

Auckland services A more inclusive and widely informed approach to the planning,

funding and provision of mental health services in the Auckland region Better operational systems and procedures to ensure that service users

can access and move between services when they need to Attention to workforce recruitment, retention and morale Adequate funding to provide the required services More collaboration between providers, whether they be DHBs or NGOs,

and with other government agencies More recognition of the contribution of primary care to mental health

services.

This report recommends the following actions, which are expanded in more detail below:

Action 1: Appointing a General Manager, Regional Mental Health Services and establishing a Mental Health Services Coalition to better manage the contracting and co-ordination of mental health services and inform the planning across the three DHBs in Auckland

Action 2: Providing additional capacity for accommodation with intensive support and crisis respite services

Action 3: Allocating adequate funding to the three Auckland DHBs to provide the required services

Action 4: Ensuring all contracts and service specifications support the implementation of an integrated ‘continuum of services’

Action 5: Ensuring primary care practitioners are integrated into the mental health continuum of services, through the implementation of the Primary Health Strategy

Action 6: Establishing policy and service linkages between government agencies at national and local levels.


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The package of actions reflects a desire to work within existing arrangements. There were persuasive arguments to establish a separate DHB specifically for mental health in Auckland. There was also some support for one of the three DHBs to take overall responsibility for mental health. However, another structural reconfiguration of services is not the preferred option at this time.

The process of finalising the action plan involved a number of steps as follows:

Initial actions developed by the Review were submitted in draft to the Chief Executives of the three DHBs for comment (see Appendix 3 : Letter of Response from Chief Executives , Auckland Region District Health Boards).

A draft report including a proposed action plan was submitted to the Minister of Health.

The three Auckland DHBs were invited by the Minister to respond to the draft report and the proposed action plan.

A response was received from the three Auckland DHB Chairs “generally supporting Actions 2 through 6” but offering an alternative framework for co-ordinating and managing services across the three DHBs.

Further discussion involving the Ministry of Health, the Mental Health Commission and the three Auckland DHBs resulted in a reworked Action 1 that was acceptable to all parties. Initially Action 1, as recommended by the Review, involved the establishment of a Mental Health Agency as a separate legal entity to manage the contracting and co-ordination of mental health services across the three DHBs in Auckland. Concerns expressed by the Auckland DHBs about creating a new structure and a belief that modifications to existing arrangements would achieve the desired outcomes were taken on board and are reflected in the final action plan.

It is recommended that:

5.1 Action (1): Appoint a General Manager, Regional Mental Health Services and establish an Auckland Regional Mental Health Service Coalition to co-ordinate services within and across the three DHBs in Auckland.

The Review has established that there is no coherent and co-ordinated system of accountability for the provision of mental health services across metropolitan Auckland. This has led to many providers not being able to function as effectively for service users as they should. For service users it often leads to a sense that there is not a responsive “system” willing and able to help. Without the appointment of a General Manager, Regional Mental Health Services with the authority and accountability for overall service co-ordination and the establishment of an Auckland Regional


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Mental Health Service Coalition, it is likely that problems with service integration and fragmentation will continue.

The purpose of the proposed new role and the establishment of the Auckland Regional Mental Health Service Coalition is to achieve maximum integration and co-ordination of services within and across all three DHB mental health services in Auckland. It is also to ensure a direct voice and active participation in regional funding decisions from the providers and other important stakeholders in services, and to ensure that contracts are reviewed, managed and delivered to achieve maximum integration of services for the service user.

The Auckland Regional General Manager Mental Health will report directly to the three DHB CEOs. The General Manager will be a member of the Board of the DHB Shared Service Agency and have overall delegated responsibility for the planning and funding of mental health services in the Auckland region and the integration and co-ordination of service delivery. This includes: Reviewing existing contracts and services Managing and monitoring contracts Ensuring the delivery of a co-ordinated and recovery focussed

continuum of services. Ensuring the quality of services Balancing the distribution of resources to ease pressure points, address

service priorities and respond to any shortfall in provider capacity. Managing the implementation of regional plans and ensuring a

consistent and co-ordinated approach to service development. Managing the interface between primary, secondary and tertiary

mental health services Playing a significant role in workforce planning, including input to staff

recruitment, retention and training across the sector.

The General Manager, Regional Mental Health Services will also provide overall clinical direction, leadership and oversight of the Auckland regional services.

The Auckland Regional Mental Health Service Coalition will have a suggested membership from the three DHB Mental Health Service Managers, three NGO providers, three clinical directors, two union representatives, three consumers, an alcohol and other drugs service provider, and a primary health care representative. There will be someone employed in the NDSA to provide organisational leadership and support to the Coalition.

The purpose of the Coalition is to promote an integrated continuum of services in metropolitan Auckland. The General Manager, Regional Mental Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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Health Services will use the expertise of the Coalition to inform and provide oversight of all tasks required to achieve service integration and co-ordination.

The Coalition will directly influence the work of the Regional Mental Health Funding and Planning Team, through regular meetings and through their employed “leader”.

Appendix 9 presents a diagram of the proposed mental health structure and relationships.

Appendix 10 provides more detail as to the proposed responsibilities of the General Manager and Service Coalition.

5.2 Action (2): Provide additional capacity for accommodation with intensive support and crisis respite services.

The immediate task of the three Auckland DHBs will be to establish additional accommodation with intensive support and crisis respite services. The Review confirms that the provision of intensive accommodation and crisis respite services is inadequate for the demand. This gap impacts on the capacity of acute services to manage the acute caseload. Either DHB or NGO intensive accommodation services, or a mix of both, are needed. There is also inadequate provision of crisis respite options, which can also place strain on acute services. These options could include acute home-based treatment services and crisis respite houses.

If additional capacity for intensive accommodation and crisis respite services is not provided, acute services will continue to be placed under an intolerable burden that will threaten their sustainability. Residual goodwill between acute and other services will disintegrate, and service users will not get the care they need.

TimeframeThe establishment and commission of more intensive accommodation and crisis respite services should be a 2 stage process:

Stage 1: the three Auckland DHBs should commission the provision of at least 20 packages of additional services, with either NGOs or DHBs. This work should start immediately.

Stage 2: General Manager, Regional Mental Health Services to commence planning for additional accommodation with intensive support and crisis respite services for implementation in 2003 – 04.

CostsSubject to confirmation from the ringfence project, unspent money from 2001 – 02 (should that be a finding of the ringfence project), along with Blueprint money for 2002 – 03, will be allocated to funding the urgent intensive accommodation and crisis respite services. An indicative cost is Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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given by the DHBs in their reply to the Review’s draft actions (see Appendix 3). The three Auckland DHBs should examine the funding requirements, taking into account the findings of the ringfence project.

5.3 Action (3): Allocate adequate funding to the three Auckland DHBs to provide the required service.

The current funding level has compromised the ability of the three Auckland DHBs to deal with the demand for services, both in the short and longer term. The three DHBs and the Ministry of Health must review and revise the present funding plans for mental health services in the Auckland region. The Ministry of Health must then release the funding necessary to provide the required services. The General Manager, Regional Mental Health Services should be involved in any review of funding arrangements. The funding review should address both short-term imperatives and the medium to long-term funding path.

Failure to address the funding will compromise the proposed continuum of services, with continuing fragmentation of services, service gaps, and declining workforce morale.

5.4 Action (4): Ensure all contracts and service specifications support the implementation of an integrated continuum of services.

Current contracts and their associated service specifications, together with the contracting processes, inhibit integration, innovation and collaboration between providers. The lack of regular service reviews, quality monitoring and the persistent rolling over of contracts without review of the effectiveness of outcomes for service users has also contributed to increasingly fragmented services.

It will be necessary to examine all contracts to ensure that services are properly linked to secure an integrated continuum of services.

Specific tasks include: Review of contracts and service specifications, including

identification of impediments to proper assessment, treatment and recovery.

Establish and operationalise care pathways, likely to include pathways for older people, young people, those who are new to mental health services, and those with drug and alcohol addictions.

A needs assessment to identify the best mix of components necessary to meet the needs of people in Auckland with a serious mental illness.

Establishment of an effective monitoring process to ensure that contracted services – including quality and recovery requirements – are actually provided.


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The Ministry of Health should assist the General Manager, Regional Mental Health Services and his/her Funding and Planning Team with this action because of the implications for the National Service Framework for mental health. It is a substantial piece of work in the medium to long-term that will require dedicated resources.

5.5 Action (5): Ensure primary care practitioners are integrated into the mental health continuum of services, through the implementation of the Primary Health Strategy.

There are financial barriers to the development of sustainable primary mental health care effectively linked to specialist mental health services as it contributes to an integrated continuum of services. The planning process of the DHBs needs to more effectively engage with primary health care providers and mental health services to ensure that primary mental health services are developed and integrated with secondary and tertiary services in the Auckland region. The General Manager, Regional Mental Health Services needs to establish closer relationships between primary and secondary mental health services to support the integrated continuum of services. A primary care practitioner needs to be included on the Service Coalition.

The risks of not integrating primary care practitioners into the mental health continuum of services are that secondary and tertiary services will continue to receive inappropriate and unnecessary referrals that will lead to continued de-skilling of the primary care workforce. Costs will increase as more secondary, and in some cases tertiary, services are required to deal with those who could and should have been assessed as part of primary care. Service users and families will continue to experience barriers to accessing timely and appropriate mental health and general practice care.

This Action is planned for the medium term. The 2003/04 District Annual Plans (DAPs) for the three DHBs should demonstrate progress on this matter.

5.6 Action (6): Establish policy and service linkages between government agencies at national and local levels.

There is a significant gap in joint policy development and/or linkages across the various government agencies that contribute to policy and planning for mental health services at both the national and local levels. These agencies include the Police, CYF, HNZC, Work and Income, and Immigration Service

If effective co-ordination among agencies is not established and maintained, policy and planning inconsistencies will continue to prejudice the integrated continuum of services. Poorly co-ordinated policy development will continue to impact on service users and their families.


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The Mental Health Commission needs to incorporate into its monitoring evidence that DHBs are maintaining local service linkages with these government agencies. The Ministry of Health needs to ensure that any advice to Government by these government agencies must include potential impact on mental health policy and services.

This Action is planned for the medium to longer term.


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References

Ministry of Health 2002-11-20 Atlas of New Zealand’s District Health Boards

Occasional Bulletin 13 Public Health Intelligence Group, Public Health Directorate, Ministry of Health - Wellington

The Audit Office 1993 Report of the Controller and Auditor-General on Community Care for People with Mental Illness, The Audit Office - Wellington

Statistics New Zealand 2001 Census Snapshot 4 Maori, Statistics New Zealand – Wellington

Statistics New Zealand 2001 Census Snapshot 6 Pacific Peoples, Statistics New Zealand – Wellington

Statistics New Zealand 2001 Census Snapshot 15 Asian People, Statistics New Zealand – Wellington

Mental Health Commission 1998 Blueprint for Mental Health Services in New Zealand, Mental Health Commission – Wellington

Ministry of Health August 2002 Advice to the Incoming Minister of Health; Background Briefing Papers, Ministry of Health – Wellington


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Appendix 1: Terms of ReferenceThe Minister has directed that this review look at the continuum of care for those with mental illness – from primary and community interventions, through to in-patient mental health services and provision of long term care in residential or community settings.

The Terms of Reference are:

1. The Mental Health Commission will undertake an independent review of the continuum of care and services mix as funded by DHBs in the Auckland region (particularly Waitemata, Auckland and Counties Manukau DHBs), which will inform the Minister of Health on the actions that the Ministry of Health and the DHBs in the Auckland region, whether collectively or independently, can take urgently to significantly improve mental health care, over the medium and long term, to achieve the standards set out in the National Mental Health Strategy, the Blueprint and the National Mental Health Sector Standard.

2. As well as other factors influencing the continuum of care and services mix in the Auckland region, the Review will consider:

Governance and management (including financial management)

Clinical practice Regional co-ordination of planning, funding and service

delivery.

3. The Mental Health Commission will provide to the Minister: A report on progress with the Review by 30th June 2002

(which may include recommendations for changes to District Annual Plans for 2002/03)

A draft action plan by 30th August 2002 A final action plan and Review report by 30th September

2002. The Mental Health Commission work with the support of the

Ministry and District Health Boards to achieve the outcomes required of the Review.


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Appendix 2: Members of the Review Team:

John Ayling Project Leader

Dr Anthony Duncan Deputy Director of Mental Health - Ministry

of Health

Marion Blake CEO – Platform

Wi Keelan Chief Advisor, Maori Health - Ministry of

Health

Margie Hamilton Community Liaison Officer - Lakes DHB

Dr Margaret Southwick Head of Pacific Studies – Whitireia

Polytechnic


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Appendix 3: Letter of response from Chief Executives, Auckland Region District Health Boards (3):30 September 2002

John AylingMHC Review Team Mental Health CommissionPO Box 12 479ThorndonWELLINGTON

Dear John

REVIEW OF AUCKLAND MENTAL HEALTH SERVICESDRAFT ACTION PLAN

Thank you for the opportunity to review the Draft 7-Point Action Plan, and provide our comments, these are outlined in appendix 1.

During discussions between the DHBs and the Review Team, you have signaled that the Review Team will provide the DHBs with the draft report for comment, prior to its submission to the Minister.

We look forward to receiving the draft report. We have prepared our own summary of key messages we would, from our discussions with you, be expecting to be reflected in the body of the report and have enclosed this document for your information.

As requested in a meeting between the review team and us the three Auckland Metro DHBs have prepared a high level response to inform the MHC Action Plan. Included is a reference to key regional projects (some currently in train) and additional initiatives and their estimated value that could be implemented during the coming nine months to address the immediate crisis (Appendix 2). We would anticipate wider consultation around these, and negotiation with the Ministry of Health about their exact nature where additional funding to be made available.

Key MessagesThe Terms of Reference of the MHC review required the identification of “actions that the Ministry of Health and DHBs in the Auckland region, whether collectively or independently, can take urgently to significantly improve mental health care, over the medium and long term to achieve the standards set out in the National Mental Health Strategy, the Blueprint and the National Mental Health Sector Standards”.


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The three Auckland Metro DHBs have agreed the following key messages which must be made explicit in the body of the review report, and be reflected in any proposed Action Plan.

a) The key themes that have been identified as a result of this review reflect issues found nationwide within the mental health sector

b) The most significant issue that differentiates Auckland is the inequity of funding against Blueprint benchmarks

c) An explicit funding path to equity is required and should be indicated in the Report along with accompanying timeline

d) While we remain so far behind Blueprint Benchmarks the region does not support changes to our current planning documents (Regional Mental Health Plan 2002/03, local DHB strategic plans), or a reconfiguration of existing resources. Regional and District plans for 02/03 arose out of careful consideration of the need to re-orient the sector to a community model over time. This requires a long-term steady effort paced to match the resources available.

e) There is a need to continue to strengthen regional funding and planning approaches for the allocation of any new and additional funding, service development and capacity building.

f) Stakeholder communication, engagement, and participation is actively supported, with a commitment to build the capacity of the regional and local stakeholder networks.

We look forward to receiving the draft report for comment.

Yours sincerely

SIGNED SIGNED SIGNED

Graeme Edmond Stephen McKernan Dwayne CrombieCEO ADHB CEO CMDHB CEO WDHB

Copies to:GM Funders Mental Health Manager – NDSAMental Health Funding and Planning Managers – ADHB, CMDHB, WDHB


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Appendix 1

Feedback on the MHC Draft Action Plan 20/09/02

The MHC has identified the following seven Action points in their draft action plan. The Auckland DHBs have reviewed this draft and provide the following comments. The following comments indicate proposed changes to the content of certain action points, and the rationale for these.

Action 1:To manage the fragmentation of mental health services by establishing across the three DHBs a consortium of providers of mental health services for the effective management and coordination of an integrated continuum of care.

We support reducing fragmentation in the sector, If a new structure is proposed, the role, function, and mandate of such

a structure would need further clarification The structure would need to have a limited lifespan and lines of

accountability clearly identified. In order to further avoid duplication and fragmentation we would see

such a structure needing to be positioned as a workstream under the Regional Stakeholder Network who hold a regional brief for input into planning and funding. Their brief could expand to include overseeing a continuum of care within Auckland through the consortium.

We consider enhancing the existing structures to be the preferred option.

Action 2: To make immediate arrangements to provide additional capacity in the provision of sub-acute rehabilitation services.

It is not explicit where any additional funding would come from for such services; - the review team need to state explicitly in Action 2 that there is no current resource for these services and that this matter is covered under Action 3.

DHBs are willing to work with the MoH to apply any additional funding to build service capacity according to identified local and Regional DHB priorities as outlined in the Regional Mental Health Plan and targeted at addressing Blueprint benchmark gaps


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Action 3:To ensure that the three Auckland DHBs receive the funding necessary to provide the required services

The wording of this action is open to misinterpretation. We suggest a need to strengthen this action point to specifically state

that there is an issue re historical inequity of funding, and that additional funding from Government will be needed to address the funding and equity issue.

It is important that there is no inference that this can be achieved through reallocation of existing funds, but rather that a clear statement is made regarding the need for additional funding as part of a clearly defined 3-5 year funding path to address historical inequity.

Action 4: For there to be more effective provision of the core clinical community mental health services (crisis, community and continuing care mental health teams) in Auckland.

We support this Action point, however, ask that the term “more effective provision of services” is clearly defined in the Action Plan

That the Action Plan specifically recognises and outlines the need to build infrastructure capacity to support service growth (e.g. quality monitoring, workforce development etc)

‘Rationale’ in Action Point 4. The statement is incorrect, we suggest that it be reworded to accurately reflect DHB practice i.e. Blueprint funding is applied to new and additional services to increase service capacity and to further develop the continuum of care.

Action 5:To examine all contracts and service specifications for the purposes of ensuring that their terms and conditions support the implementation of an integrated “continuum of care”

We support the approach and seek no amendment. This is a matter on which the MOH should take leadership, with active engagement and participation from DHBs

Action 6:To assess opportunities within implementation of the Primary Health Strategy for primary care practitioners to be integrated into the mental health continuum of care.

We support the assessment of opportunities to improve integration with primary care practitioners in line with the Primary Health Strategy and Primary Mental Health – Review of Opportunities document.

Action 7:


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To establish policy and service linkages by which Health, Housing, Police, Corrections and other Crown Agencies such as Child, Youth and Family and Immigration, communicate at regional and local levels.

We support this action and will actively encourage linkages with local and regional stakeholder networks.


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Appendix 2

Current and Proposed Regional Actions

Auckland Metro DHBs Immediate Actions (July 02 – June 03)

The Northern Regional Mental Health Funding Team (NRMHFT) met with the sector prepared a paper to the Regional Funding Forum (RFF) proposing that CCPS funding underspend be applied to some one-off initiatives aimed at reducing some of the pressures being experienced. The agreed actions are contained in Table One below.

It is important to note that these initiatives have been funded from 2001/02 “one-off” underspend as an emergency response, and are time-limited. As a result there is no sustainable funding pathway to allow the region to continue funding these initiatives. Any continued delivery of these services will result in increased DHB deficit.

Table One: Immediate Service Actions

Activity/Service DHB Location Annualongoing

cost

3 level iv rehabilitation packages of care

Additional Respite, Respite Co-ordination and Community based services

CMDHB $730k

Additional resources to acute services

community mental health services services and respite

ADHB $750k

Establishment of pre-assessment unit for acute admissions,

additional resources to respite, crisis team and inpatient nurses (general and acute mental health)

WDHB $700k

Project worker to identify and develop options for accommodation on discharge from Acute services, link closely with Acute and

1 FTE to cover Auckland Metro DHBS

One off nil ongoing


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Support service reviews

Auckland Metro DHBs Proposed Short-term actions (July 02- June 03)

Seek a sustainable Mental Health funding path, identifying key issues in both the Review of Acute Services and Mental Health ring fence review.

New services have been identified in the Northern Regional Mental Health Plan as part of the 2002/03 Blueprint funding allocation. The identified service developments are the highest priority for the Auckland region currently, and target those clients with the highest and most complex needs. Auckland DHBs are committed to establishing these services as soon as Blueprint funding is received.

Immediate service developments

While most of the immediate focus is on building capacity within adult Community-based clinical teams, there is still a need to invest in more Acute, Sub Acute and Intensive Support Rehabilitation services that have a community focus or are community based. This is consistent with points 2-4 of the Draft Action Plan and will strengthen the continuum of care.

Table 2 below outlines key additional services that could be purchased and operational in the Northern region within a 6-9 month timeframe, should additional resource become available. The three DHBs will ensure, as is with current practice, any additional resource would be applied to the priorities identified and agreed to in the Regional Mental Health Plan, continue to target Blueprint benchmark gaps, and are consistent with the regionally agreed principles for funding and planning.

Table Two: Additional service options

Service/Activity DHB location

Indicative New Funding required (annual)

4 additional ICU beds – Connoly Unit. As part of the re-building programme, there will be extra capacity to provide these beds, but currently no funding available to

ADHB – regional access

$2,000,000


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resource this. 5 Intensive support

Rehabilitation beds, Pacific focus (Proposed ADHB & NGO joint venture)

Flexible packages of care for people unable to leave inpatient units but no longer requiring inpatient care


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Service/Activity DHB location

Indicative New Funding required (annual)

Reconfiguration of existing high support services (19 beds to subacute level)

Flexible packages of care for people unable to leave inpatient units but no longer requiring inpatient care

Enhanced Crisis response

WDHB $2,000,000

Continued funding of 5 Acute Inpatient beds existing but no sustainable funding

4 additional sub-acute beds Enhanced Crisis response Flexible packages of care for

people unable to leave inpatient units but no longer requiring inpatient care

CMDHB $2,000,000

Summary

Table 3 below summarises the total level of additional funding that would ensure sustainability of current short term measures aimed at addressing the immediate problems within Metro Auckland (see Table 1 above) and would allow implementation of the proposed additional services (see Table 2 above).

Table 3 Summary of additional funding needed

DHB Annualised ongoing funding for existing one off services (Table 1)

Indicative new funding required for proposed additional service options (Table 2)

Annualised Total

ADHB $750K $2,000,000 $2,750,00WDHB $700k $2,000,000 $2,700,00


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CMDHB $730K $2,000,000 $2,730,00

Total $2,180,000 $6,000,000 $8,180,00

In the 2002/03 financial year the cost of the additional services is likely to be less than the amount shown in Table 3 above, since it will be part year costs only and since some CCPS underspend has already been allocated.


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Key Projects

In addition to a number of potential service options as identified above, the Northern region DHBs are committed to building a sustainable and robust mental health infrastructure via a number of strategic regional and local projects. These projects will support the development of a continuum of care, improved service delivery models, and provide for a more inclusive and informed approach to the planning and provision of mental health services.

Auckland Metro DHBs Proposed Medium-term actions (July 03- June 04)

DHBs will continue to build on and invest in Local and Regional stakeholder networks to ensure a robust process is developed to maintain active community engagement in funding and service planning issues.

Within this context we aim to:

Implement Regional Mental Health Action Plan (seek early draw down on 03/04 Blueprint funding to apply to service and infrastructure development).

Revisit Blueprint targets in line with current levels of service provision, and population needs, and align with 2001 census data.

Use this information to plan for 2003/04 Blueprint funding allocation (from MoH: indicative Northern region allocation is in the $8 million range).

Implement Regional Maori Mental Health Action Plan Implement Regional Pacific Mental Health Action Plan Implement Regional Workforce Mental Health Action Plan Move towards equity of funding and service levels in line with

national Blueprint benchmarks Retain Mental Health Funding ringfence Plan for the application of Future Funding Track (FFT) to ensure

existing mental health services are sustainable, within the context of deficit management

Reconfigure services to ensure they are being purchased on the most cost effective and efficient manner (eg. Implementation of the recommendations from the National Support Services Review)

Summary

This Work Plan goes some way to outlining regionally supported actions that will alleviate pressure on Auckland’s adult mental health services in the short-to medium term if additional funding is made available.


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Appendix 4: List of Meetings Held by the Auckland Review Team:Organisation Meeting held withAcquired Brain Injury Max Cavitt

Louise ArmstrongADHD Association Susan HampAuckland Central Police John Palmer (Acting Dist Commander standing in for Sup. Int

Howard Broad)Auckland District Health Board Graham Edmond, Chief Executive Officer

Roger Mysliwiec, Clinical Director, Eating DisordersCAT TeamsRC ManagersClinical Directors Mental Health Services (MHS) plus key staff Barry Bublitz, Manager Maori Mental Health ServicesTe Puea Winiata, Maori AdvisorFionnagh Dougan, Manager MHSLorrima Cranstoun, Acting Manager Pacific Island MHS

Deirdre Mulligan, Manager Funding and Planning for MHSNick Argyle, Severe Personality DisordersEileen Swann & Dr Helen Cooney, Maternal MHSConolly UnitBuchanan ClinicBrenda Strathern, Kari CentreAnnette Shea, Taylor Centre

Auckland Hospital Greg FunnicaneAwahitia Te Whanau Pani Trust (Bi cultural services – nurses) Tarati BurkesSouth Auckland Bipolar Support Group 12 membersCentral Auckland Forum for Mental Health Provider ForumCEOs of the 3 DHBs Stephen McKernan

Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region 68

Organisation Meeting held withDwayne CrombieGraeme Edmond

Challenge Trust Lina Samu Consumer Strategy Group South Auckland / Counties Manukau

Child Youth and Family Alan NewmanMike Munnelly

Chinese speaking Psychiatrist Dr Sai WongClinician David CordyeComprehensive Health Services Dr Julian Roberts, Chairperson & Hugh Kininmonth, CEOAuckland Consumer Network Consumers from wider Auckland region - approximately 50

personsCoroners Office 2 CoronersCounties Manukau DHB Ron Pearceson , Acting Chief Executive Officer

Ross Keenan, ChairpersonDebbie SorrensonSue HallwrightDr Lyndy Matthews, Clinical Leadership Group / GP LiaisonKelly Johnstone,Dr David HughesDr Margaret Aimer, Dr Sylvia Van Altvorst, Dr Michael Rimm, Dr Verity Humberstone, Dr Siale Foliaki,Dr John CosgriffHui at Tiaho MaiICT team representatives Tricia Dore and 3 others


Organisation Meeting held withManagement GroupSylvia van Altvorst & Sharon McFarland, Maori Clinical TeamIan McKenzie, General Manager , MHSDr Murray Patton, Clinical Director, MHSStaff forumShirley Frear and team, Maternal Mental Health Services

Counties Manukau Police Superintendent Ted Cox and senior officersDistrict Inspector Phil Recordon plus 2 non contracted providersEastHealth (IPA) Paul Cressey & Michael ClarkeEating Disorders Carol DrewElderly Persons Mental Services (3 DHBs) Jill Calverly and others from 3 DHBsFramework Trust Jeff RadfordGeneral Managers Mental Health Services for the three DHBs Dave Davies, Ian McKenzie and Fionnagh DouganGP – Ex Physic Registrar Neville GearyHapai Te Hauora Tapui Ltd Regional Maori Consumer NetworkHousing NZ – Community Housing Paula Comerford, Blair Badcock and Rosemary SimpsonIntegrated Primary Care Services Alan Greenslade (GM)

Dr Lannes Johnson (Chair)Korean Counsellor Hyeeun KimLotofale Mental Health Service, Auckland DHB Lita Foliaki, Maliaga Erick, Ita Martin, and Peti TeviMalologa Trust Leu ManeaManaaki House, Auckland DHB Leith Carter, ManagerMaori Mental Health Forum 20+ peopleMason Clinic – Forensic Unit, Waitemata DHB Epa Auimatangi, Samoan Social Worker

Bruce TalbotCharles Joe

Mason Clinic – Regional Forensic Services, Waitemata DHB Sandy SimpsonDave Davies


Organisation Meeting held withMental Health Foundation – Youth Mental Health Network Steering Committee (12 members)Mind and Body Consultancy Auckland DHB Consumer AdvisorMinistry of Health Te Puea Winiata (plus others) Hui Te Atea Narino

David ChaplowTodd KreibleGina LomaxAna LongLinda JacobsJanice WilsonKristan Johnson

NDSA – Regional Mental Health Team Frank TraceyRussell GrahamDeirdre MulliganLindsaySue Hallwright Pete CarterBram Kukler

North Shore / Waitakere / Rodney Police Super Intendent Roger Carson, District Commander and senior officers

Northern DHB Support Agency Ltd (NDSA) William Grainger, General ManagerFrank Tracey

Northern Region NGO Provider Groups – CEO Meeting 20+ peopleNorthern Regional CA and Reps Groups 50 + Consumer Advisors and consumer representatives

NZ Police, National Headquarters Catherine CoatesOdyssey House John ChallisOlders Person Mental Health Services Lorrima Cranstoun and Representatives of the DHBsOpen Forum Approximately 75 peopleOrder of St John Peter Tranter (Director of Ambulance Operations and 3


Organisation Meeting held withoperational managers

Others David KingPacificare Kuresa FaleseugaPathways Paul Ingle (GM)Procare (IPA) Dr Tom Marshall (Chair)

Mark Wills (CEO), William Fergusson (Clinical), Mark Vela (GM MHS)

Professional Advisors / Leaders – 3 x DHBs 12 peoplePSA Richard Wagstaff and regional delegates – 30 peopleRaukura Hauora o TanuiTanui Mapo

Winston ManiapotoDi Moss

Refugees as Survivors Patrick JacksonRegional Alcohol & Drug Service, Waitemata DHB Frances Agnew plus 8 peopleSF Auckland Mike Loveman

Field Workers25 family members

SFWU Duane Leo and 10 membersStarship Michael Gudex + senior members of his teamStewart Centre Denis DentonTamaki Oranga, Counties Manukau DHB Wayne HusseyTe Ara Hou Mental Health Services Breakfast meeting with NGO sectorTe Korowai Aroha Barbara Anderson

Alistair RussellBarbara AndersonCarol Seymour

Te Kotuku Ki Te Rangi Tipa Compain

Tihi Ora Maho Temiha CooksonUNITEC Institute of Technology School of Health Science Ruth de Souza


Organisation Meeting held with

Waipareira Trust Reg RatahiNelda TauruaMental Health ServicesManager of Wai Health & Social Services

Waitemata DHB Dwayne Crombie, Chief Executive OfficerKay McKelvie, Chairperson15 Consultant PsychiatristsPauline Hinds, Consumer AdvisorVaoita Turituri & Dave Davies, Isa LeiTimoti George & Dave Davies, Maori Mental Health ServicesPaula Huxley, Maternal Mental HealthSenior NursesProfessional AdvisorsDistrict Mental Health ServicesRegional Alcohol and Drug ServicesRegional Coordination ServiceRegional Coordination Service

Marcus Wells John Hopkins Amanda Bleckmann Mirella Allen Pauline Hinds Dave Davies

West Auckland Family Start Programme Mary WattsWINZ Barry Fisk, Regional Commissioner


Appendix 5: Reference GroupMonica Cartner

Maxine Gay

John Tovey

Professor Graham Mellsop

Cindi Wallace

Kate Prebble

Robyn Priest

Fuimaono Karl Pulotu-

Endemann

Kay Saville-Smith

Mental Health Commission

Bob Henare

Mary O’Hagan

Jan Dowland

Mark Jacobs

Sue Ellis

The Reference Group met three times during the review. Once at the early stages to provide advice as to the review approach and twice to receive and comment on the initial findings of the Review team. Once the draft report was submitted to the Minister of Health the Reference Group had no further involvement in the process. The advice of the Reference Group was not sought on the content of the final report or details of the action plan.


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Appendix 6: Briefing Paper – Maori Perspective

Review Of Mental Health Services In Auckland Metropolitan Area

MENTAL HEALTH COMMISSION REVIEW TEAM

September 2002


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Recommendation

It is recommended that: the Review team include the objectives allocated to: District Health Board Funders and Maori Co-Purchasers, the Northern District Support Agency, and Provider Services in the Action Plan for Maori, into the overall Action Plan for the Review of Mental Health Services in Auckland Metropolitan Area.

1. Introduction

The purpose of the briefing paper is to summarise the information in the Action Plan for Maori, from the review of mental health services in Auckland metro. It will inform the Mental Health Commission and the District Health Boards about the needs and aspirations of Maori, as identified by key stakeholders in the Maori community.

2. Background

A Review team has been established by the Mental Health Commission to undertake a review of the care provided to those with mental illness by District Health Boards in the Auckland metropolitan area. Maori quality and safety issues were not raised specifically during instigation by the Public Service Association, however such issues are included in the Commission’s brief to the Review team and this is entirely appropriate in view of the significant Maori population in Auckland metro, as well, it is thought, the prevalence of mental illness may be higher amongst Maori. It is well known that patterns of mental illness are different for Maori9 and that since 1995, Maori rates of mental illness have increased, while rates for Maori in a number of primary health problems such as heart disease and infant mortality have declined10. It is known, Maori have much higher rates of presentation to crisis, acute and forensic services than non-Maori and they are much more likely to suffer from alcohol and drug disorders11.

3. Current Situation

Auckland metro contains the highest concentration of Maori in the country, accounting for 12% of population (144,078). Current data analysis shows a disproportionately high use of almost all District Health Boards, both local and regional mental health services, by Maori. For example in Waitemata, Maori, 9.6% of the population, use: (44%) forensic, (35%) regional co-ordination and (22%) of acute services12. In Auckland central, Maori, 9% of the population, use (30%) and (89%) of intensive rehabilitation services at Buchanan clinic and Manawanui respectively,

9 Te Puni Kokiri, Ministry of Maori Development, 1996. Nga Ia o Te Oranga Maori – Trends in Maori Mental Health, 1984 – 1993, Wellington.10 Durie M. 1997. Puahou: A five Point Plan for Improving Maori Mental Health. Maori Mental Health Summit.11 MHC. 1998. Blueprint for Mental Health Services in New Zealand: How things need to be. Wellington: Mental Health Commission.12 Mental Health Information Service, Waitemata District Health Board, July 2001-June 2002.Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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and (23%) of acute services13. At Counties Manukau, Maori, 18% of the population, use over (50%) of intensive care team resources, (30%) of secure long-term rehabilitation and 24% of acute services14.

13 Mental Health Information Service, Auckland District Health Board, July 2001-June 2002.14 Mental Health Information Service, Counties Manukau District Health Board, July-August 2002.Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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Maori suffer a greater burden of disease than non-Maori, even after eliminating variations by age, gender, and socio-economic deprivation, they experience higher prevalence in most disease groups, all these factors major predictors for greater use of mental health services15.

The development of mental health services for Maori by Maori has proceeded to the point where there are now 16 contracted kaupapa Maori services in the area. Iwi relationships are progressing with District Health Boards and Maori co-purchasers are in place to represent the Treaty partnership. However, there are many gaps in services, and much work needs to be accomplished by District Health Boards with their Treaty partners in appropriately leading and planning mental health service for Maori, particularly with respect to:

Building effective relationships with key stakeholders in the Maori community;

Establishing a comprehensive ten-year regional mental health strategy for Maori;

Over time, planning and purchasing local Maori mental health care continuums; and

Developing fiscally prudent objectives and long term plans for investing in kaupapa Maori services.

4. Consultation

The Action Plan was developed in partnership with key Maori stakeholders represented in the Te Kotahitanga Maori Mental Health Network and the Maori Advisory Group. Other individuals and groups from regional and local funding and provision services of the District Health Boards participated in the review, as did many non-government organisations.

5. Implications For Maori

Currently, the Maori population structure is much younger than non-Maori. In 1996, the Pakeha 0-14 cohort accounted for 18.2% of their total population as opposed to 37.5% for Maori aged 0-14 years. Over the next 20 years Auckland metro will experience the largest growth in Maori up 61,200 or 46% on 1996 census figures. This means that District Health Boards will require an effective regional mental health strategy, to eliminate health disparities for Maori.

What resource is required to build an effective mental health service continuum for all people in Auckland metro? Difficult to answer at this time, particularly for Maori, because a module for them has yet to be been determined, and having accomplished that, we will still need to identify, how the module sits inside a generic mental health care continuum.

Mental health services do not appear to have been purchased using a comprehensive quality continuum of care approach. Instead, much of the 15 Ministry of Health 2000. Social Inequalities in Health: New Zealand 1999. Wellington. P 12.Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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focus for purchasing services has been in accordance with the “Blueprint.” benchmark of 3%, for those with serious mental illness. For Maori, this has resulted in many small fragmented and stressed kaupapa Maori services, scattered throughout Auckland metro. It is the Review teams contention that, continuing topping up toward 3% without proper regard for constructing an appropriate and effective mental health care continuum, would be throwing good money after bad! There was a suggestion that there is too much emphasis on the 3% with serious mental illness and not enough on the 17% who currently use ineffective primary health services. This was described as “ the ambulance at the bottom of the cliff”. There is strong support by Maori for a more preventive model and a suggestion that the wide-ranging inter-sectoral services similar to Wai-Health be closely looked at as their preferred model for future Maori primary health organisations.

It should be noted there is nothing new or outside of what would be regarded as core business for the District Health Boards requested in the Action Plan for it is based on current Government policy. These are all actions that they should be carrying out already with respect to providing effective services for Maori.

There is an expectation that the Ministry if Health will fund and then monitor the Action Plan for a minimum of two years and that all District Health Boards in Auckland metro will include the actions in their regional mental health plan.

6. Maori Needs and Aspirations

Throughout the review Maori people voiced their needs and aspirations for the future. They said, District Health Boards need to:

Recognise and acknowledge the principles of the Treaty and incorporate them into all aspects of mental health service planning, funding, provision and evaluation;

Recognise that in order to diminish inequalities in mental health it is imperative that Maori are given opportunities to lead, plan, and monitor services for Maori;

Enable Maori co- purchasers and Maori communities to develop and implement whanau strategies for health improvement and Maori provider workforce development.

Support Maori co-purchasers and Maori providers in the development of appropriate outcome measures for whaiora and whanau health and well being.

Develop fiscally prudent objectives and long term plans for investing in kaupapa Maori services.

7. The Action Plan for Maori


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The Action Plan is framed to identify, allocate and timeline accountabilities to the organisations who have responsibility for funding and providing mental health services.

7.1 District Health Boards Funders and Maori Co-Purchasers

The planning and funding mental health managers employed within individual District Health Boards are responsible, alongside Maori co-purchasers, for the planning and funding local mental health services. In order to carry out the role effectively, they must:


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7.1.1 Building Capability and Capacity

(Timelines are indicative only, as Auckland metro District Health Boards will have to consider these actions alongside their existing regional mental health plan).

Objective Year 1 Milestone

Cost Year 2 Milestone Cost

With, Maori co-purchaser develop and implement Treaty of Waitangi Responsiveness framework in all planning, funding services of the District Health Boards.

April 2003

With, Maori co-purchaser develop plan for improving accuracy and appropriateness of collection of Maori health information.

May 2003

With Maori co-purchaser develop explicit quality requirements including clinical and cultural outcome measures for all kaupapa Maori contracts and mainstream contracts involving the provision of care to Maori whanau.

July 2004

With Maori co-purchaser establish a managed and regular programme for monitoring and evaluating mainstream and Maori provider effectiveness in meeting Maori needs.

August 2004

With Maori co-purchaser Commission an independent review of the capacity and capability of Maori co-Purchaser to provide appropriate planning, funding and contracting processes for all kaupapa Maori services.

October 2004

With Maori co- Purchaser develop fiscally prudent objectives and long term plans for investing in kaupapa Maori services.

November 2004

7.2 Northern District Support Agency

The Agency is responsible for funding mental health services. In this role it co-ordinates, analyses and project manages for the range of processes that require regional collaboration. Its work is central to improving Maori mental health gain.

7.2.1 Building Capability and Capacity (Timelines are indicative only, as Auckland metro District Health Boards will have to consider these actions alongside their existing regional mental health plan). Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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Cost Year 2 Milestone Cost

Develop guidelines and policy for communicating with iwi, and other Maori stakeholders in Auckland metro.

October 2002

Establish Maori Mental Health Advisory Group to the Northern District Support Agency.

October 2002


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Cost Year 2 Milestone

Cost

Investigate and action regional funding inequities: Level 4 residential prices Maori provider contracts with

respect to lack of increases to keep pace with inflation.

Disparity in price between mainstream and Maori provider FTEs.

April 2003

Develop intersectoral regional relationships that will positively affect Maori health outcome.

May 2002

With Maori co-purchaser develop a ten-year Maori Mental Health Strategy.

August 2004

Develop a regional Risk Mitigation Strategy for whaiora currently residing in “unregistered Boarding Houses” in Auckland metro.

September 2004

7.3 Provider Services

Non-government and mainstream providers, including Maori should organise their services around the structures and needs of whanau, hapu and iwi.

7.3.1 Building Capability and Capacity (Timelines are indicative only, as Auckland metro District Health Boards will have to consider these actions alongside their existing regional mental health plan).


Cost Year 2 Milestone

Cost

Establish plan to build appropriate relationships key Maori groups and other providers of mental health services.

October 2002

Develop and implement systems for improving collection of accurate Maori data.

February 2003

Develop and implement Treaty of Waitangi Responsiveness Framework

March 2003

Develop appropriate tool for assessing Maori whaiora satisfaction with the service.

June 2003

Establish a policy and process for working with relevant

July 2004


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intersectoral agencies.Establish plan to develop and introduce clinical and cultural outcome measures of service.

August 2004

Identify Maori health workforce development needs and provide plan to resource Maori staff recruitment, retention and development.

September 2004

8. Risk Management

There are inherent risks for Maori in the health sector. The table below contains an analysis of perceived risks from the Maori perspective that are covered in the Action Plan.

Description of Risk Mitigation Factor

1. Failure to achieve appropriate relationships with key Maori stakeholders.

Boards have appropriate partnerships with iwi.Funder and provider services have appropriate relationships: with Maori co-purchasers, and Maori providers, and adopt Treaty principles in working with Maori.

2. No “buy in” from regional Maori community to health planning.

Northern District Support Agency has appropriate Maori representation on its Maori advisory group.

3. Inadequacy of information technology systems collection of appropriate Maori data.

Implement Maori Information System Project within the Information Strategy of District Health Boards.

4. Shortage of skilled Maori Workforce. Develop local Maori workforce planning initiatives.

5. Quality failures. Funders build robust relationships with kaupapa Maori services. Funders and providers, develop Quality Plan including long-term plan for measurable clinical and cultural outcomes.

6. No capacity building occurring in the Maori community.

Develop Intersectoral Strategy.Identify Maori Provider Development plan.

7. Untoward community incidents. Assess needs of whaiora including those in “unregistered accommodation”.

8. No “Closing Gaps” between Maori in mental health services and other New Zealanders.

Include specific performance expectation in services agreements and contract for whole systems that will produce the desired results.Monitor all providers against those expectations.Develop fiscally prudent objectives and long term plans for investing in kaupapa Maori services

BibliographyReview of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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1. Te Puni Kokiri, Ministry of Maori Development, 1996. Nga Ia o Te Oranga Maori- Trends in Maori Mental Health, 1984-1993. Wellington: Te Puni Kokiri.

2. Durie M. 1997. Puahou: A Five Point Plan for Improving Maori Mental Health. Maori Mental Health Summit.

3. MHC. 1998. Blueprint for Mental Health Services in New Zealand: How things need to be. Wellington: Mental Health Commission.

4. Mental Health Information Service, Waitemata District Health Board, July 2001-June 2002.

5. Mental Health Information Service, Auckland District Health Board, July 2001-June 2002.

6. Mental Health Information Service, Counties Manukau District Health Board, July-August 2002.5.

7. Ministry of Health 2000. Social Inequalities in Health: New Zealand 1999. Wellington. P 1

Appendix 7: History of the delivery of mental health services

DeinstitutionalisationTwenty-five years ago the majority of mental health services in the Auckland region were delivered from hospitals that provided inpatient facilities and attached outpatient clinics. Acute short term hospitalisation was provided at the three major psychiatric hospitals: Carrington, Oakley, Kingseat, and Ward 10 at Auckland Hospital. Longer term treatment and residential support for service users were provided within the longer term inpatient units at the psychiatric hospitals.

Key factors that resulted in the move away from residential care in large psychiatric hospitals were: The international development of community based mental health

care, both to support services users in their own home environments, and to intervene before people become significantly unwell.

Changed views on the rights of people with disabilities, including psychiatric disabilities, and a growing recognition that they have a valid place in society

Changes in the way mental illness is managed. Newer medications mean that symptom reduction and elimination have become practicable for an increasing number of service users.

Increasing attention to the roles of demoralisation, the secondary consequences of having a mental illness including "institutionalisation", stigma and discrimination, in perpetuating chronicity of mental illness.

Despite the necessity for deinstitutionalisation in Auckland, there is evidence that it precipitated wide ranging and on-going funding problems. For example, the deinstitutionalisation programme at Carrington coincided with a breakdown in management structures within the Auckland Area


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Health Board, resulting in the process being poorly and hurriedly executed16. People were discharged to alternative residential accommodation before appropriate support services were set up in the community. Approximately $18 million earmarked to provide some of the community support facilities was not ringfenced and consequently some community services never eventuated. Furthermore, plans to provide services for people with serious mental illnesses already in the community, including supported accommodation, were never fully implemented or funded. Thus one of the key foundations on which current mental health service provision is built in Auckland was underfunded and seriously flawed in terms of planning for service provision.

Longer-term service users who had previously lived in a psychiatric hospital have experienced particular difficulties with the move to community-based services. In hospitals, longer-term service users had free and direct access to a range of services such as dentists, general practitioners, physiotherapy, recreational and social activities. Cost for provision of these services does not appear to have been transferred to funds for care in the community. Recent service descriptions have not included the requirement for providers to fund all such services. Service users have had to rely on additional support through the benefit system for services that were formerly free. Accessing and negotiating such support places particular stresses on those with multiple problems.

The types of accommodation provided for service users have also seen considerable change. Funding for residential services was transferred from Social Welfare to Health in 1995. Initially, many of the residential homes were established as “homes for life,” but now residential services are provided for people who need them for as long as they need them, with the expectation that most people will move to more independent living situations. Since 1995 funders have funded more supported housing at levels 3 and 4 while exiting levels 1 and 2. In addition, more community support services have been funded to support people in their own homes. The newer, antipsychotic medications available have made independent living a reality for more people.

With the shift in funding of residential services from Social Welfare to Health, only the funding for people living in registered homes and who were receiving maximised benefit payments through the Community Funding Agency was transferred to Health. A number of accommodation providers who were registered under the DPCW Act but were not funded by the Community Funding Agency, were not contracted under the new regime. However, the so-called ‘non-contracted’ providers (such as boarding houses) provide the accommodation for a significant number of mental health service users and many believe that because they meet the current registration standards they should be funded by Health. To comment on the validity of their individual claims is clearly outside to scope of this review, however their contribution to care provision does need to be acknowledged. 16 Auditor General's Report on the closure of Carrington Hospital – full reference needed. The Audit Office 1993 Report of the Controller and Auditor-General on Community Care for People with Mental IllnessReview of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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The move to people with psychiatric illness living in the community has meant that most are now directly reliant on government income support through the benefit system. They face a range of issues including a lack of additional benefits for people with a psychiatric disability living in community accommodation, and the impacts of benefit abatement rates on part-time work.

The contracting modelThe present purchasing arrangements are a carry-over from the era of the ‘funder/provider’ split. Since 1993 health services have been typified by the separation of ‘funders’ and ‘providers’ whereby services have been specified (and in many cases priced) by the ‘funder’ and then provided by a ‘provider’. A contract has been the means by which the interests of both are managed.

A characteristic of the separation of funder from provider was competition between providers (particularly NGOs) for the provision of specific components of the service according to contract specifications.

Increasing demands for a wider range of servicesOver the last thirty years there have been growing expectations that mental health services will manage a wider range of conditions than before. The move into the community has meant that the potential coverage of mental health services has been seen to be much wider. Thus while there has been more money going into mental health services, at the same time there have been increasing demands on mental health services to do more with it.

Rapidly changing and diverse social conditions have placed increasing demands in mental health services. A massive upsurge in the use of illicit drugs, particularly marijuana, along with complex combinations of major mental illness, substance abuse, and personality issues have also exacerbated demands in both the range and extent of services.

Consumer advocacyAdvocacy by an increasingly political service user movement in Auckland since 1987 has led to calls for more responsive and less paternalistic services. There are a number of service user run services in Auckland, as well as the desire to provide service user run alternatives to services such as acute services.

Alongside these changes has been the advocacy of a recovery approach particularly through the Mental Health Commission Blueprint and subsequent publications such as the “Recovery Competencies for NZ Mental Health Workers”. These have been reinforced by recovery workshops for both service users and staff especially in one of the DHBs. The Consumer Advisors in that DHB report that the impact of these workshops has been to significantly change the culture within services and attitudes of clinicians with direct benefits to service users.Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

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The Mental Health Act The passage of the Mental Health (Compulsory Assessment and Treatment) Act in 1992 brought with it a number of fundamental changes to the way compulsory assessment and treatment for service users with mental health disorders were managed. Major changes were the requirement that people be cared for in the least restrictive environment possible, and a focus on the protection of individual rights. Clinicians are required to formally review a service user’s/tangata whaiora need for compulsory treatment at prescribed intervals. District inspectors appointed by the Ministry of Health have wide powers and have a role to ensure service users’/tangata whaiora rights are upheld. There are key linkages with the Justice system, including Family Court Judges and with the Police.

Some sections of the public and media see the Act’s focus on the individual rights of service users as directly conflicting with society’s need to be kept safe. There is a perception that people with mental illness have a higher risk of violence than any other members of the community. The infrequent but often sensationalised violent incidents concerning mental health service users have often created a climate of fear in the community, and calls for secure psychiatric institutions. Community care, appropriately resourced and managed, provides adequate safety for the community. It is also clear that for the vast majority of service users it provides a much better quality of life.


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Appendix 8: Expenditure Current and Guideline by DHB, as at 30/6/2002

Total Funding 2001/02** Total Funding Blueprint Guidelines$M 2001/2 %Blueprint Population* $M/100000 $M Population* $M/100000

New Zealand $675 65% 3,862,506 17.49 $1,047 4,134,965 25.32

NORTH $241 58% 1,371,132 17.61 $417 1,556,893 26.75Northland $25 57% 146,446 16.77 $43 156,574 27.50

Auckland Total $217 58% 1,224,686 17.71 $373 1,400,319 26.67Waitemata $88 64% 442,256 19.83 $137 512,122 26.73

Auckland DHB $78 67% 391,684 20.01 $116 441,309 26.39Counties Manukau

$51 42% 390,746 12.99 $120 446,888 26.88

MIDLAND $127 58% 761,764 16.71 $219 804,466 27.23Waikato $63 67% 329,175 19.09 $94 346,454 27.20

Bay of Plenty $25 46% 180,842 14.08 $56 206,120 26.97Lakes $14 49% 100,268 13.99 $29 105,060 27.45

Taranaki $16 59% 104,844 15.62 $28 101,532 27.37Tairawhiti $7 58% 46,635 15.56 $13 45,301 27.76CENTRAL $138 73% 801,442 17.25 $189 813,868 23.19

Hawkes Bay $19 57% 146,911 13.20 $34 147,354 23.08Whanganui $14 92% 67,000 20.76 $15 64,354 23.48Manawatu $22 56% 161,585 13.43 $39 168,046 23.18

Hutt $20 66% 136,271 14.91 $31 134,104 23.05Capital and

Coast$57 94% 251,376 22.73 $61 262,638 23.24

Wairarapa $6 67% 38,299 15.01 $9 37,371 22.83SOUTH $168 76% 928,168 18.15 $223 959,738 23.19Nelson

Marlborough$18 59% 122,089 14.66 $30 130,712 23.22

Canterbury $84 78% 437,851 19.21 $108 468,200 23.13West Coast $8 110% 32,407 25.24 $7 31,567 23.54

South Canterbury

$6 51% 53,713 11.25 $12 51,573 23.07

Otago $39 95% 176,733 22.07 $41 176,499 23.26Southland $13 56% 105,376 12.52 $24 101,187 23.23


* Populations are from 1996 Based DHB medium population projections projected to 2001 and 2010.

**Note many regional services have been allocated to a lead DHB within the region rather than geographically spread


Appendix 9: Revised metropolitan Auckland Mental Health Structures and Relationships



Appendix 10: Mental Health Structures and Relationships1. General Manger, Regional Mental Health Services (GMRMH)

Primary responsibility: To ensure the provision of a co-ordinated mental health service and a seamless continuum of care for service users in metropolitan Auckland.

The GMRMH will be required to oversee the development of the regional strategic and annual plans and be responsible for the distribution of funds through suitable service contracts. In carrying out this work the GMRMH will seek advice from the Auckland Regional Mental Health Service Coalition to ensure co-ordination of a regional system of services. The GMRMH will have a role of ‘clinical’ oversight to assist with the co-ordination of inter-district admission, discharge and transfer. The GMRMH will be gazetted as a DAMHS for the three districts.

The GMRMH will be accountable to the CEOs of Auckland, Waitemata and Counties Manukau DHBs and will be a full member of the NDSA Board.

2. PlanningThe planning team will be required to prepare the regional mental health plan. This plan will inform the district strategic and annual plans of each DHB. The regional plan must be informed by the Auckland Regional Mental Health Service Coalition. The planning team will be responsible for advising on the allocation of funds across the service continuum.

The planning team will also work with each DHB to ensure co-ordination with the DAP process and alignment with other services (eg primary care).

3. Auckland Regional Mental Health Service CoalitionThe Service Coalition will comprise representatives of providers, both private and public, together with union, consumer and clinical representation. Its responsibility will be to coordinate all services within metropolitan Auckland taking into account service user need and include balancing resources, both clinical and support resources, ensuring quality provision, determining service requirements and advising adjustments to service contracts to achieve improved outcomes. The Service Coalition will also be required to assist with capacity building and to encourage alliances to obtain more effective and efficient service provision.

4. ContractingThe existing NDSA has considerable contracting experience and it is envisaged that that expertise will be used in terms of document formulation, general administration and monitoring against specifications. Contracts will be constructed to enable adjustments to be made during the tenure of the contracts. This will be important during the early stages of development.

5. The Regional Mental Health System


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To place the change in perspective, the mental health services in Auckland will be viewed by the GMRMH as a system of providers and service users. This means that providers will need to work collaboratively in pursuing system-wide objectives that promote pathways to recovery for individuals with mental health problems. The GMRMH will be responsible for the leadership of this vision.


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Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region

Documents

review team

mental health commission

mental health system

auckland services

mental health sector

provision of mental

review process

minister of health